Every finding on record at Willow Ridge Wellness & Rehabilitation

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (adjacent hallway to the 300 Hall) out of 2 hallways reviewed for accidents and hazards.1.The facility failed to ensure that 3 of 3 mechanical lifts on the hallway adjacent to the 300 Hall were locked and secured when not in use.This failure could place residents, visitors and staff at risk of falls and/or injuries. Findings Included:Observation of the hallway adjacent to the 300 Hall on 03/29/26 at 4:36 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall. Observation of the hallway adjacent to the 300 Hall on 03/29/26 at 7:01 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall. Observation of the hallway adjacent to the 300 Hall on 03/30/26 at 3:50 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall.Observation of the hallway adjacent to the 300 Hall on 03/30/26 at 5:26 PM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall. Observation of the hallway adjacent to the 300 Hall on 03/31/26 at 9:33 AM revealed 3 unlocked and unsecured mechanical lifts parked on the hallway adjacent to the 300 Hall.Observation on 03/31/26 at 9:36 AM revealed that RN A was standing at the Nurses Station on the 300 Hall, which was located in the front of the hallway adjacent to the 300 Hall.In an interview on 3/31/26 at 9:45 AM with RN A, she stated that she had been employed at the facility for 2 years. RN A stated that she was assigned to the 300 Hall. She stated that she was unaware that the 3 mechanical lifts parked in the hallway adjacent to the 300 Hall in were unlocked and unsecured. RN A stated that she had taken in-service trainings on mechanical lift safety and storage. RN A stated that she could not recall when she had previously taken in-service trainings on mechanical lift usage and safety. RN A stated that mechanical lifts were to be always locked when they were not in use. RN A stated that the 3 mechanical lifts that were observed on the hallway adjacent to the 300 Hall were the only mechanical lifts she used for residents. She stated that the 3 parked mechanical lifts in the hallway adjacent to the 300 Hall were stored in the area to charge the mechanical lifts while they were not in use. RN A stated she typically did not check the parked mechanical lifts to verify if they were locked and secured. RN A stated that she would now ensure and tell other staff members that the mechanical lifts on the hallway adjacent to the 300 Hall were always locked. RN A stated that mechanical lifts should always be locked and secure, such as the hallways when they were not being used. RN A stated that harm could be caused to anyone when a mechanical lift was unlocked, which included accidents and falls. She stated that someone could be harmed by having a serious fall with injuries, such as cuts, bruises and fractures when a mechanical lift was unlocked. In an interview on 3/31/26 at 10:10 AM with CNA B, she stated that she had been employed at the facility for 8 years. CNA B stated that she was assigned to the 300 Hall. She stated that she was unaware that the 3 mechanical lifts parked in the hallway adjacent to the 300 Hall in were unlocked and unsecured. CNA B stated that she had taken in-service trainings on mechanical lift safety and storage. CNA B stated that she did not remember when she had previously taken in-service trainings on mechanical lift usage and safety. CNA B stated that mechanical lifts should be locked and secure when they were not in use. She stated she would now check the mechanical lifts every time she passed them to ensure that they were secure and always locked. CNA B stated that if she observed a staff member store the mechanical lift, she would ask them if they ensured that the parked mechanical lifts were always locked when they were parked. CNA B stated if a mechanical lift was unlocked, there was a risk of the mechanical lift rolling. She stated that another risk of having an unlocked and unsecured mechanical lift on the hall was that someone can grab the mechanical lift and may fall. She stated that someone could be harmed by an unlocked mechanical lift and may fall and receive broken bones, fractures, head injury or death. An email was sent to the Administrator on 03/31/26 at 10:49 AM, requested the facility's policy on accidents and hazards and mechanical lifts.In an interview on 03/31/26 at 11:17 AM with the DON, she stated that she had been employed at the facility for 2 years. The DON stated that she was unaware that the 3 mechanical lifts parked on the hallway adjacent to the 300 Hall in were unlocked and unsecured on 3 days (03/29/26, 03/30/26 and 03/31/26). The DON stated that her expectation was that all mechanical lifts in the building were to be locked when they were not in use. The DON stated that all staff have been educated and trained on the proper usage and safety of mechanical lifts, which included always locking at always securing them. The DON stated that she could not recall when the staff received their last in-service training on mechanical lifts. She stated that she will reeducate staff with in-service training on mechanical lifts safety and storage. The DON stated that the in-service training for staff would also include education on performing routine checks of the mechanical lifts in the building. The DON stated that the 3 mechanical lifts that were observed were parked on the hallway adjacent to the 300 Hall were the only mechanical lifts used by staff and were parked there to be plugged up while not in use. She stated that there was a risk to anyone to be injured due to an unlocked and unsecured mechanical lift. The DON stated that there was potential for harm to anyone who attempted to lift themselves with the unlocked and unsecured mechanical lift, which could cause injuries, such as broken bones, fractures and worst-case scenario death. The DON stated that the facility did not have any policies regarding accidents and hazards.In an interview with the Administrator on 03/31/26 at 12:19 PM, she stated that the facility did not have a policy for accidents and hazards relating to mechanical lift safety and storage. Record Review of facility's policy for Total Mechanical Lift, did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage.

Based on observation, interview and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for one (Resident #1) of seven residents reviewed for dignity. 1. Staff failed to ensure Resident # 1 was not laying directly on the sealed protective plastic packaging with her bare skin touching the plastic on 01/29/26. The failure could place residents at risk for skin irritation, poor sleep quality, and suffocation hazards.Findings included: Resident #1Record review of Resident #1's admission record, dated 01/29/26, reflected an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included sequelae of cerebral infarction (aftereffects of stroke such as memory loss, paralysis, depression and chronic pain, that has impacted daily life and independence), glaucoma in both eye (this is an eye disease that causes vision loss), Congestive heart failure, and Type 2 diabetes (a problem in the way the body regulates and uses sugar as fuel). Resident #1 was her own responsible party. Record review of resident #1's quarterly MDS Assessment, dated 11/10/25 reflected a BIMS score of 8, indicating moderate cognitive patterns. She was always incontinent with bowels and bladder and dependent on staff with toileting, showers, and transfers. The MDS did not indicate any wounds or pressure sore. Record review of Resident #1's care plan, initiated 05/09/25, reflected the following: Focus: [Resident #1] had ADL self-care deficit related to debility [physical weakness]. Goal: To improve/maintain current level of function in all ADLs through the review date 02/17/26. Intervention: Bed mobility: The resident requires extensive assistance by 2 staff to turn and reposition in bed, skin inspection: The resident requires skin inspection every week. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.' Record review of Resident #1's reentry skin assessment completed on 1/19/26 by RN A, revealed bruising on her right wrist and back of her palm due to an IV. The assessment did not reveal any concerns for pressure wounds. Observation 01/29/26 at 09:33 AM revealed Resident #1 was in bed. Resident #1 was lying on top of the protective plastic packaging of her brand-new mattress. Resident #1's back area with skin exposed was directly touching the plastic as she laid on her back. Resident #1 could communicate well; however, she could not recall the exact times or date that she had been on the plastic packaging of the new mattress. Resident #1 stated Oh that is the sound I hear when I move some. When asked how long she had been on the plastic with her skin exposed on it, she stated God knows how long but my legs are hurting. Resident #1 requested for her legs to be moved, and the call light was activated for staff to assist her. Continuous observation and interview on 01/29/26 at 09:36 AM, revealed RN A came into Resident #1's room and repositioned Resident #1's legs. Resident #1's bare calf area on both legs had been lying flat on the plastic. RN A said that she did not know who had placed the resident on the mattress without removing the plastic cover. She said she was not sure how long she had been on it. She said when Resident #1 readmitted she was on a regular mattress without the plastic packaging on it. She said failure to remove the plastic packaging placed the resident's skin directly on the plastic and at risk for skin irritation and breakdown and it was not a homelike environment. She said the facility had just received new mattresses but was unsure on the date or who had placed Resident #1 on the new mattress. She stated she would have the packaging removed right away. In an interview with CNA C on 01/29/26 at 09:46 AM, she said Resident #1 had been in the hospital and had been back in the facility for one week. She said she did not know why the person who put Resident#1 on the new mattress did not remove the packaging or extend the bottom sheet so that the resident's skin was not directly on the plastic. CNA C stated some mattresses did not require to have a bottom sheet on them such as air mattress but the one on Resident #1's bed was the actual packaging of the mattress. She said the risk was skin problems. In an interview with CNA D on 01/29/26 at 12:31 PM he said he had been assigned to Resident #1 as her aide. He said he had noticed today at 6:30 AM the mattress was still with the plastic packaging on it but he thought it might have been a specialized type of mattress. He said he did not verify with the nurse because some mattresses came that way and he thought it was part of a compressor bed. He said that the facility worked with different vendors such as hospice and he was not sure when Resident #1 was placed on the new mattress. He stated the risk was rubbing of the skin on the plastic packaging and creating a bed sore. In an interview with the MDS nurse on 01/29/26 at 1:58 PM, revealed Resident #1 was on her angel rounds. She said angel rounds were when department heads went to different residents' rooms and had a one-on-one time with the resident, made sure they had ice water, the call light was working, and they had no immediate concerns. She said that she did not notice that Resident #1 was laying on top of the plastic packaging. She said she did not know how she missed it. She said she had visited Resident #1 after returning from the hospital (1/19/26) and she did not recall Resident #1 on the mattress with the packaging still on it. When the nurse was asked why the packaging was not removed before placing Resident #1 on the bed, she said she could not speak on the actions of others and why they did not remove the plastic packaging. She said the expectation was that the plastic packaging was removed, a fitted or bottom sheet was placed on the mattress prior to putting the resident in bed. She said that the risk to Resident #1 was skin breakdown. Interview with DON on 01/29/26 at 2:42 PM revealed she was not aware of Resident #1 situation of being laid on plastic packaging. She said the expectation was that packaging was removed off the mattress and bed was made up with clean linen. She said the risk to the resident was skin breakdown. She said all nursing staff were responsible. Interview with the Administrator on 01/29/26 at 2:58 PM, she said they had just gotten new mattresses for the facility in the past 4 days. She said she would get the DON to complete a skin assessment on Resident #1. She said the expectation was that the staff would remove the mattresses out of the plastic packaging before placing them on the mattress. She said that she would also start an in-service on the new mattresses because all the residents were getting new mattresses. She said except for Resident 1 all the residents that had already gotten a new mattress did not have the plastic packaging still on. She said she had gone around to check the rooms. She said due to plastic packaging being non-breathable plastic, the risk to the residents was potential skin breakdown. She said all residents had a right to a comfortable environment. Record review of facility policy titled Residents Rooms and Environment revised 08/2020 revealed Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to thefollowing:A. Cleanliness and order;B. Private closet space in each resident room;C. Lighting that is comfortable (minimum glare) yet adequate (suitable to the task);D. Personalized furniture and room arrangements;E. Pleasant, neutral scents;F. Comfortable levels of ventilation;G. Comfortable temperatures; andH. Comfortable noise levels. II. The resident will be provided with a bed of proper size and height for safety and convenienceof the resident.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to provide an environment that was free of accident hazards for one (Resident #1) of five residents reviewed for accidents. -The facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents when Resident #1 cut his wrist with a sharp object, had to be hospitalized with a 4cm laceration to his wrist and was admitted for a psychiatric evaluation. Resident #1 had diagnoses of mental illness and IDD, a history of having razors in his possession, and a history of aggressive behaviors. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 8/12/25 and ended on 8/14/25. The facility had corrected the non-compliance before the state's investigation began. This failure could place residents at risk for accidents that could lead to serious injury, harm, or death. Findings included: Record review of Resident #1's face sheet, dated 8/15/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 8/12/25. Resident #1 had diagnoses that included: vascular dementia (brain disorder that affects thinking, memory, and behavior caused by a stroke), type 2 diabetes (body's inability to control blood sugar), schizophrenia (mental disorder that affects thinking, mood, and behavior), and moderate IDD (significant limitations in intellectual and adaptive behaviors). Record review of Resident 1's quarterly MDS assessment, dated 6/18/25, reflected the resident's BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section D-Mood, reflected Resident #1 had not shown any mood problems within the last two weeks and rarely isolated. The MDS Assessment under Section E-Behavior, reflected Resident #1 had not exhibited any behaviors. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 required supervision with all ADL's. Record review of Resident #1's care plan, revised 8/12/25, reflected the resident had a potential for mood problem r/t dx of schizophrenia with interventions that included: administering medications as ordered, providing a program of activities, behavioral health consult as needed, monitoring and recording change in mood or possession of weapons and reporting to MD as needed. Further review of the document reflected Resident #1 had a behavior problem AEB physical aggression with interventions that included: anticipating the resident's needs, providing positive interaction and attention, administering medication as ordered, assessing contributing sensory deficits, providing physical and verbal cues to alleviate anxiety, intervening as necessary to protect the rights and safety of others and self, modifying environment, and monitoring, documenting and reporting PRN any s/sx of resident posing danger to self and others. Record review of Resident #1's psychiatric progress note, dated 7/28/25, reflected in part the following: Reason for Referral:[Resident #1] was referred to [Behavioral Health Provider] due to: vascular dementia, schizophrenia, agitation, aggressive behavior.Chief Complaint/HPI:[Resident #1] is being seen today for the management of psychotropic medications and side effects, and to monitor the effect of medication and for dosage adjustment. [Resident #1's] psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the [Resident #1's] condition and to prevent relapse or hospitalization. [Resident #1] reports to I'm okay. Staff report [Resident #1's] behavior has improved.[Resident #1] is seen in the secure memory care unit. [Resident #1] does not appear to be feeling sad, nervous, angry, or elated today. [Resident #1] presents no delusions and does not appear to be responding to internal stimuli. [Resident #1] has been sleeping well, with adequate daytime energy. [Resident #1] has a good appetite. [Resident #1] participates in some of the available activities.Current Medication:Other MD:1 Benztropine Mes 0.5 Mg Tab SIG: Take 1 twice daily (used to treat Parkinson's Disease)2 Melatonin 3 Mg Odt SIG: 1 po q 24h (a natural hormone that regulates sleep)3 Oxcarbazepine 150 Mg Tablet SIG: Take 1 twice daily (used to treat seizure and mood disorder)4 Risperdal 1 Mg Tablet SIG: 1 at night (anti-psychotic medication)5 Sertraline Hcl 100 Mg Tablet SIG: 2 po qd (used to treat mood disorder)6 Trazodone 50 Mg Tablet SIG: 1 po qhs (used to regulate sleep and stabilize mood) Assessment/Plan:Schizophrenia: Sertraline, RisperidoneSleep: Trazodone, MelatoninSz and mood stabilization: Oxcarbazepine. Record review of Resident #1's progress notes, dated 7/1/25 at 7:08 AM by LVN Q, reflected the following: CNA removed razors from [Resident #1's] room and [Resident #1] became upset, knocking carts over in hallway and attempting to grab and hit CNA. CNA went into nursing station and [Resident #1] sttempted [sic] to reach over door to hit and grab CNA. [Resident #1] made threats that he was going to come after CNA and ‘get him.' [LVN Q] explained that razors are not allowed to be left in the room and that staff has to follow the regulations. [Resident #1] yelled at [LVN Q] that he can have them and that he had a lot of razors in his room. Record review of Resident #1's progress notes, dated 8/12/25 at 1:28 PM by LVN A, reflected the following: [Resident #1] was informed that the money is available but [Resident #1] continued to want the money immediately, the business lady informed resident that she will bring [Resident #1] his money as soon as she cashes [Resident #1's] check but [Resident #1] did not want to wait., [Resident #1] continued to kick the door and asking for his money. Record review of Resident #1's progress notes, dated 8/12/25 at 1:33 PM by LVN A, reflected the following:[LVN A] was called to come to the entrance door of the unit by [Activity Director], on arrival [LVN A] noticed [Resident #1] bleeding from his wrist and that [Resident #1] had cut his wrist with a razor and was bleeding heavily. [LVN A] collected towel and applied pressure to stop the bleeding. [LVN A] asked for other employees to come help stop the bleeding by applying pressure. [LVN A] called 911 and asked for paramedics and police to come and transport [Resident #1] to [local hospital] for eval and treatment. Record review of Resident #1's progress notes, dated 8/12/25 at 1:43 PM by LVN A, reflected the following: [NP] notified of [Resident #1] cutting his wrist and [Resident #1] was being sent to [local hospital] for treatment and eval. Paramedics arrived and transported [Resident #1] to ER. Record review of Resident #1's hospital records, dated 8/12/25, reflected in part the following: HPI: [Resident #1] is a 70 y.o male who presents with 4cm left wrist laceration after [Resident #1] became angry at his group home for not giving him the cash from his social security checks fast enough. [Resident #1] States he was not trying to kill himself, he was just trying to make a point. [Resident #1] denies any decreased sensation distal (farther from) to the laceration. [Resident #1] with difficulty of wrist flexion (action of bending). [Resident #1] has no issue with MCP (knuckle), PIP (middle joint of each finger), or DIP (fingertips) flexion.Physical Exam:Laceration: Volar laceration (involves multiple structures) of the proximal forearm. Exposed tendon within the laceration most likely FCR (tendons that help bend wrist). Tendon appears partially intact. FDS and FDP (tendons that help bend fingers) intact. [Resident #1] with severe difficulty in wrist flexion. FPL (tendons that help bend thumb) intact. [Resident #1] denies decreased sensation distal to the laceration. Strong ulnar artery (major blood vessel in forearm) pulse using Doppler. Weak radial pulse (pulse in wrist) using Doppler.Flexlon Cascade (natural resting posture of hand): No scissoringTendons: FDS and FDP intact in the index, middle, ring, small finger. FPL intact in thumb. No extensor lag (inability to extend) present. Able to fully extend all digits.Sensation: Sensation intact to light touch on the radial and ulnar border aspect of all digits. Sensation intact to light touch in the radial, ulnar and median nerve (major nerve that runs from arm to hand) distribution.Vascular: Less than 2 sec capillary refill present in all digits.Motor: Positive [NAME], PIN (nerves responsible for motor function), ulnar nerve function.Imaging: XR left hand: There is a soft tissue laceration but no acute fracture.Assessment:-Left wrist laceration-Suicidal ideation-Admit [Resident #1] to intermediate care-Bedside sitter-Psychiatric consultation-Bedside repair (closed laceration). Record review of Resident #1's EHR reflected the resident was discharged from the facility and at a local hospital; therefore, Resident #1 was unable to be interviewed. In an interview on 8/15/25 at 9:25 AM with the Administrator and DON, the Administrator stated Residen#1 resided on the secured unit due to diagnosis of dementia and was receiving psychiatric services for management of medication and behaviors. She stated on 8/12/25 it was reported that Resident #1 became frustrated about not receiving his money and pulled out a sharp object and cut his wrist. The Administrator stated the Activity Director was on the unit and attempted to stop Resident #1 however, it happened so fast he was unable to. The DON stated she was called onto the unit and assisted with stopping the bleeding until EMS arrived. She stated she was occupied with tending to the wound and never saw the sharp object that Resident #1 used. The Administrator also denied seeing the sharp object and stated she did not know how Resident #1 could have obtained a sharp object to cut himself as all sharp objects were locked up. The DON stated it had not been reported that Resident #1 expressed any thoughts of suicide or behaviors just prior to the incident; however, he was diagnosed with schizophrenia and had a history of aggression when things did not happen right when he wanted them to. The Administrator stated staff did a full sweep of the entire facility immediately after the incident to check for and remove any unsafe objects. The DON stated Resident #1 had a parole officer; however, the facility did not have any information about why he was on parole and the resident's parole officer had not visited the facility. The DON stated Resident #1 was his own responsible party and did not have any family involvement. In an interview on 8/15/25 at 9:42 AM, the Activity Director stated he was on the unit preparing to take residents out for a smoke break when he heard Resident #1 upset and kicking on the door. The Activity Director stated he went to talk to Resident #1 to calm him down and the resident stated he was upset because he did not have his money. The Activity Director stated Resident #1 said he was going to cut his wrist, then pulled out a sharp object and proceeded to do cut himself. The Activity Director stated he tried to stop Resident #1 but was unable to. The AD stated he did not know what object Resident #1 used to cut himself and he never saw the object afterwards. He stated he walked away and let the nurse take over. He stated he immediately called for LVN A and CNA B to help, and they came to take over. The Activity Director stated he interacted with Resident #1 all the time because the resident was a smoker, and he often supervised the smoke breaks. The Activity Director stated Resident #1 was normally calm especially if he could smoke, and he had never seen him agitated or aggressive. The Activity Director stated he always made sure the residents who smoked had cigarettes and went to break on time because that made them happy. He denied having concerns for any residents being abused or neglected at the facility. The Activity Director stated staff were often trained on abuse and neglect and had in-services regarding resident safety, rights, and suicidal behaviors after the incident this week. In an interview on 8/15/25 at 10:17 AM, the BOM stated Resident #1's funds were in the facility's trust fund, and he would get $45 a month. The BOM stated initially there were some issues with the facility becoming payee over Resident #1's money, but she was finally able to get it worked out and the resident had 2 checks for $45 available. The BOM stated she was just waiting for the Administrator to go to the bank and cash the checks. The BOM stated Resident #1 became a little agitated after she explained that the checks were available but needed to be cashed. In an interview on 8/15/25 at 10:44 AM, LVN A stated he worked at the facility for 10 years and worked with Resident #1 on the male secured unit. LVN A stated he worked on 8/12/25 when the incident occurred. LVN A stated he was assisting other residents in the dining area on the unit when the Activity Director called for his assistance because Resident #1 was agitated. LVN A stated by the time he made it down the hallway, Resident #1 had cut himself and he saw a lot of blood. LVN A stated he grabbed towels and wrapped them on Resident #1's arm to stop the bleeding while calling 911. LVN A stated he did not see the object that Resident #1 used and could not state what happened to it after the incident. LVN A stated Resident #1 had a history of being aggressive towards other residents but was normally calm until something triggered him. LVN A stated Resident #1 had been involved in physical altercations with other residents for them getting in his space. He stated Resident #1 never showed any signs of being suicidal. LVN A stated Resident #1 was independent with most ADL's; however, the CNAs were still expected to monitor him while shaving and to immediately dispose of the razors in a sharps container. LVN A stated the residents were not allowed to keep disposable razors in their rooms, and he denied ever seeing any razors left in resident rooms. He stated new razors were always locked in a supply closet that was on the unit. In an interview on 8/15/25 at 10:58 AM, Resident #4 stated he felt safe at the facility. He stated staff assisted him with ADL's as needed; however, he was able to do some things on his own and it made him feel good about himself. Resident #4 stated he used to keep a disposable razor in his room because he liked to shave himself daily without bothering staff, but all razors were removed a couple of days ago after an incident happened at the facility. Resident #4 stated he understood it was for safety, but it also felt like they were taking some of his independence. Resident #4 stated staff told him that he could still shave himself every day, they just had to bring in the razor and monitor him. In an interview on 8/15/25 at 11:08 AM, the Floor Technician stated he cleaned the floors at the facility, including in resident rooms. He stated when cleaning in the resident rooms, there were times he saw disposable razors in the bathrooms prior to the incident. The Floor Technician stated he did not remove the razors because he had not been told to do so and he did not report it to nursing because he thought the residents were allowed to have the disposable razors to shave. In an interview on 8/15/25 at 11:15 AM, CNA B stated she worked at the facility since 1988. She stated she worked on the male secured unit with Resident #1 and worked on 8/12/25 when the incident occurred. CNA B stated Resident #1 had been asking about his money all morning but did not seem agitated at first. CNA B stated the BOM came to the unit to speak to Resident #1 about his money around lunch time and shortly after, the resident started kicking the door and repeating that he wanted his money. CNA B stated she began directing all other residents to the dining area for safety and the Activity Director was with Resident #1 trying to calm him down. CNA B stated she suddenly heard more yelling and when she turned around, she saw blood coming from Resident #1. She stated LVN A went to help Resident #1 while she remained with the other residents. She stated she was not sure how Resident #1 was able to get anything sharp to cut himself with. CNA B stated they kept razors for shaving locked in the closet. CNA B stated when she showered residents, she would assist them with shaving if needed then immediately put the razors in a sharps container. She denied ever leaving a razor out and in a resident's possession, not even the residents who were able to shave themselves. The CNA stated she could not speak for all staff and there were times they would come on shift and find razors left out prior to the incident. CNA B stated she would always remove any razors she found. In an interview on 8/15/25 at 12:01 PM, CNA C stated she worked on the male secured unit and was familiar with Resident #1; however, she did not work on 8/12/25 when the incident occurred. CNA C described Resident #1 as pleasant and denied ever seeing him agitated or exhibiting signs of being suicidal. CNA C stated the aides were responsible for assisting and monitoring residents with shaving and had to remove the razors immediately. She stated she would always place the razors in a sharps container outside of the resident rooms. CNA C stated staff were expected to check drawers, sinks, and bathrooms in resident rooms daily for things like silverware, razors, electric shavers, or other items that could be unsafe before and after the incident. CNA C stated sometimes during her checks she would find disposable razors left in the bathrooms and she would remove them and report it to the nurse. She denied seeing any razors since the incident occurred. CNA C stated the disposable razors were locked in the supply closet; however, the residents were smart and would sometimes figure out the code by watching staff. CNA C stated she found Resident #1 inside of the supply closet one day and after she reported it the code was changed. CNA C stated although she was off on 8/12/25, the DON called and in-serviced her by phone regarding resident safety, rights, behaviors and abuse and neglect. She stated prior to the incident, staff received those trainings periodically. Further interview on 8/15/25 at 5:31 PM, the Administrator stated the expectation was for staff to check resident rooms with a fine-tooth comb for unsafe items and monitor residents closely for any changes in mood or behavior. She stated management would also complete ambassador rounds to check rooms and visit with residents. The Administrator stated reports would be shared every morning during stand-up to discuss any incidents or changes in residents. The Administrator stated they would continue to educate residents and RPs on what items are allowed in rooms. She stated staff would also continue to be educated on maintaining a safe environment, which would include being aware of packages received at the facility. The Administrator stated staff were aware of resident rights and that permission was needed to check personal belongings; however, safety was first. The Administrator stated not adequately supervising residents and ensuring a safe environment could place the residents at risk of harm. Review of the facility's policy titled Safety of Residents, revised August 2020, revealed in part the following:Purpose: To provide a safe environment for residents and Facility Staff. Policy: Residents who display combative behaviors receive prompt and appropriate intervention. Procedure:I. ScreeningA. Prior to admission, all inquiries are evaluated by the Director of Nursing (DON) for potential combative behavior based on historical data, diagnoses, and medication regimen. II. PreventionA. Upon admission, residents will be monitored for behavioral triggers including, but not limited to:i. Tension in body language or facial expression;ii. Increased pacing or wandering;iii. Elevated voice volume;iv. Rapid mood changes; andv. Increased anger or frustration. III. Response to Unsafe BehaviorA. If a resident's behavior becomes abusive, hostile, or unmanageable in a way that compromises his or her safety or the safety of others, the Charge Nurse and the DON are notified immediately.B. B. The Charge Nurse will:i. Identify and remove the source of the problem, if known;ii. Calmly reassure the resident and direct him/her to a more relaxing area; andiii. Maintain one-on-one supervision of the resident until the behavior has subsided or other arrangements have been secured. C. The DON will:i. Notify the resident's Attending Physician and obtain orders, if necessary;ii. Notify the resident's representative;iii. Notify the Administrator; andiv. Task an available CNA to ensure all other residents are safe and provide calm reassurance on the unit. Record review of a document provided by the Administrator, untitled and undated, revealed in part the following: .Safety ConcernsThe following is a list of items that are not allowed in resident rooms due to potential for harm/fire/or other dangerous situations:. Sharp objects, scissors, knives, razors, unsecured glass objects, crochet needles. The non-compliance was identified as past non-compliance (PNC). The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review on 8/15/25 of a document provided by the Administrator titled AD HOC Quality Assurance and Performance Improvement Plan, dated 8/13/25, reflected a QAPI meeting was held to discuss the incident and interventions put in place, which included: Resident #1 being sent to an acute care hospital for evaluation and/or treatment, daily ambassador rounding to check for unsafe items in resident rooms, the facility providing extra cigarettes as needed to prevent related agitation/behaviors, inventory sheets completed at admission and updated for all current residents, staff educated on unsafe items not allowed in resident rooms, behavior identification and suicidal thoughts and de-escalation, notification and documentation of incidents, off-cycle resident council meeting to review items not allowed in rooms and inventory sheets with residents. Record review on 8/15/25 of Resident #1's EHR reflected the resident was discharged from the facility to the local hospital on 8/12/25. Record review on 8/15/25 of documents provided by the DON titled Inventory of Personal Belongings,, dated 8/12/25, reflected all current residents' personal inventory was updated. Record review on 8/15/25 of an in-service document, dated 8/12/25, reflected all staff received education regarding checking for unsafe items in resident rooms during rounds, updating resident inventory sheets, and policy and procedures for abuse and neglect and resident rights. Record review on 8/15/25 of an in-service document, dated 8/12/25, reflected all staff received education regarding identifying behaviors and suicidal prevention. Record review on 8/15/25 of a check-off resident census provided by the Administrator, dated 8/12/25-8/15/25, reflected safety checks of all resident rooms began and was on-going to ensure a safe environment. Observations on 8/15/25 from 9:45 AM-11:00 AM, of the facility's environment including resident rooms and bathrooms, shower rooms, and supply closets reflected the environment was free of potential hazardous and unsafe items. All razors were locked in the supply closet and requires a code to enter. Record review on 8/15/25 of Residents #1, #2, #3, #4, and #5 EHRs, who were all at risk for accidents, revealed their care plans included interventions to address ADL and behavioral needs as appropriate to ensure adequate supervision/assistance and safety. Resident #1's care plan was revised on 8/12/25 to reflect his behavior and harm to self with appropriate interventions. Interviews on 8/15/25 from 10:15 AM-11:00 AM with Resident #4's RP and Residents #1, #2, #3, #4, and #5, who were all at risk of accidents, revealed no concerns for inadequate supervision or safety. Interview on 8/15/25 at 4:43 PM with the MD revealed she was made aware of Resident #1's incident on 8/12/25. The MD stated she was also a part of the QAPI meeting on 8/13/25 and agreed with interventions put in place to ensure the safety of all residents. The MD stated the IDT would have to review the final evaluation from the hospital to determine if Resident #1 would be a good fit for the facility and appropriate protocol would be followed. Interviews on 8/15/25 from 9:25 AM-5:31 PM conducted with the Administrator, DON, nurses and CNAs: LVN A (1st shift/weekdays), CNA B (1st shift/rotating days), CNA C (1st shift/rotating days), RN D (1st shift/rotating days), CNA E (1st shift/rotating days), RN F (1st shift/weekdays), CNA G (1st shift/rotating days), CNA H (2nd shift/ rotating days), CNA I (2nd shift/ rotating days), RN J (2nd shift//weekdays), RN K (1st/2nd shift/double weekends), CNA L (2nd shift/rotating days), RN M (PRN), LVN N (3rd shift/weekdays), CNA O (3rd shift/ rotating days), CNA P (3rd shift/ rotating days), indicated they all participated in in-services 8/12/25-8/14/25, and prior to the start their shifts. All staff were able to state that they were responsible for ensuring the safety of all residents by checking all resident rooms and common areas for unsafe items, removing the items and reporting it to the Administrator. All staff were able to state how to identify s/sx of suicidal ideations and changes in residents' mental and physical conditions, who to report it to, and to documents all incidents. The Administrator stated it was management's responsibility to ensure that staff were educated on identifying and reporting changes in residents' mental and physical conditions, behaviors, and ensuring the safety of residents, and ongoing trainings to ensure retention of education. The Administrator stated management would be updated on any changes or updates daily during stand-up meetings. The DON stated resident behaviors were monitored, the medical director involved, and psychiatric services were put in place as needed. All staff were able to state in their own words the facility's policy and procedures regarding resident rights and abuse and neglect. All staff were able to describe abuse, neglect, and exploitation, when to report it, and who to report it to. All staff were able to state that residents have the right to have personal items and must give permission for staff to go through their personal items; however, any unsafe items observed would be removed and reported to the Administrator.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for food safety. The facility failed to ensure the stand-by refrigerator free of personal food itemsThe facility failed to ensure the walk-in refrigerator food items were dated, labeled and securely stored.The facility failed to ensure the walk-in freezer food items were dated, labeled and securely stored.The facility failed to ensure the dry storage food items were dated, labeled and securely stored.The facility failed to ensure that canned good food items were free of dents.The facility failed to ensure that dishwashing protocol was followed.The facility failed to ensure that prepared foods were held correctly and maintained safe temperatures. These failures could place residents at risk for foodborne illnesses.Findings included: Observation on 07/22/2025 at 09:03AM of the walk-in refrigerator revealed the following:Deli sandwiches dated 7/21/25 in an unsealed plastic bag and no use by date.Unsealed plastic bag of lettuce in a box dated 7/14 and no use by date.Unsealed plastic bag of sausage patties, with no label and no use by date.Open package of turkey deli meat, with no use by date.A saran wrapped piece of unsliced deli meat, with no label of the type of deli meat and no use by date.A saran wrapped block of slice cheese dated 7/20/25, with no label of the type of cheese and no use by date.Brown gravy in a metal pan with a lid, dated 7/20/25 and shelf life 7/27/2025. The lid loosely covered the pan and did not securely seal the gravy. An interview on 07/22/2025 at 09:07AM the DM stated guess not when asked if the gravy was properly sealed and proceeded to discard the gravy. Observation on 07/22/2025 at 09:09AM of the walk-in freezer revealed an unsealed bag of frozen lima beans. Observation on 07/22/2025 at 09:12AM of the dry storage closet revealed the following:A can of peach slices with a hole puncture and yellow-orange liquid on the bottom of the can.An open bag of grits dated 7-.3-2.A large container labeled Yellow Corn, with no date.A large container labeled Bread Crumbs dated 2/6/25, with no use by date.A large container labeled Dry Cereal, with no opened on or use by date and label the cereal type.A large container labeled Honey Nut Rings, with no opened on or use by date. An interview on 07/22/2025 at 09:18 AM with the DM revealed she was not aware of the puncture on the canned good of peaches. She explained that punctured and dented canned goods can lead to the risk of rust and contamination and the residents can get sick as a result of eating the foods. The DM stated she expected every food item to be dated and labeled when received. She further stated opened food items were supposed to be in Ziploc bags, with the date the food item was opened, and a use by date. She explained the importance of dating, labeling, and sealing foods was so the staff know if foods were safe to use after opening and to avoid contamination because residents can get sick. Observation on 07/23/2025 at 11:21AM upon reentry to the kitchen revealed the following:An uncovered tray of breadsticks on the steam table.Peanut butter pie sitting on meal trays. Observation on 07/23/2025 at 11:40AM of lunch food temperature check revealed the following:The temperature of the peanut butter pie was 64 F.Cook A was observed washing a strainer using the 3-compartment sink. [NAME] A proceed to wash the strainer in the 1st compartment. In the 2nd compartment, [NAME] A turned on the faucet and rinsed the strainer with running water. The cook then sat the strainer out to air-dry. An interview on 07/23/2025 at 11:45 AM with the DM revealed that the temperature for cold foods should be 41 F. She proceeded to substitute the dessert with ice cream because the holding temperature was above 41 F. She stated cold foods can be held on ice to maintain appropriate temperatures before being placed on trays. The DM stated food not covered exposes them to contamination. An interview on 07/23/2025 at 11:54 AM with [NAME] A revealed the cook does utilize the 3-compartment sink to clean dishes. [NAME] A stated dishes are to be washed, rinsed, and then sanitized the dishes in the 3-compartment sink. She explained the 3rd compartment was to be used for sanitizing dishes; the sink was filled with the sanitizing solution and the solution was tested using a chemical test strip. [NAME] A stated she did wash the strainer and it was clean. At this time the DM intervened and stated the strainer was not cleaned based on the policy for 3-compartment sink use for sanitizing dishes in quaternary ammonia. Record review of the facility's Food Storage policy, dated 2018 reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure:1. Dry storage rooms.d. To ensure freshness, store opened and bilk items in tightly covered containers. All containers must be labeled and dated.2. Refrigerators.d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.3. Freezers.e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility's Kitchen Sanitation to Prevent the Spread of Viral Illness policy, dated revised 8/17/20 reflected: Policy: The Nutrition and Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of cross contamination and potential illness such as influenza and COVID 19.Procedure:3. Employees should follow general sanitation guidelines from the CDC and food code when working in the NFS department.g. Ware Washinga. In order to ensure that all dishware is appropriately cleaned and sainted, the dish machine and 3 compartment sink must be operated at the appropriate temperature and temperature level. This should be monitored by staff and the dietary manager as per the facility policy. If the machine is not operating at the appropriate levels, dishware may be contaminated and could spread illness throughout the facility. Record review of the facility's Manual Cleaning and Sanitizing of Utensils and Portable Equipment policy, dated approved October 1 2018 reflected: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize risk of food hazards.Procedure: .6. In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120 F.7. Rinse in the second sink using clear, clean water between 120 F and 140 F to remove all traces of food, debris, and detergent.8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by .:b. Immerse for at least 60 seconds in a clean sanitizing solution containing: .iii. The concentration and contact time for quaternary ammonium impounds shall be in accordance with the manufacturer's label and direction. Record review of the U.S. FDA Food Code 2022 reflected: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above. (2) At 5 C (41 F) or less. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness .A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows:. (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.

Based on observations, interviews, and record review, the facility failed to provide a clean and homelike environment for three of five residential halls (Hall 200, Hall 300, and Hall 400) reviewed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure six air duct registers were free of small black spots, rust, paint chipping and securely fit into ceiling tiles. These failures could place residents at risk for decline in health and decreased quality of life due to living in unclean and non-homelike environment.Findings included: Observation on 07/22/2025 at 10:26AM in Hall 200 revealed: S One ceiling air duct register covered with small black spots. S One ceiling air duct register, with rust and peeled paint chips. Observation on 07/24/2025 at 11:59AM in Hall 300 revealed: S Two ceiling air duct registers covered with small black spots and rust S One ceiling air duct register covered with small black spots Observation on 07/24/2025 at 12:07PM in Hall 400 revealed: S One ceiling air duct register with small black spots in a white ceiling tile with small black spots lining the air duct register. The ceiling air duct register did not securely fit in the ceiling tile. An interview on 07/24/2025 at 01:11PM with the maintenance manager revealed housekeeping was responsible for cleaning the air ducts and maintenance replaces air duct registers. The maintenance manager explained he will talk with staff about maintenance requests, but staff must put in a work order. This surveyor showed the maintenance manager an image of the condition of one air duct register located in Hall 200; he stated that housekeeping would clean the air duct register, but maintenance would replace the air duct register based on its dirty appearance. The maintenance manager stated the substance on the air duct was not black mold, but it may be mold or dirt. The maintenance manager discussed that to resolve the problem with the air duct registers, he would replace them. An interview on 07/24/2025 at 01:45PM with the housekeeping manager revealed housekeeping staff was responsible for maintaining cleanliness of the air duct registers and maintenance replaces air duct registers. The housekeeping manager stated housekeeping staff cleaned resident rooms every day. She expected the air duct registers to be checked daily; if housekeepers see an issue, they inform her or nurses so a maintenance work order can be placed. The housekeeping manager stated housekeeping staff will check all air duct registers and make a list of the ones that need replaced. During an interview on 07/24/2025 at 02:03PM with the DON revealed room rounds are done to check the condition each room. The DON stated that she had not checked air duct registers. This surveyor showed the DON an image of the condition of one air duct register located in Hall 200, and she stated she will now check the air duct registers closely. She stated she would report the condition of the air duct register to housekeeping to have it cleaned. The DON stated clean air duct registers are important because resident rooms should be homelike, and so that the residents stay healthy and don't have issues because of a dirty air duct register. Record review of the facility policy Homelike Environment revised February 2021 reflected: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation. The community team members and management maximize, to the extent possible, the characteristics of the community that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards as is possible for 1 (Resident #42) of 15 residents and 6 residents on the south suits hall reviewed for accidents and hazards in that; 1. Resident #42 had an electrical extension cord and a multiple receptacle plug-in adaptor in his room.2. The facility failed to secure the exit door at the end of south suites hall. This failure could place residents at risk of harm due to wondering or elopement.1. Record review of Resident #42's face sheet, dated 07/22/25, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], with diagnoses of stroke, depression, uncontrolled blood sugar, hemiplegia and hemiparesis following cerebral infraction affecting the left non-dominant side (this is the paralysis and numbness after a stroke on the left side), limited mobility, and age related nuclear cataract in both eyes ( this is the clouding and yellowing of the lens in the eyes causing blurred vision). Record review of Resident #42's quarterly MDS assessment, dated 06/05/25, reflected Resident #42 had a BIMS score of 15, indicating that he was cognitively intact. Resident #42 had a clear speech and was able to understand others and was understood by others. Resident #42. Resident #42's range of motion was impaired on one side of his upper body and lower body. He was able to feed herself with only moderate assistance from staff (helper does less than half the effort.) He was always continent of bowel and bladder. Review of Resident #42's care plan, 06/26/25, reflected the following:Problem: Resident #42 barricaded himself in the room to keep staff out, he was agitated with having a roommate and smashing into front sliding doors causing damage.Goal: Resident #42 would have fewer episodes of behaviors through the next review date. Interventions: -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.-Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. In an observation and interview on 07/22/23 at 10:40 AM, it was revealed that Resident #42 was in his room seated in a motorized wheelchair, he had a laptop and multiple cords under his bed. There was a standard wall dual outlet plate on the wall by his headboard and plugged into the wall outlet was a four-outlet adapter extender plugged into the wall and the adapter had four long cables plugged into it including a white extension cord with a flexible cable that had a plug on one end and a two-pong outlet on the other end. Resident #42 said all the staff were aware he had the adaptor and extension cords. He said the facility had talked to him a few months ago that the cords were a tripping hazard, but he did not agree the cords were a tripping hazard because he got assistance from staff to get up from his bed to the wheelchair and back. Interview with the housekeeper on 07/24/25 at 10:55 AM, revealed that she cleaned Resident #42's room and she said he had too many cords in his room which made it difficult to clean his floors. She said she did not report the extension cord because she thought he was allowed. She said she had not received any in-service on extension cords and power strips but that she was aware they were a fire hazard. In an interview with maintenance personnel on 07/24/25 at 11:02 AM, revealed different management personnel were assigned and designated to monitor different areas of the facility and during a rounding a few weeks ago it had come to his attention that Resident #42 had an extension card in his room. He said he had notified the nursing department including ADM about Resident #42 having an extension cord. He said Resident #42 did not like him, so he did not go into his room unless it was to fix something. He said nursing was responsible for monitoring residents' rooms and if something needed to be fixed, they would notify maintenance, but he was not allowed to remove or search residents' belongings. He said space heaters, electric blankets, power cords, and extension cords were not allowed in the facility. He said these items were a fire hazard and could start a fire. In an interview with DON on 07/24/25 at 2:02 PM, it was revealed the ADON's were responsible for room rounds on different hallways however the two ADON's were new and had not yet been assigned the responsibilities of room rounds. She said the nursing staff was responsible for monitoring the residents' rooms and reporting issues to the necessary departments. She said the staff were having a difficult time with Resident #42 because he did not allow them to touch anything in his room. She said he usually refused to have his room cleaned as well. She said the risk of using an extension cord was it could start a fire. In an interview with ADM on 07/24/25 at 3:00 PM, it was revealed she was not aware that Resident #42 had an extension cord prior to today. She said she had removed and stored the extension cord in her safe after discovering it today. She said she filed a grievance for Resident #42 regarding the power cord because he was very upset when it was taken from him. She said the issue will be addressed in Resident #42's care conference next week and the ombudsman had been informed of the incident. She said the expectation was that when something was discovered during room rounds it was discussed between the department heads to come up with a solution. She said the risk of using an extension cord in the room was that it was a safety issue. Record review of facility policy titled Items Prohibited in Resident Rooms undated reflected. No electrical appliances or extension cords. No cooking or ironing equipment, electric blankets, heaters, etc. 2. In an observation on 07/23/2025 at 2:49 PM reflected, the exit door at the Suites south hall was ajar and the door alarm was turned off with no staff present in the hallway. In an interview with ADON on 07/23/2025 at 2:51 PM stated she did not know why the door was left ajar or who left the door open but she would call maintenance. In an observation and interview with Maintenance Director on 07/23/2025 at 2:55 PM reflected, he drove up to the south side of the building entered through the unlocked door, subsequently, secured the door and resent the alarm. He stated the door was unlocked to allow the plumber access to the hall to repair a resident's toilet. In an interview with DON on 07/23/2025 at 3:00 PM reflected, all residents were accounted for in the building. In an interview with Maintenance Director on 07/24/2025 at 1:04 PM, he stated the plumber came in and the maintenance assistant unlocked the door to allow the plumber easy access to the room on that hall. He stated the maintenance assistant was called away to the secure unit and he left the door unlocked. He stated the door led to a back street and the risk of not watching the door there was a chance a resident could go into the street. In an interview with maintenance assistant on 07/24/2025 at 1:40 PM reflected he was called away to help with an issue in the secure unit. He stated he propped the door open (not fully open but ajar) and he told one of the nurses to watch the door (he was unable to tell or point out the nurse he asked to watch the door). He stated the risk was the residents could get out and walk away. In an interview with DON on 07/24/2025 at 2:22 PM reflected we are not supposed to have the door open, when we have issues with securing the doors we have someone stand guard for the safety of the residents. In an interview with ADMIN on 07/24/2025 at 3:04 PM reflected her expectation was for maintenance to remain at the door to make sure the door was secure for resident safety. She stated she did not have a policy regarding unsecure doors.

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable well-being for one resident (Resident #54) of seven residents reviewed for care plans. The facility failed to complete care plans addressing Resident #54's behavior of picking and scratching at wounds on her arm, or her skin condition. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.Findings included: Review of Resident #54's face sheet, dated 07/22/25, reflected she was an [AGE] year-old female, admitted on [DATE], with diagnoses which atopic neurodermatitis (a type of eczema which causes intense itching, leading to thick, leathery patches of skin), stroke affecting her left side, and anxiety disorder. Review of Resident #54's admission MDS assessment, dated 06/17/25, reflected she was usually able to understand others, and was usually able to be understood. She had a BIMS score of 13, indicating intact cognition. The document reflected no concerns regarding her mood, mental status, or behavior. Resident #54 used a wheelchair, and had one-sided impairment. While Resident #54 was noted to be at risk for skin breakdown, no skin issues were noted in the document. Review of Resident #54's Medication Administration Records and Treatment Administration Record from her admission on [DATE] through 06/22/25 reflected no orders having to do with the care of the resident's skin problem on her arms, or her behavior of picking and scratching. Review of Resident #54's order summary, dated 07/24/25, reflected an order for Triple Antibiotic External Ointment (Neomycin- Bacitracin-Polymyxin) Apply to Left outer elbow topically two times a day for Skin tear, started on 07/23/25. Review of Resident #54's care plans reflected the following:- The resident has an ADL self-care performance deficit r/t Date Initiated: 06/04/2025 The resident will maintain current level of function in [sic] through the review date. Date Initiated: 06/04/2025 Revision on: 07/22/2025 Target Date: 09/18/2025 BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 06/04/2025 (.) PERSONAL HYGIENE: The resident requires (SPECIFY assistance) by (X) staff with personal hygiene and oral care. Date Initiated: 06/04/2025- The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t Date Initiated: 06/04/2025- The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 06/04/2025 Revision on: 07/22/2025 Target Date: 09/18/2025 Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 06/04/2025 Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 06/04/2025 Pad bed rails, wheelchair arms or any other source of potential injury if possible. Date Initiated: 06/04/2025 An interview and observation on 07/22/25 at 10:51 AM with Resident #54 revealed her to be alert, and sitting in her wheelchair in her room. Resident #54 had two round scabbed areas, surrounded by flaky skin (approximately the size of a dime, including the flaky areas), and a vaguely rectangular spot of open skin approximately a centimeter and a half wide, and three centimeters long, appearing like the skin had been scraped off. When asked about the sores on her arm, the resident started to scratch and pick at one of the round areas, and explained she was a picker and that she fell at home, before she came to the facility, and scraped a bunch of skin off. She said it never healed all the way, because she constantly scratched and picked at them. Resident #54 said they would get better, then get bad again, because she could not leave them alone. She said the facility had wrapped her arm, to help her remember to leave the wounds alone, but it itched so she took it off. She did not remember if they had tried anything else. She said she was not upset by the sores, and she had always been a picker. An interview on 07/23/25 at 2:59 PM with RN A revealed she thought Resident #54 had problems with her skin on her arm when she was admitted . She said it would heal, then she would pick and scratch at it, and it would open up again. She said they wrapped her arm sometimes to discourage her from picking it, but she took the wrap off. An interview on 07/23/25 at 3:18 PM with CNA B revealed he was not sure how long Resident #54 had the problem with her skin on her arm, but he remembered that it was an on-going issue with her, and it got better, then it got worse again. An interview and observation on 07/24/25 at 10:14 AM with Resident #54 revealed the open wound on her arm appeared to be missing more skin than on previous observation, and she was actively scratching her arm when the surveyor entered the room. Her arm, in the area of the wound, had developed some redness (a possible sign of infection.) She was wearing a fabric sling on her left arm. She said she thought it was to keep her from scratching, but she did not like it, because it hurt her neck, and gave her a headache. She said the nurse said it looked like the open sore might be getting infected, so she called the doctor about it. An interview on 07/24/25 at 10:16 AM with the DON revealed she knew they had been addressing Resident #54's arm, and she thought they tried a sleeve before, but the resident did not like it because she felt like it was squeezing the top of her arm, and took it off, just like she took off the wraps. She felt the resident also simply did not like being unable to pick at her sore. She said they had called the Nurse Practitioner about the issue and would continue to try different things. She said the resident was able to communicate well with them, and she thought they would be able to find something that worked. An interview on 07/25/25 at 10:20 AM with ADON C revealed she was the person who had been working with Resident #54 about her arm. She said the sling was not to keep her from scratching, but because she could not hold that arm up, and she would let it hang outside her power wheelchair, and run into doorways and walls with it, re-opening the wound on her arm. They hoped the sling would help her keep her arm pulled up. She did say the resident complained about it putting pressure on her neck, so she moved the strap to the edge of her shoulder, and asked if they could try it there, so it would not push on her neck. The ADON said she noticed that morning that it looked like it might be getting infected, so she called the Nurse Practitioner. An interview on 07/24/25 at 1:42 PM with MDS revealed she wrote the care plans under the direction of the DON, since she was an LVN. She said she updated them upon completion of the MDS assessments, but the acute care plans were mostly done by the DON or ADON, and if something came up between the MDS assessments, they usually took care of those care plans. She said the behavior of picking at skin and causing open wounds should be care planned. MDS said the point of the care plans was for everyone to be on the same page about resident care. An interview on 07/24/25 at 1:55 PM with ADON C revealed the ADON role was new to her, and she had only been doing it for about six weeks, so she was still learning the job duties. She said she had not, at the time of the interview, been informed that writing care plans was one of her duties, and she had not reviewed them. She said the reason individualized care plans were important was to make sure the residents were getting care that was specialized for them. An interview on 07/24/25 at 2:02 PM with the DON revealed Resident #54 had not had the problem with her skin the entire time, but she did have a behavior of scratching and picking, and that should have been care-planned. She was not aware that Resident #54's care plan was not individualized. She said MDS was overall responsible for making sure care plans were accurate and updated, and was the one who reviewed them before the DON signed them. She said she signed them for completion, but not accuracy. An interview on 07/25/25 at 2:51 PM with the Administrator revealed the IDT was responsible for keeping the care plans updated and individualized. She said the risk of them not being kept up to date and not being individualized was that the residents might not get the services they needed. Review of the facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, reflected Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: l. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. (.) 7. The care planning process will: (.) b. Include an assessment of the resident's strengths and needs; (.) 8. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (.) g. Incorporate identified problem areas; (.) h. Incorporate risk factors associated with identified problems; 1. Build on the resident's strengths; J. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; I. Identify the professional services that arc responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; (.) o. Reflect currently recognized standards of practice for problem areas and conditions. (.) 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. (.) 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. (.) 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (.). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change

Based on observations, interview, and record review, the facility failed to ensure residents have a right to a dignified existence for one resident (unidentified resident) of one resident reviewed for resident rights. The facility failed to ensure one staff member was not on the phone while assisting one resident with their meal. This failure could cause residents to have a negative psychosocial outcome.Findings included: Observation on 07/23/2025 at 12:23PM revealed LVN F was on the phone while assisting a resident (unidentified) during lunch. During an interview on 07/24/2025 at 12:29PM LVN F revealed he was on the phone with the doctor while assisting a resident with their meal. He stated it was not okay to be on the phone while assisting residents with their meals. He explained it drew attention away from the resident, they could pick up something they should not put in their mouth, and its disrespectful. He stated he would not have liked it (if he was in the resident's position) and would want the utmost respect. During an interview on 07/24/2025 at 02:03PM with DON revealed while staff assist residents with their meals, she expected staff to sit next to the resident, assist one resident at a time, to make sure they clean and sanitize their hands before assisting each resident. She stated it was not acceptable for staff to be on the phone while assisting a resident. She further stated an in-service was done the month prior regarding the topic. She explained it was not okay for staff to be on the phone because staff would not be giving the resident their full attention, it can be a HIPAA issue, and its not professional; staff should try to find someone else to assist the resident so they can talk to the doctor. She stated the policy was a to not be on the phone in the patient care area. Record review of the facility's policy Resident Rights revised December 2016 reflected: Policy StatementTeam members shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a dignified existencebe treated with respect, kindness, and dignity

Based on observations and interviewsm the facility failed to maintain medical records on each resident that are accurate for 1 of 5 residents (Resident #1) reviewed for resident records. CNA A failed to accurately document in Resident #1's EHR on 06/06/25 when she documented her care using CNA B's log-in credentials. This failure could lead to incorrect documentation of resident care. Findings included: Record review of Resident #1's undated admission Record reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's, dementia, and high blood pressure. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he had severe cognitive impairment. His Functional Status assessment indicated he was dependent on staff for all of his ADLs. Record review of Resident #1's care plan, dated 05/30/25, reflected he had an ADL self-care deficit, and impaired cognition being non-verbal. Record review of Resident #1's Tasks in her EHR reflected on 06/06/25 CNA B had documented all of the resident's cares as being completed. In an interview on 06/08/25 at 2:20 PM, CNA B stated she had not worked with Resident #1 on 06/06/25 because she had been assigned to another unit. She stated CNA A had been assigned to work with Resident #1 on that date. In a phone interview on 06/08/25 at 2:47 PM, CNA A stated she had provided Resident #1 with care on 06/06/25. She stated she had documented under CNA B's log-in credentials. She stated her log-in kicked her out all the time, so she used CNA B's log-in. She stated CNA-B was logged into the EHR when she tried to log-in, so she just used CNA B's log-in. She stated she had told people about the issue but nothing had been done. She stated she knew she was not supposed to use someone else's log-in. In a follow up interview on 06/08/25 at 3:06 PM, CNA B stated she must not have signed off the computer at the end of her shift, which was how CNA A was able to chart under her name. She stated she knew not to share her log-in credentials with anyone. She stated the DON was responsible for re-setting credentials when needed. In an interview on 06/09/25 at 3:08 PM, CNA C stated it was not allowed to use someone else's log-in to chart and it was also not allowed to share your log-in with anyone else. In an interview on 06/09/25 at 3:10 PM, RN D stated it was not allowed to use someone else's log-in to chart, or to share your log-in with anyone else. She stated the risk to the resident was another discipline, such as a CNA, charting as a nurse or incorrect information being documented. In an interview on 06/09/25 at 3:13 PM, RN E stated they were not allowed to document using someone else's log-in. She stated there was a risk of incorrect documentation being done and difficulty identifying who had documented something. In an interview on 06/09/25 at 3:18 PM, RN F stated staff were not allowed to share log-ins or document using someone else's log-in. She stated the risk was someone documenting as a nurse when they were not. In an interview on 06/09/25 at 3:20 PM, the ADON stated it was absolutely not allowed to share log-ins or document as someone other than oneself. She stated it would be considered false documentation and there were multiple risks with that. In an interview on 06/09/25 at 3:35 PM, the DON stated it was not allowed to share log-ins with anyone else. She stated if a staff member had an issue with their log-in, she could reset it in a few minutes. She stated anyone documenting using another person's log-in was creating a false document. In an interview on 06/09/25 at 3:30 PM, the Administrator stated she did not have a policy addressing not using other staff member's log-in credentials. She stated it was common sense not to do that.

Based on observations, interviews, and record review, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 residents (Resident #1 and #2) of 6 residents reviewed for adequate supervision. The facility failed to provide adequate supervision to Resident #1 and Resident #2 when both residents got into a physical altercation and fell to the ground. As a result, Resident #1 sustained a superior endplate fracture suspected at T4 vertebral body (top part of the T4 spinal bone is cracked/broken) and right periorbital hematoma (black right eye). An IJ was identified on 05/28/25. The IJ template was provided to the facility on [DATE] at 5:05pm. While the IJ was removed on 05/29/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of severe injury, hospitalization, and decline in quality of life. Findings included: On 05/28/2025 at 1:11 PM Video footage identified by the DON as having occurred during the incident was reviewed on the DON's cell phone. The residents observed in the video were identified by the DON. The video revealed: 0:10 Resident#2 walking on hallway and enters Resident#1 room. No other staff or residents were observed in view. Min 1:06 Resident#1 appeared to be holding Resident#2 by her neck/head and pushing her out of Residents#1's room, Resident#2 had her hands grabbing Resident#1. The residents hit the wall across the hall from Resident#1's room. Resident#2 fell onto her buttocks, then Resident#1 appeared to hit her head on the wall and fell on top of Resident #2 then rolled to the side. min1:45 CNA F walks into frame. Both residents were observed sitting up. Resident #1 appeared to be holding Resident#2's hands then Resident#2 punched Resident #1 on the face. Resident #1 grabbed Resident#2's hand then the video clip ends. Record review of Resident #1's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Record review of Resident #1's MDS Assessment, dated 03/31/25, reflected she had a BIMS score of 05, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Orthostatic Hypotension(a sudden drop in blood pressure when a person stands up after sitting or lying down), Traumatic Brain Injury(,damage to the brain caused by an external physical force, often a blow or impact to the head) Depression, Bipolar Disorder(a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood to periods of depression), Psychotic Disorder, Insomnia due to mental disorder'. Record review of Resident #1's care plan, initiated 1/30/2025, reflected the following: Focus: 1/30/25- [Resident #1] had a Behavior problem as evidenced by physical aggression towards other resident/ staff, verbally aggressive towards staff and other residents, coming out of the room without clothes on. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Notes reflected the following: 05/22/25 at 9:30PM - The writer heard a loud scuffle, and when the writer looked on the camera the writer observed both residents sitting on the doorway on the floor across from each other. The residents [sic] were immediately separated, and the resident was assisted back into bed. The MD was contacted but has not responded. The DON and administrator were made aware of the incident. The resident daughter (daughters name) was called but did not answer. Writer left a voicemail. This entry was written by LVN B 05/22/2025 10:10PM The writer rounded on the resident and rechecked blood pressure. The resident blood pressure is substantially lower than when the incident happened, and the resident c/o's of a headache, so the resident was sent to the ER for evaluation and treatment. DON and the administrator were notified. This entry was written by LVN B. Record review of Resident #1's hospital records, dated 05/22/25, reflected the following: Patient was a [AGE] year-old female who presents to the Emergency department via EMS due to an assault at 7:00 PM by another pt at her rehab facility. EMS was called a few hours after the assault a night nurse check. She is c/o neck pain and a headache. She is only oriented to self. She was given 1 push dose epi (drug used to treat low blood pressure or heart rate), 4L fluid, 4L of O2 and 5 levophed (drug used to treat severe low blood pressure). She denies smoking and drug usage. Per EMS pt had a blood pressure of systolic 56. Record review of Radiology Results Report, CT spine cervical without contrast dated 05/22/2025 reflected: Right periorbital hematoma (bruising around the eye), Superior endplate fracture suspected at T4(fourth thoracic vertebral body). Record review of Resident #1's History and physical assessment dated [DATE] of the skin reflected small laceration with hematoma on the left orbit. Record review of Resident #2's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] then readmitted [DATE]. Record review of Resident #2's MDS Assessment, dated 02/15/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Depression, anxiety, Altered Mental Status unspecified. Record review of Resident #2's care plan, initiated 11/17/2022, and revised on 05/24/2025 reflected the following: Focus: [Resident #2] Behaviors: has behavior problem OF Wandering, Physical Aggression toward residents, Verbal aggression towards other residents and staff. Interventions include to Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #2's Progress Notes reflected the following: 05/22/2025 10:09PM Note Text: The resident was observed on the floor with another in the hallway. She was assessed for apparent injury; none was noted. The resident was redirected back to the dining area. She does not complain of pain or discomfort and is moving all four extremities at her normal baseline. The provider, DON, administrator, and Resident#2 FM (family members name) were notified. Resident#2s (family members name) not answer, and a voicemail was left to call the facility regarding fall. This entry was written LVN B 05/24/2025 12:50pm Late entry Note Text: Spoke with [NAME], NP, with] COMPANY NAME] regarding resident#2 incident with another resident. No new orders his time. This entry was written by DON. 05/26/2025 8:30PM Resident#2 continues ABT. She was given fluids multiple times this shift. Bruising still visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN G 05/27/2025 03:43 am Note Text: Resident#2 continues ABT TX for UTI. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No sis of pain or distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN H 05/28/2025 04:31 am Note Text: Resident#2 continues PABT TX for UTI day 1/3. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No s/s of distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. Medicated 1 for generalized pain. Nursing will continue to monitor. This entry was entered by LVN H In a phone interview on 05/27/2025at 9:50am with Hospital Social Worker revealed that Residents#1's FM stated that she was confused. When she admitted at the hospital Resident#1 stated that she was assaulted by her boyfriend. Hospital Social Worker stated that Resident #1 also told the nurse that she was assaulted by her baby's father. The Hospital Social Worker stated that Residents# 1 FM stated that after she had the brain injury Resident#1 would make up stories. Hospital Social Worker stated that Resident #1's FM told her that that FM received a call from the nursing home that Resident #1 was in an altercation, and she had black eye. When the Hospital Social Worker met with Resident#1 on 05/23/2025, the resident was talking and answering questions but then she would change her answers. The Hospital Social Worker stated that Resident #1 had a compression fracture of her thoracic spine and that the resident remained admitted at the hospital. In a phone interview on 05/27/2025 at 11:49 AM with Resident #1's FM revealed that the facility left a voicemail on Thursday 5/22/2025 that Resident#1 had gotten in a scuffle with another resident, and she had a black eye. Resident #1's FM stated the next day Friday 05/23/2025 the hospital called the FM and told her that Resident#1 was admitted at the hospital. Resident #1's FM stated that Resident#1 was initially admitted to ICU, but she had been transferred to a regular room. Resident #1's FM stated that Resident#1 right eye was swollen and bruised, and that Resident #1 also had bruises on her arms. Resident #1's FM stated that Resident #1 had been at the facility for over a year. Resident #1's FM stated Resident #1 had gotten into altercations before, but no one was injured. Resident #1's FM stated that when she was at the facility in the past there was no staff watching the residents. Resident #1's FM stated that Resident#1 had a history of a brain injury, and she remembered her name only. Resident #1's FM stated that she called the nursing facility but they never responded to her calls, they called her on Saturday (05/25/25) and the administrator told her that Resident#1 fell and said she was going to do an investigation. Resident #1's FM stated that she told the administrator that the injuries did not look like she fell. Resident #1's FM told the administrator that it was unacceptable they put her daughter's life in jeopardy, and she was not happy at all. In an interview on 05/27/2025 at 10:49AM with LVN A revealed that she has been employed for about 8 month and worked 6am-2 pm Monday through Friday in the Locked unit. LVN A stated that the altercation between Resident #1 and #2 had happened on the evening shift when she was not there. She stated that Resident #1 had a diagnosis of dementia and traumatic brain injury from car accident. LVN A stated that Resident#1 was physically aggressive to residents, staff or to anyone who did not understand what she wanted. LVN A stated that before Resident #1's behavior was controlled, she would agitate other residents like move their food and push other residents. LVN A stated that she spoke to the nurse practitioner who reviewed and adjusted Resident#1's medication and she has had less behaviors. . LVN A stated that there was one CNA and one nurse on the locked unit. LVN A did not feel like the staffing was sufficient based on the needs and supervision of the residents. In an interview on 05/27/2025 at 11:20am with CTA C she said she had been employed for a year and worked in transportation and when she was not taking residents to appointments, she helped in the locked unit. CTA C stated that she was not at the facility when the altercation happened. CTA C stated that sometimes there had been altercations in memory care. In a phone interview on 05/27/2025 at 12:23pm with CNA F revealed that she had been employed for a year and she worked the evening shift from 2-10 pm. CNA F stated that around 7: 30PM she was documenting on the computer at the nurses' station when she heard a scuffle. She noted that Resident#2 who was not on the couch where she had been sleeping. CNA F glanced at the camera, and she saw Resident#1 and Resident#2 on the floor. CNA F stated she separated the two residents while they were still on the floor. CNA F stated that she was the only staff on the unit at the time of the altercation. CNA F stated that nurse (LVN B) told her she had gone to get medication, she was gone for about 15 min to 30 mins. CNA F stated that she wanted the residents to be safe and not fight again. CNA F stated she walked Resident#1 to her room, assisted to her to bed then told Resident#2 to go towards the dining area. CNA F then called the nurse (LVN B) via telephone and reported that she had found the residents on the floor. CNA F stated that at 8pm while doing her rounds she saw the bump on Resident #1's head and the black eye and reported immediately to LVN B. LVN B assessed Resident#1 and made some phone calls then the nurse mentioned that she was going to send Resident#1 to the hospital. CNA F stated that the bump on Resident#1 did not show when she initially separated the residents. CNA F stated that Resident #2 would walk on the hall; she was a high fall risk and could be combative. Resident#1 and Resident#2 had a history of aggression towards each other, and they needed to be separated. CNA F stated that there had been previous altercations between Resident#1 and Resident#2 and the staff separated them to make sure they were safe. CNA F stated that she had been documenting on Residents#2's aggression and refusing care. CNA F stated that Resident#1 showed aggression towards Resident#2 sometimes. CNA F felt that she could manage the unit but with dementia units it would be better to have additional staff because the midst of dealing with the altercation she had another resident who was trying to get up. CNA F stated that the unit was staffed with one CNA and one nurse per shift. CNA F stated sometimes there was only one staff member on the unit, when the other one steps out for lunch. CNA F stated the residents were not one on one care supervision. An attempt on 05/27/2025 at 12:12pm to interview LVN B via telephone was unsuccessful. Second attempt on 05/27/2025 at 12:52PM to interview LVN B via telephone was unsuccessful. A third attempt on 5/27/2025 2:37 PM was made to LVN B via telephone and was unsuccessful. In an interview on 5/27/2025 at 2:13pm with the DON revealed that on 05.22.2025 at around 9 pm she was notified by LVN B, that Resident#1 wandered to Resident#2's room and there was an altercation. The DON stated that she instructed the nurse to document, complete an incident report, notify MD, the resident's family, and administrator. The DON stated that Resident#1 had had aggressive cycles, and they were worse when she was on her monthly periods. The DON stated that Resident#2 had a tendency to agitate other residents but neither Resident #1 nor Resident #2 sought to be aggressive toward each other. The DON stated that Resident#2 wandered and tried to take other residents' belongings which irritated other residents. The DON stated that following the incident LVN B and CNA F had been suspended pending investigation and the other staff had in-serviced on Abuse and neglect, managing resident behavior, and fall precaution. The DON stated that on the locked unit the nurse was to be at the nurse station to monitor the residents in the dining room, and the CNA was to sit on the hallways to watch any resident on the hallway. The DON stated that if the nurse left the unit another nurse was to come and monitor the residents until the nurse returned. She stated the risk to the residents if the unit was left unsupervised was there can be accidents and the residents can be hurt. In a phone interview on 05/27/2025 at 2:43PM with Resident #2's FM revealed that Resident #2 had dementia, she wanders a lot and goes into other residents' rooms. Resident #2's FM stated that she used to get into altercations, but he was not aware of any altercation lately. Resident #2's FM stated that he was at the facility every other day to help feed Resident#2 lunch. Resident #2's FM stated that there was not enough staff to supervise when he was there. In an interview on 05/27/2025 at 4:34 pm with the Administrator revealed that she initially reported the incident as an unwitnessed fall. Administrator stated that LVN B called and said there was a scuffle between Resident #1 and #2, and residents were observed on the floor. Administrator stated when the nurse interviewed Resident#1, the resident said she was hit. Administrator stated the nurse told her there were no injuries. Administrator stated that the nurse called her later and said she was sending Resident#1 to the hospital because her blood pressure had dropped. Administrator stated that the diagnostic report from the hospital showed that there was a T4 fracture, but it wasn't clear if it was new or old. Administrator stated that the hospital admitting diagnosis was hypotension (low blood pressure), but it also mentioned assault, and the resident told the hospital that the family did it. Administrator stated that CNA F said she heard a scuffle and when she looked at the video and she saw Resident#1 and Resident#2 on the floor. The Administrator stated that Resident#2 wanders and had behaviors that could provoke other residents. The Administrator stated that there were always two staff on the locked unit. The Administrator stated she felt that they had sufficient staffing with 10 residents on the locked unit. The Administrator stated that it was okay to have one staff on the unit if the other staff was to leave for a short break as long as there was one staff left in the unit. In an observation and interview on 05/27/2025 at 5:30 PM of Resident#1 at the hospital, revealed she was alert and awake and responded to her name. Resident#1 was observed with large bruising to right eye, bruising to both arms and bruising to her left leg. When asked what happened Resident #1 pointed at her FM and said, she did it. FM was at bedside stated that the resident would not be returning to the facility because the family did not feel like she was going to be safe. In an interview on 05/28/2025 at 8:09 AM with Hospital Case Manager revealed that Resident#1 was admitted with injuries including Right periorbital hematoma, suspected T4 fracture that was undetermined, and it was not being treated, but the resident had orders to follow up with x-rays after discharge. Hospital Case Manager mentioned that the FM did not want the resident to return to the facility. Hospital records requested and provided by staff. Record review of the facility's incidents/accidents report from 03/27/25 to 05/27/25 reflected there were no other situations that involved Resident #1 or Resident #2. Record review of the facility's policy, revised September 2022, and titled Resident to Resident Altercations Reflected: All altercations, including those that may represent resident-to-resident abuse, are investigated, and reported to the nursing supervisor, the director of nursing services and to the administrator. Intervention includes: 1.Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff 2.Behaviors that may provoke a reaction by residents or others include: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating. b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. c. Sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing. d. Taking, touching, or rummaging through other's property; and e. Wandering into others' rooms/space. 3.Occurrences of such incidents arc promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating. 4.If two residents are involved in an altercation, staff: a. Separate the residents, and institute measures to calm the situation. b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. c. Notify each resident's representative and attending physician of the incident. d. Review the events with the nursing supervisor and director of nursing services and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents. e. Consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. f. Make any necessary changes in the care plan approaches to any or all of the involved individuals. g. Document in the resident's clinical record all interventions and their effectiveness. h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. Record review of the facility's policy, revised April 2022, Titled Falls and Fall Risk, Managing Reflected: Resident-Centered Approaches to Managing Falls and Fall Risk I. Upon admission, Fall Risk Evaluation will be completed to determine risk for falls. 2.The interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 3.If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4.Examples of initial approaches might include exercise and balance training, a rearrangement of room fur-niture, improving footwear, changing the lighting, etc. 5.In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 6.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 7.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 8.ln conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 5/28/2025 at 4:48PM, due to the above failures and the IJ Templated was provided at 5:00PM. In an interview on 5/29/20205 at 11:30 AM with Regional Nurse Consultant revealed that she had worked for the company for almost three years. Regional Nurse Consultant stated when she came on Saturday 05/24/2025 she did all skin assessments, all safe surveys, and in-serviced the Staff. She stated that she did an assessment on Resident#2 that revealed a small laceration, bruise left eye hematoma on the eyebrow. All bruising's on her forehead were from previous falls. She stated that saw the video footage of the altercation on 05/29/2025. She stated that she wished the altercation did not happen. She stated that the CNA F said the nurse had gone on break and the CNA F was the one that heard the scuffle and intervened and then she told the nurse. She stated that the staffing patterns are always a nurse and one CNA on the memory unit. When the staff left for lunch, there should always be one person on the unit. She stated that she did not feel there was a risk when the incident occurred because the residents were in bed, but dementia residents have a tendency to wander. She stated that the facility was aware that Residnet#1 and Resident#2 had behaviors. Resident#2 was the typical dementia patient, she would wander and get into stuff, she doesn't purposely seek to attack a person. Resident#1 was more alert than Resident#2 she was able to respond to questions and communicate. She stated that things are going to happen on the dementia units. She did not think there was an immediacy because interventions have been put in place to show that the facility was going to mitigate any further incidents. Resident#2 was put on one-on-one monitoring to prevent her from wandering and going into other residents' rooms. She stated that the facility added 12 hours for supervision in the memory unit during peak hours, from 7am to 7pm, because most of the residents go to bed early and staff were to take lunch and breaks while that additional staff was present. On 5/29/2025 at 1:15PM an interview with DON revealed that the one nurse and one CNA was sufficient because they had 10 residents in the locked unit. She stated that they try to have additional staff on the day shift, the transportation person, when she is not doing transportation, is back there. She stated that on the evening shift the nurses from upfront go back there to help. The charge nurses were responsible to ensure the unit was covered. If there is an issue getting someone back there, they let me know. It was always one nurse and one CNA. On the male unit there was one nurse and two CNAs because there were 20 residents. The DON stated that she had not been able to contact LVN B. The DON stated that LVN B had no disciplinary action Interview on 05/29/2025 at 1:10PM with the Administrator revealed that she did not know how long LVN B was gone from the unit when the altercation happened. She stated that peak hours will be from 7am to 7 pm because those are the most active hours. She stated that when the altercation happened the one staff was sufficient to intervene because the unit was calm and most residents were in bed. The facility POR for immediate jeopardy was accepted and on 05/29/25 at 9:49AM and reflected the following: Identify residents who could be affected. All Residents on the unit have the potential to be affected. The Facility census on 05/28/25 on the memory care unit was 11. Resident #1 was sent to the hospital for evaluation on 5/22/25 by Physician and remains in the hospital. Identify what action was taken to prevent further abuse: Resident #2 was placed on one-to-one monitoring on 5/24/25 on the 6/2 shift. Resident #2 was evaluated by psychiatry services on 05/26/25 with no new recommendations issued. Upon readmission, Resident #1 will be evaluated by psychiatry, and any new recommendations will be initiated. Nurse Consultant conducted 100% resident rounds on the unit to determine if further allegations of abuse were made. This was completed on 05/28/25. Safe surveys were conducted on the unit on 5/24/25 by Nurse Consultant. A skin sweep was completed by the Nurse Consultant on 05/24/25 with no additional findings. The Administrator reviewed the results of the completed safe surveys and skin sweep with no additional findings on 05/28/25. An additional 12 hours of staff will be added to the staffing pattern to allow for additional supervision of the residents during peak hours. This will be initiated on 5/29/25. The DON/Designee will be responsible for monitoring the new staffing pattern. The Nurse and Aide who worked the unit on 5/22/25 were suspended on 5/23/25 pending further investigation. In-Service conducted. The Abuse Coordinator and DON were educated on 05/28/25 by the Nurse Consultant on how to investigate suspicions of abuse and the importance of thorough investigation and interventions to prevent Abuse/Neglect and supervision to prevent resident-to-resident altercations. In-service was conducted by the Administrator/ADON on Managing Aggressive Behavior. Beginning on 5/23/25, [psychology services company name] provided additional training on de-escalation techniques, which was completed on 5/28/25. In-servicing was initiated by Administrator/DON on Abuse investigation, interventions, and completion of Incident Reports beginning 05/25/25 and completed on 5/28/25. In-service will be provided to all staff on Immediate Notification of Allegations to the Facility Abuse Coordinator or designee when not in a facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse, Neglect, and Misappropriation, and notification of proper local and state entities by DON and ADON. Agency staff who work in the facility or staff on PTO or LOA will have in-service training completed prior to working the floor by the DON/Designee. The DON/Designee will in-service the staffing coordinator and unit nurses regarding the new staffing pattern. Abuse and Neglect training will be a part of the new hire orientation, effective immediately, and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse, and resident protection from abuse/neglect. This will be completed at the time of hire by HR/DON and verified by the Administrator. Any resident who is deemed an imminent threat to others will be placed on one-to-one monitoring until alternate placement can be arranged or the threat is no longer viable. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 05/29/25 at 10:46 AM to 4:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN A, LVN G, LVN N , CTA C, CNA D, CNA E, CNA F, CNA L, CNA M, CNA K, RN I, RN J, Receptionist, housekeeping, DON, and the Administrator. Record review of a QAPI Agenda, dated 05/28/25, reflected Administrator and DON were in attendance. Record review of in-service sign in sheets, dated 05/24/25, and titled Accidents and Incident and Resident to Resident altercation reflected both the DON and Administrator had signed. Record review of Accident and Incidents - Investigating and Reporting in-service dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of Resident-to-Resident Altercations in-service, dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of a Falls and Fall Risk Managing in-service, dated 05/23/25 - 05/28/2025 reflected 95 staff had been in-serviced. Record review of an in-service sign in sheets, dated 05/28/25, and titled Reporting and Investigation of Abuse and Neglect Managing Difficult behavior Supervision and Preventing Abuse reflected both the DON and Administrator had signed. 5/29/2025 12:13 PM Observed Resident#2's FM assisting Resident #2 with lunch tray. Resident#2 appeared well groomed, calm, and followed direction. Resident#2's FM stated that the bruises on her face were from previous falls and that psychiatrist had discontinued some of Resident#2's medication after her last hospitalization. 5/29/2025 12:08 PM interview with LVN A revealed that there were 11 residents in the unit. The unit was staffed with one nurse and two CNAs. She stated that is she had requested to have additional staff on the unit. She stated that when she left the unit to clock out, she notified CNA. She stated that Resident#1 and Resident#2 did not get along and she kept them separated in the daytime because they used to fight over t[TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure that residents were free from abuse for two (Resident #1 and #2) of six residents reviewed for abuse and neglect. The facility failed to protect Resident #1 and #2 from abuse on 05/22/25 when both residents got into a physical altercation and fell to the ground. As a result, Resident #1 sustained a superior endplate fracture suspected at T4 vertebral body (top part of the T4 spinal bone is cracked/broken) and right periorbital hematoma (black right eye). An IJ was identified on 05/28/25. The IJ template was provided to the facility on [DATE] at 1:30 PM. While the IJ was removed on 05/29/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed residents at risk for abuse, neglect, and emotional and psychological harm. Findings included: On 05/28/2025 at 1:11 PM Video footage identified by the DON as having occurred during the incident was reviewed on the DON's cell phone. The residents observed in the video were identified by the DON. The video revealed: 0:10 Resident#2 walking on hallway and enters Resident#1 room. No other staff or residents were observed in view. Min 1:06 Resident#1 appeared to be holding Resident#2 by her neck/head and pushing her out of Residents#1's room, Resident#2 had her hands grabbing Resident#1. The residents hit the wall across the hall from Resident#1's room. Resident#2 fell onto her buttocks, then Resident#1 appeared to hit her head on the wall and fell on top of Resident #2 then rolled to the side. min1:45 CNA F walks into frame. Both residents were observed sitting up. Resident #1 appeared to be holding Resident#2's hands then Resident#2 punched Resident #1 on the face. Resident #1 grabbed Resident#2's hand then the video clip ends. Record review of Resident #1's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Record review of Resident #1's MDS Assessment, dated 03/31/25, reflected she had a BIMS score of 05, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Orthostatic Hypotension(a sudden drop in blood pressure when a person stands up after sitting or lying down), Traumatic Brain Injury(,damage to the brain caused by an external physical force, often a blow or impact to the head) Depression, Bipolar Disorder(a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood to periods of depression), Psychotic Disorder, Insomnia due to mental disorder'. Record review of Resident #1's care plan, initiated 1/30/2025, reflected the following: Focus: 1/30/25- [Resident #1] had a Behavior problem as evidenced by physical aggression towards other resident/ staff, verbally aggressive towards staff and other residents, coming out of the room without clothes on. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #1's Progress Notes reflected the following: 05/22/25 at 9:30PM - The writer heard a loud scuffle, and when the writer looked on the camera the writer observed both residents sitting on the doorway on the floor across from each other. The residents [sic] were immediately separated, and the resident was assisted back into bed. The MD was contacted but has not responded. The DON and administrator were made aware of the incident. The resident daughter (daughters name) was called but did not answer. Writer left a voicemail. This entry was written by LVN B 05/22/2025 10:10PM The writer rounded on the resident and rechecked blood pressure. The resident blood pressure is substantially lower than when the incident happened, and the resident c/o's of a headache, so the resident was sent to the ER for evaluation and treatment. DON and the administrator were notified. This entry was written by LVN B. Record review of Resident #1's hospital records, dated 05/22/25, reflected the following: Patient was a [AGE] year-old female who presents to the Emergency department via EMS due to an assault at 7:00 PM by another pt at her rehab facility. EMS was called a few hours after the assault a night nurse check. She is c/o neck pain and a headache. She is only oriented to self. She was given 1 push dose epi (drug used to treat low blood pressure or heart rate), 4L fluid, 4L of O2 and 5 levophed (drug used to treat severe low blood pressure). She denies smoking and drug usage. Per EMS pt had a blood pressure of systolic 56. Record review of Radiology Results Report, CT spine cervical without contrast dated 05/22/2025 reflected: Right periorbital hematoma (bruising around the eye), Superior endplate fracture suspected at T4(fourth thoracic vertebral body). Record review of Resident #1's History and physical assessment dated [DATE] of the skin reflected small laceration with hematoma on the left orbit. Record review of Resident #2's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] then readmitted [DATE]. Record review of Resident #2's MDS Assessment, dated 02/15/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her MDS indicated she had signs and symptoms of delirium and wandering. Her diagnoses included Non-Alzheimer's Dementia, Depression, anxiety, Altered Mental Status unspecified. Record review of Resident #2's care plan, initiated 11/17/2022, and revised on 05/24/2025 reflected the following: Focus: [Resident #2] Behaviors: has behavior problem OF Wandering, Physical Aggression toward residents, Verbal aggression towards other residents and staff. Interventions include to Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of Resident #2's Progress Notes reflected the following: 05/22/2025 10:09PM Note Text: The resident was observed on the floor with another in the hallway. She was assessed for apparent injury; none was noted. The resident was redirected back to the dining area. She does not complain of pain or discomfort and is moving all four extremities at her normal baseline. The provider, DON, administrator, and Resident#2 FM (family members name) were notified. Resident#2s (family members name) not answer, and a voicemail was left to call the facility regarding fall. This entry was written LVN B 05/24/2025 12:50pm Late entry Note Text: Spoke with [NAME], NP, with] COMPANY NAME] regarding resident#2 incident with another resident. No new orders his time. This entry was written by DON. 05/26/2025 8:30PM Resident#2 continues ABT. She was given fluids multiple times this shift. Bruising still visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN G 05/27/2025 03:43 am Note Text: Resident#2 continues ABT TX for UTI. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No sis of pain or distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. This entry was entered by LVN H 05/28/2025 04:31 am Note Text: Resident#2 continues PABT TX for UTI day 1/3. Resident resting in bed with eyes closed. Respirations are even and unlabored at 18. No s/s of distress noted at this time. Bruising remains visible on forehead and hands. Resident was closely monitored to prevent falls. Medicated 1 for generalized pain. Nursing will continue to monitor. This entry was entered by LVN H In a phone interview on 05/27/2025at 9:50am with Hospital Social Worker revealed that Residents#1's FM stated that she was confused. When she admitted at the hospital Resident#1 stated that she was assaulted by her boyfriend. Hospital Social Worker stated that Resident #1 also told the nurse that she was assaulted by her baby's father. The Hospital Social Worker stated that Residents# 1 FM stated that after she had the brain injury Resident#1 would make up stories. Hospital Social Worker stated that Resident #1's FM told her that that FM received a call from the nursing home that Resident #1 was in an altercation, and she had black eye. When the Hospital Social Worker met with Resident#1 on 05/23/2025, the resident was talking and answering questions but then she would change her answers. The Hospital Social Worker stated that Resident #1 had a compression fracture of her thoracic spine and that the resident remained admitted at the hospital. In a phone interview on 05/27/2025 at 11:49 AM with Resident #1's FM revealed that the facility left a voicemail on Thursday 5/22/2025 that Resident#1 had gotten in a scuffle with another resident, and she had a black eye. Resident #1's FM stated the next day Friday 05/23/2025 the hospital called the FM and told her that Resident#1 was admitted at the hospital. Resident #1's FM stated that Resident#1 was initially admitted to ICU, but she had been transferred to a regular room. Resident #1's FM stated that Resident#1 right eye was swollen and bruised, and that Resident #1 also had bruises on her arms. Resident #1's FM stated that Resident #1 had been at the facility for over a year. Resident #1's FM stated Resident #1 had gotten into altercations before, but no one was injured. Resident #1's FM stated that when she was at the facility in the past there was no staff watching the residents. Resident #1's FM stated that Resident#1 had a history of a brain injury, and she remembered her name only. Resident #1's FM stated that she called the nursing facility but they never responded to her calls, they called her on Saturday (05/25/25) and the administrator told her that Resident#1 fell and said she was going to do an investigation. Resident #1's FM stated that she told the administrator that the injuries did not look like she fell. Resident #1's FM told the administrator that it was unacceptable they put her daughter's life in jeopardy, and she was not happy at all. In an interview on 05/27/2025 at 10:49AM with LVN A revealed that she has been employed for about 8 month and worked 6am-2 pm Monday through Friday in the Locked unit. LVN A stated that the altercation between Resident #1 and #2 had happened on the evening shift when she was not there. She stated that Resident #1 had a diagnosis of dementia and traumatic brain injury from car accident. LVN A stated that Resident#1 was physically aggressive to residents, staff or to anyone who did not understand what she wanted. LVN A stated that before Resident #1's behavior was controlled, she would agitate other residents like move their food and push other residents. LVN A stated that she spoke to the nurse practitioner who reviewed and adjusted Resident#1's medication and she has had less behaviors. . LVN A stated that there was one CNA and one nurse on the locked unit. LVN A did not feel like the staffing was sufficient based on the needs and supervision of the residents. In an interview on 05/27/2025 at 11:20am with CTA C she said she had been employed for a year and worked in transportation and when she was not taking residents to appointments, she helped in the locked unit. CTA C stated that she was not at the facility when the altercation happened. CTA C stated that sometimes there had been altercations in memory care. In a phone interview on 05/27/2025 at 12:23pm with CNA F revealed that she had been employed for a year and she worked the evening shift from 2-10 pm. CNA F stated that around 7: 30PM she was documenting on the computer at the nurses' station when she heard a scuffle. She noted that Resident#2 who was not on the couch where she had been sleeping. CNA F glanced at the camera, and she saw Resident#1 and Resident#2 on the floor. CNA F stated she separated the two residents while they were still on the floor. CNA F stated that she was the only staff on the unit at the time of the altercation. CNA F stated that nurse (LVN B) told her she had gone to get medication, she was gone for about 15 min to 30 mins. CNA F stated that she wanted the residents to be safe and not fight again. CNA F stated she walked Resident#1 to her room, assisted to her to bed then told Resident#2 to go towards the dining area. CNA F then called the nurse (LVN B) via telephone and reported that she had found the residents on the floor. CNA F stated that at 8pm while doing her rounds she saw the bump on Resident #1's head and the black eye and reported immediately to LVN B. LVN B assessed Resident#1 and made some phone calls then the nurse mentioned that she was going to send Resident#1 to the hospital. CNA F stated that the bump on Resident#1 did not show when she initially separated the residents. CNA F stated that Resident #2 would walk on the hall; she was a high fall risk and could be combative. Resident#1 and Resident#2 had a history of aggression towards each other, and they needed to be separated. CNA F stated that there had been previous altercations between Resident#1 and Resident#2 and the staff separated them to make sure they were safe. CNA F stated that she had been documenting on Residents#2's aggression and refusing care. CNA F stated that Resident#1 showed aggression towards Resident#2 sometimes. CNA F felt that she could manage the unit but with dementia units it would be better to have additional staff because the midst of dealing with the altercation she had another resident who was trying to get up. CNA F stated that the unit was staffed with one CNA and one nurse per shift. CNA F stated sometimes there was only one staff member on the unit, when the other one steps out for lunch. CNA F stated the residents were not one on one care supervision. An attempt on 05/27/2025 at 12:12pm to interview LVN B via telephone was unsuccessful. Second attempt on 05/27/2025 at 12:52PM to interview LVN B via telephone was unsuccessful. A third attempt on 5/27/2025 2:37 PM was made to LVN B via telephone and was unsuccessful. In an interview on 5/27/2025 at 2:13pm with the DON revealed that on 05.22.2025 at around 9 pm she was notified by LVN B, that Resident#1 wandered to Resident#2's room and there was an altercation. The DON stated that she instructed the nurse to document, complete an incident report, notify MD, the resident's family, and administrator. The DON stated that Resident#1 had had aggressive cycles, and they were worse when she was on her monthly periods. The DON stated that Resident#2 had a tendency to agitate other residents but neither Resident #1 nor Resident #2 sought to be aggressive toward each other. The DON stated that Resident#2 wandered and tried to take other residents' belongings which irritated other residents. The DON stated that following the incident LVN B and CNA F had been suspended pending investigation and the other staff had in-serviced on Abuse and neglect, managing resident behavior, and fall precaution. The DON stated that on the locked unit the nurse was to be at the nurse station to monitor the residents in the dining room, and the CNA was to sit on the hallways to watch any resident on the hallway. The DON stated that if the nurse left the unit another nurse was to come and monitor the residents until the nurse returned. She stated the risk to the residents if the unit was left unsupervised was there can be accidents and the residents can be hurt. In a phone interview on 05/27/2025 at 2:43PM with Resident #2's FM revealed that Resident #2 had dementia, she wanders a lot and goes into other residents' rooms. Resident #2's FM stated that she used to get into altercations, but he was not aware of any altercation lately. Resident #2's FM stated that he was at the facility every other day to help feed Resident#2 lunch. Resident #2's FM stated that there was not enough staff to supervise when he was there. In an interview on 05/27/2025 at 4:34 pm with the Administrator revealed that she initially reported the incident as an unwitnessed fall. Administrator stated that LVN B called and said there was a scuffle between Resident #1 and #2, and residents were observed on the floor. Administrator stated when the nurse interviewed Resident#1, the resident said she was hit. Administrator stated the nurse told her there were no injuries. Administrator stated that the nurse called her later and said she was sending Resident#1 to the hospital because her blood pressure had dropped. Administrator stated that the diagnostic report from the hospital showed that there was a T4 fracture, but it wasn't clear if it was new or old. Administrator stated that the hospital admitting diagnosis was hypotension (low blood pressure), but it also mentioned assault, and the resident told the hospital that the family did it. Administrator stated that CNA F said she heard a scuffle and when she looked at the video and she saw Resident#1 and Resident#2 on the floor. The Administrator stated that Resident#2 wanders and had behaviors that could provoke other residents. The Administrator stated that there were always two staff on the locked unit. The Administrator stated she felt that they had sufficient staffing with 10 residents on the locked unit. The Administrator stated that it was okay to have one staff on the unit if the other staff was to leave for a short break as long as there was one staff left in the unit. In an observation and interview on 05/27/2025 at 5:30 PM of Resident#1 at the hospital, revealed she was alert and awake and responded to her name. Resident#1 was observed with large bruising to right eye, bruising to both arms and bruising to her left leg. When asked what happened Resident #1 pointed at her FM and said, she did it. FM was at bedside stated that the resident would not be returning to the facility because the family did not feel like she was going to be safe. In an interview on 05/28/2025 at 8:09 AM with Hospital Case Manager revealed that Resident#1 was admitted with injuries including Right periorbital hematoma, suspected T4 fracture that was undetermined, and it was not being treated, but the resident had orders to follow up with x-rays after discharge. Hospital Case Manager mentioned that the FM did not want the resident to return to the facility. Hospital records requested and provided by staff. Record review of the facility's incidents/accidents report from 03/27/25 to 05/27/25 reflected there were no other situations that involved Resident #1 or Resident #2. Record review of the facility's policy, revised September 2022, and titled Resident to Resident Altercations Reflected: All altercations, including those that may represent resident-to-resident abuse, are investigated, and reported to the nursing supervisor, the director of nursing services and to the administrator. Intervention includes: 1.Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff 2.Behaviors that may provoke a reaction by residents or others include: a. Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating. b. Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. c. Sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing. d. Taking, touching, or rummaging through other's property; and e. Wandering into others' rooms/space. 3.Occurrences of such incidents arc promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating. 4.If two residents are involved in an altercation, staff: a. Separate the residents, and institute measures to calm the situation. b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. c. Notify each resident's representative and attending physician of the incident. d. Review the events with the nursing supervisor and director of nursing services and evaluate the effectiveness of interventions meant to address distressed behavior for one or both residents. e. Consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. f. Make any necessary changes in the care plan approaches to any or all of the involved individuals. g. Document in the resident's clinical record all interventions and their effectiveness. h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. Record review of the facility's policy, revised April 2022, Titled Falls and Fall Risk, Managing Reflected: Resident-Centered Approaches to Managing Falls and Fall Risk I. Upon admission, Fall Risk Evaluation will be completed to determine risk for falls. 2.The interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 3.If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 4.Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 5.In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 6.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 7.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 8.ln conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 6/12/2025 at 1:30 PM, due to the above failures. In an interview on 5/29/20205 at 11:30 AM with Regional Nurse Consultant revealed that she had worked for the company for almost three years. Regional Nurse Consultant stated when she came on Saturday 05/24/2025 she did all skin assessments, all safe surveys, and in-serviced the Staff. She stated that she did an assessment on Resident#2 that revealed a small laceration, bruise left eye hematoma on the eyebrow. All bruising's on her forehead were from previous falls. She stated that saw the video footage of the altercation on 05/29/2025. She stated that she wished the altercation did not happen. She stated that the CNA F said the nurse had gone on break and the CNA F was the one that heard the scuffle and intervened and then she told the nurse. She stated that the staffing patterns are always a nurse and one CNA on the memory unit. When the staff left for lunch, there should always be one person on the unit. She stated that she did not feel there was a risk when the incident occurred because the residents were in bed, but dementia residents have a tendency to wander. She stated that the facility was aware that Residnet#1 and Resident#2 had behaviors. Resident#2 was the typical dementia patient, she would wander and get into stuff, she doesn't purposely seek to attack a person. Resident#1 was more alert than Resident#2 she was able to respond to questions and communicate. She stated that things are going to happen on the dementia units. She did not think there was an immediacy because interventions have been put in place to show that the facility was going to mitigate any further incidents. Resident#2 was put on one-on-one monitoring to prevent her from wandering and going into other residents' rooms. She stated that the facility added 12 hours for supervision in the memory unit during peak hours, from 7am to 7pm, because most of the residents go to bed early and staff were to take lunch and breaks while that additional staff was present. On 5/29/2025 at 1:15PM an interview with DON revealed that the one nurse and one CNA was sufficient because they had 10 residents in the locked unit. She stated that they try to have additional staff on the day shift, the transportation person, when she is not doing transportation, is back there. She stated that on the evening shift the nurses from upfront go back there to help. The charge nurses were responsible to ensure the unit was covered. If there is an issue getting someone back there, they let me know. It was always one nurse and one CNA. On the male unit there was one nurse and two CNAs because there were 20 residents. The DON stated that she had not been able to contact LVN B. The DON stated that LVN B had no disciplinary action Interview on 05/29/2025 at 1:10PM with the Administrator revealed that she did not know how long LVN B was gone from the unit when the altercation happened. She stated that peak hours will be from 7am to 7 pm because those are the most active hours. She stated that when the altercation happened the one staff was sufficient to intervene because the unit was calm and most residents were in bed. The facility POR for immediate jeopardy was accepted and on 05/29/25 at 9:49AM and reflected the following: Identify residents who could be affected. All Residents on the unit have the potential to be affected. The Facility census on 05/28/25 on the memory care unit was 11. Resident #1 was sent to the hospital for evaluation on 5/22/25 by Physician and remains in the hospital. Identify what action was taken to prevent further abuse: Resident #2 was placed on one-to-one monitoring on 5/24/25 on the 6/2 shift. Resident #2 was evaluated by psychiatry services on 05/26/25 with no new recommendations issued. Upon readmission, Resident #1 will be evaluated by psychiatry, and any new recommendations will be initiated. Nurse Consultant conducted 100% resident rounds on the unit to determine if further allegations of abuse were made. This was completed on 05/28/25. Safe surveys were conducted on the unit on 5/24/25 by Nurse Consultant. A skin sweep was completed by the Nurse Consultant on 05/24/25 with no additional findings. The Administrator reviewed the results of the completed safe surveys and skin sweep with no additional findings on 05/28/25. An additional 12 hours of staff will be added to the staffing pattern to allow for additional supervision of the residents during peak hours. This will be initiated on 5/29/25. The DON/Designee will be responsible for monitoring the new staffing pattern. The Nurse and Aide who worked the unit on 5/22/25 were suspended on 5/23/25 pending further investigation. In-Service conducted. The Abuse Coordinator and DON were educated on 05/28/25 by the Nurse Consultant on how to investigate suspicions of abuse and the importance of thorough investigation and interventions to prevent Abuse/Neglect and supervision to prevent resident-to-resident altercations. In-service was conducted by the Administrator/ADON on Managing Aggressive Behavior. Beginning on 5/23/25, [psychology services company name] provided additional training on de-escalation techniques, which was completed on 5/28/25. In-servicing was initiated by Administrator/DON on Abuse investigation, interventions, and completion of Incident Reports beginning 05/25/25 and completed on 5/28/25. In-service will be provided to all staff on Immediate Notification of Allegations to the Facility Abuse Coordinator or designee when not in a facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse, Neglect, and Misappropriation, and notification of proper local and state entities by DON and ADON. Agency staff who work in the facility or staff on PTO or LOA will have in-service training completed prior to working the floor by the DON/Designee. The DON/Designee will in-service the staffing coordinator and unit nurses regarding the new staffing pattern. Abuse and Neglect training will be a part of the new hire orientation, effective immediately, and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse, and resident protection from abuse/neglect. This will be completed at the time of hire by HR/DON and verified by the Administrator. Any resident who is deemed an imminent threat to others will be placed on one-to-one monitoring until alternate placement can be arranged or the threat is no longer viable. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 05/29/25 at 10:46 AM to 4:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN A, LVN G, LVN N , CTA C, CNA D, CNA E, CNA F, CNA L, CNA M, CNA K, RN I, RN J, Receptionist, housekeeping, DON, and the Administrator. Record review of a QAPI Agenda, dated 05/28/25, reflected Administrator and DON were in attendance. Record review of in-service sign in sheets, dated 05/24/25, and titled Accidents and Incident and Resident to Resident altercation reflected both the DON and Administrator had signed. Record review of Accident and Incidents - Investigating and Reporting in-service dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of Resident-to-Resident Altercations in-service, dated 05/24/25-05/28/2025, reflected 95 staff had been in-serviced. Record review of a Falls and Fall Risk Managing in-service, dated 05/23/25 - 05/28/2025 reflected 95 staff had been in-serviced. Record review of an in-service sign in sheets, dated 05/28/25, and titled Reporting and Investigation of Abuse and Neglect Managing Difficult behavior Supervision and Preventing Abuse reflected both the DON and Administrator had signed. 5/29/2025 12:13 PM Observed Resident#2's FM assisting Resident #2 with lunch tray. Resident#2 appeared well groomed, calm, and followed direction. Resident#2's FM stated that the bruises on her face were from previous falls and that psychiatrist had discontinued some of Resident#2's medication after her last hospitalization. 5/29/2025 12:08 PM interview with LVN A revealed that there were 11 residents in the unit. The unit was staffed with one nurse and two CNAs. She stated that is she had requested to have additional staff on the unit. She stated that when she left the unit to clock out, she notified CNA. She stated that Resident#1 and Resident#2 did not get along and she kept them separated in the daytime because they used to fight over the couch, so LVN A moved the couch and got two separated chairs. 5/29/2025 4:20pm Interview with on-call physician cove[TRUNCATED]

Based on interview and record review, the facility failed to ensure the right to be free from Misappropriation of Resident Property for 1 of 5 residents (Resident #1), reviewed for drug diversion. The facility failed to prevent the misappropriation of over 150 tablets of Norco (hydrocodone and acetaminophen an opioid which is a Schedule II controlled Substance), and 1 bottle of morphine (30 mL), by allowing the ADON (AP) to remove the medication from the nurses' cart, without authorization, for personal gain and never recovering the medication. Resident #1 experienced pain for two-three days at a level of 7-8, after his toe amputation, when his pain would have been relieved with Norco. This noncompliance was identified as a PNC. The noncompliance began on 4-14-2024 and ended on 4-28-2025. This failure could place residents at risk of misappropriation if medication resulting in unrelieved pain and substandard quality of life. Findings Included: Record review of Resident #1's Face Sheet dated 5-8-2024 revealed a 63-yer-old male who admitted to the facility on [DATE] with a primary diagnosis of Unspecified Dementia without behavioral disturbance (when someone experiences memory loss, thinking difficulties, and changes in social abilities that significantly impact their daily life, but the specific cause of the dementia is not determined), and secondary diagnoses of Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by elevated blood glucose levels due to the body's inability to effectively use insulin, or insulin resistance, and insufficient insulin production by the pancreas), End Stage Renal Disease (a severe condition where the kidneys have lost the ability to filter waste and excess fluid from the blood), Pain in Unspecified Joint (pain experienced in a joint, without a specific joint being identified), and Acquired Absence of Right Leg Below Knee (loss of the right leg distal to the knee joint, typically due to surgical amputation or a similar medical intervention). Record review of Resident # 1's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 15 indicating Resident #1 was cognitively intact. The Pain Assessment Section of the MDS conveyed Resident #1 experienced pain at a level 5 occasionally. Record review of Resident #1's Care Plan dated 1-9-2024 indicated Resident #1 had chronic pain related to Neuropathy (damage or dysfunction of the peripheral nervous system) of his below the knee amputation. Resident #1's Care Plan stated anticipate the resident's need for pain relief and respond immediately to any complaint of pain and evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Record review of Resident #1's electronic physician orders with a start date of 7-4-2024 and no end date, revealed an active order for Norco 10-325 MG to give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #1's Physician Orders dated 5-8-2025 revealed Tylenol with Codeine #3 30-300 MG and Acetaminophen 325 MG 2 tablets was ordered with a start date of 4-24-2025 at 6:30 AM. Record review of Resident #1's MAR dated 5-8-2025 indicated Resident #1 was routinely given Tylenol with Codeine #3 30-300 MG and Acetaminophen 325 MG 2 tablets totaling 650 MG, when he returned from the hospital, from 4-18-2025 until 4-28-2025. The MAR indicated the Norco Drug was restored on 4-28-2025. Resident #1's MAR indicated his pain levels were at a zero for 4-19-2025 & 4-20-2025, a 7 on 4-21-2025, no entry for 4-22-2025, 5 on 4-23-2025, a 5 on 4-24-2025, a 8 on 4-25-2025, a 5 on 4-26-2025, a 0 on 4-27-2025, and a level 7 on 4-28-2025 when Norco was restored. Record review of the facility's PIR (Provider Investigation Report) dated 4-29-2025 revealed it was discovered Resident #1 was missing 4 cards of Norco medication and another resident (not named) was missing 2 cards of Norco on 4-22-2025. LVN H said on 4-10-2025 ADON (AP) came to the Nursing cart and told her she was doing a Narcotics audit and was pulling out any Narcotics that were 90 days, not being used, or that were discontinued. LVN H said the ADON (AP) took some Narcotic cards but was not sure of everything she took. LVN H said she did not think anything wrong at the time because the ADON (AP) was part of the management team. On 4-18-2025, a Friday night, when Resident #1 came back from the hospital, after having a toe amputated, LVN H noticed Resident #1 did not have any Norco medication on the nurses' cart. LVN H then texted the DON to ask what the procedure was for pulling Narcotic cards from the nurse cart. The DON was busy at an event that night, so LVN H said she would talk with her about the procedure on Monday 4-21-2025. On Monday 4-21-2025 LVN H followed up with the DON. The DON explained to LVN H the procedure for pulling Narcotics off the nurses' cart was for the medication to be discontinued or not used for 90 days. On Tuesday morning 4-22-2025, LVN H asked the ADON (AP) about Resident #1's Norco cards and the ADON (AP) said the Norco cards for Resident #1 were destroyed because she was told Resident #1 was not coming back to the facility. LVN H then went to the DON on 4-22-2025 and asked if Resident #1's Norco Medication had been discontinued. The DON said no it had not been discontinued. LVN H then told the DON the ADON (AP) had pulled Resident #1's Norco cards and he does not have any left. The DON told LVN H no drugs had been destroyed for the facility this month. It was determined that the ADON (AP) mishandled or misplaced over 4 Norco Medication Cards that were never recovered and the ADON (AP) was terminated. The PIR indicated that on 4-24-2025 at 8:02 AM a drug test was performed on ADON (AP) showing negative results. The PIR indicated on 4-22-2025 the facility conducted in-services with all nursing staff concerning Narcotics. The facility changed its policy to reflect that moving forward only the DON may remove Narcotic cards whether empty or full. Under no circumstances will anyone, other than the DON, be allowed to remove any Narcotic medications from any cart. The PIR also indicated, in a voluntary statement dated 4-22-2025, by the Administrator given to the [Local Police Department], that one bottle of morphine (30 mL) for Resident #1 was missing. On 5-8-2025 at 10:45 AM a record review of ADON (AP)'s background check was performed with negative results. In an interview on 5-8-2025 at 11:15 AM, Resident #1 said he returned from the hospital in mid-April because he had his big toe amputated and needed pain medication. Resident #1 said he had a prescription for Norco, on file with the facility, before he went into the hospital. Resident #1 said he returned from the hospital, in about 10 days, and asked a nurse for his pain medication and the nurse told him he did not have any left because the ADON (AP) pulled them off the medication cart. Resident #1 stated he was provided Tylenol #3 with codeine, but they did not relieve his pain like the Norco. Resident #1 said his pain level was at a 7 or 8 for about 2-3 days then it subsided. Resident #1 said it was about a week until he started receiving Norco again. In an interview with CMA B on 5-8-2025 at 11:55 AM, it was learned that she was told that the ADON (AP) had illegally taken Norco pills from the medication cart and was fired. CMA B said she was in-serviced on abuse, neglect, and misappropriation to include resident Narcotics. CMA B said the new policy stated that only the DON will remove any narcotics from the med carts even if the cards are empty. CMA B said the Narcotics are kept double locked inside the medication carts. On 5-8-2025 at 2:45 PM, an attempted interview was made with the ADON (AP); however, the phone immediately went to a recording stating the phone cannot receive messages. In an interview with RN E on 5-8-2025 at 4:45 PM, it was revealed that RN E worked the 2:00 PM-10PM shift. RN E said on 4-14-2025 ADON (AP) approached her, while she was working the medication cart, and told her Resident #1 was hospitalized more than 72 hours and staff are not supposed to keep Norco medication on the Med Cart when this occurs. RN E said she did not question if this was correct as ADON (AP) was part of the management team. RN E said she found out later it was not the protocol, of the facility, to not keep Norco in the medication cart if a resident was hospitalized over 72 hours. RN E said on 4-14-2025 ADON (AP) took 4 Norco cards over 100 pills from the nurse's cart that evening. RN E said she was in-serviced later, after the facility determined that Norco was missing, that the facility implemented a new policy that only the DON can remove any narcotic cards from the medication carts. RN E said the Narcotics will stay double locked in the medication carts unless the DON removes them. In an interview with RN F on 5-8-2025 at 6:42 PM, it was stated the ADON (AP) came to her one evening, in the month of April 2025, and told her she cannot keep Norco over 3 months in the nurse's cart. RN F said the ADON (AP) told her it was a new policy of the facility to remove the Norco. RN F said the ADON (AP) took cards of Norco from the nurse cart she was using but she did not know how many cards of Norco she took. RN F said she was in-serviced a few weeks ago regarding removing Narcotics from the carts. The facility now has a new policy when a Narcotic medication card is empty, they contact the DON and the DON will sign for it along with another nurse. RN F said only the DON can take the Narcotics from the carts. In an interview with CMA C on 5-8-2025 at 7:23 PM, it was revealed that she was in-serviced on narcotic medications a few weeks ago. CMA C said now only the DON can discard empty Narcotic cards. CMA C said only the DON can sign for full narcotic cards so only one person is responsible for disseminating and destroying them. CMA C said the Narcotics are kept in a lockbox within the medication carts. CMA C said this new policy keeps better control of these substances, so they don't come up missing. CMA C said the risk to residents not having their Norco was it could allow their pain levels to not be controlled. In an interview with the DON on 5-8-2025 at 7:41 PM, it was revealed that before Norco medication became missing last month, when the narcotic cards were empty, the nurses would discard the cards themselves. If there were still pills left in the cards, for discarded Narcotics, they would bring the leftover pills to her, count the pills with her, and put them in a locked box attached to the wall in her office. The DON said now the policy for removing narcotic cards was only the DON can remove the cards. If there are any medications left in the cards, the policy was still to have 2 people verify it but only the DON removes them. The DON said she is responsible for the safe keeping and monitoring of Narcotics at the facility. The DON said her expectations were for all nurses and CMAs to follow the new procedures. The DON said the risk to the residents having medications missing was that they may not get the medication they need, be in pain, and could have withdrawal side effects. In an interview with the Administrator on 5-8-2025 at 7:55 PM it was conveyed, that prior to the Norco missing at the facility, the DON was responsible for monitoring the disposal and the security of Narcotics at the facility. The Administrator said now the DON is the only one who can remove the Narcotics from the medication carts for disposal. The Administrator believed this would prevent Narcotics from missing at the facility. The Administrator said the risk to residents by having narcotic medication missing was there would be delayed pain treatment. Record review of the facility's Proper Storage of Controlled Medications dated 4-25-2025 stated: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) . The charge nurse on duty maintains the keys to controlled substance containers. The [DON] maintains a set of back-up keys for all medication storage areas . The Director of Nursing (DON) identifies staff members who are authorized to handle controlled substances . Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed .The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers.

Based on interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2 was free from staff to resident abuse when CMA A slapped a glass of water out of Resident #2's hand on 4-23-2025, causing her to cry experiencing psychosocial harm. This noncompliance was identified as a PNC. The noncompliance began on 4-23-2024 and ended on 4-30-2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem, and mental anguish. Findings Included: Record review of Resident #2's Face Sheet dated 5-8-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Dementia with other behavioral disturbance (a decline in mental ability severe enough to interfere with daily life) and secondary diagnoses of Parkinsonism (a broad term encompassing various conditions that share similar movement symptoms with Parkinson's disease, such as slowness, stiffness, and tremors), Epilepsy without Epilepticus (a neurological disorder characterized by recurrent, unprovoked seizures), and Bipolar Disorder (a mental health condition characterized by extreme mood swings, including periods of intense elation or irritability (mania or hypomania) and periods of deep sadness or hopelessness). Record review of Resident #2's Comprehensive MDS assessment dated [DATE], indicated Resident #2 had a BIMS Score of 13 which indicated she was cognitively intact. Behavioral Symptoms reflected: Physical and Verbal behavioral symptoms directed toward others 0 meaning behavior not exhibited. Record review of Resident #2's Care Plan dated 2-10-2025 revealed Resident #2 was identified as PASRR (Preadmission screening and resident review) positive for having an intellectual disability and epilepsy and was care planned for using anti-anxiety medications. Record review on 5-8-2025 at 10:00 AM, of the facility's Provider Investigation Report (PIR) #1005912 dated 4-30-2025, revealed CMA A was witnessed slapping a glass of water out of Resident #2's hand on 4-23-2025. The facility's self-report failed to name a time of the incident. The PIR stated FNP G sent an email of the incident to the Administrator on 4-23-2025 at 6:06 PM. The email stated FNP G was sitting across from the DON's Office, in a conference room, on 4-23-2025 at approximately 5:00 PM, when she heard Resident #2 speaking with CMA A. FNP G stated in the email the conversation between Resident #2 and CNA A started to get louder when FNP G heard Resident #2 call CMA A a bitch. CMA A responded to Resident #2 saying who are you speaking to. Resident #2 responded back to CMA A I'm speaking to myself. CMA A then responded back to Resident #2 saying You better be glad you are talking to yourself, or I will pour the cold water you are holding, on your head. FNP G stated right after that statement she heard a slapping sound and Resident #2 started crying. FNP G went to see what occurred and CMA A was picking the water cup up off the floor. CMA A then proceeded to get in Resident #2's face telling her to apologize. Resident #2 continued to cry and ask for staff to call the cops. Resident #2 then said she would throw herself on the floor. FNP G then stated staff then escorted Resident #2 to her room away from the situation. FNP G stated she asked RN E, who witnessed the incident, what occurred, and RN E said CMA A slapped the water out of Resident #2's hand. The facility's PIR stated the Administrator interviewed CMA A on 4-23-2025 at 5:30 PM and revealed CMA A said that Resident #2 had called her a bitch. CMA A then said she told Resident #2 you better not be talking to me and apologize. CMA A then said Resident #2 did not apologize to her, so I slapped the glass of water on her. She shouldn't have called me a bitch. The PIR further indicated the Administrator interviewed Resident #2 and asked Resident #2 what happened today with CMA A. Resident #2 stated I called her a bitch, and she poured the glass of water on me. It went on my shirt and on my face. I told her I was sorry. The PIR indicated the allegation of CMA A abusing Resident #2 was confirmed and CMA A was terminated. The PIR revealed abuse and neglect in-services were completed for staff on 4-30-2025 and safe surveys were completed with cognitive residents showing no additional findings of abuse. On 5-8-2025 at 10:45 AM, record review of CMA A's background check was performed on CMA A showing a clear status. On 5-11-2025 at 10:19 PM, an email was sent to FNP G asking FNP G to call me to speak with me about the event on 4-23-2025 between CNA A and Resident #2. No email or phone called was received from FNP G. In an interview with CMA B on 5-8-2025 at 11:55 AM, it was conveyed that CMA B trained CMA A to be a medication aide. CMA B stated CMA A never exhibited aggressive behavior toward residents when she was training her but was a good aide. CMA B said she was told what CMA A did when she came back from vacation. CMA B said the facility did in-services on abuse and neglect covering different types of abuse (physical, verbal, punching, and mental) and neglect. Staff are supposed to redirect residents who are cussing, calling people names, or getting agitated. In an interview and observation on 5-8-2025 at 12:00 PM, revealed Resident #2 was sitting in a wheelchair holding a cup and drinking its contents. Resident #2 was not able to recall the event with CMA A that occurred on 4-23-2025 except she said CMA A called her a bitch. Resident #2 got confused when asked further questions about the event with CMA A. On 4-23-2025 at 3:45 PM, a phone call was made to CMA A and a voice message was left asking CMA A to return the call. A return call was never received. In an interview with RN E on 5-8-2025 at 4:45 PM, revealed RN E witnessed the incident between Resident #2 and CMA A on 4-23-2025. RN E said Resident #2 was trying to use the land line phone at the nurse's station located in the Suites section of the facility when Resident #2 called CMA A a bitch. RN E said Resident #2 was holding a glass of water in her hand at the time when CMA A slapped the glass of water out of Resident #2's hand causing the water to go all over Resident #2 and on the floor. RN E said Resident #2 began to cry after CMA A slapped the glass of water out of her hand. RN E said she then told CMA A to leave the area and CMA A did. RN E then said Resident #2 was assessed showing no physical injuries but was emotionally upset. RN E said the facility in-serviced staff on abuse and neglect on 4-23-2025 after this incident occurred. RN E said staff are never to use physical aggression and retaliate against residents because of what they say or do. In an interview with the DON on 5-8-2025 at 7:41 PM, it was conveyed that she expects facility staff to redirect residents when they are calling them names and not to react physically by slapping items out of resident's hands. The DON said the nurses are responsible to monitor the behaviors of the CNA/CMAs. The DON stated the risk to a resident, who got a glass of water slapped out of their hand, was that it could have caused emotional trauma, and they could have gotten physically hurt. In an interview with the Administrator on 5-8-2025 at 7:55 PM, it was revealed she was in the building when the incident occurred between Resident #2 and CMA A. The Administrator said she interviewed CMA A immediately after the incident occurred. The Administrator said CMA A admitted to slapping the glass of water out of Resident #2's hand, and then she suspended and escorted CMA A off the facility property right after the interview. The Administrator said the nurses on duty are responsible for monitoring the behavior and interactions of the CNAs/CMAs on duty. The Administrator said the nursing staff ultimately answers to the DON. The Administrator said the potential risk to residents who get treated the way CMA A treated Resident #2 on 4-23-2025 was that it could depress residents and they could be scared. The Administrator's expectation was for staff to remain professional and not slap water out of a resident's hand when they are called names. Record review of the facility's abuse policy titled Identifying Types of Abuse dated 2001 revised on September 2022 stated: As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents . 1. Abuse of any kind against residents is strictly prohibited . 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. a. Abuse includes .mental, and psychosocial well-being . b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . c. Abuse includes verbal abuse .and mental abuse . Mental and Verbal Abuse 1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .

Based on observation, record review, and interviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #1) reviewed for wound care services. The facility failed to enter the wound care physician's orders given on 2-10-2025 until 2-13-2025, did not put the physician's orders that were given on 2-17-2025 until 2-20-2025, according to the TAR. Treatment for the wound did not start until the dates the orders entered, according to the TAR. The facility failed to obtain orders for wound care when Resident #1 admitted to the facility on [DATE], from the hospital, with a stage II pressure injury to his buttocks. Wound care orders were not obtained until 2-10-2025 and not entered into the EHR System until 2-13-2025. Wound care orders were changed on 2-17-2025 and not entered into the EHR System until 2-20-2025. According to the TAR, treatment for Resident #1's wound did not start until the dates the orders were entered into the EHR System. Between 2-10-2025 and 2-17-2025, Resident #1's prognosis had changed from fair prognosis to poor prognosis. The wound was noted as a stage II pressure injury on 2-10-2025 and progressed to an unstageable pressure injury on 2-17-2025. Findings included: Review of Resident #1's Face Sheet dated 02/05/25 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses in part included hypertension (elevated blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord, or never problem), quadriplegia (paralysis affecting all limbs and body from the neck down), diabetes (disease affecting the body's use of sugar), obesity (complex disease involving having too much body fat), and ulcer of the right buttocks, stage II (shallow, open wound that has broken through the top layer of skin and part of the layer below). Record review of Resident #1's Care Plan Report dated 1-29-2025 and revised on 2-17-2025 revealed actual impairment to skin integrity pressure injury to the sacrum r/t immobility, disease process upon admission. Record review of Resident #1's Hospital Records dated 1-29-2025 at 10:33 AM revealed an admitted [DATE] and a discharge date of [DATE]. The record indicated Resident #1 had a stage 2 pressure injury to his right buttock upon discharge. Record review of Resident #1's Nurse Note dated 1-29-2025 at 5:21 PM revealed a skin assessment was performed indicating bilateral buttocks redness observed upon admission into the facility. Record review of Resident #1's Weekly Skin Observation Tool dated 2-7-2025 indicated Resident #1 had a pressure ulcer on his sacrum area. In a review of Resident #1's wound care notes on 2-25-2025, dated 2/10/25, Physician A noted that Resident #1's coccyx wound was a Stage II wound with fair prognosis and that resident was receiving a dressing including calcium alginate. Review of Resident #'1s TAR reflected that the resident did not begin receiving this treatment until 2/13/25. In a review of Resident #1's wound care notes on 2-25-2025, dated 02/17/25, Physician A noted that Resident #1's coccyx wound had increased in size, was unstageable, and the wound dressing would now include applying a generous amount of honey to the calcium alginate. Physician A's prognosis was poor. Review of Resident #1s TAR reflected that the resident did not begin receiving this treatment until 2/21/25. In an interview on 2-25-2025 at 3:50 PM, RN B (ADON) stated she conducted the Weekly Skin Observation Tool dated 2-7-2025 on Resident #1. RN B said she noted seeing a pressure injury on Resident #1's sacrum but did not indicate what stage it was on the form. RN B said the facility had a standing order when a pressure wound is first observed, nurses can use a barrier cream on the wound area and did so on Resident #1. RN B stated however, the facility does not document using barrier cream. RN B stated the wound care doctor saw and assessed Resident #1's pressure injury on his sacrum on 2-10-2025. RN B said the facility's wound care nurse resigned, at the beginning of February, and the ADON's were making rounds with Physician A when he came to the facility. RN B said she believed Resident #1's pressure wound was worsening due to other disease processes, he was not able to move on his own, and did not like to be repositioned at times. RN B stated Resident #1 was receiving wound care treatment once a day. RN B stated the last time she saw Resident #1's pressure wound, to his sacrum, was on 2-10-2025 and it looked yellowish with redness. In an observation on 02/28/25 at 11:15 AM, RN B provided wound care treatment to Resident #1. She was noted using appropriate PPE, infection control practices, wound care techniques, and following physician orders. The coccyx wound based appeared moist, the wound crossed the gluteal cleft (both right and left buttocks) and was unstageable (the presence of eschar [a piece of dead tissue, usually appearing as a dry, crusty, and often dark-colored scab] was noted). The resident tolerated well. In an interview on 02/28/25 at 2:24 PM, RN B reported that she would put in PCC, the wound care orders when she was the one who did the rounds with Physician A. RN B reported that Physician A would tell her the changes he was making during the rounds, and then email the orders to her later the same day. RN B reported the nurse who attended the wound care rounds with Physician A, would then put the orders into PCC that day or the following morning if they had already left the facility for the day. RN B reported that when Physician A came to the facility on [DATE], the orders were not put in because she had been running late with everything and had left the facility without putting them in. RN B reported she had expected that the facility wound care nurse would enter them the next morning. However, RN B reported that the Wound Care Nurse had not put the orders into PCC on the next day, as she typically did, and quit working at the facility that day (02/11/25). RN B stated she put the wound care orders from 02/10/25 in the EHR on 02/12/25 when she realized they were not put in. RN B reported that on 02/17/25 she did wound care rounds with Physician A and received his orders on 02/18/25. RN B stated she should have placed these orders in the EHR on 02/18/25 and thought she did. RN B reported she was not sure why those orders were not placed in the EHR until 02/20/25. RN B reported that not having new wound care orders put in place could put the resident at risk for delayed wound healing. In an interview on 02/28/25 at 3:30 PM, the DON reported that she expected staff would enter and implement wound care orders when they were received by the physician, and that a delay could result in a delay in a wound healing. In an interview on 02/28/25 at 2:26 PM, Physician A reported that Resident #1's wound prognosis had changed from when he assessed him on 02/10/25 (fair prognosis) to the 02/17/25 (poor prognosis). Physician A reported that Resident #1's wound had changed from a Stage II to an unstageable wound during that time and that he considered an unstageable wound to be more severe than a wound that is a Stage II. Physician A reported that in the case of Resident #1, when he saw him on 02/17/25 the wound was unstageable due to eschar (a layer of dead, dried tissue that forms over a wound or burn) that limited assessment. Physician A stated this decline may have been related to the resident's size (obesity) and his near complete dependence in care. Physician A reported that when he made rounds with a nurse each week, he told them what he ordered, what he was changing, and later that day gave them written orders. Physician A stated his expectation was that the order would be entered into PCC right away so that any new wound care orders would begin the next day. Physician A reported he had no knowledge of any orders being entered days after he had written them. Physician A stated it was not ideal if it took several days for an order to be entered and implemented. Physician A reported that while he couldn't say for sure what caused Resident #1's wound deterioration, he stated this delay could be one of the contributing factors. In an interview on 2-28-2025 at 6:40 PM, the DON stated when a resident admitted into the facility with a wound, the process was the admitting nurse would do an assessment, fill out the assessment form in detail, notify the wound care nurse, DON, and the wound care doctor. After that, the facility would get an order from the doctor. The DON stated when the admitting nurse sees a wound on a new resident her expectation was for the doctor to be contacted immediately and get orders from the doctor. The DON said the admitting nurse was responsible to see that this happened. The DON stated her expectation was that nurses make notes and put in the Resident's Care Plan when they have wounds. Record review of the facility's policy dated 2001 (Revised April 2018) and titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol reflected, The nursing team member and practitioner will assess and document and individual's significant risk factors for developing pressure ulcers; and shall describe and document/report the following .a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . The policy also stated that, the team member and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will order pertinent wound treatments.

Based on interview and record review, the facility failed to have physician orders for the resident's immediate care at the time a resident was admitted for 1 of 1 (Resident #1) resident reviewed for physician orders. The facility failed to obtain physician orders for immediate care when Resident #1 admitted to the facility on [DATE] with a pressure wound to receive orders for treatment. This failure could place residents at risk for delayed treatment causing a decline in health by not receiving treatment until two weeks later. Findings included: Review of Resident #1's Face Sheet dated 02/05/25 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses in part included hypertension (elevated blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord, or never problem), quadriplegia (paralysis affecting all limbs and body from the neck down), diabetes (disease affecting the body's use of sugar), obesity (complex disease involving having too much body fat), and ulcer of the right buttocks, stage II (shallow, open wound that has broken through the top layer of skin and part of the layer below). Record review of Resident #1's Care Plan Report dated 1-29-2025 and revised on 2-17-2025 revealed actual impairment to skin integrity pressure injury to the sacrum r/t immobility, disease process. Record review of Resident #1's Hospital Records dated 1-29-2025 at 10:33 AM revealed an admitted [DATE] and a discharge date of [DATE]. The record indicated Resident #1 had a stage 2 pressure injury to his right buttock upon discharge. Record review of Resident #1's Nurse Note dated 1-29-2025 at 5:21 PM revealed a skin assessment was performed indicating bilateral buttocks redness observed. Record review of Resident #1's Nurse Notes dated from 1-29-2025 to 2-10-2025 failed to indicate the facility notified a physician about the pressure wound on Resident #1. Record review of Resident #1's Weekly Skin Observation Tool dated 2-7-2025 indicated Resident #1 had a pressure ulcer on his sacrum area. In an interview on 2-25-2025 at 3:50 PM, RN B (ADON) stated she conducted the Weekly Skin Observation Tool dated 2-7-2025 on Resident #1 but did not document that she contacted the doctor about seeing the wound on Resident #1's sacrum. RN B did not remember if she contacted a doctor about seeing the pressure wound. However, RN B was sure she told Physician A about Resident #1's pressure wound, when he came to the facility on [DATE]. RN B stated not notifying the doctor timely could allow the wound to get worse. RN B stated she did not see Resident #1's wound until 2-7-2025. In an interview on 02/28/25 at 2:26 PM, Physician A reported that Resident #1's wound prognosis had changed from when he assessed him on 02/10/25 (fair prognosis) to the 02/17/25 (poor prognosis). Physician A stated the first time he was aware of Resident #1's wounds were on 2-10-2025. Physician A stated a delay in treatment could be a contributing factor in the decline of health concerning Resident #1's pressure wounds. In an interview on 2-28-2025 at 6:40 PM it was disclosed that the DON expected the admitting nurse to call the doctor immediately when it was discovered that a new resident entered the facility with a wound to get orders from the doctor. The DON said it was the Admitting Nurse's responsibility to contact the doctor immediately. The DON stated the risk to the resident by not notifying the doctor of a wound in a timely manner was the wound could get worse. Record review of the facility's policy dated 2001 (Revised April 2018) and titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol reflected, The nursing team member and practitioner will assess and document and individual's significant risk factors for developing pressure ulcers; and shall describe and document/report the following .a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . The policy also stated that, the team member and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will order pertinent wound treatments.

Based on interview and record review, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly for 1 of 2 residents (Resident #2) reviewed for resident rights. The facility failed to notify Resident #2's representative and/or family, on [DATE], as appropriate of a significant change in Resident #2's mental status. This failure could prevent their representative's authority from being notified or exercised preventing them from receiving competent choices. Findings included: Record review of Resident #2's Face Sheet dated [DATE] revealed an [AGE] year-old female with an initial admittance date of [DATE]. Resident #2's primary diagnosis was dementia without psychotic disturbance (cognitive decline characteristic of the condition, but does not exhibit symptoms of psychosis, such as hallucinations or delusions) with secondary diagnoses in part of diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), auditory hallucinations (hearing sounds or voices that are not present in the real world), cerebral infarction (stroke where blood flow to the brain is interrupted, leading to the death of brain cells), and schizoaffective disorder (a mental health disorder causing hallucinations, delusions, disorganized thinking and speech) having an onset date of [DATE]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating being cognitively intact. Record Review of Resident #2's Care Plan dated [DATE] revealed Resident #2 was care planned to use psychotropic medications on [DATE] for hallucinations and explosive disorders. Record review of Resident #2's Psychotropic Drug Regimen Review dated [DATE] revealed Prozac, Risperdal, and Trileptal were ordered on [DATE]. Record review of a Medical Power of Attorney/Living Will dated [DATE], revealed Family Member A had a medical power of attorney for Resident #2. In an interview on [DATE] at 11:00 AM it was revealed Family Member A was Resident #2's Medical Power of Attorney. Family Member A stated she was never informed or consulted that Resident #2 had been diagnosed with any type of Schizophrenia and was not told she was put on the drug Risperidone. Family Member A said the last 1.5 years of Resident #2's life, dementia was so bad she could not turn off her phone nor be competent enough to sign for new drug treatments. Record review of Resident #2's Psychiatric Care Notes dated [DATE] indicated Resident #2 was assessed with having Bipolar Disorder. Record review of Resident #2's Psychiatric Care Notes dated [DATE] indicated Resident #2 was assessed with having Bipolar Disorder with episode manic severe with psychotic features. Record review of Resident #2's Psychiatric Care Notes dated [DATE] indicated Resident #2 was assessed with having Bipolar Disorder, Schizoaffective Disorder, and Dementia. [DATE] Psychiatric Care Notes failed to indicate the facility notified Resident #2's representative(s) and/or family when there was a significant change in the resident's physical, mental, or psychosocial status. Record review of Resident #2's Progress Notes in ,d+[DATE] failed to indicate Resident #2's representative(s) and/or family about the diagnosis of Schizoaffective Disorder. Record Review of Resident #2's Consent for Antipsychotic Medication Treatment HHS Form 3713 dated [DATE], revealed Resident #2 signed the form for the treatment of Schizoaffective Disorder, Auditory Hallucinations, and to take the drug Risperidone. The form failed to state notification to Resident #2's representative(s) and/or family of this change in the treatment or diagnosis of Resident #2 Record review of Resident #2's Progress Notes dated [DATE] indicated that Resident #2 had a Medical Power of Attorney and Living Will on file with the facility. Record review of Resident #2's Progress Notes dated [DATE] titled Care Conference failed to include notice to Family Member A or any POA for Resident #2 Record review of Resident #2's Doctor's Orders revealed Resident #2 was put on hospice care on [DATE]. Record review of Resident #2's Nursing Home and Swing Bed Tracking MDS dated [DATE] revealed Resident #2 died at the facility on [DATE]. In an interview with the DON on [DATE] at 6:40 PM, it was revealed that the DON expected the facility to notify a resident's representative or family whenever there was a change in a diagnoses or treatment. The DON stated she remembered Resident #2 had a lot of behavior problems. The DON stated the facility took over the current building in 2021 and it seemed at though the family of Resident #2 stopped signing forms for Resident #2 at that point in time. The DON stated the facility had the resident sign for consent for changes in diagnoses and treatment because she was her own responsible party. The DON said the potential harm that can come to a resident for not notifying her representatives or family could be the resident might decline where she may not be competent to sign for medications for herself. Record review of the facility's Resident Rights Policy dated 2001 and revised in 2016 stated: Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of property, and exploitation . f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States . k. appoint a legal representative of his or her choice, in accordance with state law .

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, #12, and #47) of nineteen residents reviewed for call lights. The facility failed to ensure Residents #1, #12, and #47 had cords attached to their call lights so that they could pull the call light switch to activate it when they needed assistance. This failure could place the residents at risk of falling, injury, and feelings of low self-worth due to not being able to call for help. Findings included: A Review of Resident #1's face sheet, dated 06/13/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included syndrome of inappropriate antidiuretic hormone secretion a condition in which high levels of hormones cause the body to retain water, glaucoma in both eyes is an eye disease that causes vision loss, seizures, high blood pressure, cataract in both eyes and paranoid schizophrenia is a disease in which the mind does not agree with reality. Resident #1 was a full code, code status. Review of Resident #1 care plan on 06/12/24 reflected Resident #1 had communication impaired r/t dementia. The goal was for Resident #1 to make basic need known by signs and gestures. The intervention included to anticipate his needs and meet them and to ensure/provide a safe environment. Call light in reach. Resident #1 was also care planned for falls r/t walking and balance and poly medications. Goal was Resident #1 would be free of falls. Interventions were be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Care plan initiated 08/22/22, revision 01/29/24. B. Review of Resident #12's face sheet, dated 06/13/24, reflected a [AGE] year-old male that admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), muscle weakness, seizures (epilepsy), reflux, paranoid schizophrenia is a disease in which the mind does not agree with reality, high blood pressure (HTN) and heart disease without chest pain. Resident #12 had a code status of Full Code. Review of Resident #12 quarterly MDS dated [DATE], reflected a BIMS sore of three indicating severe cognitive impairment. Review of Resident #12 care plan on 06/12/24, reflected Resident #12 was a High risk for falls related to medications, high blood pressure, confusion, and Alzheimer. Goals included Resident #12 would be free from falls and he would be free of minor injury. The Intervention was Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Care plan initiated on 03/29/22, revision on 02/28/24 with a target date 03/09/24. C. Review of Resident #47's face sheet, dated 06/13/24, reflected a [AGE] year-old male that admitted to the facility on [DATE]. His diagnoses included dementia a condition of cognitive decline, high blood pressure, uncontrolled blood sugars (diabetes mellitus), eye problem due to diabetes, left arm fracture, and age related macular degenerative in both eye is an eye disease that causes vision loss in both eyes. Resident R47 was his own responsible party and had a code status of Full Code. Review of Resident #47 quarterly MDS dated [DATE], reflected a BIMS sore of three indicating severe cognitive impairment. Review of Resident #47 care plan on 06/12/24, reflected Resident #47 had ADL self-care performance deficit r/t weakness and impaired cognition. The goal was to maintain current level of function in through the review date. Interventions included encourage the resident to use bell to call for assistance. Care plan initiated 09/21/22 and target date 06/11/24. Resident #47 had fall care plan r/t impaired mobility and impaired cognition. Goal was not to sustain significant injury through the review date. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it or assistance as needed. The resident needs prompt response to all requests for assistance. Resident #47 also care planned for musculoskeletal impaired r/t left shoulder fracture. The goal was to remain free of complications related to left shoulder fracture (blood clot, contracture, immobility). Interventions included Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Care plan initiated 09/21/22, revision 06/26/23, target date 06/11/24. Observation on 06/11/24 at 10:29 AM revealed Resident #1, #12 and #47's rooms had no call lights in the room. A brown switch box approximately five by three inches that looked like a light switch observed between bed A and bed B. The switch box was approximately five feet high from the floor. The call light switch box was placed in between bed A and bed B with an on and off button on it. There was no string attached to the switch call box to activate the call light. In an interview with CNA H on 06/11/24 at 10:37 AM, she demonstrated how the call lights were activated she pulling a yellow string made of yarn that was tied to a hook on the switch box to activate the call light she then reset the call light to turn it off. She stated that call light system worked and a light outside room would light up when activated. CNA H stated that most of the residents did not need the call light. She stated that most of the residents did things by themselves. She stated that they went to the bathroom by themselves and dressed themselves. CNA H did not state the risk to residents not having call lights in their rooms because she said they did not use it. She stated that she made rounds very frequently. In an interview with LVN G on 06/11/24 at 12:52 PM, he stated that call lights system had were reported to management and he was informed by the maintenance department that it was a hazard for the residents on the unit to have call lights cords because residents could tie it around themselves or chock on it on the call light cords. He stated that he believed a resident went around and removed the yellow strings attached to the call light switch boxes in the rooms. He said that he had not seen any residents use their call lights however he believed that any resident had a right to a call light. He stated the risk to the resident not having a call light was that in a moment of clarity a resident may use a call light to get help if needed. In an interview with maintenance supervisor on 06/13/24 at 11:15 AM, he stated that he was aware of the missing strings from the call lights. He stated that the ADM had placed a work order on 06/11/24 and he had completed it. He stated that some residents went around the unit and removed the yellow strings tied to the call light switch box. He said that the call system was old and had a switch to activate and not a normal pug in with a cord call light. He stated that he had never seen a resident on that unit use a call light. He stated that a string longer than twelve feet was a hazard, and he used the facility policy when he replaced the missing strings. He did not state the risk to the residents not having call lights. He stated, the gentlemen do not use the call lights. In an interview with ADM on 06/13/24 at 05:26 PM, she stated it was the responsibility of all staff to report to maintenance anything broken. She stated that the maintenance team was always in servicing staff on the electronic work order submission by using an external link on point care click a system used by all nursing staff. She stated that she expected to report anything broken. She stated the risk to the resident was not getting care when they needed it. She stated that residents may have periods of clarity and could operate the call light if they needed help. She also stated that it was part of regulation for residents to have call lights. Record review of facility QAPIP reflected . call light in reach of resident (check function) .bathroom call lights function . Record review of the facility's policy dated 12/2016, titled, Resident Rights, reflected, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Respect and Dignity: . The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .

Based on observations, interviews and record reviews, 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. The facility failed on [DATE] to ensure items found in the walk-in refrigerator, were labeled with the use by date. These failures could place resident at risk for food-borne illness and food contamination. Findings included: Observation on [DATE] at 9:11 am revealed in the facilities only walk-in refrigerator the following items not labeled or dated: - Large Ziplock bag containing cheese. - Large Ziplock back containing a sandwich, chips, packaged crackers, personal packet of mayonnaise. - Large Ziplock bag containing cooked bacon. Observation on [DATE] at 9:11 am revealed in the facilities only walk-in refrigerator the following items in open packaging: - Box of lunch meat on the shelf uncovered. - Box of 24 count eggs with 18 eggs remaining in the open box. Interview on [DATE] at 2:20 PM with Admission Director; revealed he has been helping in the kitchen during preparation time because the dietary manager quit about three weeks ago. He stated he assist with ordering food and food preparation. He has a position within the facility that limited his time in the kitchen. He stated that he did remind dietary staff to maintain safe store practices. Interview on [DATE] at 3:06 PM with DON; she stated that food should be closed and sealed. The risk to the residents was cross contamination. Interview on [DATE] at 05:22 PM with Administrator; she stated food should be labeled for us to know that the food was not expired and safe for human consumption. Review of the policy titled Food Storage, dated 2018 reflected; d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on observation, interview and record review, the facility failed to ensure storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for one (Suites Medication Room) of two medication rooms reviewed for storage and biologicals. The facility failed to store food brought in by family or visitors with labels of resident's names, expiration date, and stored in a way that was separated and distinguishable from residents, facilities, and staff's foods in the Suites Medication Room refrigerator on [DATE]. This failure could affect residents by placing them at risk for food-borne illness. Finding included: Observation and interview with ADON on [DATE] at 03:06 PM, revealed Suites Medication Room had a tall white refrigerator with 3 shelves. Temperature reading 40 degrees Fahrenheit. No medications in the refrigerator. On the top shelf- were a box of thickened water, a 2-liter coke bottle in a shopping bag, a brown box opened at top, a gallon pitcher with red drink undated with a loose fitted plastic wrap, half a sandwich undated in an open sandwich bag, an ensure bottle and unidentified yellow/orange container open to one side in the back of refrigerator. On the second shelf- were a white empty grocery bag, a half bag of mixed shredded cheese, a Mrs. Freshley's honey bun (name of product) that was undated and a box of cinnamon Chex. On the last shelf- was an open twenty can Coca-Cola box with resident name on it, a large pizza box and 2 smaller pizza boxes stacked together from pizza [NAME] dated [DATE]. A grey bag tied at top of unknown contents with no date or name. On the very bottom of refrigerator was a slightly open drawer, yellow and brown sticky substance on bottom of refrigerator and inside door shelves. ADON said that she was unsure of the food in the refrigerator belonged to the staff or residents. She said the pizzas and the 2-liter drink belonged to a resident that liked to order uber eats (an outside food delivery service). She said the nursing staff were responsible for cleaning out the refrigerator and making sure food was up to date and labelled with resident's name as applicable. She said only nursing staff had access to medication rooms refrigerators. She said the risk to the residents was eating something that could make them sick because it had expired. In an interview with DON on [DATE] at 03:13PM, she stated that she was unaware of the status of the refrigerator in Suites Medication Room. She said that she would get it cleaned and start an in service with the nursing staff about labeling and dating the items in the fridge. She said the risk to the residents was eating something contaminated that could make them ill. In an interview with the ADM on [DATE] at 05:266 PM, she stated that she expected all nursing staff to follow facility policy and make sure that all foods labelled with resident's name and dated. She said she expected all staff to monitor that the food was safe for human consumption. She said the risk to resident was not knowing if food was safe to eat. Review of facility policy titled Food safety for Residents revised ,d+[DATE] reflected . 2. Cover, label with name, date stored and the date it must be used or discard. We recommend a use by date of 3 days after the food was prepared or purchased .plastic containers with tight fitting lids are recommended . Review of facility policy titled Cleaning & Sanitation of Refrigerators & Freezers on Units revised ,d+[DATE] reflected . Only residents' food will be stored in the pantry refrigerators. All food will be labeled, dated, and covered. Refrigerators Will be checked each day for any food or supplement over 72 hours old and any outdated food will be discarded .

49733 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 and infection for 2 of 5 staff members (CNA A and RN F) reviewed for infection control. 1. The facility failed to ensure that the designated handwashing sink located in the facility kitchen had a functional soap dispenser. Dietary Aide A used the hand soap from a bag of soap located in the sink to wash her hands instead of using the soap dispenser. 2. While assisting Resident #13 with his breakfast, CNA A failed to wash her hands before assisting him with eating. CNA picked up 2 strips of bacon with her bare hands and handed them to the resident. 3. While serving meals in the dining room, RN F failed to perform hand hygiene in between direct contact with 13 residents. These deficient practices have the potential to affect all residents in the facility by placing them at risk for cross contamination and infections. The findings included: Observation on 06/11/2024 at 9:10 am revealed designated kitchen hand washing sink had a full bag of antibacterial hand soap laying in the sink with a steel scrub pad sitting on top of it. In the bottom of the sink was food residue. Located on the ledge of the sink was a 7.5 FL OZ (ounces) empty bottle of hand soap with the top off. The wall soap dispenser did not produce soap when operated. Interview with Dietary Aide A on 06/11/2024 at 9:10 am revealed the kitchen hand washing sink was the hand washing sink that staff used to wash their hands. Observation on 06/12/2024 at 11:02 am revealed designated kitchen hand washing sink had a bag of antibacterial hand soap laying in the sink. Wall hand soap dispenser was open with no hand soap installed. During meal prep Dietary Aide A was observed going to the hand washing sink, picking up the soap in the disposable bag, squeezing the bag to dispense soap into their hands, placing the soap bag back into the sink, and finally washing their hands with soap and water. Interview with Admissions Director on 6/12/2024 at 11:02 am revealed the bag of soap located in the sink was the soap used by staff to wash their hands. Interview with Admissions Director on 06/12/2024 at 2:20 pm revealed the soap dispenser on the wall above the hand washing sink was functional and stated the reason the bag of soap was not in the dispenser was because when staff change out the bags, they throw away the spout. He stated that he did not think that squeezing the hand soap out of the bag was an infection control issue if staff did not touch the bag after they washed their hands. Interview with DON on 06/13/2024 at 3:16 pm revealed the expectation was that the soap be placed and the soap dispenser and the sink clean of all debris. The risk to the residents was cross-contamination. Review of the Policy titled Handwashing/Hand Hygiene reflected 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 2. Review of Resident #13's Face Sheet, accessed on 6/12/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Parkinsonism, unspecified (term used to describe a collection of movement symptoms associated with several conditions-including Parkinson's disease which is a disorder of the central nervous system that affects movement), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), End Stage Renal Disease (terminal illness that occurs when the kidneys can no longer function properly and support the body's needs), Dependence on Renal Dialysis (complex and evolving process that involves the use of renal dialysis (renal replacement therapy) to sustain life when the kidneys are no longer able to function properly), Anxiety Disorder (mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), age-related Nuclear Cataract, Left eye (major cause of blindness that occurs when the proteins in the eye's lens break down and clump together, causing cloudy spots in the center of the lens), and acute Osteomyelitis (inflammation of bone caused by infection). Review of Resident #13's MDS, dated [DATE], did not indicate a BIMS score. His MDS indicated the resident's functional ability in eating required substantial/maximal assistance. It further indicated the resident had an unhealed stage 4 pressure ulcer present upon admission/entry or reentry. Review of Resident #13's Care Plan, initiated on 2/16/24 and revised on 4/19/24, indicated he had an ADL self-care performance deficit r/t ESRD, Dementia, Parkinson's. Related interventions indicated the resident required extensive x 1 assistance with eating. During an observation on 6/12/24 at 8:10 AM, Resident #13 was observed sitting on the side of his bed in his room. Food tray was on his bedside table. Food on his plate consisted of scrambled eggs, bacon, and toast. CNA A entered the resident's room with coffee and assisted the resident with adding sugar and powdered creamer to his coffee and assisted him with eating. CNA A failed to sanitize her hands upon entering the room or before assisting the resident. While assisting him with eating, CNA A picked up 2 strips of bacon with her bare hands and handed them to the resident. 3. During an observation on 6/12/24 at 12:17 PM, RN F was observed passing lunch trays in the main dining room. She was observed handling resident wheelchairs and other items in the dining room and did not wash or sanitize her hands between residents when serving meal trays. During an interview on 6/13/24 at 12:00 PM with CNA A, she stated she always washed her hands prior to assisting residents with their food. She stated she would never pick up a resident's food with her bare hands. She stated she would use utensils or put gloves on. She stated that failure to sanitize hands when assisting residents or touching their food with bare hands could spread germs and could potentially cause the residents to become ill. She stated it was policy to perform hand hygiene before and after resident interactions. She stated the facility provided in-service about once a month on infection control. During an interview on 6/13/24 at 12:16 PM with CNA B, she stated she has been employed with the facility since December 2023. She stated she washes her hands before assisting residents with eating. She stated hand hygiene was important when assisting them to eat to help prevent the spread of germs. She stated that failure to wash hands could cause a resident to become sick. She stated she never touches a resident's food with her bare hands because the food can get contaminated with germs. She stated the facility provided in-service on infection control recently but could not remember when she last attended. During an interview on 6/13/24 at 12:27 PM with CNA C, she stated it was policy for staff to wash their hands before, after, and in-between resident care. She stated she helped residents with eating and always washed her hands before and after. She stated if she had to pick up a resident's food, she would put on gloves. CNA C stated sanitizing hands when caring and assisting residents was important because it stopped the spread of germs that could cause infection. She stated the staff regularly attend in-service on infection control. During an interview on 6/13/24 at 12:44 PM with the corporate nurse, she stated hand sanitizing was applicable when actually coming in contact with residents or their food. She stated hands should also be sanitized in between every few residents to prevent the spread of germs to the residents. During an interview on 6/13/24 at 1:13 PM with the RD, she stated she has been employed with the facility for one month. She stated hand hygiene was to be conducted anytime there was interaction between 2 residents to prevent the spread of germs. She stated staff should not be touching the residents' food with their bare hands for safety of the residents. During an interview on 6/13/24 at 1:19 with the DON, she stated the staff were to sanitize their hands in between residents and before assisting residents with eating. She stated staff should never touch the residents' food with their bare hands. She stated staff can have contamination on their hands and spread gems causing harm to the residents. She stated the facility had an infection control in-service on 5/31/24. During an interview on 6/13/24 at 4:13 PM with the Infection Preventionist, she stated aides were required to conduct hand hygiene prior to feeding or assisting the residents with their food. She stated aides should not use their bare hands to feed the residents. She stated they were to use utensils so there would not be contamination of the food. She stated that failure to do so could cause germs to be passed to residents and could potentially cause them harm. She stated she recently conducted an in-service on infection control. During an interview on 6/13/24 at 5:26 PM with the Administrator, she stated her expectation was for staff to use hand sanitizer to clean hands prior to feeding residents and never touch the residents' food with their bare hands. She stated their hands could have germs and the residents could get ill. She stated the staff were regularly in-serviced on infection control. Review of the facility's policy on Handwashing/ Hand Hygiene, revised August 2019, identified the policy statement as This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation included: 1. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, resident, and visitors. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .o. Before and after assisting a resident with meals. Review of the facility's policy on Infection Control, revised October 2018, identified the policy statement as This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy interpretation and implementation included: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer worker, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public;

Based on observation, interview, and record review, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 9 residents reviewed for pressure ulcers. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for Resident #1 upon readmission to the facility on [DATE] with two small open wounds on the right and left buttock. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders on 04/11/2024 when a new wound developed on Resident #1's coccyx. Resident #1 was not seen by the Wound Care Doctor until 04/22/24 and was sent out to hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 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 immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at a risk of increased pain, infections, development of new pressure ulcers, and decline in quality of life and serious harm for residents. Findings included: Record review of Resident #1's face sheet dated 04/23/2024 indicated an [AGE] year-old female initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (mile cognitive impairment), congestive heart failure (heart does not bump blood enough to meet the body's needs), hypertension (pressure in blood vessels is too high), and Type 2 diabetes (problems in the way the body regulates and uses sugar as fuel). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 4, indicating severe cognitive impairment. Resident #1 required supervision for eating, substantial/maximal assistance with toileting and personal hygiene, and dependent for transfer. She was always incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers/injuries, she did not have any unhealed pressure ulcers/injuries but had moisture associated skin damage - treatments include applications of ointments/medications. Record review of Resident #1's Comprehensive Care Plan dated 03/14/2024 reflected, [Resident #1] has an ADL self-care performance deficit r/t impaired gait2/balance, poor comprehension r/t Dementia/Alzheimer's, revised on 03/25/2024. Interventions included extensive to total x 2 for bed mobility, transfers, dressing, and toileting. [Resident #1] has actual impairment to skin integrity of the peri area r/t incontinence. Interventions: Triad cream per family request, initiated 04/04/2024. Record review of Resident #1's March 2024 Nursing MAR reflected Preventative Skin Care: Apply Moisture Barrier every shift and PRN. Start Date - 03/29/2024. D/C Date - 03/28/2024. Record review of Resident #1's March 2024 TAR did not reflect treatment orders. Record review of Resident #1's April 2024 Nursing MAR and TAR did not reflect treatment orders. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. The site(s), type, measurements, or stage were not identified. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. An unmeasured pressure wound was identified to the left and right buttocks. An unmeasured open area was identified to the Coccyx. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Wound Progress note 04/21/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the notified RP and date were blank. The physician was notified 04/21/24. The wound type was other and the location reflected wound has deteriorated rapidly in the past 2 days; Heavy exudate (drainage that seeps out of wounds); an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 9 cm x 10 cm x 0.5 cm. Additional Comments: WOUND HAS DETERIORATED LOOKS LIKE ABSCESS. Doctor notified with orders for wound care ASAP. In an interview on 04/23/2024 at 11:25 AM, ADON B stated she was the Wound Care Nurse. She said when Resident #1 admitted to the facility on [DATE], she did not have any wounds. She said Resident #1 was sent to the hospital for a UTI and returned to the facility on [DATE] with two small open wounds on her right and left buttocks. She said the family wanted them treated with cream they brought in because that seemed to help in the past. She said she did not consult the MD or Wound Care Doctor about the wounds because she attributed them to moisture related and only warranted barrier cream. She stated she completed Resident #1's wound care daily and the wound did not get better or worse. She said on 04/04/2024 she started pursuit of having the family sign a consent form to see the Wound Care Doctor because Resident #1 did not get out of bed and the wounds were not getting better. She said she did not consult with the Wound care Doctor because they would not see Resident #1 without a consent. She said she was able to have the family complete the consent on 04/08/2024 but the Wound care Doctor had already rounded for the day and did not see Resident #1. She said she had not discussed Resident #1 with the Wound Care Doctor on 04/08/2024 because she did not have the consent signed until after the Doctor left the facility. She said she was not aware that LVN A had documented the development of another wound on Resident #1's sacrum, during a skin assessment on 04/11/2024. She said the Wound care Doctor was next in the facility on 04/15/2024 but she was late on that day and was not able to provide the consent to the Doctor, therefore the Doctor, did not see Resident #1's wounds again. She stated she last saw Resident #1's wounds on 04/18/2024 and they looked normal to her. She said she worked on 04/21/2024 and LVN E called her to look at Resident #1's wound. She said it deteriorated a lot and seemed to have an abscess and measured 9 cm x 10 cm x 0.5 cm. She stated the MD was notified by LVN E and the MD told them to clean and dress the wound and referred to the WCD on 04/22/2024. She said she had not consulted with the MD or the WCD about Resident #1's wounds until 04/22/2024 when the Wound Care Doctor sent Resident #1 to the hospital for possible debridement. ADON A stated she did wound care daily, which included applying cream to the wound and dressing it, Monday through Friday and the nurses followed up with wound care on the weekends. She said it was important to follow doctor's orders for wound care, but the family only wanted triad cream applied to the wound. She said she should have consulted the WCD on 04/04/2024 when she initially felt Resident #1 should be seen by the WCD. In an interview on 04/23/2024 at 12:33 PM, the DON stated, Resident #1 returned to the facility on [DATE] from the hospital with an opening (sheer) on the sacrum. She stated the family only wanted the wound to be treated with cream. She said the family was to sign a consent for Resident #1 to see the WCD and did on 04/08/2024 after the WCD had already left the facility. She said the facility needed a consent for residents to see the WCD but not to consult with them. She said the next time the WCD was in the facility on 04/15/24, the WCN was late, and they missed each other. Resident #1 was not seen by the WCD. She said the WCN should have discussed the wound with the WCD or MD to get treatment orders in place. She said she needed to put a system in place for someone else to round with the WCD in the WCN's absence. She said on 04/22/2024, RN G called her to tell her about Resident #1's wound. She said LVN E called the MD and was instructed to clean and dress the wound and refer to the WCD the next day, 04/22/2024. She said Resident #1 was sent to the hospital by the WCD on 04/22/24. She said she expected nursing staff to follow the facility's policy and ensure they consulted the physician when changes in skin are noted. She said she expected staff to obtain and follow treatment order for all wounds. In a telephone interview on 04/23/2024 at 1:38 PM, the WCD stated she did not see residents unless there was a referral and consent completed. She said she knew the WCN was getting a consent from the facility but had not discussed the wounds with her. She said she came to the facility every Monday and on 04/15/2024 Resident #1 was not on her list of residents to see. She said the WCN was not there that day. She said the WCN provided the consents and list of residents to see. She said she would like to be notified and consulted of wound changes for all residents because wounds can deteriorate quickly. She said all wounds should have treatment orders in place if not from the WCD then from the MD. In an interview on 04/23/2024 at 1:46 PM, CNA D stated when Resident #1 returned to the facility from the hospital on 03/28/2024, she had a small opening on her bottom and the family wanted them to use cream to treat it. She said they placed signage on the walls directing this. She said she worked with Resident #1 on 04/10/2024 and again on 04/17/2024 and 04/18/2024 the wound looked the same. She said she worked with Resident #1 on 04/22/2024 and the wound looked like it burst and was huge. In an interview on 04/23/2024 at 1:53 PM, LVN C stated she sent Resident #1 to the hospital on 04/22/2024 by the WCD. She said the wound had grown, was very deep and the skin was all gone. She said it had not been like that last week. She said she had not been notified that it had worsened. An observation on 04/23/2024 at 4:15 PM at the hospital, of Resident #1 revealed her sleeping. She was propped on her side with wedges. In an interview on 04/23/2024 at 4:20 PM, Family Member O stated Resident #1 returned to the facility from the hospital on 03/28/2024. She said Resident #1's wound was about the size of a quarter and not deep or oozing but it was a little red. She said she brought cream to the facility for them to use on the wound because that seemed to help in the past. She said the WCN did not ask her to sign a consent for Resident #1 to see the WCD until 04/08/2024 and it was provided immediately. She said on 04/21/2024 the facility called her and said the wound had gotten larger and started oozing. She said the WCD saw Resident #1 on 04/22/2024 and sent her to the hospital. She said Resident #1 had surgery to remove infection. In an interview on 04/23/2024 at 4:30 PM, Hospital RN P said Resident #1 had debridement surgery this morning. She said there was an ulcer under the wound which burst and revealed deep tissue damage. She said they used wedges to position Resident #1 on her side and they alternate every 2 hours. In an interview on 04/26/2024 at 2:10 PM, LVN A stated she did the readmission assessment for Resident #1 when she returned to the facility on [DATE]. She said Resident #1 did have open areas on her buttocks. She said the top layer of skin was off. She said the family wanted to use cream on the wound and she entered that into the orders. She said she had not consulted with the MD about the cream treatment. She said when she did the skin assessment on 04/11/2024, an additional wound was on the coccyx. She said the MD should be informed of all wound changes and treatment orders requested. In an interview on 04/26/2024 at 2:49 PM, ADON B stated - she did not open the weekly skin assessments but used the report to identify new wounds and follow up, she said she would let the MD know about new wounds and request treatment orders then enter them into the clinical record. She said she did not do that for Resident #1 because the family only wanted the use of cream. She said she followed up with wounds as best she could but often had to work as a floor nurse. She said the risk to residents of not consulting the MD or WCD could result in new or worsening wounds. In a telephone interview on 04/26/2024 at 3:28 PM, LVN E stated, she called RN G on 04/20/2024 about Resident #1's deteriorating wound and informed her there were no wound treatment orders in the clinical record. She said RN G contacted the DON and they told her the family was aware of the wound and only wanted cream as treatments. She said the wound on Resident #1's right buttock was open and not as deep as the wound on the left buttocks and there was not drainage. LVN E said on 04/21/2024, Resident #1's wound was worse and developed some odor and drainage. LVN E said she notified the MD who instructed her to clean and dress the wound then refer to the WCD on 04/22/2024. In an interview on 04/26/2024 at 3:28 PM, ADON F stated when the WCN was not available nursing staff typically called her to round with the WCD. She said all treatments needed to be order and nurses needed to follow doctor's orders. She said she expected skin assessments to be completed weekly and documented in the clinical record. She said if there were changes they needed to be noted in the 24-hour report for follow up. In an interview on 04/26/2024 at 3:28 PM, RN G stated, LVN E called her on 04/20/2024 to inform her that Resident #1 did not have wound treatment orders in place. She said she asked the WCN who told her the family only wanted the wound treated with cream they brought from home. She said it did not make sense to her and called the DON who told her the same thing. She said the WCD should have seen Resident #1 on their next visit to the facility on [DATE]. She said there was not documentation that the MD or WCD had seen the wound or that treatment orders were requested. She said not consulting the MD or requesting treatment orders placed Residents at risk of worsening wounds and harm. In a telephone interview on 05/01/2024 at 8:45 AM, the MD stated he was not aware of Resident #1's wound until the facility called him on 04/21/2024 informing him of the worsening wound. He said he instructed them to clean and dress the wound and refer to the WCD on 04/22/2024. He said he had seen Resident #1 since her return to the facility on [DATE] but did not know she had a wound. He said he would expect to be informed of any wounds and would put treatment orders in place until the resident could be seen by the WCD. He said everyone who had a wound needed to be seen by the WCD to prevent new or worsening wounds. He said it seemed the delay in obtaining consent and coordination to see the wound care doctor delayed Resident #1's appropriate wound care and caused it to worsen. Record review of LVN A's nurse note dated 03/28/2024 at 4:15 PM, reflected, [Resident #1] readmitted to facility . observed having 2 small openings on each buttock, 3 cm x 2 cm on left and 2 cm x 2 cm on right, cleaned area and applied house cream . Record review of LVN E's nurse note dated 04/20/2024 at 12:00 PM, reflected, [Resident #1] was assessed after night nurse asked to follow up on findings of a open area, When assessed resident was noted to have 2 deep wounds to sacrum area, with moderate drainage. [RN G] made aware of findings. [RN G] called DON to make aware, DON stated that the family is aware of findings, family wanted only Coloplast cream to be put on wound. When relieved by evening nurse [ADON B] was made aware of findings, nurse stated she was aware of wound, and that family denied wanting any other treatment but a thick layer of the Coloplast to be put on her wound. Record review of the Weekly Wound Progress note dated 04/22/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the RP and Physician were notified 04/22/24. The wound was described as an unstageable pressure ulcer to the sacrum; Heavy exudate; an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 10 cm x 12 cm x 0.1 cm. Additional Comments: Wound MD Recommend to send to the hospital for surgical debridement. Record review of the Hospital CT findings on admission reflected, Large collection of gas and debris in the posterior midline and right of midline overlying the coccyx and inferior sacrum. Overall size of this is about 4 cm AP by a maximum of 4.3 cm transverse. Craniocaudal dimensions are about 14 cm but it should be noted that this is not 1 uniform collection. Pockets of mottled collection of gas with some areas containing debris. No definite drainable fluid collection is present. Portions of this inflammatory process about the coccyx, axial image 60 series 3, sagittal image 18 series 6 but no definite periosteal reaction at this time though early osteomyelitis would be difficult to fully exclude. The Administrator, DON and Regional Clinical Services Director were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/26/2024 at 5:15 PM, due to the above failures and the IJ template were provided. The facility's Plan of Removal was accepted on 04/27/2024 at 12:30 PM and included: In-Service conducted. DON, ADON, Wound Care Nurse and Administrator were re-educated by the Regional Clinical Services Director on policy for completing weekly skin assessments, Notification of Physician for Orders/Change of Condition and Prevention and Treatment of Pressure Ulcers. This was completed on 04/26/24. DON started re-education of nurses on 04/24/24 on completing weekly skin assessments, Notification of Physician for Orders and notifying DON/Wound Care Nurse of any new areas identified. This was completed on 4/26/24. All facility licensed nurses received education on timely notification of Physician, Pressure Ulcer Prevention and Identification and Documentation of Pressure Ulcers/Skin Conditions from Clinical Specialists in Wound Care and DON, this was initiated and completed 04/26/24. Nurses who are off, on vacation or leave of absence will be provided education prior returning to work. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation: IDT will review all Pressure Ulcers, Arterial/Stasis Ulcers or any other significant wound weekly during clinical WE CARE Meeting. All newly identified skin issues will be assessed by Wound Nurse and DON upon identification. Physician will be notified by charge nurse upon discovery of any new wound. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO will monitor compliance weekly. Implementation Date of Changes In-servicing was initiated on 04/24/24 and was completed on 04/26/24 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Agency in-serve template was placed in the agency orientation binder on 04/26/24. At this time the facility is not utilizing agency staff. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 04/26/24. Monitoring of the POR DON/Designee will monitor for compliance daily during clinical round and weekly during weekly skin rounds for 4 weeks. Involvement of QA QAPI reviewed and approved the Plan of Removal on 04/26/24. QAPI will review plan for compliance monthly for 3 months. Who is responsible for implementation of process? Administrator and DON (Director of Nursing). On 04/27/2024 at 2:00 PM the surveyor began monitoring the facility's Plan of Removal. Interviews on 04/27/2024 between 2:15 PM and 4:00 PM with RN G, LVN H, CNA I, CNA J, CNA K, LVN L, LVN M, and LVN N. Interviews with staff represented 1st, 2nd, and 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR Inservice including the identification of changes in wound condition, prevention strategies for pressure ulcers, reporting changes to the DON and physician, requesting physician orders when a change in wound condition is noted, and documenting wound status. All staff stated the DON would monitor these actions. In an interview on 04/27/2024 at 4:45 PM, the DON stated, she understood that the facility failed to ensure all wounds were seen by the physician promptly and ensure treatment orders were in place. She said she had been in serviced by the Regional Director of Clinical Services on the following: new and worsening skin, consulting with the MD, referring to the Wound Care Physician, documenting changes in condition in the 24-hour report, and entering MD orders She said they have initiated in services with staff on these topics and will continue until all staff have been in serviced. She said she would monitor this though chart reviews. In an interview on 04/27/2024 at 4:57 PM, the Administrator stated the DON, both ADONs (including ADON A - Wound Care Nurse) were in serviced by the Regional Director of Clinical Services. She stated all nursing staff were educated on notification of Physician, pressure ulcer prevention and identification and documentation of pressure ulcers/skin conditions from by an outside company specializing in wound care. She said these will be monitored by the DON through assessment reports and nursing communication records. She said she would monitor this through the IDT and QUPI process. Record review of the facility's in-service record dated 04/26/2024, and titled, Prevention, identification and notification for pressure ulcers, timely treatment, orders, and POR, reflected the in-services as conducted by the Regional Director of Clinical Services and included signatures of the Administrator, DON, and both ADONs. She stated in-servicing will be on-going to ensure all staff understand the facility's expectations. Record review of the facility's in-service record addressed to CNAs, dated 04/26/2024, and titled, You must notify charge nurse of any issue with skin. All incontinent residents must have [NAME] cream applied after every peri-care. Residents who require total care must be repositioned Q 2-hours. All residents will receive showers per schedule and notify nurse if they refuse. Record review of the facility's in-service record addressed to Nurses, dated 04/26/2024, and titled, Weekly skin assessments: All skin assessment must be completed per schedule. In new skin issues are identified, charge nurse will notify the PCP and DON. Wound nurse will initiate treatment per orders. Notification of the Wound Care Doctor as well. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 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 immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify consistent with his or her authority, the resident representative when there was a change in the resident's physical, mental, or psychosocial status for 1 resident (Resident #1) of 9 residents reviewed for notification of change of condition. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for Resident #1 upon readmission to the facility on [DATE] with two small open wounds on the right and left buttock. The facility failed to ensure the MD and/or the Wound Care Doctor were consulted for direction on wound care orders on 04/11/2024 when a new wound developed on Resident #1's coccyx. Resident #1 was not seen by the Wound Care Doctor until 04/22/24 and was sent out to hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 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 immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of increased pain, infections, development of new pressure ulcers, and decline in quality of life and serious harm for residents. Findings included: Record review of Resident #1's face sheet dated 04/23/2024 indicated an [AGE] year-old female initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia (mile cognitive impairment), congestive heart failure (heart does not bump blood enough to meet the body's needs), hypertension (pressure in blood vessels is too high), and Type 2 diabetes (problems in the way the body regulates and uses sugar as fuel). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 4, indicating severe cognitive impairment. Resident #1 required supervision for eating, substantial/maximal assistance with toileting and personal hygiene, and dependent for transfer. She was always incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers/injuries, she did not have any unhealed pressure ulcers/injuries but had moisture associated skin damage - treatments include applications of ointments/medications. Record review of Resident #1's Comprehensive Care Plan dated 03/14/2024 reflected, [Resident #1] has an ADL self-care performance deficit r/t impaired gait2/balance, poor comprehension r/t Dementia/Alzheimer's, revised on 03/25/2024. Interventions included extensive to total x 2 for bed mobility, transfers, dressing, and toileting. [Resident #1] has actual impairment to skin integrity of the peri area r/t incontinence. Interventions: Triad cream per family request, initiated 04/04/2024. Record review of Resident #1's March 2024 Nursing MAR reflected Preventative Skin Care: Apply Moisture Barrier every shift and PRN. Start Date - 03/29/2024. D/C Date - 03/28/2024. Record review of Resident #1's March 2024 TAR did not reflect treatment orders. Record review of Resident #1's April 2024 Nursing MAR and TAR did not reflect treatment orders. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. The site(s), type, measurements, or stage were not identified. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Nursing Skin assessment dated [DATE] completed by LVN A reflected, Resident #1 had observed skin issues. An unmeasured pressure wound was identified to the left and right buttocks. An unmeasured open area was identified to the Coccyx. The Notes section revealed Has wound tx to her buttocks, sacrum daily and prn. Record review of the Weekly Wound Progress note 04/21/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the notified RP and date were blank. The physician was notified 04/21/24. The wound type was other and the location reflected wound has deteriorated rapidly in the past 2 days; Heavy exudate (drainage that seeps out of wounds); an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 9 cm x 10 cm x 0.5 cm. Additional Comments: WOUND HAS DETERIORATED LOOKS LIKE ABSCESS. Doctor notified with orders for wound care ASAP. In an interview on 04/23/2024 at 11:25 AM, ADON B stated she was the Wound Care Nurse. She said when Resident #1 admitted to the facility on [DATE], she did not have any wounds. She said Resident #1 was sent to the hospital for a UTI and returned to the facility on [DATE] with two small open wounds on her right and left buttocks. She said the family wanted them treated with cream they brought in because that seemed to help in the past. She said she did not consult the MD or Wound Care Doctor about the wounds because she attributed them to moisture related and only warranted barrier cream. She stated she completed Resident #1's wound care daily and the wound did not get better or worse. She said on 04/04/2024 she started pursuit of having the family sign a consent form to see the Wound Care Doctor because Resident #1 did not get out of bed and the wounds were not getting better. She said she did not consult with the Wound care Doctor because they would not see Resident #1 without a consent. She said she was able to have the family complete the consent on 04/08/2024 but the Wound care Doctor had already rounded for the day and did not see Resident #1. She said she had not discussed Resident #1 with the Wound Care Doctor on 04/08/2024 because she did not have the consent signed until after the Doctor left the facility. She said she was not aware that LVN A had documented the development of another wound on Resident #1's sacrum, during a skin assessment on 04/11/2024. She said the Wound care Doctor was next in the facility on 04/15/2024 but she was late on that day and was not able to provide the consent to the Doctor, therefore the Doctor, did not see Resident #1's wounds again. She stated she last saw Resident #1's wounds on 04/18/2024 and they looked normal to her. She said she worked on 04/21/2024 and LVN E called her to look at Resident #1's wound. She said it deteriorated a lot and seemed to have an abscess and measured 9 cm x 10 cm x 0.5 cm. She stated the MD was notified by LVN E and the MD told them to clean and dress the wound and referred to the WCD on 04/22/2024. She said she had not consulted with the MD or the WCD about Resident #1's wounds until 04/22/2024 when the Wound Care Doctor sent Resident #1 to the hospital for possible debridement. ADON A stated she did wound care daily, which included applying cream to the wound and dressing it, Monday through Friday and the nurses followed up with wound care on the weekends. She said it was important to follow doctor's orders for wound care, but the family only wanted triad cream applied to the wound. She said she should have consulted the WCD on 04/04/2024 when she initially felt Resident #1 should be seen by the WCD. In an interview on 04/23/2024 at 12:33 PM, the DON stated, Resident #1 returned to the facility on [DATE] from the hospital with an opening (sheer) on the sacrum. She stated the family only wanted the wound to be treated with cream. She said the family was to sign a consent for Resident #1 to see the WCD and did on 04/08/2024 after the WCD had already left the facility. She said the facility needed a consent for residents to see the WCD but not to consult with them. She said the next time the WCD was in the facility on 04/15/24, the WCN was late, and they missed each other. Resident #1 was not seen by the WCD. She said the WCN should have discussed the wound with the WCD or MD to get treatment orders in place. She said she needed to put a system in place for someone else to round with the WCD in the WCN's absence. She said on 04/22/2024, RN G called her to tell her about Resident #1's wound. She said LVN E called the MD and was instructed to clean and dress the wound and refer to the WCD the next day, 04/22/2024. She said Resident #1 was sent to the hospital on by the WCD on 04/22/24. She said she expected nursing staff to follow the facility's policy and ensure they consulted the physician when changes in skin are noted. She said she expected staff to obtain and follow treatment order for all wounds. In a telephone interview on 04/23/2024 at 1:38 PM, the WCD stated she did not see residents unless there was a referral and consent completed. She said she knew the WCN was getting a consent from the facility but had not discussed the wounds with her. She said she came to the facility every Monday and on 04/15/2024 Resident #1 was not on her list of residents to see. She said the WCN was not there that day. She said the WCN provided the consents and list of residents to see. She said she would like to be notified and consulted of wound changes for all residents because wounds can deteriorate quickly. She said all wounds should have treatment orders in place if not from the WCD then from the MD. In an interview on 04/23/2024 at 1:46 PM, CNA D stated when Resident #1 returned to the facility from the hospital on 03/28/2024, she had a small opening on her bottom and the family wanted them to use cream to treat it. She said they placed signage on the walls directing this. She said she worked with Resident #1 on 04/10/2024 and again on 04/17/2024 and 04/18/2024 the wound looked the same. She said she worked with Resident #1 on 04/22/2024 and the wound looked like it burst and was huge. In an interview on 04/23/2024 at 1:53 PM, LVN C stated she sent Resident #1 to the hospital on 04/22/2024 by the WCD. She said the wound had grown, was very deep and the skin was all gone. She said it had not been like that last week. She said she had not been notified that it had worsened. An observation on 04/23/2024 at 4:15 PM at the hospital, of Resident #1 revealed her sleeping. She was propped on her side with wedges. In an interview on 04/23/2024 at 4:20 PM, Family Member O stated Resident #1 returned to the facility from the hospital on 03/28/2024. She said Resident #1's wound was about the size of a quarter and not deep or oozing but it was a little red. She said she brought cream to the facility for them to use on the wound because that seemed to help in the past. She said the WCN did not ask her to sign a consent for Resident #1 to see the WCD until 04/08/2024 and it was provided immediately. She said on 04/21/2024 the facility called her and said the wound had gotten larger and started oozing. She said the WCD saw Resident #1 on 04/22/2024 and sent her to the hospital. She said Resident #1 had surgery to remove infection. In an interview on 04/23/2024 at 4:30 PM, Hospital RN P said Resident #1 had debridement surgery this morning. She said there was an ulcer under the wound which burst and revealed deep tissue damage. She said they used wedges to position Resident #1 on her side and they alternate every 2 hours. In an interview on 04/26/2024 at 2:10 PM, LVN A stated she did the readmission assessment for Resident #1 when she returned to the facility on [DATE]. She said Resident #1 did have open areas on her buttocks. She said the top layer of skin was off. She said the family wanted to use cream on the wound and she entered that into the orders. She said she had not consulted with the MD about the cream treatment. She said when she did the skin assessment on 04/11/2024, an additional wound was on the coccyx. She said the MD should be informed of all wound changes and treatment orders requested. In an interview on 04/26/2024 at 2:49 PM, ADON B stated - she did not open the weekly skin assessments but used the report to identify new wounds and follow up, she said she would let the MD know about new wounds and request treatment orders then enter them into the clinical record. She said she did not do that for Resident #1 because the family only wanted the use of cream. She said she followed up with wounds as best she could but often had to work as a floor nurse. She said the risk to residents of not consulting the MD or WCD could result in new or worsening wounds. In a telephone interview on 04/26/2024 at 3:28 PM, LVN E stated, she called RN G on 04/20/2024 about Resident #1's deteriorating wound and informed her there were no wound treatment orders in the clinical record. She said RN G contacted the DON and they told her the family was aware of the wound and only wanted cream as treatments. She said the wound on Resident #1's right buttock was open and not as deep as the wound on the left buttocks and there was not drainage. LVN E said on 04/21/2024, Resident #1's wound was worse and developed some odor and drainage. LVN E said she notified the MD who instructed her to clean and dress the wound then refer to the WCD on 04/22/2024. In an interview on 04/26/2024 at 3:28 PM, ADON F stated when the WCN was not available nursing staff typically called her to round with the WCD. She said all treatments needed to be order and nurses needed to follow doctor's order. She said she expected skin assessments to be completed weekly and documented in the clinical record. She said if there were changes they needed to be noted in the 24-hour report for follow up. In an interview on 04/26/2024 at 3:28 PM, RN G stated, LVN E called her on 04/20/2024 to inform her that Resident #1 did not have wound treatment orders in place. She said she asked the WCN who told her the family only wanted the wound treated with cream they brought from home. She said it did not make sense to her and called the DON who told her the same thing. She said the WCD should have seen Resident #1 on their next visit to the facility on [DATE]. She said there was not documentation that the MD or WCD had seen the wound or that treatment orders were requested. She said not consulting the MD or requesting treatment orders placed Residents at risk of worsening wounds and harm. In a telephone interview on 05/01/2024 at 8:45 AM, the MD stated he was not aware of Resident #1's wound until the facility called him on 04/21/2024 informing him of the worsening wound. He said he instructed them to clean and dress the wound and refer to the WCD on 04/22/2024. He said he had seen Resident #1 since her return to the facility on [DATE] but did not know she had a wound. He said he would expect to be informed of any wounds and would put treatment orders in place until the resident could be seen by the WCD. He said everyone who had a wound needed to be seen by the WCD to prevent new or worsening wounds. He said it seemed the delay in obtaining consent and coordination to see the wound care doctor delayed Resident #1's appropriate wound care and caused it to worsen. Record review of LVN A's nurse note dated 03/28/2024 at 4:15 PM, reflected, [Resident #1] readmitted to facility . observed having 2 small openings on each buttock, 3 cm x 2 cm on left and 2 cm x 2 cm on right, cleaned area and applied house cream . Record review of LVN E's nurse note dated 04/20/2024 at 12:00 PM, reflected, [Resident #1] was assessed after night nurse asked to follow up on findings of a open area, When assessed resident was noted to have 2 deep wounds to sacrum area, with moderate drainage. [RN G] made aware of findings. [RN G] called DON to make aware, DON stated that the family is aware of findings, family wanted only Coloplast cream to be put on wound. When relieved by evening nurse [ADON B] was made aware of findings, nurse stated she was aware of wound, and that family denied wanting any other treatment but a thick layer of the Coloplast to be put on her wound. Record review of the Weekly Wound Progress note dated 04/22/24 completed by the WCN reflected, Resident #1 had 1 wound; pain management program was in place Routine and PRN; the RP and Physician were notified 04/22/24. The wound was described as an unstageable pressure ulcer to the sacrum; Heavy exudate; an undescribed exudate color or appearance; and the wound bed appearance other. The wound was measured (LxWxD): 10 cm x 12 cm x 0.1 cm. Additional Comments: Wound MD Recommend to send to the hospital for surgical debridement. Record review of the Hospital CT findings on admission reflected, Large collection of gas and debris in the posterior midline and right of midline overlying the coccyx and inferior sacrum. Overall size of this is about 4 cm AP by a maximum of 4.3 cm transverse. Craniocaudal dimensions are about 14 cm but it should be noted that this is not 1 uniform collection. Pockets of mottled collection of gas with some areas containing debris. No definite drainable fluid collection is present. Portions of this inflammatory process about the coccyx, axial image 60 series 3, sagittal image 18 series 6 but no definite periosteal reaction at this time though early osteomyelitis would be difficult to fully exclude. The Administrator, DON and Regional Clinical Services Director were notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 04/26/2024 at 5:15 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 04/27/2024 at 12:30 PM and included: In-Service conducted. DON, ADON, Wound Care Nurse and Administrator were re-educated by the Regional Clinical Services Director on policy for completing weekly skin assessments, Notification of Physician for Orders/Change of Condition and Prevention and Treatment of Pressure Ulcers. This was completed on 04/26/24. DON started re-education of nurses on 04/24/24 on completing weekly skin assessments, Notification of Physician for Orders and notifying DON/Wound Care Nurse of any new areas identified. This was completed on 4/26/24. All facility licensed nurses received education on timely notification of Physician, Pressure Ulcer Prevention and Identification and Documentation of Pressure Ulcers/Skin Conditions from Clinical Specialists in Wound Care and DON this was initiated and completed 04/26/24. Nurses who are off, on vacation or leave of absence will be provided education prior returning to work. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation: IDT will review all Pressure Ulcers, Arterial/Stasis Ulcers or any other significant wound weekly during clinical WE CARE Meeting. All newly identified skin issues will be assessed by Wound Nurse and DON upon identification. Physician will be notified by charge nurse upon discovery of any new wound. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO will monitor compliance weekly. Implementation Date of Changes In-servicing was initiated on 04/24/24 and was completed on 04/26/24 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Agency in-serve template was placed in the agency orientation binder on 04/26/24. At this time the facility is not utilizing agency staff. Involvement of Medical Director The Medical Director, was notified about the immediate Jeopardy on 04/26/24. Monitoring of the POR DON/Designee will monitor for compliance daily during clinical round and weekly during weekly skin rounds for 4 weeks. Involvement of QA QAPI reviewed and approved the Plan of Removal on 04/26/24. QAPI will review plan for compliance monthly for 3 months. Who is responsible for implementation of process? Administrator and DON (Director of Nursing). On 04/27/2024 at 2:00 PM the surveyor began monitoring the facility's Plan of Removal. Interviews on 04/27/2024 between 2:15 PM and 4:00 PM with RN G, LVN H, CNA I, CNA J, CNA K, LVN L, LVN M, and LVN N. Interviews with staff represented 1st, 2nd, and 3rd shifts and all days of the week. Staff were able to convey appropriate knowledge of the POR Inservice including the identification of changes in wound condition, prevention strategies for pressure ulcers, reporting changes to the DON and physician, requesting physician orders when a change in wound condition is noted, and documenting wound status. All staff stated the DON would monitor these actions. In an interview on 04/27/2024 at 4:45 PM, the DON stated, she understood that the facility failed to ensure all wounds were seen by the physician promptly and ensure treatment orders were in place. She said she had been in serviced by the Regional Director of Clinical Services on the following: new and worsening skin, consulting with the MD, referring to the Wound Care Physician, documenting changes in condition in the 24-hour report, and entering MD orders She said they have initiated in services with staff on these topics and will continue until all staff have been in serviced. She said she would monitor this though chart reviews. In an interview on 04/27/2024 at 4:57 PM, the Administrator stated the DON, both ADONs (including ADON A - Wound Care Nurse) were in serviced by the Regional Director of Clinical Services. She stated all nursing staff were educated on notification of Physician, pressure ulcer prevention and identification and documentation of pressure ulcers/skin conditions from by an outside company specializing in wound care. She said these will be monitored by the DON through assessment reports and nursing communication records. She said she would monitor this through the IDT and QUPI process. Record review of the facility's in-service record dated 04/26/2024, and titled, Prevention, identification and notification for pressure ulcers, timely treatment, orders, and POR, reflected the in-services as conducted by the Regional Director of Clinical Services and included signatures of the Administrator, DON, and both ADONs. She stated in-servicing will be on-going to ensure all staff understand the facility's expectations. Record review of the facility's in-service record addressed to CNAs, dated 04/26/2024, and titled, You must notify charge nurse of any issue with skin. All incontinent residents must have [NAME] cream applied after every peri-care. Residents who require total care must be repositioned Q 2-hours. All residents will receive showers per schedule and notify nurse if they refuse. Record review of the facility's in-service record addressed to Nurses, dated 04/26/2024, and titled, Weekly skin assessments: All skin assessment must be completed per schedule. In new skin issues are identified, charge nurse will notify the PCP and DON. Wound nurse will initiate treatment per orders. Notification of the Wound Care Doctor as well. An Immediate Jeopardy (IJ) was identified on 04/26/2024. While the IJ was removed on 04/27/2024 at 12:30 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 immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of nine residents reviewed for change in physical, mental, or psychosocial status. -The facility failed to notify the physician of a change in condition for Resident #1 after he exhibited unusual behaviors, became combative, and refused administration of insulin, which resulted in the resident having a fall and sustaining critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records from the local hospital, dated 10/11/23, revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E: Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on 10/10/23 during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for [AGE] years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details which lead to outcomes On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F 684 Quality of Care The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. Identify residents who could be affected. Resident [Resident #1] was assessed by the Charge Nurse prior to discharge. Three sets of neuro checks, and vital signs were obtained, first aid was provided, and MD was notified. Prior to the incident, resident was placed on frequent monitoring and staff was in the resident room checking on his needs a total of 10 times in a 6-hour period. Resident continued to resist care throughout the shift. It was also noted in the EMT report that resident was resistant to care provided by the EMT. All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13. An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day by [MDS Coordinator]. In-Services Conducted All nurses will receive education on Diabetes Clinical Protocol, documentation in the clinical record (including notification to physician), and use of the SBAR/INTERACT Tool to assess a significant change of condition. Nurses were also provided with education on the process for identifying a residents change of condition or status, including the Nurse making detailed observations and gathering relevant and pertinent information. An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts. The DON and ADON will be provided with the same in-service education by the Regional Clinical Director on 10/13/23. Implementation Date of Changes In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. . Involvement of Medical Director The Medical Director, [Medical Director] was notified about the immediate Jeopardy on 10/13/23. Involvement of QA QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for the implementation of process? Administrator and DON (Director of Nursing). Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of nine residents reviewed for a change of condition: -The facility failed to notify the physician of a change in condition for Resident #1 after he exhibited unusual behaviors, became combative, and refused administration of insulin, which resulted in the resident having a fall and sustaining critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by others and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflected Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place c-collar [neck brace] . EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records from the local hospital, dated 10/11/23, revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on 10/10/23 during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24-report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for [AGE] years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details On 10/12/2023, an Incident Investigation Survey was initiated at [nursing facility]. On 10/13/2023, a surveyor provided an Immediate Jeopardy Template notification that the Survey Agency determined that the conditions existed that constituted Immediate Jeopardy to resident health and well-being. Allegation F580 Notification of Physician - The facility failed to notify the physician when there was a change in the resident's mental and psychological status, which led to a serious injury. The facility's failure to provide services who required insulin resulted in the resident falling and sustaining serious injuries. Identify residents who could be affected, Resident [Resident #1] was assessed by the Charge Nurse prior to discharge. Three sets of neuro checks, and vital signs were obtained, first aid was provided, and MD was notified. Prior to the incident, resident was placed on frequent monitoring and staff was in the resident room checking on his needs a total of 10 times in a 6 hour period. Resident continued to resist care throughout the shift. It was also noted in the EMT report that the resident was resistant to care provided by the EMT. All Residents have the potential to be affected. The Facility census on 10/13/23 is 75. An audit will be completed on 10/13/23 for 100% of the residents to assess for any change of condition by [DON] In-Service conducted: All nurses will receive education on proper notification Change of Condition, documentation in clinical record and Notification of Physician. Education will include use of the INTERACT tools. Implementation Date of Changes In-servicing was initiated on 10/13/23 by the DON and will continue until it is completed by the DON/Designee on 10/14/23. DON and ADON will receive the same education from the Regional Director of Clinical Services. Agency staff and/or staff on leave that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Monitoring Administrator/DON/Designee will monitor change of resident status and appropriate notification, interventions, and outcomes Administrator/DON will notify Physician, Regional Nurse, and QAPI Committee of any noncompliance to plan. Involvement of Medical Director The Medical Director [MD] as notified about the immediate Jeopardy on 10/13/23. Involvement of QA QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for implementation of process? Administrator and DON. Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of nine residents reviewed for neglect. -The facility staff were aware of the goods and services Resident #1 required per his care plan and orders, and failed to provide them (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff . 2.Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records, dated 10/11/23, from the local hospital revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E: Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on 10/10/23 during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for [AGE] years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details which lead to outcomes. On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 Neglect - The facility failed to ensure a resident was free from neglect by failing to provide services to a resident with Diabetes who required insulin which led to physical harm. The failure resulted in the resident falling and sustaining a serious injury. The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. Identify residents who could be affected: Resident [Resident #1] was resistant to care on admission on 10/10/23. Resident missed one finger stick blood sugar test and one dose of insulin due to resistance to care on 10/10/23. MD was contacted on 10/14/23 to inquire about what next steps we should have taken to intervene with a resident who is resistant to care. MD stated she would have told staff to recheck the blood sugar the next morning if the resident remained combative. All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13. An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day. In-Service Conducted Nurse that was involved in resident's [Resident #1] care and who failed to document the resident's resistance to finger stick and insulin administration was previously counseled for failure to document. Subsequently, on 10/13/12, termination of employment was issued for the same failure to document properly. All staff will receive re-education on Abuse, Mistreatment, and Neglect. Specifically, what constitutes potential neglect. Any staff who are on Leave of Absence or are PRN who have not been able to be contacted will not be allowed to work until such in-services have been completed. An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts. The DON and ADON will be provided with the same In-service education by the Regional Clinical Director on 10/13/23. Implementation Date of Changes In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The Medical Director, was notified about the Immediate Jeopardy on 10/13/23. Involvement of QAPI QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for the implementation of process? Administrator and DON (Director of Nursing). Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one resident (Resident #1) of nine residents reviewed for neglect. -The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1 by not providing him goods and services (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. Findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. Record review of EMS report, dated 10/11/23, revealed in part the following: Date/Time symptom onset: not recorded: Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance . Patient Care Timeline: 10/11/23 at 12:21 AM-Unit notified by dispatch 10/11/23 at 12:21 AM-PSAP call 10/11/23 at 12:21 AM-Dispatch notified 10/11/23 at 12:21 AM-Unit en route 10/11/23 at 12:29 AM-Unit arrived on scene 10/11/23 at 12: 37 AM-Med device 10/11/23 at 12:37 AM- Arrived at patient . Review of Resident #1's medical records, dated 10/11/23, from the local hospital revealed in part the following: Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . -Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s. -Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL. -Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity). Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries: 10/10/23 4:15 PM by RN E: Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time. 10/10/23 8:13 PM by RN E: Called and left message for physician that resident returned to facility with no new orders or changes. 10/10/23 8:25 PM by RN E: Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor. 10/11/23 2:25 AM by LVN C: At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified. Record review of Resident #1's orders, dated October 2023, revealed in part the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite. -HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite. Record review of Resident #1's MAR for October 2023 revealed the following: -Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized . - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered. - HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. - HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered. -Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on 10/10/23 during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons. In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for [AGE] years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. . Documentation: . 5. How well the resident tolerated the procedure. Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. . Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following: Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an): . d. significant change in the resident's physical, emotional/mental condition; . e. refusal of treatment or medications two (2) or more consecutive times; . An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following: Summary of Details which lead to outcomes. On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 Neglect - The facility failed to ensure a resident was free from neglect by failing to provide services to a resident with Diabetes who required insulin which led to physical harm. The failure resulted in the resident falling and sustaining a serious injury. The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. Identify residents who could be affected: Resident [Resident #1] was resistant to care on admission on 10/10/23. Resident missed one finger stick blood sugar test and one dose of insulin due to resistance to care on 10/10/23. MD was contacted on 10/14/23 to inquire about what next steps we should have taken to intervene with a resident who is resistant to care. MD stated she would have told staff to recheck the blood sugar the next morning if the resident remained combative. All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13. An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day. In-Service Conducted Nurse that was involved in resident's [Resident #1] care and who failed to document the resident's resistance to finger stick and insulin administration was previously counseled for failure to document. Subsequently, on 10/13/12, termination of employment was issued for the same failure to document properly. All staff will receive re-education on Abuse, Mistreatment, and Neglect. Specifically, what constitutes potential neglect. Any staff who are on Leave of Absence or are PRN who have not been able to be contacted will not be allowed to work until such in-services have been completed. An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts. The DON and ADON will be provided with the same In-service education by the Regional Clinical Director on 10/13/23. Implementation Date of Changes In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The Medical Director, was notified about the Immediate Jeopardy on 10/13/23. Involvement of QAPI QAPI will review and approve Plan of Removal on 10/13/23. Who is responsible for the implementation of process? Administrator and DON (Director of Nursing). Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #38) of four residents reviewed diagnostic services. The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries: 05/08/23 7:53 AM This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain 05/08/23 8:12 AM Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted 05/08/23 9:38 AM Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. 05/08/23 1:06 PM .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement 05/08/23 1:20 PM Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. 05/08/23 6:40 PM Xray tech arrived and completed xray to R shoulder R hip. Will wait for results 05/09/23 5:56 AM Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. 05/09/23 8:00 AM When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment 05/09/23 12:04 PM Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following: Right Shoulder X-Ray . Impression: The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement . Review of Resident #38's hospital records dated 05/09/23 reflected the following: .Diagnosis Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report. Review of the 24-hour report dated 05/08/23 reflected the following: .[Resident #38] REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow. REMARKS(EVENING) - Results pending Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was. Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following: .1. When test results are reported to the facility, a nurse will first review the results. a. If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure Identifying Situations that Warrant Immediate Notification 1. Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following: The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 5/11/23 was 68. An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required. In-Service conducted RDCS completed in-service with DON/ADON on all education to be provided and the POR. All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures. All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting. All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO are monitoring implementation of Implementation Date of Changes In-servicing was initiated on 5/11/23 and will be completed by 5/11/23 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. Involvement of QA QAPI will review and approve Plan of Removal on 5/11/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing). Monitoring of the facility's implementation of the Plan of Removal revealed the following Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #38) of 17 residents reviewed for labs and diagnostics. The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. Findings included: Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries: 05/08/23 7:53 AM This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain 05/08/23 8:12 AM Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted 05/08/23 9:38 AM Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. 05/08/23 1:06 PM .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement 05/08/23 1:20 PM Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. 05/08/23 6:40 PM Xray tech arrived and completed xray to R shoulder R hip. Will wait for results 05/09/23 5:56 AM Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. 05/09/23 8:00 AM When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment 05/09/23 12:04 PM Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following: Right Shoulder X-Ray . Impression: The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement . Review of Resident #38's hospital records dated 05/09/23 reflected the following: .Diagnosis Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report. Review of the 24-hour report dated 05/08/23 reflected the following: .[Resident #38] REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow. REMARKS(EVENING) - Results pending Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was. Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following: .1. When test results are reported to the facility, a nurse will first review the results. a. If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure Identifying Situations that Warrant Immediate Notification 1. Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following: The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 5/11/23 was 68. An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required. In-Service conducted RDCS completed in-service with DON/ADON on all education to be provided and the POR. All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee. An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance. Implementation DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures. All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting. All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting. DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting. RDCS/RDO are monitoring implementation of Implementation Date of Changes In-servicing was initiated on 5/11/23 and will be completed by 5/11/23 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. Involvement of Medical Director The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. Involvement of QA QAPI will review and approve Plan of Removal on 5/11/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing). Monitoring of the facility's implementation of the Plan of Removal revealed the following Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could place residents at risk of harm and/or serious injury. Findings included: Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date. Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following: Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following: Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following: Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. Review of Resident #1's hospital records dated 02/18/23 reflected the following: Reason for visit: Fall Diagnosis: facial laceration Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy. Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents. An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 5 residents (Resident #1) reviewed for tube feeding. The facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide Resident #1's water flush as ordered by the physician. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalization s. Findings Included: Record review of Resident #1's electronic Facesheet, dated 08/31/22, revealed the resident was admitted to the facility on [DATE] and diagnosed with type 2 diabetes mellitus without complications, encounter for attention to gastrostomy, gastro-[CONDITION(S)] reflux disease without esophagitis, encounter for attention to [CONDITION(S)], and encounter for attention to [CONDITION(S)]. Record review of Resident #1's care plan, dated 08/15/22, revealed the following: Resident #1 had potential for dehydration due to enteral feeding with an intervention to give flushes and fluids through g-tube as ordered per physician; Resident #1 required tube feeding due to dysphagia and [CONDITION(S)] with the intervention to administer tube feeding formula hydration, and flushes per physicians order; and Resident #1 has potential for nutritional and hydration problems due to enteral feeding, NPO status, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] with the interventions to monitor/record/report to MD PRN s/sx of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months and provide enteral feeding with flushes as order per RD recommendations and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's physician order, dated 08/22/22, which was discontinued on 08/23/22, revealed enteral feeding In the evening start continuous enteral feeding. Diabetasource rate @ 60 ml/hr start at 1900 and run until 1728k cals s/d has been delivered. Record review of Resident #1's physician order, dated 08/23/22 revealed enteral feeding two times a day Diabetisource AC at 75 ml/hr x20 hours. Record review of Resident #1's physician order, dated 08/23/22 revealed enteral feeding two times a day continuous water flush 40 ml/hr x20 hours An observation on 08/31/22 at 11:16 AM revealed Resident #1 connected to his g-tube and the pump was set at 60 ml/hr per hour and flush at 50 ml/hr. The feeding bag was labeled with the date of 08/31/22 @ 09:50 AM. An observation on 08/31/22 at 3:23 PM revealed Resident #1 connected to his g-tube and the pump was set at 60 ml/hr per hour and flush at 50 ml/hr. LVN B was in the hall and was asked to come to Resident #1's room. He stated he was the nurse assigned to Resident #1's hall. LVN B stated he was agency and had worked at the facility 2-3 days per week for the last two weeks. LVN B stated he did work on Resident #1's hall on 08/29/22 and 08/30/22 on the overnight shift. He stated the previous week he worked two days, but it was on a different hall. LVN B observed the settings on Resident #1's G-Tube pump and said they were correct. He stated a new feeding bag had been hung today (08/31/22) and there were no new orders for Resident #1, so it was correct. LVN B was asked to check the orders. After he checked the orders, LVN B stated the settings on feeding pump were incorrect and should be at 75 ml/hr and flush at 40 ml/hr. He stated he had worked the past three days and had not received any new orders to change Resident #1's feeding so he assumed it was correct. LVN B stated he doesn't change the settings on the pump unless there are new orders when he changed the tube feeding bag. LVN B went to get the ADON. The ADON stated a new bag had been added this morning (08/31/22) at 9:30 AM, so the morning shift must have set it incorrectly. ADON corrected the settings on the pump to reflect 75 ML/hr and flush as 40 ml/hr. She stated staff would be in-serviced. In a phone interview on 09/01/22 at 9:38 AM, LVN A stated she was an agency worker, and this was her first week at the facility. She stated she had worked the facility a few other times but that was about 2 months ago. LVN A stated she did hang Resident #1's feeding bag on 8/31/22 @ 9:30 AM. She stated she did not check the orders to verify if was g-tube pump was set correctly, nor did she reset the machine. LVN A stated she assumed it was accurate and left it how it was already set because she did not have any new orders to change the feeding amount. She stated she did work the previous day (8/30/22) from 6 AM-2 PM and the night nurse LVN B had just changed the bag, when she started her shift, so she did not check the g-tube settings. An observation on 09/01/22 at 11:05 AM revealed the facility staff weighing Resident #1 via mechanical lift. The resident's weight was 126.4 lbs. A record review of Resident #1's electronic chart revealed he was weighed via mechanical lift on 08/03/22 and his weight was 143.0 Lbs. Resident #1's progress notes dated 08/17/22 revealed on 08/17/22 he was sent to the hospital due to respiratory arrest shortness of breath. A progress note dated 08/22/22, revealed he was readmitted to the facility on [DATE] and the facility physician required all previous orders including all previous home meds to be continued. A record review of Resident #1's hospital discharge paperwork dated 08/22/22 revealed he was weighed on 8/17/22 and weighed 140 pounds. On 8/21/22 his was weighed and his weight was recorded at 140lbs 10.5 Oz. Record review of the State Operations Manuel Appendix PP- Guidance to Surveyors for Long Term Care Facilities revealed the following formula determines percentage of weight loss: % of body weight loss = (usual weight - actual weight) / (usual weight) x 100. Accordingly, the hospital weights compared to Resident #1's current weight revealed: on 08/21/2022, Resident #1 weighed 140.10 lbs. and on 09/01/2022, he weighed 126.4 pounds which is a -9.78 % loss. In applying the formula to the weights taken by the facility revealed the following: on 08/03/2022, the resident weighed 143 lbs. and 09/01/2022, the resident weighed 126.4 pounds which is a -11.61 % loss. The Appendix PP listed significant weight loss as 5% withing 1 month interval and severe weight loss as greater than 5% withing a one-month interval. Thus, Resident #1 was considered severe weight loss. In an interview on 09/01/22 at 11:15 AM, the Regional DON stated she was made aware of Resident #1's g-tube rate being incorrect. She stated she was aware Resident #1 had a significant weight loss, but she could not definitively say his weight loss was due to the error of the g-tube because Resident #1 had been discharged to the hospital and was there for almost a week. The Regional DON stated Resident #1 could have loss weight in the hospital. After the Regional DON was informed that Resident #1's hospital discharge paperwork revealed he was weighed on 08/21/22 and his weight was 140.10, she stated she believed the mechanical lift maybe calibrated incorrectly and she would check other residents who required weights using the mechanical lift. In a follow up interview on 09/01/22 at 12:05 PM, the Regional DON stated they did test the mechanical lift and there were no issues with the other residents, so the lift was calibrated correctly. She stated the error with the g-tube feeding could have contributed to the Resident #1's weight loss. She stated Resident #1's previous orders were 60 ml/hr for feeding and 50 ml/hr for the flush. The Regional DON stated when Resident #1 readmitted from the hospital his old orders were continued but then the RD saw him on 08/23/22 and had the orders changed to add calories. She stated the new orders were placed in Resident #1's electronic chart and was set to start on 08/24/22. The Regional DON stated majority of the staff are agency and believed there was a miscommunication with staff getting the new orders. She stated being that majority of staff are agency, could have also contributed to staff not noticing Resident #1 had loss weight. The Regional DON stated regardless the staff should have been checking the orders when placing a new feeding bag to ensure the feeding pump is set correctly. She stated the risk to the residents are malnourishment and dehydration, which could lead to hospitalization . The Regional DON stated staff had been in-serviced starting yesterday (08/31/22) that they were required to check g-tube orders each time a new feeding bag is hung to verify the settings are correct. She stated a process in which all new orders will be documented on an internal memo and nursing staff will be required to sign at the beginning of their shifts to verify they received notification of new orders had been put into place. The Regional DON stated the ADON and DON had been in-serviced they would be responsible for monitoring that each nurse had received the notifications of new order each shift and also for any new g-tube orders they were required to check the g-tube pumps to ensure they have been changed to the new orders. She stated they have started in-services for all nurses that are currently at the facility and will continue each shift prior to them starting their shift. A record review of the facility's policy titled Enteral Feeding-Safety Precautions, dated November 2018 revealed Purpose: To ensure the safe administration of enteral nutrition. Promoting feed tolerance: 1. Check the enteral nutrition label against the order before administration. Check the following information . f. Method (pump, gravity, syringe); and rate of administration (ml/hour). 2. On the formula label document initials, date and time the formula was hung, and initial that was checked against order.

Based on observation, interview, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of COIVD-19 for 1 of 16 staff reviewed for infection control (CNA C). CNA C had a family member who resided with him showing signs and symptoms of COVID-19. CNA C did report to the faciality of his possible exposure to the virus and was not screened for COVID-19 for 5 days prior to starting his shift. CNA C failed wear proper PPE and perform hand hygiene while working on the warm and cold zones on the same shift. An Immediate Jeopardy (IJ) situation was identified on 01/18/22 at 3:15 pm. While the IJ was removed on 01/19/2022, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failure could affect residents and staff members by placing them at risk for the transmission of COVID-19 and death. Findings included: During an observation on 01/18/22 at 8:48 am revealed CNA C revealed wearing a surgical mask while picking up trays on the cold unit. While going from room to room, CNA C did not sanitize his hands after removing the trays and going to the next resident room. He left the cold zone are and went on the warm zone area with the same surgical mask. He did not don PPE while picking up the trays from the residents on the warm zone. The doors of the residents located on the warm zone, reflected signage that stated all must don gloves, gowns ,N95 and eye protection before entering the room. Observation and interview on 01/18/22 at 10:04 am while walking with the ADM revealed CNA C walking near the facility kitchen with a surgical mask. After communicating to the ADM that surgical mask were not allowed during an outbreak. The ADM asked CNA C to remove the surgical mask and place on an N95 mask. An interview with CNA C on 01/18/22 at 10:29 am revealed he has not worn an N95 mask until requested to change mask by the ADM. He stated he did not want to wear an N95 mask because the masks are hot He had been vaccinated. He stated he was told by the receptionist earlier to remove his surgical mask; however he did not change his mask he stated . He confirmed he did not sanitize hands between picking up trays for the residents. He stated he did not place on full PPE before entering the rooms of residents on the warm zone. He stated his family member lived with him was currently having symptoms of COVID-19 starting on 01/16/22 and he had not informed anyone at the facility. An interview with the Receptionist on 01/18/22 at 10:47 am revealed she had not screened in CNA C, she stated CNA C would arrive to the facility earlier than she arrived at 6am. The screening process was done completely electronically. She asked CNA C at 8:15 am to change his mask to an N95 mask and thought he had. An interview with the ADM on 01/18/22 at 11:06 am after reviewing the electronic screening record for CNA C revealed CNA C had not screened for COVID -19 but once in 5 days( 01/15/22). CNA C was written up and was sent home. Review of CNA C work schedule reveaeled he worked 01/13/22, 01/14/22. 01/15/21, 01/17/22 and 01/18/22. An interview with CNA C at 11:15 am as he exited the facility revealed he had not completed the screening for COVID-19 several days. He stated he had no reason other than he arrived at the facility at 5:45 am and wanted to get straight to work. An interview with the ADM on 01/18/22 at 11:34 am revealed he was not aware CNA C had not been screened for COVID-19 in five days. He expected all staff to be screened prior to entering the facility. He stated the facility staff must wear full PPE when working on the warm zone. The facility policy was to follow the COVID-19 Nursing facility response plan revised 12/31/21 . COVID-19 Response for Nursing Facilities, updated on 12/31/2021 (Version 4.1), states on pg. 18, Actively screen, monitor, and surveil everyone who comes into the NF. Active screening - The CDC and CMS recommend, and the NF COVID-19 Response rules require, NFs screen all staff prior to entering the NF at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat and other symptoms of COVID-19. The ADM was notified of an Immediate Jeopardy (IJ) on 01/18/22 at 3:15 p.m. The ADM was provided with the IJ template on 01/18/22 at 3:30 p.m. The Plan of Removal was accepted on 01/19/22 at 9:30 am and included: Administrator initiated infection control in services for all facility staff on 01/18/22. Inservice includes using the COVID-19 Response for Nursing Facilities Version 4.1, 12/31/21 and the usage of proper PPE, and COVID-19 screening and requirements. Completion date 1/18/22 and any staff that is unavailable will be in serviced prior to working their next shift. All staff members including any contract agency staff members will be screened according to the COVID-19 Response for Nursing Facilities Version 4.1, 12/31/21. Administrator initiated infection control in services for all facility staff on 1/18/22. Inservice includes using the COVID-19 Response for Nursing Facilities Version 4.1, 12/31/21 and the usage of proper PPE, and COVID-19 screening requirements .Completion date 1/18/22 and any staff that is unavailable will be in serviced prior to working their next shift. Administrator/DON/Designee will monitor daily to ensure employees are screened prior to working their shift by pulling and reviewing the employee line listing form the COVID-19 screening advance entry tool used by the facility Administrator-designee will complete QAPI mask monitoring tool daily Any negative outcomes will be reported to QAPI Committee. Infection Preventionist will monitor staff for potential exposure to covid-19 All new hires and agency staff will be in serviced using the COVID-19 Response for Nursing Facilities Version 4.1, 12/31/21 on the usage of proper PPE, and COVID-19 screening and requirements before starting their shift. The Medical Director was notified about the immediate Jeopardy on 1/18/22 at 4:10pm A QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal Monitoring Observation on 01/19/22 revealed all staff in the facility wearing an N95 mask. Staff working on the warm zone and hot zone donned appropriate PPE. Record review revealed the facility had completed education of all staff regarding wearing the proper PPE when working on the warm zone, all staff must wear N95 mask in the facility and all staff must screen for COVID-19 prior to their shift. Record review on 01/19/22 an audit of all staff at the facility revealed all staff have been screened for COVID -19. An interview with CNA E, LVN F, CNA G and LVN H, on 01/19/22 (6am-2pm) revealed they had been educated regarding PPE when working on the warm zone, all staff must wear N95 mask in the facility and all staff must screen for COVID-19 prior to their shift. An interview with CNA K, CNA L and LVN J on 01/19/22 (2pm-10) revealed they had been educated regarding PPE when working on the warm zone, all staff must wear N95 mask in the facility and all staff must screen for COVID-19 prior to their shift. An interview with CNA M, LVN Q, LVN P on 01/19/22 (10pm-6am) revealed they had been educated regarding PPE when working on the warm zone, all staff must wear N95 mask in the facility and all staff must screen for COVID-19 prior to their shift. An interview with the ADM on 01/19/22 at 2:12 pm revealed he had audited all staff to ensure they all had screened prior to their shift for COVID-19. The staff had been educated and all of the staff understand the expectations or wearing N95 masks in the facility. If they saw any staff without the proper mask to contact him. All staff must wear full PPE when working on the warm zones. The ADM was informed the Immediate Jeopardy was removed on 01/19/22 at 2:30 p.m. The facility remained out of compliance at a severity level of the potential for more than minimal harm and a scope isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to 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 in response to a COVID-19 [CONDITION(S)] outbreak for two (Positive Unit and Quarantined Unit) for two halls reviewed for infection control. 1. The facility failed to provide designated staff to provide care for residents positive for COVID-19 and residents quarantined due to exposure. Staff were doffing contaminated PPE in the same area clean PPE was stored. 2. The facility failed to ensure residents on the COVID-19 unit were able to notify staff of their need for assistance and where within line of sight of staff. Call lights were handing from the wall and were not within reach of residents. 3. Facility staff failed to utilize Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. An Immediate Jeopardy was identified on 07/11/20. While the IJ was lowered on 07/15/20, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. The facility was provided the IJ templated on 07/11/20. 4. The facility failed to clean and disinfect the designated COVID-19 unit effectively and regularly 5. The facility failed to document assessments of residents for signs and symptoms of COVID-19 for residents on the positive unit and the quarantine unit. These failures placed residents and staff at risk of exposure to COVID-19, which could result in illness, hospitalization , or even death. Findings included: 1. During an interview and observation on 07/11/20 at 9:00 AM, surveyors were escorted to the COVID-19 designated wing. Upon entry into the COVID-19 unit RN A was at her medication cart. ADON A was observed coming through the plastic barrier which separated the positive residents from the presumptive residents. There were several large fans circulating air in the area. RN A stated this was the presumptive wing and the positive residents were further down the hall. The two sections of the hall were separated by two opaque plastic barriers with zippers down the middle creating an approximately six foot area where clean PPE was stored along with discarded, soiled PPE. RN A stated residents on the presumptive wing had been exposed but had not been tested for COVID-19. RN A stated there were 13 residents on the presumptive wing and four residents on the positive wing. RN A stated she was the nurse assigned for both the positive and presumptive residents. RN A stated she was way behind on getting to each resident. RN A stated she did not have any paperwork to document or monitor signs and symptoms of residents. During an interview on 07/11/20 at 9:10 AM, ADON A stated the facility currently had four residents who were COVID-19 positive and 13 presumptive residents. ADON A stated she was working as the CNA for both positive and presumptive residents today as they did not have enough staff. ADON A stated the DON brought up getting extra staff with the Administrator on [07/08/20]. ADON A stated they don't have enough people and she knew they were behind on what they need to be doing. During a continuous observation on 07/11/20 from 9:25 AM to 10:40 AM of the COVID-19 Positive Unit, it was revealed there were five residents on the positive unit. Residents were lying in bed with their doors open. The air conditioning unit was out on one side of the hallway with the temperature reading 78 degrees Fahrenheit. During this continuous observation, no staff member came to check on the COVID-19 positive residents. There was a sink for handwashing but there was no soap, paper towels, or alcohol-based hand rub available. During an interview on 07/11/20 at 10:30 AM, ADON A stated one of the residents on the positive unit must have returned during the night but there had been four residents on 07/10/20. During an observation on 07/11/20 at 5:58 PM, ADON A was instructed by the Administrator to remove the plastic barriers between the COVID-19 Positive Unit and presumptive unit. ADON A began to remove the barrier when surveyor intervened to stop the removal. During an interview on 07/11/20 at 6:00 PM, the Administrator stated he was going to have the barrier removed so staff could fully see down the hall. Upon further discussion with the surveyors, the Administrator agreed to dedicate a staff member to the COVID-19 Positive Unit. During an interview on 07/11/20 at 6:40 PM, the Administrator stated the DON had said she was tired of fighting these staffing issues. During a continuous observation on 07/12/20 from 2:00 PM to 3:00 PM on the presumptive unit, the plastic barrier separating the positive residents from the presumptive residents was completely unzipped and open. LVN A was present on the hall. The barrier remained unzipped for 20 minutes until the surveyor went through the barrier. During an observation on 07/12/20 at 3:51 PM, no staff were observed on the COVID-19 Positive Unit. Resident #1 could be heard coughing loudly then began to vomit on himself. No staff were able to hear or see Resident #1. Surveyor went to the plastic barrier to alert CNA A. CNA A came to the positive side and assisted Resident #1. During an interview on 07/13/20 at 10:00 AM on the COVID Positive Unit, CNA B stated she did not know if the residents she was working with were COVID -19 positive or just presumptive. CNA B stated she was from a sister facility and had been asked to come work here for a few weeks. CNA B stated no one had oriented her to the residents and she did not have access to any care plans or information on the residents. Review of facility policy Surveillance Plan: Infection Control Surveillance COVID19, revised 06/02/20, reflected: .the facility have separate staffing teams and unit/wings/floor for COVID-19 positive residents and presumptive residents . Resident that is presumptive or COVID-19 positive will immediately be placed in a private room or cohorted with the door closed in the designated area .Actively monitor all residents upon admission and at least three times a day for fever and respiratory symptoms Review of CDC guidance dated 04/30/20, titled Responding to Coronavirus (COVID-19) in Nursing Homes, reflected: .Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit Assign environmental services [EVS] staff to work only on the unit If there are not a sufficient number of EVS staff to dedicate to this unit despite efforts to mitigate staffing shortages, restrict their access to the unit. 2. During a continuous observation on 07/11/2020 between from 9:25 AM to 10:40 AM of the COVID-19 Positive Unit, it was revealed in each resident room the call light was tied up to the wall, out of the residents' reach. The COVID-19 Positive Unit was not visible to staff from the presumptive unit. During an interview on 07/11/20 at 9:55 AM, Resident #1 stated the only time they saw staff was at mealtimes. He stated there was no way to call for help. Resident #1 stated on 07/10/20 he tried to yell for help as his roommate, Resident #2, was falling out of bed. Resident #1 stated he did not know how long he yelled but no one ever came, and he lost his voice for the rest of the day. Resident #1 stated he decided to use his cell phone to call 911 instead and the police department responded. Resident #1 stated a staff member came back to ask why he had called 911 and found Resident #2 dangling halfway out of the bed. During an interview on 07/11/2020 at 10:30 AM, ADON A Resident #1 was able to make his needs known and was cognizant. ADON A stated most of the residents on the positive unit were not able to make their needs known. Review of facility policy titled, Call Light/Bell Response, dated 08/11/13, reflected: .Place call light/bell within patient's reach regardless of patient location such as: in bed, on commode, unaccompanied sitting area . 3. During an observation on 07/12/20 at 11:00 AM, LVN A and CNA A were working on the presumptive unit. LVN A and CNA A were both wearing a surgical type mask underneath the N95 mask. Both staff members were observed going in and out of resident rooms and performing resident care while not properly wearing the N95 mask. During an interview on 07/12/20 at 11:10 AM, LVN A stated they were wearing the surgical mask under the N95 mask because it was more comfortable. LVN A stated no one had trained them to wear it that way. Review of the CDC's document Strategies for Optimizing the Supply of N95 Respirators, updated 06/28/20, revealed N95 respirators are the PPE most often used to control exposures to infections transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use Training employees on the proper use of respirators, including putting on and removing them, limitations on their use, and maintenance is essential for effective use of respiratory protection. HCP should be thoroughly trained before they are fit tested to ensure they are comfortable donning the respirator and know how to conduct a user seal check. HCP should be trained on the respirator they are expecting to use at work. 4. During an interview and observation on 07/11/20 at 9:00 AM, surveyors were escorted to the COVID-19 designated wing. There was a room designated for donning PPE right outside the COVID-19 unit. There were discarded gloves, gowns and masks throughout the room. It was observed in a box containing clean gowns there were discarded, soiled gloves During an interview on 07/11/2020 at 9:10 AM, ADON A stated she did not know when housekeeping cleaned the COVID-19 unit and did not know if it was the same staff member or cart for both presumptive and positive sides. She stated she did not wipe down any common touch areas and asked if that was something staff should have been doing. During a continuous observation on 07/11/2020 between from 9:25 AM to 10:40 AM of the COVID-19 Positive Unit, it was revealed there was discarded PPE (gloves and masks) in the hallway and in resident rooms. There was debris pushed along the hall. There was a spilled liquid at the end of the COVID-Positive hall and a large brown stain on the floor. There was no housekeeping cart on the unit. Just outside the exit to the COVID-19 Positive Unit there were four large cardboard boxes filled with overflowing discarded PPE. Review of CDC guidance Preparing for COVID-19 in Nursing Homes, dated 06/25/20, reflected: Environmental Cleaning and Disinfection: Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment Use an EPA-registered disinfectant from List N on the EPA website to disinfect surfaces that might be contaminated with [CONDITION(S)]-CoV-2. Ensure HCP are appropriately trained on its use. 5. Review of the facility COVID-19 signs and symptoms monitoring sheets on 07/11/20 reflected there were no monitoring sheets for the five residents on the COVID-19 Positive Unit or the 13 residents on the presumptive unit. During an observation on 07/11/20 at 12:45 PM, no signs and symptoms or assessment sheets for residents could be located on the nurse's cart on the presumptive unit or on the treatment cart on the positive unit. During an interview on 07/11/20 at 6:30 PM via telephone, the facility's corporate Chief Nursing Officer stated the facility was monitoring for signs and symptoms and the Administrator would have those forms. The Corporate Nurse stated those forms would not be stored on the COVID-19 Unit or on the Nurse's carts. During an interview on 07/11/2020 at 6:40 PM, the Administrator stated there were no signs and symptoms assessment forms for the COVID-19 Positive Unit and the presumptive unit. The Administrator stated they had been done for the rest of the facility but not for those residents. Review of CDC guidance Preparing for COVID-19 in Nursing Homes, dated 06/25/20, revealed: Actively monitor all residents upon admission and at least daily for fever (T?100.0oF) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0oF might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19 Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any with new symptoms The Administrator was notified on 07/11/20 at 5:19 PM of the Immediate Jeopardy due to the above failures. The IJ template was signed on 07/11/20. The following Plan of Removal was submitted by the Administrator on 07/12/20 at 6:38 PM and accepted by the Survey Team on 07/13/20 at 1:57 PM. The facility's plan of removal was as follows: On 07/11/2020 Administrator and RDO reviewed all current full time and PRN nurses and CNAs. Administrator and RDO assigned dedicated nurses and CNAs for dedicated presumptive and positive areas. The facility administrator/designee will obtain temporary staff from sister facilities and working with local agencies including [company names]. On 07/11/2020 [ADON A] was assigned as dedicated nurse on the COVID Unit for the 2-10 shift. [RN A] was assigned as dedicated nurse on the Presumptive Unit for the 2-10 shift. Beginning today 07/11/2020 there will be a dedicated nurse/staff assigned exclusively to the COVID Unit and to the Presumptive Unit. Dedicated staff will be tracked on the Daily Unit Assignment Form. Administrator validated that all call lights on COVID Unit were untied and attached to the bed and within reach of residents. A dedicated housekeeper and cart have been assigned to the COVID Unit and Presumptive Unit. All staff were given hand sanitizer to be used between each patient by the Administrator. Biohazard waste will be covered with a lid and taken to biohazard storage area every shift by the nursing staff. Consistent surface cleaning and disinfection will occur daily and on a regular basis with a detailed focus on high touch areas to include, but not limited to: toilet flush handles, bed rails, tray tables, call buttons, TV remote, toilet seats, resident chairs, sinks and faucets, light switches, door knobs and levers, floors with immediate removal of debris. Sanitizing will occur on a regular basis and daily, when soiling and spills occur, when a resident is discharged from the facility. Medical Director was notified of immediate jeopardy by the Administrator. In-service education will be completed by the Administrator/designee on Call Light Response Guideline for all staff. In-service education was started on Surveillance Plan COVID-19: Dedicated Staff by the Administrator/designee. The education will continue till 100% of staff is completed. In-service education will be completed by the Administrator/designee on Hand Hygiene Policy and location of extra hand sanitizer for all staff. The housekeeping supervisor and housekeeping staff will be in-serviced on the Surveillance Plan on Dedicated staffing for the COVID and Presumptive Units and Environmental Services Cleaning Procedures for Common Items. In-service education will be provided by the Administrator/designee on bedside water pitcher policy. In-service education will be provided by the Administrator/designee on Personal Protective Equipment Policy. The estimated date that all staff in-services will be completed is 07/13/2020. Monitoring of the facility's Plan of Removal revealed the following: During an interview on 07/13/20 at 2:00 PM, the Administrator stated they were in process of moving presumptive residents to Hall 1 and turning it into a quarantine hall. He stated this would allow for them to keep the positive and presumptive residents separate and ensure staffing was separate. The Administrator stated this would also allow for staff who worked on either hall to fully exit the facility once their shift was complete. During an observation and interview on 07/14/20 at 4:55 AM, all presumptive residents had been moved to hall 1 with appropriate signs posted regarding PPE and directing people to the donning area. Staff were observed attending to resident needs. CNA C stated the facility had been providing in-services on COVID-19, PPE usage and assessments. CNA C stated she was familiar with all 13 residents on the presumptive unit and could identify where to find information if she had questions. During an observation and interview on 07/14/20 at 5:00 AM, LVN B stated she only had three residents on the positive unit. LVN B stated the facility was doing a lot of in-servicing regarding COVID-19 and infection control. LVN B stated she was very familiar with the residents and was conducting assessments on them regularly. LVN B showed the surveyor the signs and symptoms assessment form filled out for the residents on the unit. Further observation of the unit revealed it to be clean with no boxes of discarded PPE stored outside the unit. LVN B stated they had moved the residents to better consolidate the hall and converted a room to the doffing room. Observation of the new doffing room revealed it to be clean with appropriate containers for discarded PPE. During an observation on 07/15/20 at 10:52 AM, staff was observed on the presumptive unit assisting to resident needs. There was a dedicated housekeeper on the unit who was ensuring the common areas were being cleaned. All residents had water within reach. During an observation and interview on 07/15/20 at 11:45 AM, CNA B was observed on the positive unit attending to resident needs. CNA B stated the morning handoff had gone much better today and the night nurse had personally walked her through each resident's needs. Residents were observed to have call lights in reach and had water. Review of in-services dated 07/11/20 through 07/13/20 reflected the facility had conducted training on donning/doffing PPE, proper wear of the N95 mask, hand hygiene, procedures for entering the COVID-19 positive and presumptive units, assessments of presumptive and positive residents, and ensuring residents have access to call lights and water. The Administrator was informed on 07/15/20 at 12:00 PM the Immediate Jeopardy was removed, and that the facility remained out of compliance at severity level of no actual harm but potential for more than minimal harm and a scope of pattern.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (Resident #1) of five residents reviewed for fall incidents. 1. LVN A failed to appropriately assess Resident #1 after the resident sustained [REDACTED]. 2. LVN B failed to conduct a timely assessment of Resident #1 for injury after learning Resident #1 sustained a fall on [DATE]. As a result, Resident #1 experienced a delay in care after suffering a fracture to the left knee from her fall that occurred around 5:00 a.m. on [DATE]. The resident was not taken to the hospital by E[CONDITION] until 10:00 a.m. according to documentation. The failure placed residents at risk of experiencing prolonged incidents of pain, discomfort, and further injury. Findings included: Review of Resident #1's undated face sheet revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's care plan, last revised on 04/03/19, revealed the resident had the potential for falls. The care planned interventions included to follow the facility's fall protocol and to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review of Resident #1's Progress Notes dated [DATE] at 5:00 a.m. revealed Resident #1 had an attended fall with staff members around 4:50 a.m. The progress note documented by LVN A reflected, Upon nursing assessment, resident didn't seem to injure herself at this time, she is able to move extremities normally, vitals taken (blood pressure) 120/71 (pulse) [AGE] (respirations) 18 (temperature) 96 (oxygen saturation level) 98. LVN A also documented, Resident recovered to chair and stable, PCP (Primary Care Physician) and POA (Power of Attorney) made aware, zero new orders, will cont. with extra nursing monitor. Review of Resident #1's Progress Notes dated [DATE] at 10:08 a.m. written by LVN B revealed Resident #1's left knee was swollen. She documented that a report was called in to the doctor, and new orders were received to send to the resident for evaluation and treatment. LVN B documented that the ambulance was called to transport the resident to the hospital, and Resident #1 left facility at 10:00 a.m. LVN B documented the resident's family was notified. Interview with CNA C on [DATE] at 2:38 p.m. revealed Resident #1 was walking from the dining area and she asked Resident #1 to go sit down and pointed back at the table. She stated Resident #1 was agitated because she was ready to eat but the food was not out yet. She stated that the resident fell , so she called LVN A who was washing his hands in the bathroom. She said LVN A looked at the resident and then told her, let's get her up. She did not recall if LVN A assessed Resident #1, and the resident did not express any type of pain; however, she looked really agitated. CNA C revealed they grabbed a chair and sat Resident #1 in the chair. She revealed she was in the middle of her rounds and after they got the resident up, she went back to finish getting the other residents up. CNA C stated the resident had a tendency to fall when she would get mad and the incident happened around 5:45 a.m., which was close to the end of her shift. CNA C stated she could not recall if the facility's phones were working that morning but stated there were always problems with the phones. Review of the statement submitted by CNA C in the facility's investigation synopsis revealed the following: To whom it may concern on the morning of October 2, 2019 patient was walking mad. Turned round(sic), and got on the floor, I called nurse and helped the patient, (Resident #1). Interview with LVN A at 12/12/19 at 8:52 AM revealed he had been employed at the facility for five years and was filling in the night of [DATE] when Resident #1 fell . He stated he did not usually work back in the locked unit where Resident #1 resided. He stated what he knew of the resident was that she would use her walker. He revealed the night he worked on [DATE], they had a lot of residents to get up and there was only him and CNA C that were working. He helped CNA C to get Resident #1 up and to the dining room then he went to the bathroom to wash his hands. He said that CNA C and the resident were behind him. He said that when he came out of the bathroom, CNA C called to him and told him that the resident sat on the floor and he stated that when he saw the resident she was lying on her right side. He said that at the time, the resident had not complained of any pain. He looked at her and asked her if she was alright and said that she was able to move; however, she refused to move and stated that she did not want to get up. He said that he left her sitting in a dining room chair. LVN A revealed that another resident fell by the door and he and CNA C went to assist the resident up, and then another resident fell in the dining room that they had to go assist. LVN A said after getting the other resident up, he went back to Resident #1 and noticed the resident was unable to move her leg or stand. He said the phone was not working but that he called the doctor to get an order for [REDACTED]. There was no additional evidence based on record review and interview that LVN A conducted an initial assessment or re-assessment of the resident. There was also not any indication that LVN A ordered any x-rays, contacted 9-1-1, or the family. He said that he reported the incident to the oncoming nurse, LVN B, and revealed he was still working after the 6 AM - 2 PM nurse came on shift to complete paperwork. He said he was suspended, and he assumed that he was terminated because no one ever called him back regarding the results of the investigation. Review of the statement on submitted by LVN A in the facility's investigation synopsis dated 10/04/19 revealed the following: I (LVN A) the charge nurse working 10-6 shift, the night of 10/02/2019 was called to the dining area (at 5:00 a.m.) by the (CNA C), observed resident (Resident #1) lying on the floor, (CNA C) informed this nurse that resident intentionally spinned(sic) around and consequently sat on the floor on her bottom and to a lying position, assessed zero noted apparent injuries assessed, vitals within normal limits, recovered to dinning(sic) chairs but refused to be assisted back to her room as she kept saying I(sic) didn't wanna get up. Safety measures observed and Resident left in the sitting position in chair and her walker in her front and in a state of comfort. Nursing protocol carried out, this nurse transferred responsibilities and report to oncoming nurse and left the unit. Interview with LVN B on 12/04/19 at 12:42 p.m. revealed when she came onto her shif on [DATE], LVN A advised her there had been a fall sustained by Resident #1. LVN B revealed she did not assess the resident right away when she came on shift because she was getting the report and information from LVN A, She revealed when she assessed Resident #1, the resident's knee was red and Resident #1was swatting at LVN B when she tried to assess her. She revealed she called the ADON and was told to send the resident out at that time. She did not contact the resident's representative because it was on that day that the phones were not working. LVN B also revealed she was written up due to false documentation and said that she did not call the family. LVN B did stated that she used her personal phone to call the physician, E[CONDITION], and the ADON but did not use it to call the family because they did not need to have her personal number. Interview with Resident #1's family member on 12/04/19 at 3:24 p.m. revealed she never received a phone call from the facility that Resident #1 had sustained a fall. She stated that it was 24 hours before she received a call after the resident had been transferred to the hospital. She stated the only call she received was from the local hospital stating that since no one was going to come to the hospital, that they needed a verbal consent over the phone to admit Resident #1. Resident #1's family member stated she was the Power of Attorney for the resident, and the hospital caseworker told her that Resident #1 had admitted to the hospital the day before. She advised that once she learned Resident #1 was in the hospital, she then called the facility and spoke to the Administrator and was told that the nurse for the resident's unit had attempted to call her. She advised the Administrator that no one had tried to contact her based on her phone records and advised the Administrator that she did not receive a call and he needed to verify this information. She revealed that the Administrator called her back and said that the nurse (LVN B) did not call because she did not want to call from her personal phone and did not want the family to have her personal number. She also stated that she was advised the facility phones had not been working for over 24 hours. She also stated there was a video recording of the incident because the Administrator initially advised her that when E[CONDITION] arrived, Resident #1 was still on the floor, but after watching the recording, the Administrator called her back advising her that Resident #1 was sitting up in a chair when E[CONDITION] arrived. Interview with the ADON on 12/04/19 at 4:08 p.m. revealed she did not have any involvement with writing up LVN B for anything and stated that LVN A was terminated pending an internal investigation regarding the incident with Resident #1. The ADON revealed there were issues with his notifications because he did not notify her or the DON. She said he did contact the doctor, but it was after the staff learned that the resident sustained [REDACTED].#1 because the resident could not stand and LVN B did not know what was going on with the resident. She revealed that based on the facility's investigation, LVN A did not properly assess the resident and advised administration that the resident had stumbled. She revealed that LVN A was terminated as a result. Interview with the DON on 12/04/19 at 4:21 p.m. revealed LVN A never showed back up to work pending their investigation, and they attempted to call him to come in and give a statement. She said he refused to come in and did not show back up to work and was termed due to failure to cooperate with an investigation. The DON said she did not receive a call from LVN B and she first learned of the event through the Administrator who contacted her. When asked if she had seen the video of the incident, the DON revealed that she had viewed the video and stated that the resident was coming up the hallway when she fell . She said the resident fell while turning, walking from her room to turn down the hallway that leads to the common area. LVN A sat the resident up into a chair and, kind of looked at the resident's knee but didn't do much else. She revealed that LVN A left the resident in the chair and went to do something else. She revealed that LVN A stated that he assessed Resident #1, but he did not, and they learned that LVN A copy/pasted the resident's vital signs that he had taken earlier that morning while the resident was still in bed. The DON stated that LVN A did not go back to check or assess the resident after he got her up and assisted her to the chair, and that he did not do any evaluations based on the video she watched. She revealed at that time, the business phones were not working, and it was just understood that staff needed to use their personal phones to contact management if an issue occurred with a resident. She stated staff should understood that they were supposed to call families, responsible parties, and the resident's representatives if something occurred with a resident. Based on review of incident reports, the DON stated that LVN A documented the resident's family member was notified at 5:30 p.m.(meant a.m.), and that he notified the DON at 5:40 a.m. During this interview, the DON pulled out her cell phone to check her text messages and revealed LVN A notified her of the incident at 8:20 a.m. She stated she learned later that morning on [DATE] around 11:00 a.m. that the family of the resident had not been notified. The DON revealed that her expectations for staff when a resident sustained [REDACTED]. She also stated that from viewing the video she could tell the resident was in pain because she couldn't really put weight on her knee. The DON advised that LVN B was written up for not calling the family once the injury was identified and the resident was sent to the hospital. Interview with the Administrator on 12/04/19 at 6:44 p.m. revealed the phones were working on [DATE]. He revealed they had an incoming staff phone located on Hall 2 nurses' station and had educated the staff on notifying administration and to call the family. He revealed that was the only phone and that it was far from the secured unit and perhaps that is why it was not utilized by LVN B to contact the family. The Administrator revealed that the video he viewed revealed that CNA C was guiding Resident #1's walker. She put her hand on the front of Resident #1's walker to guide the walker and the resident didn't step. The resident fell . CNA C called LVN A and he came out and saw Resident #1 on the ground and they think LVN A and CNA C asked the resident what happened. He could not confirm because the video did not have any audio. LVN A and CNA C picked Resident #1 up and noticed that the resident couldn't stand. When asked if there was a copy of the video or if the video could be viewed, the Administrator revealed the cameras are on a continuous loop and video footage only goes back seven days and video footage of the incident that occured on [DATE] had not been archived. He stated that during the investigation, according to LVN A, Resident # 1 was not injured. They later determined that he used the same vitals for the fall/pain assessment he completed prior to her falling while Resident #1 was still in bed and that was why he was terminated.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for its 95 residents. 1. The Administrator, Corporate Management Company, President, and CEO failed to ensure supply vendors and the water company were paid. The residents and staff did not have supplies such as incontinence briefs, hand soap, paper towels, and laundry and kitchen chemicals on a consistent basis for the care of the residents. The facility was delinquent with several vendors resulting in a water disconnect notice and cash only payment for the electric company. The facility was out of or in short supply of several items needed for the operation of the facility. 2. The Administrator, Corporate Management Company, President, and CEO failed to ensure sufficient funds were available for staff to cash their payroll checks. The facility failed to have sufficient resources to pay debts for payroll on 10/23/18 and 11/06/18 in a timely manner. Four (09/26/18, 10/09/18, 10/23/18 and 11/06/18) of four payrolls reviewed revealed the facility lacked sufficient financial resources. An Immediate Jeopardy (IJ) was identified on 11/15/18. The Administrator and Vice President of Operations were notified. The IJ was not removed due to the facility failure to submit an acceptable plan of removal. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy. These failures placed the residents at risk for the development of food borne illnesses, infections, alterations in comfort, and not having required staff to provide care for them. Findings included: Observation on 11/06/18 at 2:15 p.m. revealed the public bathroom on Hall 300 and the bathroom by the Administrator's office did not have soap available for hand washing. Observation of facility's housekeeping supply room on 11/07/18 at 12:30 p.m. revealed the facility did not have paper towels or soap. Observation of the facility's housekeeping supply room on 11/15/18 at 2:10 p.m. revealed the facility had one package of toilet paper and two 5-gallon containers of laundry detergent. Interview with Housekeeper Y on 11/08/18 at 8:20 a.m. revealed she had worked in the facility [AGE] years and stated housekeeping had been out of gloves for approximately one month out of the past three months. There were no supplies available to refill the paper towel or soap dispensers. Interviews with the Housekeeping Supervisor on 11/07/18 at 12:10 p.m., 12:30 p.m., and 11/15/18 at 2:00 p.m. revealed he received an order for [REDACTED]. He had not received any supplies such as hand soap, paper towels, or floor cleaner for the last three months. Observation of the medical supply room and interview with ADON E on 11/07/18 at 7:30 a.m. revealed the facility did not receive their order of medical supplies. The Administrator had been notified and told her the supplies were on vendor hold. The facility was out of perineal cleansing wipes and size 3 briefs. Staff were instructed to use larger briefs until the facility received the supplies. Observation of the Hall 300 medication room on 11/07/18 at 1:00 p.m. revealed the soap dispenser was empty. Observation of the [MEDICAL CONDITION] Unit medication room and interview with RN U on 11/07/18 at 1:35 p.m. revealed the sink had no soap, paper towels, or running water. She was hired on 09/18/18 and reported she did not know the last time the water had worked in this medication room. Observation of the Sun Room on 11/07/18 at 1:15 p.m. revealed the hand washing sink did not have paper towels or soap. Observation and interview with LVN R on 11/07/18 at 2:25 p.m. revealed she was passing medications on Hall 300. She entered a resident's restroom to wash her hands. She placed one hand beneath the soap dispenser and pressed the lever to dispense the soap. The dispenser was empty. She walked approximately 70 feet along the hall to a public restroom to wash her hands. There were no paper towels available. She used toilet tissue to dry her hands. She said she had been using the public restroom for hand washing for approximately two weeks. Observation of LVN T on 11/07/18 at 2:35 p.m. on the men's secured unit revealed she went to the sink to wash her hands. She was not able to dry her hands because the paper towel dispenser was empty. Observation of the Westside Spa Room on 11/07/18 at 3:45 p.m. revealed the soap and paper towel dispensers were empty. Observation and interview with RN S on 11/08/18 at 7:40 a.m. and 7:50 a.m. revealed she was passing medications. She did not wash her hands with soap and water. She used hand sanitizer between residents. She said she did not wash her hands because hand washing supplies were not available in most resident rooms. Observation of the women's secure unit on 11/08/18 at 8:45 a.m. revealed the soap and towel dispenser were empty in the dining room area. Observation of the facility's laundry room on 11/07/18 at 2:00 p.m. revealed three containers of chemicals currently in use with hoses attached. The soap container was observed to have approximately 1½-gallon of chemical in a five-gallon drum. Further observation revealed there was no back-up supply of soap observed in the laundry. Interview with Laundry Aide V on 11/07/18 at 2:00 p.m. in the laundry room revealed one dryer had been broken for three months and she had notified maintenance and her supervisor to fix it. She said she had enough chemicals to do laundry for one more day. She said the laundry room heater also did not work last winter and was still unrepaired. Observation of kitchen sanitation supplies on 11/15/18 at 2:35 p.m. revealed a total of ½-gallon of dish machine sanitizer and one dish machine warewashing detergent (Solid Power) unit was in the dish machine. One additional gallon of sanitizer was found in the kitchen chemical storage area. Observation of the kitchen on 11/16/18 at 10:00 a.m. revealed the dish machine was out of dish machine warewashing detergent (Solid Power). The dish machine sanitizer was empty, with one gallon still available in storage. The facility was not able to use the dish machine because they were out of dish soap. Interview with Dietary Aide J on 11/06/18 at 10:15 a.m. regarding supplies for resident dining revealed the facility received deliveries of food on Tuesdays and Fridays. The facility had a new milk supplier who did not provide milk in individual cartons. The milk had to be poured into individual glasses, but the facility did not have enough glasses for all residents to receive milk. Interview with the Speech Therapist on 11/07/18 at 3:00 p.m. revealed she purchased hand soap and disposable dishes for the therapy residents, as well as snacks and various drinks because the facility did not provide these items consistently. She stated the facility kitchen was unable to provide snacks due to budget cuts, and the kitchen staff frequently borrowed from her disposable dishes for use in the kitchen in order to serve the residents. Interviews with the Dietary Manager on 11/08/18 at 11:50 a.m., 11/15/18 at 2:25 p.m., and 11/16/18 at 10:10 a.m. regarding supplies for resident dining revealed the kitchen did not have enough glasses, plates, and bowls to serve the residents. She ordered more a month prior, but still had not received the order. On 11/16/18, the dish machine warewashing detergent (Solid Power) ran out after breakfast. The dish machine was not available for use, and the kitchen would serve lunch on paper and plastic products which they had in stock. Interview with Resident #1 on 11/06/18 at 2:53 p.m. revealed the facility did not always have enough supplies to take care of her, and they did not have enough wash cloths. Interview with Resident #3 on 11/06/18 at 2:30 p.m. revealed the facility did not have enough supplies to care for him. The facility did not always have enough barrier cream and incontinence care briefs for him. Interview with Resident #19 on 11/06/18 at 2:35 p.m. revealed the facility had been out of cereal, milk, bread, and sausage at different times. He said the facility was supposed to have an always available menu but were out of some of the items frequently. Additionally, Resident #19 stated the facility had run out of incontinence briefs in his size for most of a week, and he only got his size two days ago. He said it was uncomfortable for him to have to wear incontinence briefs that were too large. Interview with Resident #31 on 11/09/18 at 10:25 a.m. revealed the facility did not always have enough supplies for her care. The facility did not have enough briefs, wash cloths, towels, or bed linens. The resident stated during meals salt and pepper were not available because the facility did not have any. Interview with Resident #2 on 11/15/18 at 1:55 p.m. revealed towels and bed linens were hard to get and sometimes they use a sheet to dry me. Interview with CNA F on 11/07/18 at 2:16 p.m. revealed staff were instructed to cash their checks at local convenience stores. Multiple convenience stores refused to cash their checks because the checks would bounce (return with an insufficient funds notice). When she tried to cash her paycheck in her bank account, the funds would be held for ten days. The bank had to make sure the facility had the funds to clear the check. Multiple staff had left the facility because they could not cash their paychecks. CNA F reported the facility also had a supply problem that affected the residents. They were not always able to get bed linens, and they would run out of appropriately sized briefs. CNA F stated the facility owed money to multiple vendors. CNA F stated last year residents had to be removed from their beds after vendors arrived to repossess beds, wheelchairs, and oxygen tanks for non-payment. Interview with CNA G on 11/07/18 at 1:49 p.m. regarding employee payroll checks and facility supplies revealed staff could not deposit facility payroll checks in the bank because they would bounce. The bank would show they had a negative balance in their account. In (MONTH) (YEAR), staff went a month before receiving their payroll check that was due every two weeks. They were not paid as scheduled on 07/06/18 and did not receive a full paycheck until 07/17/18. Staff had to take notes to their apartment complexes, because they could not pay their rent. CNA G stated the situation was getting worse. CNA G reported the facility also ran out of supplies needed to provide care to the residents. They would run out of briefs, towels, bed linens, cups and plates. Interview with CNA L on 11/08/18 at 11:15 a.m. regarding employee payroll checks and facility supplies revealed she had problems often with cashing her check and got another job because of the problem. She had to travel a long distance to find a place that would cash her check, and she did not want to deal with the situation any longer. She stayed on at the facility as a PRN staff only and had not worked at the facility in a couple of weeks. She said the facility was frequently short on supplies needed to provide care to the residents including briefs, glasses, and silverware. Interview with CNA M on 11/08/18 at 11:35 a.m. regarding employee payroll checks and facility supplies revealed she quit working at the facility on 10/31/18. She received one paycheck from the facility but had trouble cashing it. She said the facility was always short on supplies needed to provide care to the residents including appropriately sized briefs, bed linens, and towels. Staff had to dry residents with bed sheets because no towels were available. Interview with LVN K on 11/08/18 at 10:20 a.m. revealed the facility did not always have paper towels for hand washing. In regards to payroll checks, LVN K stated when she deposited a payroll check into her bank account, the check would bounce, so she had to cash her checks at a check cashing place for a fee. Interview with Floor Tech B on 11/06/18 at 12:00 p.m. regarding employee payroll checks revealed he had a hard time cashing his payroll checks because his payroll checks had bounced. Interview with LVN C on 11/06/18 at 12:03 p.m. revealed he had been employed at the facility for eight years, and for the past three years employee payroll checks had been a problem. LVN C stated he usually cashed his payroll checks at the convenience store but was no longer able to due to returned checks. He stated he had to pay high check cashing fees to cash his payroll checks from the facility. Interview with LVN P on 11/07/18 at 2:45 p.m. regarding employee payroll checks revealed she had problems cashing her paychecks. She stated it had been a problem for the last three months, and she could not deposit her paycheck in her bank account because the bank would place it on hold for seven days due to a history on non-payment. Interview with LVN O on 11/08/18 at 4:14 p.m. regarding employee payroll checks revealed she had been employed with the facility from (MONTH) (YEAR) to (MONTH) (YEAR). While she was at the facility, she had problems cashing her paychecks because the banks would not accept the checks. She would try to cash her checks at three or four places, but those places would refuse to cash the checks. Interview with the Physical Therapy Director on 11/06/18 at 11:15 a.m. revealed she placed an order for [REDACTED]. In regards to her pay, she stated she had problems with her paycheck being returned for insufficient funds on her first two payroll checks. Interview with the DON on 11/16/18 at 10:05 a.m. revealed she was not aware of any payroll issues. She was responsible for all of the residents in the facility and ensuring they had the clinical supplies they needed. She did not know why the facility ran out of towels and bed linens. She thought it was possibly due to staff throwing them away on accident. Residents would have to miss showers because there were no towels to dry them with. She also did not know why the facility ran out of hand soap, paper towels, and toilet paper. Prior to her hire in (MONTH) (YEAR), the facility ran out of appropriately sized incontinence briefs and perineal cleansing wipes because the vendor had placed their account on hold. She reported it was no longer an issue. She was not aware of any water issues, other than the medication room on the [MEDICAL CONDITION] Unit of the facility not having water. A work order had been placed to fix it. Staff were supposed to use hand sanitizer to clean their hands for hand washing, and if their hands were grossly contaminated, they were supposed to wash them the best they could with water and use hand sanitizer and hand sanitizer wipes. Interview with the Convenience Store Representative on 11/07/18 at 8:35 a.m. revealed he had been in contact with the Regional HR Director at the facility. The facility still owed him money for returned checks and he refused to cash anymore payroll checks for the facility. He spoke to the Regional HR Director and was asked to redeposit the payroll checks that were returned. He had about 30 returned checks. He agreed to redeposit the checks, but the facility still had over $1,050.00 in penalty fees. He had submitted the requested documentation to the facility but was still waiting for payment on the penalty fees. Interview with the Collections Department at a check cashing service on 11/07/18 at 10:40 a.m. revealed the facility owed them $6,566.20 in returned checks fees. The facility paid the balance in a wire transfer on 10/22/18. Review of wire transfer files provided by the facility revealed several transfers to check cashing places for employee payroll checks that did not clear. Facility records showed that on the following dates check cashing places received reimbursement checks due to employee payroll checks being cashed with insufficient funds: 08/09/18 - $1,622.93; 08/09/18 - $8,325.78; 08/15/18 - $2,137.13; 09/12/18 - $74.34; 10/22/18 - $6,566.20 Interview with the Regional HR Director on 11/06/18 at 4:07 p.m. revealed the facility had issues in the past with cashing pay checks. Facility staff had a hard time cashing their checks due to past problems with payments. Facility staff had to travel further away from the facility to find a place that was willing to cash their check. The facility had agreed to reimburse employees if they had to pay excessive fees to cash their checks, but they would not receive the reimbursement until the next paycheck. Interview with the Administrator on 11/06/18 at 1:15 p.m. revealed wire transfers were made to various banks in the past couple of months to cover employee payrolls checks that did not clear and the associated fees. Interview with the Healthcare Cleaning/Sanitizing Supply Representative on 11/08/18 at 2:05 p.m. revealed the facility was on vendor-hold for eight invoices that dated back to (MONTH) (YEAR). Orders would not be filled for the facility until all invoices were paid. Review of order sheets provided by the Housekeeping Director reflected seven orders had been placed for housekeeping supplies from 10/02/18 to 11/07/18, but the supplies were never received. Interview with the Water Company on 11/06/18 at 4:29 p.m. revealed the facility was past due on their bill. The bill was due on 10/15/18. The facility had a history of [REDACTED]. The facility remained on the Disconnect List and had received their last disconnect notice for 10/22/18. The facility was going to receive a certified letter for disconnection on 11/12/18, and 10 days after the notice date, the water would be disconnected. Interview with the Manager at the Water Company on 11/14/18 at 3:35 p.m. revealed they had not issued the letter to disconnect water service to the facility and were giving the facility until Friday, 11/16/18 to make payment. If payment was not received by that date, they would be issuing the notice to the facility on Monday, 11/19/18. She stated she had been in communications with both the facility and the facility's corporate office, but they still had not received any payments this month (November). Review of Facility Water Notice, dated 09/25/18, revealed: .Please contact Customer Service regarding this account. Interview with the Administrator on 11/08/18 at 10:18 a.m. revealed he contacted the water company after receiving notice on 09/25/18. He was told the water bill was due. He was not aware of any disconnection notices. He stated the CEO was responsible for the water bill payment. Interview with the energy company on 11/08/18 at 2:20 p.m. revealed they no longer accepted any payment form other than cash from the facility due to a history of returned payments. Interview with the Vice President of Operations on 11/15/18 at 2:15 p.m. revealed she reported to the management company, and her bosses were the CEO and President of the company. She stated there were no contracts or agreements between the facility and the management company. The management company was responsible for all financial decisions in the facility. She reported the facility was in financial distress because they did a change of ownership in (MONTH) (YEAR). She stated Medicare and Medicaid held the facility's funds for six months, but because of a glitch in the computer system on the Medicare/Medicaid side, they still had not received all funds that were due to them. The management company shared ownership of the facility with an out-of-town hospital; however, the hospital did not make any financial decisions for the facility. Interview with the Hospital CEO, who represented the hospital district that was Owner/Licensee for the facility, on 11/15/18 at 4:30 p.m. revealed they were not part of the governing body for the facility. He did not have anything to do with the operations or management of the facility. Additionally, the Hospital CEO stated he was not aware of any financial issues in the facility. Interviews with the Management Company CEO on 11/15/18 at 4:15 p.m. and 5:10 p.m. revealed he and the President of the management company were the responsible parties for the facility and controlled the financial decisions of the facility. He was involved with the day-to day financial operations of the facility and communicated daily with the Administrator and corporate management staff. Any financial mismanagement by the Administrator, or any other member of management would result in disciplinary action, including possible termination. The Management Company CEO stated employee payroll checks had been an issue in the past, but it was the fault of the bank. He stated the issue had been corrected. Interview with the Management Company President on 11/15/18 at 4:40 p.m. revealed he was aware of the financial issues in the facility. He reported the water bill payments were not made on time, but the bill always got paid. Employee payroll checks had not cleared at their banks because the facility switched banks in (MONTH) (YEAR) and there were some hiccups with the transfer. The banks were placing the employee payroll checks on hold because of the problem, but he did not have any control over the banks. Employees could cash their checks at check cashing facilities, but he did not have control over any fees the employees had to pay. He was not aware of any supply concerns because he said the Administrator had not notified him. Review of the Facility's General Protocol for Ordering Supplies, dated (MONTH) (YEAR), revealed the following: .5. Any issues with order will be called to the supplier and action taken. 6. Any urgent needs - we call supplier for overnight, local sister facility, or use facility debit to acquire. Review of the Job Description for the Administrator provided by the facility reflected: Prepared annual budget with Regional Vice President of Operations or other corporate representative .Provides input to purchasing for all budgeted capital expenditures and purchases above guideline amounts. An Immediate Jeopardy was identified on 11/15/18. The Immediate Jeopardy continued at the time of exit. The Administrator was informed of the Immediate Jeopardy on 11/15/18 at 1:07 p.m. and given the opportunity to provide a Plan of Removal to remove the Immediate Jeopardy. The facility submitted the following Immediate Jeopardy Plan of Removal on 11/15/18. The Plan of Removal reflected the HR Department was notified about the employee payroll checks that were not being cashed by local banks and vendors. If the employees were unable to cash their checks or if a hold was placed on the checks, the information of the employees that had bank accounts information was sent to the corporate HR Department and then to the corporate controller where funds were wired to the employee's personal bank account. The plan reflected the local gas station agreed to cash employee check that did not have bank accounts, and the facility agreed to reimburse for any checks that are not funded in a normal way. In regards to supplies, the Plan of Removal reflected that linen orders were placed on 11/09/18 and partial received today (11/15/18), and monthly orders would be placed for linen. Med orders for supplies were placed and delivered, and these orders include enteral supplies, over-the-counter medications, nursing supplies, incontinence supplies, and orders would continue to be placed at a minimum twice a month. The plan reflected a supply inventory was completed and no issues were identified. The plan further reflected that any supplies that were needed that were not available in the facility may be purchased locally. The facility administrator and/or designee was to request funding of the petty cash card, the dollar amount needed, and for what needed supplies, and the funds would be wired to the petty cash card. At the time of exit on 11/16/18, the Plan of Removal had not been observed to be implemented. The Plan of Removal did not identify the persons responsible for monitoring the effectiveness of the plan and supply levels and availability of funding for day-to-day operation of the facility. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy.

Based on observation, interview, and record review, the governing body failed to implement policies regarding the management and operation of the facility. 1. The corporate management company failed to be actively engaged and involved in the management of the facility, which resulted in the facility being on vendor hold with several supply vendors, being unable to pay utility bills and receiving disconnection notices, and being unable to meet employee payroll needs. 2. The corporate management company failed to ensure the facility was meeting the needs of its residents and staff by not having needed supplies available because of the non- payment of medical, chemical and food supply vendors. An Immediate Jeopardy (IJ) was identified on 11/15/18. The Administrator and Vice President of Operations were notified. The Immediate Jeopardy was not removed due to the facility failure to submit an acceptable plan of removal. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy. These failures placed the residents at risk for the development of food borne illnesses, infections, alterations in comfort, and not having required staff to provide care for them. Findings included: Observation on 11/06/18 at 2:15 p.m. revealed the public bathroom on Hall 300 and the bathroom by the Administrator's office did not have soap available for hand washing. Observation of facility's housekeeping supply room on 11/07/18 at 12:30 p.m. revealed the facility did not have paper towels or soap. Observation of the facility's housekeeping supply room on 11/15/18 at 2:10 p.m. revealed the facility had one package of toilet paper and two 5-gallon containers of laundry detergent. Interview with Housekeeper Y on 11/08/18 at 8:20 a.m. revealed she had worked in the facility [AGE] years and stated housekeeping had been out of gloves for approximately one month out of the past three months. There were no supplies available to refill the paper towel or soap dispensers. Interviews with the Housekeeping Supervisor on 11/07/18 at 12:10 p.m., 12:30 p.m., and 11/15/18 at 2:00 p.m. revealed he received an order for [REDACTED]. He had not received any supplies such as hand soap, paper towels, or floor cleaner for the last three months. Observation of the medical supply room and interview with ADON E on 11/07/18 at 7:30 a.m. revealed the facility did not receive their order of medical supplies. The Administrator had been notified and told her the supplies were on vendor hold. The facility was out of perineal cleansing wipes and size 3 briefs. Staff were instructed to use larger briefs until the facility received the supplies. Observation of the Hall 300 medication room on 11/07/18 at 1:00 p.m. revealed the soap dispenser was empty. Observation of the [MEDICAL CONDITION] Unit medication room and interview with RN U on 11/07/18 at 1:35 p.m. revealed the sink had no soap, paper towels, or running water. She was hired on 09/18/18 and reported she did not know the last time the water had worked in this medication room. Observation of the Sun Room on 11/07/18 at 1:15 p.m. revealed the hand washing sink did not have paper towels or soap. Observation and interview with LVN R on 11/07/18 at 2:25 p.m. revealed she was passing medications on Hall 300. She entered a resident's restroom to wash her hands. She placed one hand beneath the soap dispenser and pressed the lever to dispense the soap. The dispenser was empty. She walked approximately 70 feet along the hall to a public restroom to wash her hands. There were no paper towels available. She used toilet tissue to dry her hands. She said she had been using the public restroom for hand washing for approximately two weeks. Observation of LVN T on 11/07/18 at 2:35 p.m. on the men's secured unit revealed she went to the sink to wash her hands. She was not able to dry her hands because the paper towel dispenser was empty. Observation of the Westside Spa Room on 11/07/18 at 3:45 p.m. revealed the soap and paper towel dispensers were empty. Observation and interview with RN S on 11/08/18 at 7:40 a.m. and 7:50 a.m. revealed she was passing medications. She did not wash her hands with soap and water. She used hand sanitizer between residents. She said she did not wash her hands because hand washing supplies were not available in most resident rooms. Observation of the women's secure unit on 11/08/18 at 8:45 a.m. revealed the soap and towel dispenser were empty in the dining room area. Observation of the facility's laundry room on 11/07/18 at 2:00 p.m. revealed three containers of chemicals currently in use with hoses attached. The soap container was observed to have approximately 1½-gallon of chemical in a five-gallon drum. Further observation revealed there was no back-up supply of soap observed in the laundry. Interview with Laundry Aide V on 11/07/18 at 2:00 p.m. in the laundry room revealed one dryer had been broken for three months and she had notified maintenance and her supervisor to fix it. She said she had enough chemicals to do laundry for one more day. She said the laundry room heater also did not work last winter and was still unrepaired. Observation of kitchen sanitation supplies on 11/15/18 at 2:35 p.m. revealed a total of ½-gallon of dish machine sanitizer and one dish machine warewashing detergent (Solid Power) unit was in the dish machine. One additional gallon of sanitizer was found in the kitchen chemical storage area. Observation of the kitchen on 11/16/18 at 10:00 a.m. revealed the dish machine was out of dish machine warewashing detergent (Solid Power). The dish machine sanitizer was empty, with one gallon still available in storage. The facility was not able to use the dish machine because they were out of dish soap. Interview with Dietary Aide J on 11/06/18 at 10:15 a.m. regarding supplies for resident dining revealed the facility received deliveries of food on Tuesdays and Fridays. The facility had a new milk supplier who did not provide milk in individual cartons. The milk had to be poured into individual glasses, but the facility did not have enough glasses for all residents to receive milk. Interview with the Speech Therapist on 11/07/18 at 3:00 p.m. revealed she purchased hand soap and disposable dishes for the therapy residents, as well as snacks and various drinks because the facility did not provide these items consistently. She stated the facility kitchen was unable to provide snacks due to budget cuts, and the kitchen staff frequently borrowed from her disposable dishes for use in the kitchen in order to serve the residents. Interviews with the Dietary Manager on 11/08/18 at 11:50 a.m., 11/15/18 at 2:25 p.m., and 11/16/18 at 10:10 a.m. regarding supplies for resident dining revealed the kitchen did not have enough glasses, plates, and bowls to serve the residents. She ordered more a month prior, but still had not received the order. On 11/16/18, the dish machine warewashing detergent (Solid Power) ran out after breakfast. The dish machine was not available for use, and the kitchen would serve lunch on paper and plastic products which they had in stock. Interview with Resident #1 on 11/06/18 at 2:53 p.m. revealed the facility did not always have enough supplies to take care of her, and they did not have enough wash cloths. Interview with Resident #3 on 11/06/18 at 2:30 p.m. revealed the facility did not have enough supplies to care for him. The facility did not always have enough barrier cream and incontinence care briefs for him. Interview with Resident #19 on 11/06/18 at 2:35 p.m. revealed the facility had been out of cereal, milk, bread, and sausage at different times. He said the facility was supposed to have an always available menu but were out of some of the items frequently. Additionally, Resident #19 stated the facility had run out of incontinence briefs in his size for most of a week, and he only got his size two days ago. He said it was uncomfortable for him to have to wear incontinence briefs that were too large. Interview with Resident #31 on 11/09/18 at 10:25 a.m. revealed the facility did not always have enough supplies for her care. The facility did not have enough briefs, wash cloths, towels, or bed linens. The resident stated during meals salt and pepper were not available because the facility did not have any. Interview with Resident #2 on 11/15/18 at 1:55 p.m. revealed towels and bed linens were hard to get and sometimes they use a sheet to dry me. Interview with CNA F on 11/07/18 at 2:16 p.m. revealed staff were instructed to cash their checks at local convenience stores. Multiple convenience stores refused to cash their checks because the checks would bounce (return with an insufficient funds notice). When she tried to cash her paycheck in her bank account, the funds would be held for ten days. The bank had to make sure the facility had the funds to clear the check. Multiple staff had left the facility because they could not cash their paychecks. CNA F reported the facility also had a supply problem that affected the residents. They were not always able to get bed linens, and they would run out of appropriately sized briefs. CNA F stated the facility owed money to multiple vendors. CNA F stated last year residents had to be removed from their beds after vendors arrived to repossess beds, wheelchairs, and oxygen tanks for non-payment. Interview with CNA G on 11/07/18 at 1:49 p.m. regarding employee payroll checks and facility supplies revealed staff could not deposit facility payroll checks in the bank because they would bounce. The bank would show they had a negative balance in their account. In (MONTH) (YEAR), staff went a month before receiving their payroll check that was due every two weeks. They were not paid as scheduled on 07/06/18 and did not receive a full paycheck until 07/17/18. Staff had to take notes to their apartment complexes, because they could not pay their rent. CNA G stated the situation was getting worse. CNA G reported the facility also ran out of supplies needed to provide care to the residents. They would run out of briefs, towels, bed linens, cups and plates. Interview with CNA L on 11/08/18 at 11:15 a.m. regarding employee payroll checks and facility supplies revealed she had problems often with cashing her check and got another job because of the problem. She had to travel a long distance to find a place that would cash her check, and she did not want to deal with the situation any longer. She stayed on at the facility as a PRN staff only and had not worked at the facility in a couple of weeks. She said the facility was frequently short on supplies needed to provide care to the residents including briefs, glasses, and silverware. Interview with CNA M on 11/08/18 at 11:35 a.m. regarding employee payroll checks and facility supplies revealed she quit working at the facility on 10/31/18. She received one paycheck from the facility but had trouble cashing it. She said the facility was always short on supplies needed to provide care to the residents including appropriately sized briefs, bed linens, and towels. Staff had to dry residents with bed sheets because no towels were available. Interview with LVN K on 11/08/18 at 10:20 a.m. revealed the facility did not always have paper towels for hand washing. In regards to payroll checks, LVN K stated when she deposited a payroll check into her bank account, the check would bounce, so she had to cash her checks at a check cashing place for a fee. Interview with Floor Tech B on 11/06/18 at 12:00 p.m. regarding employee payroll checks revealed he had a hard time cashing his payroll checks because his payroll checks had bounced. Interview with LVN C on 11/06/18 at 12:03 p.m. revealed he had been employed at the facility for eight years, and for the past three years employee payroll checks had been a problem. LVN C stated he usually cashed his payroll checks at the convenience store but was no longer able to due to returned checks. He stated he had to pay high check cashing fees to cash his payroll checks from the facility. Interview with LVN P on 11/07/18 at 2:45 p.m. regarding employee payroll checks revealed she had problems cashing her paychecks. She stated it had been a problem for the last three months, and she could not deposit her paycheck in her bank account because the bank would place it on hold for seven days due to a history on non-payment. Interview with LVN O on 11/08/18 at 4:14 p.m. regarding employee payroll checks revealed she had been employed with the facility from (MONTH) (YEAR) to (MONTH) (YEAR). While she was at the facility, she had problems cashing her paychecks because the banks would not accept the checks. She would try to cash her checks at three or four places, but those places would refuse to cash the checks. Interview with the Physical Therapy Director on 11/06/18 at 11:15 a.m. revealed she placed an order for [REDACTED]. In regards to her pay, she stated she had problems with her paycheck being returned for insufficient funds on her first two payroll checks. Interview with the DON on 11/16/18 at 10:05 a.m. revealed she was not aware of any payroll issues. She was responsible for all of the residents in the facility and ensuring they had the clinical supplies they needed. She did not know why the facility ran out of towels and bed linens. She thought it was possibly due to staff throwing them away on accident. Residents would have to miss showers because there were no towels to dry them with. She also did not know why the facility ran out of hand soap, paper towels, and toilet paper. Prior to her hire in (MONTH) (YEAR), the facility ran out of appropriately sized incontinence briefs and perineal cleansing wipes because the vendor had placed their account on hold. She reported it was no longer an issue. She was not aware of any water issues, other than the medication room on the [MEDICAL CONDITION] Unit of the facility not having water. A work order had been placed to fix it. Staff were supposed to use hand sanitizer to clean their hands for hand washing, and if their hands were grossly contaminated, they were supposed to wash them the best they could with water and use hand sanitizer and hand sanitizer wipes. Interview with the Convenience Store Representative on 11/07/18 at 8:35 a.m. revealed he had been in contact with the Regional HR Director at the facility. The facility still owed him money for returned checks and he refused to cash anymore payroll checks for the facility. He spoke to the Regional HR Director and was asked to redeposit the payroll checks that were returned. He had about 30 returned checks. He agreed to redeposit the checks, but the facility still had over $1,050.00 in penalty fees. He had submitted the requested documentation to the facility but was still waiting for payment on the penalty fees. Interview with the Collections Department at a check cashing service on 11/07/18 at 10:40 a.m. revealed the facility owed them $6,566.20 in returned checks fees. The facility paid the balance in a wire transfer on 10/22/18. Review of wire transfer files provided by the facility revealed several transfers to check cashing places for employee payroll checks that did not clear. Facility records showed that on the following dates check cashing places received reimbursement checks due to employee payroll checks being cashed with insufficient funds: 08/09/18 - $1,622.93; 08/09/18 - $8,325.78; 08/15/18 - $2,137.13; 09/12/18 - $74.34; 10/22/18 - $6,566.20 Interview with the Regional HR Director on 11/06/18 at 4:07 p.m. revealed the facility had issues in the past with cashing pay checks. Facility staff had a hard time cashing their checks due to past problems with payments. Facility staff had to travel further away from the facility to find a place that was willing to cash their check. The facility had agreed to reimburse employees if they had to pay excessive fees to cash their checks, but they would not receive the reimbursement until the next paycheck. Interview with the Administrator on 11/06/18 at 1:15 p.m. revealed wire transfers were made to various banks in the past couple of months to cover employee payrolls checks that did not clear and the associated fees. Interview with the Healthcare Cleaning/Sanitizing Supply Representative on 11/08/18 at 2:05 p.m. revealed the facility was on vendor-hold for eight invoices that dated back to (MONTH) (YEAR). Orders would not be filled for the facility until all invoices were paid. Review of order sheets provided by the Housekeeping Director reflected seven orders had been placed for housekeeping supplies from 10/02/18 to 11/07/18, but the supplies were never received. Interview with the Water Company on 11/06/18 at 4:29 p.m. revealed the facility was past due on their bill. The bill was due on 10/15/18. The facility had a history of [REDACTED]. The facility remained on the Disconnect List and had received their last disconnect notice for 10/22/18. The facility was going to receive a certified letter for disconnection on 11/12/18, and 10 days after the notice date, the water would be disconnected. Interview with the Manager at the Water Company on 11/14/18 at 3:35 p.m. revealed they had not issued the letter to disconnect water service to the facility and were giving the facility until Friday, 11/16/18 to make payment. If payment was not received by that date, they would be issuing the notice to the facility on Monday, 11/19/18. She stated she had been in communications with both the facility and the facility's corporate office, but they still had not received any payments this month (November). Review of Facility Water Notice, dated 09/25/18, revealed: .Please contact Customer Service regarding this account. Interview with the Administrator on 11/08/18 at 10:18 a.m. revealed he contacted the water company after receiving notice on 09/25/18. He was told the water bill was due. He was not aware of any disconnection notices. He stated the CEO was responsible for the water bill payment. Interview with the energy company on 11/08/18 at 2:20 p.m. revealed they no longer accepted any payment form other than cash from the facility due to a history of returned payments. Interview with the Vice President of Operations on 11/15/18 at 2:15 p.m. revealed she reported to the management company, and her bosses were the CEO and President of the company. She stated there were no contracts or agreements between the facility and the management company. The management company was responsible for all financial decisions in the facility. She reported the facility was in financial distress because they did a change of ownership in (MONTH) (YEAR). She stated Medicare and Medicaid held the facility's funds for six months, but because of a glitch in the computer system on the Medicare/Medicaid side, they still had not received all funds that were due to them. The management company shared ownership of the facility with an out-of-town hospital; however, the hospital did not make any financial decisions for the facility. Interview with the Hospital CEO, who represented the hospital district that was Owner/Licensee for the facility, on 11/15/18 at 4:30 p.m. revealed they were not part of the governing body for the facility. He did not have anything to do with the operations or management of the facility. Additionally, the Hospital CEO stated he was not aware of any financial issues in the facility. Interviews with the Management Company CEO on 11/15/18 at 4:15 p.m. and 5:10 p.m. revealed he and the President of the management company were the responsible parties for the facility and controlled the financial decisions of the facility. He was involved with the day-to day financial operations of the facility and communicated daily with the Administrator and corporate management staff. Any financial mismanagement by the Administrator, or any other member of management would result in disciplinary action, including possible termination. The Management Company CEO stated employee payroll checks had been an issue in the past, but it was the fault of the bank. He stated the issue had been corrected. Interview with the Management Company President on 11/15/18 at 4:40 p.m. revealed he was aware of the financial issues in the facility. He reported the water bill payments were not made on time, but the bill always got paid. Employee payroll checks had not cleared at their banks because the facility switched banks in (MONTH) (YEAR) and there were some hiccups with the transfer. The banks were placing the employee payroll checks on hold because of the problem, but he did not have any control over the banks. Employees could cash their checks at check cashing facilities, but he did not have control over any fees the employees had to pay. He was not aware of any supply concerns because he said the Administrator had not notified him. Review of the Facility's General Protocol for Ordering Supplies, dated (MONTH) (YEAR), revealed the following: .5. Any issues with order will be called to the supplier and action taken. 6. Any urgent needs - we call supplier for overnight, local sister facility, or use facility debit to acquire. Review of the Job Description for the Administrator provided by the facility reflected: Prepared annual budget with Regional Vice President of Operations or other corporate representative .Provides input to purchasing for all budgeted capital expenditures and purchases above guideline amounts. An Immediate Jeopardy was identified on 11/15/18. The Immediate Jeopardy continued at the time of exit. The Administrator was informed of the Immediate Jeopardy on 11/15/18 at 1:07 p.m. and given the opportunity to provide a Plan of Removal to remove the Immediate Jeopardy. The facility submitted the following Immediate Jeopardy Plan of Removal on 11/15/18. The Plan of Removal reflected the HR Department was notified about the employee payroll checks that were not being cashed by local banks and vendors. If the employees were unable to cash their checks or if a hold was placed on the checks, the information of the employees that had bank accounts information was sent to the corporate HR Department and then to the corporate controller where funds were wired to the employee's personal bank account. The plan reflected the local gas station agreed to cash employee check that did not have bank accounts, and the facility agreed to reimburse for any checks that are not funded in a normal way. In regards to supplies, the Plan of Removal reflected that linen orders were placed on 11/09/18 and partial received today (11/15/18), and monthly orders would be placed for linen. Med orders for supplies were placed and delivered, and these orders include enteral supplies, over-the-counter medications, nursing supplies, incontinence supplies, and orders would continue to be placed at a minimum twice a month. The plan reflected a supply inventory was completed and no issues were identified. The plan further reflected that any supplies that were needed that were not available in the facility may be purchased locally. The facility administrator and/or designee was to request funding of the petty cash card, the dollar amount needed, and for what needed supplies, and the funds would be wired to the petty cash card. At the time of exit on 11/16/18, the Plan of Removal had not been observed to be implemented. The Plan of Removal did not identify the persons responsible for monitoring the effectiveness of the plan and supply levels and availability of funding for day-to-day operation of the facility. The facility remains out of compliance at a scope of widespread and severity of Immediate Jeopardy.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented neglect one (Resident #16) of four residents reviewed for elopement and 90 of 92 residents who received meals from the facility's only kitchen. 1. The facility failed to prevent Resident #16 from eloping from the men's secured unit on 06/10/18. The facility was unaware the resident had exited the unit, and as a result, the resident made it 3.7 miles to his family's home before the facility was contacted regarding his whereabouts. An Immediate Jeopardy (IJ) was identified on 07/26/18 at 4:50 p.m. While the Immediate Jeopardy was removed on 07/30/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures have the potential to affect 42 residents on two secured units that were identified as elopement risks and had the potential to result in serious bodily harm, [MEDICATION NAME] physical impairment, or death. 2. The Administrator, Social Worker/AIT, and Maintenance Director failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize dishes and laundry. 3. The Dietary Manager (previous) failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize dishes. The facility's only dish machine required a water temperature of 160 degrees Fahrenheit to wash and a water temperature of 180 degrees Fahrenheit to rinse. The water supplying the dish machine on 07/20/18 was 125 degrees Fahrenheit. On 07/20/18, the dish machine did not have dish detergent available. The facility failed to ensure it maintained water temperatures hot enough to sanitize dishes in the kitchen's only 3-compartment sanitizing sink. The 3-compartment sanitizing sink required a water temperature of 120 degrees Fahrenheit. On 07/20/18, the water temperature for the 3-compartment sink was 90 degrees Fahrenheit. The facility failed to ensure it had sanitizer available for use in the 3-compartment sanitizing sink. On 07/20/18, the sanitizer serving the sink was not functioning due to a faulty supply tube. The facility failed to supply hand soap for the kitchen's only dedicated staff hand-washing sink. On 07/20/18, there was no soap available for use at the kitchen's only staff dedicated hand washing sink. An IJ was identified on 07/20/18 at 1:40 p.m. While the IJ was removed on 7/23/18, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread because the facility was still monitoring the Plan of Removal. These failures placed the 90 residents, who received their meals from the facility's only kitchen, at risk for food contamination and food borne illness. These failures placed all residents in the facility requiring laundry service at risk for obtaining infections requiring contact precautions. Findings included: 1. Review of the facility's policy for Abuse and Neglect, dated (MONTH) (YEAR), revealed the residents had the right to be free from neglect. 2. Review of Resident #16's MDS assessment, dated 06/22/18, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He had severe cognitive impairment and no wandering behaviors identified. Resident #16's care plan revealed the following dates, focus areas, and interventions: Initiated 06/15/18 - Dementia - Interventions included monitoring, documenting and reporting any changes in cognitive function to the physician. Initiated 06/11/18 - Wandering - Interventions included attempting to determine patterns of wandering, maintaining a clutter-free environment, having direct supervision while off of the locked unit and informing staff and volunteers of elopement risk while supervised off of locked unit. There was no care plan nor interventions available for elopement risk while on the secured unit or exit-seeking behaviors. Review of Resident #16's Wandering Risk Assessment, dated 06/08/18, revealed the resident was receiving antipsychotics, antidepressants, and anti-anxiety/hypnotic medications. The assessment did not have selections made for sections involving cognitive orientation, behavior/mood disruptions, diagnosis (which included dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]), or history of wandering. The assessment was signed by LVN I. Review of Resident #16's Progress Notes revealed the following dates and information: 06/08/18 at 6:38 p.m. - ADON M spoke with Resident #16's family and was advised the resident had one-to-one care due to attempt to leave and was advised resident was at risk for elopement. ADON M documented observing the Resident #16 wandering in the hallway, entering other rooms on the hall. ADON M obtained verbal consent to send the resident to the secure unit if resident attempted to elope or entered an occupied room. The resident was redirected and oriented to his room and its amenities. 06/09/18 at 3:10 p.m. - Resident #16 was observed going into another resident's room. He was redirected and assisted back to his room. 06/09/18 at 5:05 p.m. and 06/09/18 at 5:26 p.m. - Resident #16 was transferred from a hall within the facility to the secured unit due to wandering. Documentation revealed he appeared confused and forgetful. The next of kin and physician were notified and a verbal order was received for the transfer for resident safety. 06/10/18 (Sunday) at 6:34 p.m. - Resident #16 was in the dining room with his sister. No wandering, confusion or aggression was noted during the shift. The resident was ambulatory, able to make his needs known, and able to identify his room. The note was signed by LVN N. 06/10/18 at 9:54 p.m. - Resident #16 was identified as being back into the unit. The physician was notified and gave orders for the resident to be on a one-on-one observation. Weekend Supervisor said there was no need for 15-minute checks since resident was on one-on-one observation. The note was signed by LVN N. 06/10/18 at 10:01 p.m. - A note was drafted in the computer system and not entered by LVN I reflecting the resident ate his dinner and went to his room. His sister was visiting at the time. The next piece of information revealed the fire department brought Resident #16 back to the facility. There was no further information available. 06/10/18 at 10:17 p.m. - A note entered by weekend supervisor, RN O, revealed a Code White (missing resident) was announced around 8:30 p.m. over the intercom. The weekend supervisor rushed to the unit and determined Resident #16 was missing. A thorough search was conducted, but the resident could not be found. While searching, RN O got a call the resident was found in town. He then received a second call from a fire officer to confirm Resident #16's identity, and the resident was brought in by the police. The physician emphasized Resident #16 be put on one-on-one watch. Review of Progress Notes dated 06/11/18 at 6:26 a.m. and 06/11/18 at 9:24 p.m. for Resident #26 revealed continuing exit-seeking behaviors, and the resident remained on 15-minute checks. No further elopement attempts were documented. Review of Resident #16's Safety Check Log, dated 06/10/18, revealed 15-minute check documentation for the resident began at 9:15 p.m. on 06/10/18. Interview with Resident #16 on 07/24/18 at 8:45 a.m. revealed he remembered taking a walk outside the facility last month and called a bus to return him to the facility. He said he apparently passed out or something. When asked how he called for a bus to return if he passed out, Resident #16 said he called someone who told him everything he needed to know over the phone. He said he was made to go to the doctor afterwards because he was confused, but he was currently doing better. When asked if he knew where he went, he said he walked down the block to the department store. Resident #16 said he loved living at the facility and played basketball every day for an activity. Interview with the Social Worker/AIT on 07/24/18 at 2:32 p.m. revealed he had received a call one night that Resident #16 was missing. Resident #16 was a new admission and had been moved to the secured unit because they felt it would be better there. The resident had dinner with a family member because they had not seen each other for a while, and afterwards it was noticed the resident was missing. By the time the Social Worker/AIT got the call, Resident #16 was back to his room and had been assessed by the nurse. The Social Worker/AIT said it was his understanding that the police and fire department had found the resident and returned him to the facility. The report did not say how far the resident had gotten from the facility, but the Social Worker/AIT believed he was still in the vicinity of the facility and within primary city limits. The Social Worker/AIT explained the resident was trying to get to a housing area that was approximately two miles from the facility, and located across city lines. The Social Worker/AIT said the facility was only four blocks from the city line. The resident was returned by the police for the facility's city. The Social Worker/AIT said when he got to the facility and was able to interview Resident #16, the resident did not have a recollection of leaving. The resident could only say that he thought he was going to the housing area where his family resided, and he had decided to go home. The Social Worker/AIT said they had not determined which facility door the resident had exited from, but from his survey, believed the resident would have had to exit the back door of the building. The front exit required an automatic handicap button to be pressed in order for the doors to open from the inside, and the back door could be opened easily just by pushing, even if locked. The Social Worker/AIT said the staff who were on duty reported Resident #16 was at dinner, then they passed out snacks and the resident was talking with his family member. They did not notice the resident leaving. They said it was about 8:00 p.m. when he left and around 9:00 p.m. when he returned. The Social Worker/AIT said the staff were in-serviced on monitoring residents and elopement. Though the Social Worker/AIT believed the elopement occurred the day Resident #16 was admitted , he was informed about the resident's admitted and the transferring of rooms and units for the resident. The Social Worker/AIT said Resident #16's care plan should have addressed wandering, elopement, and the resident's monitoring needs. He also said that following the elopement, the CNAs were placed standing in or near the hallway and one in the dining room so the doors could be monitored. Observation of the men's secured unit on 07/25/18 at 10:03 a.m. revealed there were no staff in the hall. LVN B and CNA R were sitting in the nurses' station while CNA A was assisting a resident in the resident's room. Once finished with providing care, CNA A exited the resident's room and took waiting residents outside for a smoke break in the courtyard located off the secured unit's dining area. CNA R remained in the nurses' station. Two visitors were observed on the hallway. A television monitor in the nurse's station showed two views of the secured unit; one view showed the length of the hallway and the other showed a downward angle near the nurses' station in the hallway which was obscured by lines and blurs on the screen. Interview with Weekend Supervisor/RN O on 07/25/18 at 9:20 a.m. revealed he usually sat in the ADON's office or walked around passing supplies but was on the female secured unit when he heard a Code White called on the night of Resident #16's elopement. He said he did not see anyone walking around the halls on that evening. RN O said the code was called just after dinner when it was beginning to get dark. RN O said Resident #16 was confused and was on the secured unit because he wandered. He said he did not know if the resident had exit-seeking behaviors because he was a new admission. He stated he had been told the resident was transferred from one of the regular halls to the secured unit due to wandering and exit-seeking behaviors. RN O said he was aware of how Resident #16 got off the secured unit on that day, but he did assist in the search for the resident. He also said he spoke with the nurse on duty that evening who told him the police had the resident. RN O said he told the nurse to verify that the resident belonged to the facility and to let the police know the facility's address. RN O said he was not aware the resident was gone until he heard the Code White called, and his roll in elopement incidents was to help with the search, inform all of the administrative staff, and to make sure staff gave their statements and received in-services. RN O said he and the DON conducted the in-services together. RN O was able to confirm the staff on duty the evening of the elopement were LVN N, CNA P, and CNA Q. Review of time punch detail reports for RN O dated 06/10/18 revealed RN O clocked in from 8:07 a.m. to 12:02 a.m., and there were no clock out punches made during the shift. Interview with LVN N on 07/25/18 at 1:25 p.m. revealed he was a nurse on the male secure unit. He revealed the elopement incident with Resident #16 occurred on a weekend. He stated the resident had just eaten dinner, someone had visited, and the resident followed the visitor out of the unit. The staff then received a call from the family saying the resident had been found. Though LVN N was not sure, he thought it was a random visitor (not belonging to the resident directly) that Resident #16 followed out of the unit. LVN N said that at the time, he had taken a brief break, about 15 minutes, and had two CNAs on duty trying to help get residents ready for bed. LVN N said there was not a nurse covering for him while he was on break, and the CNAs were already working to get the residents to bed. He said he thought the resident was gone for 45 minutes to one hour. LVN N said the resident was on the secured unit wandering from one resident room to another. LVN N said he worked on double weekends, referring to double shifts. He said it was not standard or procedure to leave a unit without a nurse, and that since the incident he was to leave his keys with the weekend supervisor or someone who could provide coverage during a break. He said he had been trained since the elopement occurred, and that the codes had been changed. He said that though breaks used to be an hour long, they had been reduced to only 30 minutes. LVN N said Resident #16 did not currently try to exit-seek, but did verbalize that he was going home. The staff would redirect him and the resident would go back to his room. Review of time punch detail reports for LVN N dated 06/10/18 revealed LVN N clocked in from 11:47 a.m. to 10:30 p.m., and there were no clock out punches made in the evening. Interview with CNA P on 07/25/18 at 2:00 p.m. revealed at the time of the incident she was just coming back from a break. She said there was only one CNA actively on duty when she got back because the nurse had taken a break as well. She said that at the time, breaks were an hour long so it would often leave one person on the unit for an hour at a time. Once she returned, she and the other CNA were doing care rounds when one of Resident #16's family members called and said the resident was at their home. CNA P said she asked the family how the resident was at their home, but the family did not know. CNA P said she became aware Resident #16 had followed a visitor off the unit because when he returned to the facility, he told numerous staff members, I followed the man out. CNA P said there was a male family member visiting another resident that evening of which she was aware. CNA P said she could not remember if she took her break from 7:00 - 8:00 p.m. or from 8:00 - 9:00 p.m. since those were her usual break times, but she believed she had taken a break from 8:00 - 9:00 p.m. that night because she arrived back to the unit a little before 9:00 p.m. She said the family resided in a housing area previously identified as being over the city line. She was not sure how far away the location was from the facility. The staff called a Code White for a missing resident once they found out he was gone. The police were called and that was how the resident was returned. CNA P said they were not in-serviced after the incident regarding the issue. The nurse assessed the resident that evening, but administration did not come to the facility. CNA P said it had become normal practice to leave the unit without a nurse when working double weekends because breaks were an hour long. The nurse was just coming back to the unit when she received the phone call from the family. CNA P said the resident had been brought to the unit because he was trying to leave from the regular hallway. She said they were never instructed how to properly monitor residents to prevent them from getting out of the secured double doors. Review of time punch detail reports for CNA P dated 06/10/18 revealed CNA P clocked out from 7:12 p.m. to 8:17 p.m. with a final clock out at 10:06 p.m. Interview with LVN I on 07/27/18 at 3:51 p.m. revealed he had been working outside of the men's secured unit the day of the elopement incident with Resident #16. LVN I received the call from the resident's family saying that Resident #16 was with them and transferred the call to LVN N. He received the call after 8:00 p.m. that evening. Review of time punch detail reports for LVN I dated 06/10/18 revealed LVN I clocked out from 9:10 p.m. to 9:45 p.m. with a final clock out at 10:38 p.m. Interview with CNA Q, men's secured unit CNA, on 07/28/18 at 1:28 p.m. revealed he usually worked double shifts on weekends and was working the night Resident #16 eloped. He said the lead CNA and the nurse had taken a lunch break. The nurse, LVN N, took lunch at 7:00 p.m. The other aide took hers at approximately 6:30 p.m. and CNA Q was on the unit alone. Right after dinner, which was served at 5:00 p.m., CNA Q said he began laying residents down. He said he thought it was, roughly, 6:00 p.m. He said he remembered seeing Resident #16 right after dinner, and at the time the resident's room was right by the door. Another resident's family member had come in to visit, and that was the last time he saw Resident #16. CNA Q said he took his lunch break at 8:30 p.m., and when he came back at 9:30 p.m., he was told the police had just returned Resident #16 to the facility. CNA Q said he did not know the resident had eloped. He said he knew the resident had to have left through the secured unit doors because there was an alarm on the fire exit doors on the secured unit, and their courtyard was key coded. CNA Q said someone would have had to let Resident #16 off the secured unit in order for him to leave, but because he was laying residents down for the evening, he was unable to see what time the resident left. CNA Q said it was difficult for all three staff to squeeze in an hour lunch break when working double shifts, so it was normal for the nurse to leave the unit and not have anyone to relieve him on the secured unit. He said after dinner, most everyone would go to bed, so it did not matter that there was not a nurse or possibly only one staff member. He said everyone on the secured unit paced back and forth, and they had cameras that could see what the residents were doing. Many of them would go to bed on their own. However, CNA Q said that out of everyone on the men's secured unit, there were not any residents who would try to go out the door as Resident #16 had. CNA Q said the nurse from the regular hall Resident #16 had transferred from told the staff that she was transferring him to the secured unit because he was exit-seeking, trying to elope, and she could not watch him and do her work as well. Placing him on the secured unit would allow him to walk up and down the halls. CNA Q said people who were actively trying to get out of the doors on the secured unit were usually brought to the nurses' station to be monitored more closely, but Resident #16 would get up and walk around like clockwork. Review of time punch detail reports for CNA Q dated 06/10/18 revealed CNA Q clocked out from 8:33 p.m. to 9:30 p.m. with a final clock out at 10:08 p.m. Interview with the Administrator on 07/25/18 at 2:48 p.m. revealed the facility did not have a policy that dictated required staffing numbers. He stated the facility tried to have enough staff on the secured units to meet the residents' needs, but the staffing was based on the census. He said there should be a nurse on the unit at all times and another nurse should relieve him/her if a break was needed. Interview with Resident #16's family member on 07/25/18 at 3:37 p.m. revealed Resident #16 had previously been in the hospital before being transferred to the facility. The family member said the facility was always supposed to have had the resident in a secured unit, but when he was first admitted they did not, and he was not sure what the miscommunication was about his placement upon admission. He said the resident eloped on a Sunday from the facility. The resident came back to the family's home, which was located over the city line. The family member provided the exact address location for the home where Resident #16 was found. The family member said he was unsure how the resident made it so far as the home was a distance away from the facility. He said it was about 6:00 p.m. when he got the call that Resident #16 was at the house. The family member said he was not at the home when Resident #16 was there, but he instructed the rest of the family to contact 9-1-1 and explain the situation so the resident could be transported back to the facility. He said he was unsure if the facility had been made aware of Resident #16's need for a secured unit upon admission because he was not the one who handled the admission. Interview with LVN S on 07/26/18 at 1:53 p.m. revealed Resident #16 was originally admitted to her hall, but he was exit-seeking so she had to move the resident to the secured unit. She stated the facility did not have a WanderGuard system so residents with exit-seeking behaviors did not reside on the halls outside of the secure units. Interview with CNA R on 07/24/18 at 8:38 a.m. revealed Resident #16 needed to be watched because after lunch he would become exit-seeking, saying that it was time for him to go to work. Then after dinner, he would again go to the door and say that it was time for him to go home. She said Resident #16 could talk about the past but was not able to discuss the present. CNA R stated Resident #16 had not gotten off the secured unit that she was aware of, and she had received training on elopement last month. Follow-up interview with CNA R on 07/26/18 at 8:21 a.m. revealed she had not been given any special instructions for monitoring residents since Resident #16's elopement, of which she had become aware. CNA R said she was only instructed that if someone was missing staff were to take a head count, search everywhere, and inform the charge nurse. CNA R said there should be two people on the unit at all times. She said there used to be times when there was only one staff member on the secured unit, but there now had to be two. She said there needed to be one staff member sitting in the hall and one in the common area. She said if one staff member was in the common room, they watched the station monitor. She said the rule for positioning had been in place even before Resident #16's elopement, and that she had worked in the facility for four years. CNA R said no one instructed the staff to be positioned in the specific areas after Resident #16's elopement. Observation of the men's secured unit on 07/26/18 at 8:18 a.m. revealed one male resident was actively exit-seeking at that time. Resident #17 was attempting to press and open the coded and alarmed door leading off the unit and to the outside grounds of the facility. CNA R was sitting in the nurses' station, LVN B was standing at his medication cart by the nurses' station, and CNA A was around the corner in the kitchen area of the common room. Observation of the men's secured unit on 07/26/18 at 8:30 a.m. revealed LVN B was passing medications in the common area. There was no staff member sitting on or near the hallway. Two staff from outside the unit were observed exiting the unit at that time, and a housekeeping staff member was observed with a cleaning cart at the end of the hall near the unit doors. Interview with CNA A, men's secured unit CNA, on 07/26/18 at 8:37 a.m. revealed the staff was supposed to do 15-minute checks for Resident #16 since his elopement. She said the facility did not give them any instructions for any other exit-seeking residents to prevent elopement. She said the staff always walked the halls and watched the monitors. She said they were supposed to have two aides and a nurse on the hall. She also said the facility did not tell them to be physically posted anywhere specific on the unit, but if they were having problems with a particular resident, they were position themselves within range of the resident. CNA A said she had worked at the facility for four years. CNA A said they monitored Resident #16 now because he would get in moods where he thought he was going to the housing area where his family lived or that he was going to work. She said the staff would watch him on the television monitor. Interview with LVN B, men's unit nurse, on 07/25/18 at 10:05 a.m. revealed Resident #16 required supervision for the secured unit. He initially admitted on one of the hallways in the facility but was moved to the secured unit. LVN B said he was informed that Resident #16 had eloped over the weekend when he first admitted . Since the elopement, Resident #16 would sometimes take his belongings and say he was going to leave, but staff would then redirect him. LVN B said the staff had been in-serviced on counting residents, following the elopement procedures, and laying eyes on the residents. He also said that the staff would tell visitors to watch for residents who were close by the door when exiting to prevent someone from following them out. Follow-up interview with LVN B on 07/26/18 at 8:32 a.m. revealed the facility had given the staff on the men's secured unit no new procedures after Resident #16's elopement. No one had specified that staff should be positioned in specific locations, only that they should be conducting rounds and Resident #16 was to receive 15-minute checks. LVN B said two staff were to be on the unit at all times; however, the rule for two staff being on the unit was not a new procedure. LVN B specified that there was always supposed to be a nurse on the unit, and if he was to take a break, he needed to find another nurse to cover for him. LVN B said there were occasions he could not find another nurse and would have to stay on the unit. LVN B confirmed on 07/26/18 at 12:21 p.m. that Resident #16 did not require any evening medications and received only B12 and Amplodipine in the mornings. Interview with MA T on 07/26/18 at 5:06 p.m. revealed she was the medication aide for the men's secured unit, and she was aware of Resident #16's elopement. She stated she was not told to do anything new with regards to monitoring the resident once he was returned to the facility. MA T said the staff were told to redirect the resident and keep a close eye on him, but were never instructed that one staff had to be positioned on the hall and one needed to be positioned in the common room. MA T said the staff paid more attention to residents who were exit-seeking. If the staff were busy, residents who were exit-seeking would be brought to the nurse so that they could be watched. MA T said two staff should be on duty at all times. Interview with ADON M on 07/26/18 at 5:38 p.m. revealed elopement evaluations were completed on residents who were exit-seeking. She did not recall having an in-service after Resident #16 eloped. Interview with MDS Coordinator U on 07/26/18 at 6:18 p.m. revealed Resident #16 had exit-seeking behaviors, and she thought the resident had a care plan for the secured unit. MDS Coordinator U said the resident should have had supervision as an intervention. Resident #16 also required someone to be with him when coming off of the secured unit. She said the same requirement for monitoring should be in place while on the secured unit as well. MDS Coordinator U said staff needed to keep up with the resident while off of the unit because some of the doors only stayed shut for 15 seconds and then opened, so the resident could be harmed. That was why there were two aides on the unit to keep him from wandering outside and to assist with activities of daily living. MDS Coordinator U said the importance of having an exit-seeking care plan would be for monitoring of Resident #16 on and off the secured unit. Interview with the Medical Director on 07/30/18 at 11:40 a.m. revealed the layout of the facility was not conducive to good monitoring, and he wished the facility had more supervision. The Medical Director said there had been a lot of turnover at the building in the last six months, and it had been a difficult time for the facility. He said that there were a lot of rooms around the secured unit doors and the nurses' stations were far away, so unless the staff were proactive and vigilant, someone could get out the door. Interview with Resident #16's physician, Physician X, on 07/30/18 at 11:52 a.m. revealed Resident #16's real risk was wandering. Physician X said that Resident #16 could not manage his own affairs, and it was apparent to him that the family felt the same if they had called to get the resident returned to the facility. He said as long as Resident #16 was going to show wandering behaviors, he was going to have to be on a secured unit. The only way that could change is if the resident had a significant change in condition that would stop that behavior. Interview with the Administrator on 07/25/18 at 4:47 p.m. revealed there had been no other elopements from the facility since Resident #16's. The facility had put a plan in place once Resident #16 was returned to the facility where one staff member would be assigned to the hallway area and one would be assigned to the common room area. This plan would be in place for both the male and female secured units. The in-service for this plan was done informally and per shift, where each shift was informed only verbally about the incident and what they would be doing going forward. There was no other information that could be provided about this plan, including any written records of training. The Administrator said it was his understanding the fire department or police department had seen Resident #16 walking around, assumed he belonged to the facility, and brought him back. The Administrator said the facility did contact the police but did not believe they obtained a police report number. Telephone interview with the police records department for the city the resident's family resided in revealed two call records dated 06/10/18 at 8:53 p.m. from the family's address. The two calls were made within minutes of one another and there was no police report made. The records department stated that police responded but the fire department took over. Observation of the men's and women's secured unit doors on 07/26/18 at 12:05 p.m. revealed a sign on the door with instructions to make sure the doors were closed completely before walking away. Signs were posted on the inside and outside of th

Based on observation, interview, and record review, the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen which served food to 90 of the facility's 92 residents. 1. The facility failed to ensure it maintained water temperatures hot enough to wash and sanitize dishes, kitchen utensils, and cook ware in the facility's only dish machine. The facility's only dish machine required a water temperature of 160 degrees Fahrenheit to wash and a water temperature of 180 degrees Fahrenheit to rinse. The water supplying the dish machine on 07/20/18 was 125 degrees Fahrenheit. 2. The facility failed to supply dish detergent for the facility's dish machine. On 07/20/18, the dish machine did not have dish detergent available. 3. The facility failed to ensure it maintained water temperatures hot enough to sanitize dishes in the kitchen's only 3-compartment sanitizing sink. The 3-compartment sanitizing sink required a water temperature of 120 degrees Fahrenheit. On 7/20/18, the water temperature for the 3-compartment sink was 90 degrees Fahrenheit. 4. The facility failed to ensure it had sanitizer available for use in the 3-compartment sanitizing sink. On 07/20/18, the sanitizer serving the sink was not functioning due to a faulty supply tube. 5. The facility failed to supply hand soap for the kitchen's only dedicated staff hand-washing sink. On 07/20/18 There was no soap available for use at the kitchen's only staff dedicated hand washing sink. As a result of these failures, residents were put at unnecessary risk for the development of food borne illnesses. An Immediate Jeopardy (IJ) was identified on 07/20/18 at 1:40 p.m. While the IJ was removed on 7/23/18, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread because the facility was still monitoring the Plan of Removal. These failures placed the 90 residents, who received their meals from the facility's only kitchen, at risk for food contamination and food borne illness. Findings included: Observation and interview on 07/20/18 at 9:00 a.m. with Cook C and Cook D revealed the dish machine was not working. Both Cooks stated the kitchen did not have hot water available and the hot water had not been working consistently for over a month. They stated they did not have dish detergent for the dish machine and had stated the issues to the former Dietary Manager. They stated they did not have any way to clean the dishes and the City Fire Marshal had visited the kitchen on 07/19/18 and stated the kitchen equipment was not sanitary to use without proper water temperatures and dish detergent. They stated they were also unable to use their steam table because they did not have supplies to clean it. Observations of the dish machine revealed it was off and dirty dishes were stacked up. The floor was dirty, and the kitchen had multiple flies and gnats on the dishes and flying around. Cook C revealed she had served bacon, toast, and fruit for breakfast the morning of 07/20/18 and had to cook the bacon on a sheet pan that was not properly cleaned. She stated she knew she was not supposed to use cookware that had not been cleaned properly, but felt it was important to have a protein to serve the residents for breakfast. An observation revealed there was a pan in the kitchen with sausage and bacon in it. They both stated the facility's Dietary Manager was released from duty on 07/19/18. Interview with the Administrator on 07/20/18 at 9:15 a.m. revealed the facility's hot water had only been working intermittently for the last several weeks, but he did not know why it had not been fixed. Observation on 07/20/18 at 9:42 a.m. with Resident #15 revealed he was drinking milk from a disposable milk carton and had a banana, toast, and ground bacon for breakfast. The breakfast was served on a disposable plate with disposable utensils but was sitting on a non-disposable serving tray from the kitchen. Interview and observation on 07/20/18 at 9:55 a.m. and 10:30 a.m. with Cook D revealed on 07/19/18 Cook C tried to clean some of the dishes using boiled water. Cook D walked to the dish room and turned on the dish machine. She tested the water temperature and revealed it was only reaching 125 degrees Fahrenheit. She stated she did not know if the dish machine was a high temp or a low temp machine and tested the chlorine level in the dish machine using a chlorine testing the strip. The strip did not show any evidence of chlorine in the water. The water temperature in the 3-compartment sink was tested , and it only reached 90 degrees Fahrenheit. The only available sink dedicated to staff hand washing did not have soap available. Interview with the Administrator on 07/20/18 at 10:40 a.m. revealed the facility would be serving lunch on paper and plastic ware, and he was not aware the kitchen staff did not have hand soap available for use. Observation and interview on 07/20/18 at 11:17 a.m. with Cook [NAME] revealed the dish machine was a high temp machine and the machine had to reach 160 degrees Fahrenheit to wash the dishes effectively. Cook [NAME] tested the water of the dish machine using water temperature testing strips. The bottle indicated the strip color must turn black to show the water was at 160 degrees Fahrenheit. The strip color changed from white to a light gray color. She stated the kitchen's hot water supply had worked on and off for the past several weeks and she was instructed on 07/19/18 to stop using it. Cook [NAME] checked to see if the machine had dish detergent flowing to the dish machine and revealed it did not. Cook [NAME] removed the dish detergent bottle from the dispensing area. The bottle contained a watery, white, chunky fluid. Cook [NAME] stated the kitchen staff had to provide any cleaning materials used in the kitchen from their own money. Observation on 07/20/18 at 11:30 a.m. and 12:00 p.m. revealed kitchen staff were assembling sandwiches and chips for lunch. Gnats and flies were being swatted off the food by kitchen staff. The Administrator and Cook [NAME] brought a linen cart into the kitchen and stated they were going to use it to transport the food to residents. The cart was visibly dirty. Cook [NAME] took the linen cart to the food cart washing area, but could not find soap to clean it with, so she stated they would not be able to use it. Cook [NAME] returned to the food prep area and foil was observed laying on the counter surface. Cook [NAME] stated staff had cleaned the food prep area using germicidal wipes and would be serving lunch using paper and plastic products. Cook [NAME] stated kitchen staff did not start using paper products until after the City Fire Marshal arrived at the facility on 07/19/18. Interview with the DON on 07/20/18 at 1:00 p.m. revealed the plumber was able to repair plumbing for the kitchen and it was expected that the boiler would reach appropriate hot water temperatures by 5:00 p.m. on 07/20/18. She stated she did not know how long the kitchen had been without hot water. Observation and interview on 07/20/18 at 4:10 p.m. and 4:20 p.m. revealed staff were washing dishes in the dish machine. The Service Technician stated he had provided soap for the machine and tested the water temperature. An observation of the water temperature test strip revealed the water was not at 160 degrees Fahrenheit and was a light gray color. He tested the sanitizer used at the 3-compartment sink and found the sanitizing supply tube was not functioning because it had a hole it. He replaced the supply tube and the sanitizer flowed into the 3-compartment sink without difficulty. Interview with the Regional Vice President of Operations on 07/20/18 at 4:58 p.m. revealed she had interviewed kitchen staff and found that the 3-compartment sink had been out since 07/07/18, and the dish machine has been down intermittently since 07/07/18. She stated kitchen staff informed her before 07/20/18 they were using the 3-compartment sink to wash pots and pans, and then running them through the dishwasher. Observation on 07/20/18 at 7:08 p.m. revealed the water temperature of the 3-compartment sink was at 172 degrees Fahrenheit as tested by the Regional Director of Clinical Services. He tested the water temperature of the dish machine and stated it was not maintaining a temperature of 160 degrees Fahrenheit. He looked at the machine and turned a lever on top of the machine. After turning the lever, the water temperature in the dish machine reached 180 degrees Fahrenheit. He stated he did not know when the lever had been turned off and would have to instruct staff not to turn it off. Staff were instructed to re-wash the dishes. Interview and written statement received from the Maintenance Director on 07/20/18 at 8:40 a.m. revealed he was notified on 07/16/18 by the Maintenance Assistant that the boilers behind laundry were not working. He stated the laundry was receiving cold water only and water temperatures in the kitchen would fluctuate. On 07/17/18, he stated two boilers serviced laundry, but only one boiler was needed. He stated he successfully repaired the water issue in the laundry by taking parts from one boiler and adding them to the other boiler. He stated on 07/18/18 the water had to be shut off due to a water leak in the electrical room in the kitchen. He stated he requested funds from the Administrator to fix the problem, and he did not receive approval for the funding. On 07/19/18, the City Fire Marshal inspected the problem and informed them they had to have a plumber pull a city permit to make the repairs. The Maintenance Director stated the Administrator gave him his personal debit card to purchase the needed parts, so they would be on hand when a plumber was hired. The Maintenance Director stated he also purchased paper products for use in the kitchen after the City Fire Marshal inspected the kitchen. The Maintenance Director stated the water remained off to the building on 07/19/18. He stated the morning of 07/20/18, the plumber arrived, reviewed the work that had been completed and checked the kitchen boiler. The boiler and plumbing were turned back on and tested , and no leaks were found. The Maintenance Director stated the Service Technician for the dish machine arrived at the facility to repair the dish machine and found the dish machine had sanitizing tubes that had been cut and no sanitizer was available for the dish machine. The Service Technician told him the dish machine would require a temperature of 160 degrees Fahrenheit to wash dishes. He stated the water temperature to the dish machine was at 180 degrees Fahrenheit. Interview with the Maintenance Assistant on 07/23/18 at 9:40 am revealed he had started employment with the facility four months prior. He stated he was first made aware that the hot water to the kitchen was not working properly on 07/05/18. He stated that sometimes the water to the kitchen was hot, but sometimes it was not. He stated he had notified the Administrator and the Social Worker/AIT, when he identified the issue, and was told to fix it. He stated he tried, but he did not know how so he contacted a plumbing company to check the issue sometime around 07/07/18. He stated the plumber did not know what was wrong and recommended a boiler expert be called. He stated the boiler expert checked the boiler, unknown date, and stated the issue might be a metering valve in the boiler. He stated he told the Administrator and Social Worker/AIT about the results and was instructed to do what he needed to do to fix it. He stated he informed them he did not know how to fix it but did try opening and closing valves on the boiler to get it to work. Interview with the Social Worker/AIT on 07/23/18 at 10:30 a.m. revealed he was also the Administrator In-Training at the facility. He stated on 07/06/18 he was told the hot water in the kitchen was going out and a plumber was called to fix the issue. He stated the previous Dietary Manager informed him the following day that the kitchen had hot water. He stated he was out of the facility 07/09/18 - 07/16/18 and when he returned he was told the 3-compartment sink did not have hot water. On 07/17/18, he stated the Maintenance Director informed him he needed to order a part to fix the plumbing and on 07/19/18 the Dietary Manager informed him that areas of the kitchen still did not have hot water. He stated on 07/19/18, the Maintenance Director got the part to fix the issue but was not able to do the repair because he did not have a city permit to work with the plumbing. He stated he purchased paper products for the kitchen to use on 07/19/18 but was told prior to that the kitchen did not need to use paper products. He revealed the facility had a disaster in plan in place for water issues, but the facility had not followed the disaster plan. Interview with the Former Dietary Manager on 07/23/18 at 11:40 am revealed she first identified issues with the hot water in the kitchen on 06/25/18 and notified both the Administrator and Social Worker/AIT. She stated sometimes the kitchen had hot water and sometimes it did not. She stated she arrived to work early on 07/19/18 and found that the hot water was still not fixed and discussed the issue with the Maintenance Director and was told the part to fix the plumbing had been ordered. She stated she was concerned the residents were going to be sick because they had been eating off dirty dishes for almost 30 days. She stated she told Administration the residents could not keep eating off dirty dishes and the Social Worker purchased paper products for kitchen use. She stated the kitchen was out of dish machine detergent because she had ordered it but received a different product instead of dish detergent and had to return it. She stated she had contacted the Service Technician about the dish machine because it was not functioning well and was told the machine needed to be replaced. She stated she had been purchasing dishwashing soap for the kitchen out of her own pocket and when the City Fire Marshal entered the facility on 07/19/18, he found the facility did not have hot water available. Interview with the Administrator on 07/24/18 at 11:45 a.m. revealed he was first notified about the kitchen hot water issue near the end of (MONTH) (YEAR) or early in (MONTH) (YEAR). He stated sometimes the kitchen had hot water and sometimes it did not, and maintenance would have to adjust it. He stated a plumber was at the facility to fix the plumbing problems on 07/07/18 and 07/12/18 but they were not able to fix the problems. He stated the plumber said he thought the issue at that time was the mixing valve. He stated the kitchen was instructed to use paper products starting on 07/12/18. He stated he was not made aware that the dish machine did not have dish detergent available until the City Fire Marshal arrived on 07/19/18 and stated to him the facility did not have hot water or soap available. He stated he was not aware the sanitizer to the 3-compartment sink was not functioning properly. He stated the facility had a disaster plan to address water issues, but it was not followed because he did not think it had been available for review and was not clearly directed to the staff. Interview with the City Fire Marshal on 07/26/18 at 12:45 p.m. revealed he visited the facility on 07/19/18 after receiving multiple reports that the facility did not have hot water. He stated when he arrived at the facility he found they did not have hot water and did not have dish detergent to clean the dishes. He stated he informed them they would need to use paper products because they did not have soap or hot water to clean their dishes. He stated to make plumbing repairs at the facility, the facility needed a master plumber and a permit from the city. Review of the City Fire Marshal's Report, dated 07/19/18, revealed the facility boiler had worked on and off since (MONTH) (YEAR). There was no hot water available in the kitchen. Review of the Plumber's Report, dated 07/09/18, revealed it was recommended that a boiler company look at the kitchen boiler. Review of the facility's current, undated Specification Information for the dish machine revealed water temperatures had to reach 160 degrees Fahrenheit to wash and 180 degrees Fahrenheit to rinse the dishes. Review of the facility's current Dishwashing Temperature/Sanitizing Log, dated (MONTH) (YEAR), revealed dish machine water temperatures were taken 07/01/18 - 07/18/18 with temperatures ranging from 120 - 125 degrees Fahrenheit. Review of the facility's current, undated Dietary Policy and Procedure Manual revealed all facilities needed to be prepared for interruption of water services and had to keep janitorial supplies on hand. Review of the facility's current Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated (MONTH) (YEAR), revealed employees in the kitchen could not substitute alcohol-based hand rub for hand washing. Review of the U.S. Food Code, dated 2013, revealed the following: Duties. The person in charge shall ensure that: employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, pH, temperature, and exposure time for chemical sanitizing. An Immediate Jeopardy (IJ) was identified on 07/24/18 at 4:00 p.m. The Administrator and DON were notified, and a plan of removal was requested at that time. The plan of removal was accepted on 07/23/18 at 4:40 p.m. and included: Dietary Services: 1. Provided education to staff regarding the 3-compartment sink disinfection process on 07/20/18. 2. The dish machine was repaired by (Service Company) on 07/20/18 at 3:15 p.m. 3. The residents would be served dinner on plastic ware on 07/20/18. 4. Appropriate water temperatures for the dish machine were reached on 07/20/18 at 3:20 p.m. Infection Control: 1. Water temperature checks every 30 minutes. 2. All residents would be assessed for ill effects related to hot water failure. No ill effects were identified. 3. Monitoring to be completed by Quality Assurance daily, monthly, and quarterly starting on 07/20/18. Administration: 1. Education provided to the Administrator regarding facility needs and follow-up. 2. Administrator to review dietary disinfectant system process with the Dietary Manager daily. 3. Every dish was rewashed starting on 07/20/18 at 3:00 p.m. 4. Kitchen staff were instructed to check dish machine water temperatures and document them throughout the cleaning cycle. 5. Kitchen staff were instructed to stop the dish machine if it was out of temperature range and contact Administration. 6. The facility contacted a licensed plumber who arrived at the facility on 07/20/18. 7. The Maintenance Director checked the water temperatures in the kitchen and the water temperatures had been maintained. Interviews were started on 07/24/18 at 10:25 a.m. and continued through 07/24/18 at 1:10 p.m. with 5 staff members. The kitchen staff interviewed were Cooks C, E, F, G, and H. The facility did not have a Dietary Manager. The interviews revealed the kitchen staff had been in-serviced on: 1. Checking water temperatures for the dish machine and 3-compartment sink. 2. Checking the soap dispenser on the soap machine. 3. Checking the sanitizer level in the 3-compartment sink. 4. The procedure to follow if the water temperatures were out of range, the dish detergent or hand soap was not available, and if there were issues with the hot water. Interview with the Administrator on 07/24/18 at 11:45 a.m. revealed going forward a maintenance log would be available in the kitchen to assist in identifying issues and ensuring follow-up on the issues. He stated the kitchen staff had been instructed to notify him if there were any issues in the kitchen because the facility did not have a dietary manager. Review of the facility's accepted Plan of Removal Form, dated 07/20/18, revealed there were two residents who did not receive food from the kitchen. Review of the facility's census dated 07/20/18 revealed there were 92 residents in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for one (Resident #16) of four residents reviewed for elopement and 90 of 92 residents who received meals from the facility's only kitchen. 1. The facility failed to prevent Resident #16 from eloping from the men's secured unit on 06/10/18. The facility was unaware the resident had exited the unit, and as a result, the resident made it 3.7 miles to his family's home before the facility was contacted regarding his whereabouts. An Immediate Jeopardy (IJ) was identified on 07/26/18 at 4:50 p.m. While the Immediate Jeopardy was removed on 07/30/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures have the potential to affect 42 residents on two secured units that were identified as elopement risks and had the potential to result in serious bodily harm, [MEDICATION NAME] physical impairment, or death. 2. The Administrator, Social Worker/AIT, and Maintenance Director failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize dishes and laundry. 3. The Dietary Manager (previous) failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize dishes. The facility's only dish machine required a water temperature of 160 degrees Fahrenheit to wash and a water temperature of 180 degrees Fahrenheit to rinse. The water supplying the dish machine on 07/20/18 was 125 degrees Fahrenheit. On 07/20/18, the dish machine did not have dish detergent available. The facility failed to ensure it maintained water temperatures hot enough to sanitize dishes in the kitchen's only 3-compartment sanitizing sink. The 3-compartment sanitizing sink required a water temperature of 120 degrees Fahrenheit. On 07/20/18, the water temperature for the 3-compartment sink was 90 degrees Fahrenheit. The facility failed to ensure it had sanitizer available for use in the 3-compartment sanitizing sink. On 07/20/18, the sanitizer serving the sink was not functioning due to a faulty supply tube. The facility failed to supply hand soap for the kitchen's only dedicated staff hand-washing sink. On 07/20/18, there was no soap available for use at the kitchen's only staff dedicated hand washing sink. As a result of these failures, residents were put at unnecessary risk for the development of food borne illnesses and infections requiring contact precautions. An IJ was identified on 07/20/18 at 1:40 p.m. While the IJ was removed on 7/23/18, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread because the facility was still monitoring the Plan of Removal. These failures placed the 90 residents, who received their meals from the facility's only kitchen, at risk for food contamination and food borne illness. These failures placed all residents in the facility requiring laundry service at risk for obtaining infections requiring contact precautions. Findings included: 1. Review of Resident #16's MDS assessment, dated 06/22/18, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He had severe cognitive impairment and no wandering behaviors identified. Resident #16's care plan revealed the following dates, focus areas, and interventions: Initiated 06/15/18 - Dementia - Interventions included monitoring, documenting and reporting any changes in cognitive function to the physician. Initiated 06/11/18 - Wandering - Interventions included attempting to determine patterns of wandering, maintaining a clutter-free environment, having direct supervision while off of the locked unit and informing staff and volunteers of elopement risk while supervised off of locked unit. There was no care plan nor interventions available for elopement risk while on the secured unit or exit-seeking behaviors. Review of Resident #16's Wandering Risk Assessment, dated 06/08/18, revealed the resident was receiving antipsychotics, antidepressants, and anti-anxiety/hypnotic medications. The assessment did not have selections made for sections involving cognitive orientation, behavior/mood disruptions, diagnosis (which included dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]), or history of wandering. The assessment was signed by LVN I. Review of Resident #16's Progress Notes revealed the following dates and information: 06/08/18 at 6:38 p.m. - ADON M spoke with Resident #16's family and was advised the resident had one-to-one care due to attempt to leave and was advised resident was at risk for elopement. ADON M documented observing the Resident #16 wandering in the hallway, entering other rooms on the hall. ADON M obtained verbal consent to send the resident to the secure unit if resident attempted to elope or entered an occupied room. The resident was redirected and oriented to his room and its amenities. 06/09/18 at 3:10 p.m. - Resident #16 was observed going into another resident's room. He was redirected and assisted back to his room. 06/09/18 at 5:05 p.m. and 06/09/18 at 5:26 p.m. - Resident #16 was transferred from a hall within the facility to the secured unit due to wandering. Documentation revealed he appeared confused and forgetful. The next of kin and physician were notified and a verbal order was received for the transfer for resident safety. 06/10/18 (Sunday) at 6:34 p.m. - Resident #16 was in the dining room with his sister. No wandering, confusion or aggression was noted during the shift. The resident was ambulatory, able to make his needs known, and able to identify his room. The note was signed by LVN N. 06/10/18 at 9:54 p.m. - Resident #16 was identified as being back into the unit. The physician was notified and gave orders for the resident to be on a one-on-one observation. Weekend Supervisor said there was no need for 15-minute checks since resident was on one-on-one observation. The note was signed by LVN N. 06/10/18 at 10:01 p.m. - A note was drafted in the computer system and not entered by LVN I reflecting the resident ate his dinner and went to his room. His sister was visiting at the time. The next piece of information revealed the fire department brought Resident #16 back to the facility. There was no further information available. 06/10/18 at 10:17 p.m. - A note entered by weekend supervisor, RN O, revealed a Code White (missing resident) was announced around 8:30 p.m. over the intercom. The weekend supervisor rushed to the unit and determined Resident #16 was missing. A thorough search was conducted, but the resident could not be found. While searching, RN O got a call the resident was found in town. He then received a second call from a fire officer to confirm Resident #16's identity, and the resident was brought in by the police. The physician emphasized Resident #16 be put on one-on-one watch. Review of Progress Notes dated 06/11/18 at 6:26 a.m. and 06/11/18 at 9:24 p.m. for Resident #26 revealed continuing exit-seeking behaviors, and the resident remained on 15-minute checks. No further elopement attempts were documented. Review of Resident #16's Safety Check Log, dated 06/10/18, revealed 15-minute check documentation for the resident began at 9:15 p.m. on 06/10/18. Interview with Resident #16 on 07/24/18 at 8:45 a.m. revealed he remembered taking a walk outside the facility last month and called a bus to return him to the facility. He said he apparently passed out or something. When asked how he called for a bus to return if he passed out, Resident #16 said he called someone who told him everything he needed to know over the phone. He said he was made to go to the doctor afterwards because he was confused, but he was currently doing better. When asked if he knew where he went, he said he walked down the block to the department store. Resident #16 said he loved living at the facility and played basketball every day for an activity. Interview with the Social Worker/AIT on 07/24/18 at 2:32 p.m. revealed he had received a call one night that Resident #16 was missing. Resident #16 was a new admission and had been moved to the secured unit because they felt it would be better there. The resident had dinner with a family member because they had not seen each other for a while, and afterwards it was noticed the resident was missing. By the time the Social Worker/AIT got the call, Resident #16 was back to his room and had been assessed by the nurse. The Social Worker/AIT said it was his understanding that the police and fire department had found the resident and returned him to the facility. The report did not say how far the resident had gotten from the facility, but the Social Worker/AIT believed he was still in the vicinity of the facility and within primary city limits. The Social Worker/AIT explained the resident was trying to get to a housing area that was approximately two miles from the facility, and located across city lines. The Social Worker/AIT said the facility was only four blocks from the city line. The resident was returned by the police for the facility's city. The Social Worker/AIT said when he got to the facility and was able to interview Resident #16, the resident did not have a recollection of leaving. The resident could only say that he thought he was going to the housing area where his family resided, and he had decided to go home. The Social Worker/AIT said they had not determined which facility door the resident had exited from, but from his survey, believed the resident would have had to exit the back door of the building. The front exit required an automatic handicap button to be pressed in order for the doors to open from the inside, and the back door could be opened easily just by pushing, even if locked. The Social Worker/AIT said the staff who were on duty reported Resident #16 was at dinner, then they passed out snacks and the resident was talking with his family member. They did not notice the resident leaving. They said it was about 8:00 p.m. when he left and around 9:00 p.m. when he returned. The Social Worker/AIT said the staff were in-serviced on monitoring residents and elopement. Though the Social Worker/AIT believed the elopement occurred the day Resident #16 was admitted , he was informed about the resident's admitted and the transferring of rooms and units for the resident. The Social Worker/AIT said Resident #16's care plan should have addressed wandering, elopement, and the resident's monitoring needs. He also said that following the elopement, the CNAs were placed standing in or near the hallway and one in the dining room so the doors could be monitored. Observation of the men's secured unit on 07/25/18 at 10:03 a.m. revealed there were no staff in the hall. LVN B and CNA R were sitting in the nurses' station while CNA A was assisting a resident in the resident's room. Once finished with providing care, CNA A exited the resident's room and took waiting residents outside for a smoke break in the courtyard located off the secured unit's dining area. CNA R remained in the nurses' station. Two visitors were observed on the hallway. A television monitor in the nurse's station showed two views of the secured unit; one view showed the length of the hallway and the other showed a downward angle near the nurses' station in the hallway which was obscured by lines and blurs on the screen. Interview with Weekend Supervisor/RN O on 07/25/18 at 9:20 a.m. revealed he usually sat in the ADON's office or walked around passing supplies but was on the female secured unit when he heard a Code White called on the night of Resident #16's elopement. He said he did not see anyone walking around the halls on that evening. RN O said the code was called just after dinner when it was beginning to get dark. RN O said Resident #16 was confused and was on the secured unit because he wandered. He said he did not know if the resident had exit-seeking behaviors because he was a new admission. He stated he had been told the resident was transferred from one of the regular halls to the secured unit due to wandering and exit-seeking behaviors. RN O said he was aware of how Resident #16 got off the secured unit on that day, but he did assist in the search for the resident. He also said he spoke with the nurse on duty that evening who told him the police had the resident. RN O said he told the nurse to verify that the resident belonged to the facility and to let the police know the facility's address. RN O said he was not aware the resident was gone until he heard the Code White called, and his roll in elopement incidents was to help with the search, inform all of the administrative staff, and to make sure staff gave their statements and received in-services. RN O said he and the DON conducted the in-services together. RN O was able to confirm the staff on duty the evening of the elopement were LVN N, CNA P, and CNA Q. Review of time punch detail reports for RN O dated 06/10/18 revealed RN O clocked in from 8:07 a.m. to 12:02 a.m., and there were no clock out punches made during the shift. Interview with LVN N on 07/25/18 at 1:25 p.m. revealed he was a nurse on the male secure unit. He revealed the elopement incident with Resident #16 occurred on a weekend. He stated the resident had just eaten dinner, someone had visited, and the resident followed the visitor out of the unit. The staff then received a call from the family saying the resident had been found. Though LVN N was not sure, he thought it was a random visitor (not belonging to the resident directly) that Resident #16 followed out of the unit. LVN N said that at the time, he had taken a brief break, about 15 minutes, and had two CNAs on duty trying to help get residents ready for bed. LVN N said there was not a nurse covering for him while he was on break, and the CNAs were already working to get the residents to bed. He said he thought the resident was gone for 45 minutes to one hour. LVN N said the resident was on the secured unit wandering from one resident room to another. LVN N said he worked on double weekends, referring to double shifts. He said it was not standard or procedure to leave a unit without a nurse, and that since the incident he was to leave his keys with the weekend supervisor or someone who could provide coverage during a break. He said he had been trained since the elopement occurred, and that the codes had been changed. He said that though breaks used to be an hour long, they had been reduced to only 30 minutes. LVN N said Resident #16 did not currently try to exit-seek, but did verbalize that he was going home. The staff would redirect him and the resident would go back to his room. Review of time punch detail reports for LVN N dated 06/10/18 revealed LVN N clocked in from 11:47 a.m. to 10:30 p.m., and there were no clock out punches made in the evening. Interview with CNA P on 07/25/18 at 2:00 p.m. revealed at the time of the incident she was just coming back from a break. She said there was only one CNA actively on duty when she got back because the nurse had taken a break as well. She said that at the time, breaks were an hour long so it would often leave one person on the unit for an hour at a time. Once she returned, she and the other CNA were doing care rounds when one of Resident #16's family members called and said the resident was at their home. CNA P said she asked the family how the resident was at their home, but the family did not know. CNA P said she became aware Resident #16 had followed a visitor off the unit because when he returned to the facility, he told numerous staff members, I followed the man out. CNA P said there was a male family member visiting another resident that evening of which she was aware. CNA P said she could not remember if she took her break from 7:00 - 8:00 p.m. or from 8:00 - 9:00 p.m. since those were her usual break times, but she believed she had taken a break from 8:00 - 9:00 p.m. that night because she arrived back to the unit a little before 9:00 p.m. She said the family resided in a housing area previously identified as being over the city line. She was not sure how far away the location was from the facility. The staff called a Code White for a missing resident once they found out he was gone. The police were called and that was how the resident was returned. CNA P said they were not in-serviced after the incident regarding the issue. The nurse assessed the resident that evening, but administration did not come to the facility. CNA P said it had become normal practice to leave the unit without a nurse when working double weekends because breaks were an hour long. The nurse was just coming back to the unit when she received the phone call from the family. CNA P said the resident had been brought to the unit because he was trying to leave from the regular hallway. She said they were never instructed how to properly monitor residents to prevent them from getting out of the secured double doors. Review of time punch detail reports for CNA P dated 06/10/18 revealed CNA P clocked out from 7:12 p.m. to 8:17 p.m. with a final clock out at 10:06 p.m. Interview with LVN I on 07/27/18 at 3:51 p.m. revealed he had been working outside of the men's secured unit the day of the elopement incident with Resident #16. LVN I received the call from the resident's family saying that Resident #16 was with them and transferred the call to LVN N. He received the call after 8:00 p.m. that evening. Review of time punch detail reports for LVN I dated 06/10/18 revealed LVN I clocked out from 9:10 p.m. to 9:45 p.m. with a final clock out at 10:38 p.m. Interview with CNA Q, men's secured unit CNA, on 07/28/18 at 1:28 p.m. revealed he usually worked double shifts on weekends and was working the night Resident #16 eloped. He said the lead CNA and the nurse had taken a lunch break. The nurse, LVN N, took lunch at 7:00 p.m. The other aide took hers at approximately 6:30 p.m. and CNA Q was on the unit alone. Right after dinner, which was served at 5:00 p.m., CNA Q said he began laying residents down. He said he thought it was, roughly, 6:00 p.m. He said he remembered seeing Resident #16 right after dinner, and at the time the resident's room was right by the door. Another resident's family member had come in to visit, and that was the last time he saw Resident #16. CNA Q said he took his lunch break at 8:30 p.m., and when he came back at 9:30 p.m., he was told the police had just returned Resident #16 to the facility. CNA Q said he did not know the resident had eloped. He said he knew the resident had to have left through the secured unit doors because there was an alarm on the fire exit doors on the secured unit, and their courtyard was key coded. CNA Q said someone would have had to let Resident #16 off the secured unit in order for him to leave, but because he was laying residents down for the evening, he was unable to see what time the resident left. CNA Q said it was difficult for all three staff to squeeze in an hour lunch break when working double shifts, so it was normal for the nurse to leave the unit and not have anyone to relieve him on the secured unit. He said after dinner, most everyone would go to bed, so it did not matter that there was not a nurse or possibly only one staff member. He said everyone on the secured unit paced back and forth, and they had cameras that could see what the residents were doing. Many of them would go to bed on their own. However, CNA Q said that out of everyone on the men's secured unit, there were not any residents who would try to go out the door as Resident #16 had. CNA Q said the nurse from the regular hall Resident #16 had transferred from told the staff that she was transferring him to the secured unit because he was exit-seeking, trying to elope, and she could not watch him and do her work as well. Placing him on the secured unit would allow him to walk up and down the halls. CNA Q said people who were actively trying to get out of the doors on the secured unit were usually brought to the nurses' station to be monitored more closely, but Resident #16 would get up and walk around like clockwork. Review of time punch detail reports for CNA Q dated 06/10/18 revealed CNA Q clocked out from 8:33 p.m. to 9:30 p.m. with a final clock out at 10:08 p.m. Interview with the Administrator on 07/25/18 at 2:48 p.m. revealed the facility did not have a policy that dictated required staffing numbers. He stated the facility tried to have enough staff on the secured units to meet the residents' needs, but the staffing was based on the census. He said there should be a nurse on the unit at all times and another nurse should relieve him/her if a break was needed. Interview with Resident #16's family member on 07/25/18 at 3:37 p.m. revealed Resident #16 had previously been in the hospital before being transferred to the facility. The family member said the facility was always supposed to have had the resident in a secured unit, but when he was first admitted they did not, and he was not sure what the miscommunication was about his placement upon admission. He said the resident eloped on a Sunday from the facility. The resident came back to the family's home, which was located over the city line. The family member provided the exact address location for the home where Resident #16 was found. The family member said he was unsure how the resident made it so far as the home was a distance away from the facility. He said it was about 6:00 p.m. when he got the call that Resident #16 was at the house. The family member said he was not at the home when Resident #16 was there, but he instructed the rest of the family to contact 9-1-1 and explain the situation so the resident could be transported back to the facility. He said he was unsure if the facility had been made aware of Resident #16's need for a secured unit upon admission because he was not the one who handled the admission. Interview with LVN S on 07/26/18 at 1:53 p.m. revealed Resident #16 was originally admitted to her hall, but he was exit-seeking so she had to move the resident to the secured unit. She stated the facility did not have a WanderGuard system so residents with exit-seeking behaviors did not reside on the halls outside of the secure units. Interview with CNA R on 07/24/18 at 8:38 a.m. revealed Resident #16 needed to be watched because after lunch he would become exit-seeking, saying that it was time for him to go to work. Then after dinner, he would again go to the door and say that it was time for him to go home. She said Resident #16 could talk about the past but was not able to discuss the present. CNA R stated Resident #16 had not gotten off the secured unit that she was aware of, and she had received training on elopement last month. Follow-up interview with CNA R on 07/26/18 at 8:21 a.m. revealed she had not been given any special instructions for monitoring residents since Resident #16's elopement, of which she had become aware. CNA R said she was only instructed that if someone was missing staff were to take a head count, search everywhere, and inform the charge nurse. CNA R said there should be two people on the unit at all times. She said there used to be times when there was only one staff member on the secured unit, but there now had to be two. She said there needed to be one staff member sitting in the hall and one in the common area. She said if one staff member was in the common room, they watched the station monitor. She said the rule for positioning had been in place even before Resident #16's elopement, and that she had worked in the facility for four years. CNA R said no one instructed the staff to be positioned in the specific areas after Resident #16's elopement. Observation of the men's secured unit on 07/26/18 at 8:18 a.m. revealed one male resident was actively exit-seeking at that time. Resident #17 was attempting to press and open the coded and alarmed door leading off the unit and to the outside grounds of the facility. CNA R was sitting in the nurses' station, LVN B was standing at his medication cart by the nurses' station, and CNA A was around the corner in the kitchen area of the common room. Observation of the men's secured unit on 07/26/18 at 8:30 a.m. revealed LVN B was passing medications in the common area. There was no staff member sitting on or near the hallway. Two staff from outside the unit were observed exiting the unit at that time, and a housekeeping staff member was observed with a cleaning cart at the end of the hall near the unit doors. Interview with CNA A, men's secured unit CNA, on 07/26/18 at 8:37 a.m. revealed the staff was supposed to do 15-minute checks for Resident #16 since his elopement. She said the facility did not give them any instructions for any other exit-seeking residents to prevent elopement. She said the staff always walked the halls and watched the monitors. She said they were supposed to have two aides and a nurse on the hall. She also said the facility did not tell them to be physically posted anywhere specific on the unit, but if they were having problems with a particular resident, they were position themselves within range of the resident. CNA A said she had worked at the facility for four years. CNA A said they monitored Resident #16 now because he would get in moods where he thought he was going to the housing area where his family lived or that he was going to work. She said the staff would watch him on the television monitor. Interview with LVN B, men's unit nurse, on 07/25/18 at 10:05 a.m. revealed Resident #16 required supervision for the secured unit. He initially admitted on one of the hallways in the facility but was moved to the secured unit. LVN B said he was informed that Resident #16 had eloped over the weekend when he first admitted . Since the elopement, Resident #16 would sometimes take his belongings and say he was going to leave, but staff would then redirect him. LVN B said the staff had been in-serviced on counting residents, following the elopement procedures, and laying eyes on the residents. He also said that the staff would tell visitors to watch for residents who were close by the door when exiting to prevent someone from following them out. Follow-up interview with LVN B on 07/26/18 at 8:32 a.m. revealed the facility had given the staff on the men's secured unit no new procedures after Resident #16's elopement. No one had specified that staff should be positioned in specific locations, only that they should be conducting rounds and Resident #16 was to receive 15-minute checks. LVN B said two staff were to be on the unit at all times; however, the rule for two staff being on the unit was not a new procedure. LVN B specified that there was always supposed to be a nurse on the unit, and if he was to take a break, he needed to find another nurse to cover for him. LVN B said there were occasions he could not find another nurse and would have to stay on the unit. LVN B confirmed on 07/26/18 at 12:21 p.m. that Resident #16 did not require any evening medications and received only B12 and Amplodipine in the mornings. Interview with MA T on 07/26/18 at 5:06 p.m. revealed she was the medication aide for the men's secured unit, and she was aware of Resident #16's elopement. She stated she was not told to do anything new with regards to monitoring the resident once he was returned to the facility. MA T said the staff were told to redirect the resident and keep a close eye on him, but were never instructed that one staff had to be positioned on the hall and one needed to be positioned in the common room. MA T said the staff paid more attention to residents who were exit-seeking. If the staff were busy, residents who were exit-seeking would be brought to the nurse so that they could be watched. MA T said two staff should be on duty at all times. Interview with ADON M on 07/26/18 at 5:38 p.m. revealed elopement evaluations were completed on residents who were exit-seeking. She did not recall having an in-service after Resident #16 eloped. Interview with MDS Coordinator U on 07/26/18 at 6:18 p.m. revealed Resident #16 had exit-seeking behaviors, and she thought the resident had a care plan for the secured unit. MDS Coordinator U said the resident should have had supervision as an intervention. Resident #16 also required someone to be with him when coming off of the secured unit. She said the same requirement for monitoring should be in place while on the secured unit as well. MDS Coordinator U said staff needed to keep up with the resident while off of the unit because some of the doors only stayed shut for 15 seconds and then opened, so the resident could be harmed. That was why there were two aides on the unit to keep him from wandering outside and to assist with activities of daily living. MDS Coordinator U said the importance of having an exit-seeking care plan would be for monitoring of Resident #16 on and off the secured unit. Interview with the Medical Director on 07/30/18 at 11:40 a.m. revealed the layout of the facility was not conducive to good monitoring, and he wished the facility had more supervision. The Medical Director said there had been a lot of turnover at the building in the last six months, and it had been a difficult time for the facility. He said that there were a lot of rooms around the secured unit doors and the nurses' stations were far away, so unless the staff were proactive and vigilant, someone could get out the door. Interview with Resident #16's physician, Physician X, on 07/30/18 at 11:52 a.m. revealed Resident #16's real risk was wandering. Physician X said that Resident #16 could not manage his own affairs, and it was apparent to him that the family felt the same if they had called to get the resident returned to the facility. He said as long as Resident #16 was going to show wandering behaviors, he was going to have to be on a secured unit. The only way that could change is if the resident had a significant change in condition that would stop that behavior. Interview with the Administrator on 07/25/18 at 4:47 p.m. revealed there had been no other elopements from the facility since Resident #16's. The facility had put a plan in place once Resident #16 was returned to the facility where one staff member would be assigned to the hallway area and one would be assigned to the common room area. This plan would be in place for both the male and female secured units. The in-service for this plan was done informally and per shift, where each shift was informed only verbally about the incident and what they would be doing going forward. There was no other information that could be provided about this plan, including any written records of training. The Administrator said it was his understanding the fire department or police department had seen Resident #16 walking around, assumed he belonged to the facility, and brought him back. The Administrator said the facility did contact the police but did not believe they obtained a police report number. Telephone interview with the police records department for the city the resident's family resided in revealed two call records dated 06/10/18 at 8:53 p.m. from the family's address. The two calls were made within minutes of one another and there was no police report made. The records department stated that police responded but the fire department took over. Observation of the men's and women's secured unit doors on 07/26/18 at 12:05 p.m. revealed a sign on the door with instructions to make sure the doors were closed completely before walking away. Signs were posted on the inside and outside of the doors. Sign

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 90 of 92 residents who received food from the facility's only kitchen. 1. The Administrator, Social Worker/AIT, and Maintenance Director failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize dishes and laundry. 2. The Dietary Manager (previous) failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize dishes. The facility's only dish machine required a water temperature of 160 degrees Fahrenheit to wash and a water temperature of 180 degrees Fahrenheit to rinse. The water supplying the dish machine on 07/20/18 was 125 degrees Fahrenheit. On 07/20/18, the dish machine did not have dish detergent available. The facility failed to ensure it maintained water temperatures hot enough to sanitize dishes in the kitchen's only 3-compartment sanitizing sink. The 3-compartment sanitizing sink required a water temperature of 120 degrees Fahrenheit. On 7/20/18, the water temperature for the 3-compartment sink was 90 degrees Fahrenheit. The facility failed to ensure it had sanitizer available for use in the 3-compartment sanitizing sink. On 07/20/18, the sanitizer serving the sink was not functioning due to a faulty supply tube. The facility failed to supply hand soap for the kitchen's only dedicated staff hand-washing sink. On 07/20/18, there was no soap available for use at the kitchen's only staff dedicated hand washing sink. 4. The Laundry Supervisor failed to implement facility policies, procedures, and disaster plans when the facility developed problems maintaining water temperatures hot enough to wash and sanitize laundry. Resident #17 was in contact isolation with ESBL (bacterial infection in urine requiring contact isolation) and the resident's clothes were not always washed according to policy and manufacture recommendation. As a result of these failures, residents were put at unnecessary risk for the development of food borne illnesses and infections requiring contact precautions. An Immediate Jeopardy (IJ) was identified on 07/20/18 at 1:40 p.m. While the IJ was removed on 7/23/18, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread because the facility was still monitoring the Plan of Removal. These failures placed the 90 residents, who received their meals from the facility's only kitchen, at risk for food contamination and food borne illness. These failures placed all residents in the facility requiring laundry service at risk for obtaining infections requiring contact precautions. Findings included: 1. Observation and interview on 07/20/18 at 9:00 a.m. with Cook C and Cook D revealed the dish machine was not working. Both cooks stated the kitchen did not have hot water available and the hot water had not been working consistently for over a month. They stated they did not have dish detergent for the dish machine and had stated the issues to the former Dietary Manager. They stated they did not have any way to clean the dishes and the City Fire Marshal had visited the kitchen on 07/19/18 and stated the kitchen equipment was not sanitary to use without proper water temperatures and dish detergent. They stated they were also unable to use their steam table because they did not have supplies to clean it. Observations of the dish machine revealed it was off and dirty dishes were stacked up. The floor was dirty, and the kitchen had multiple flies and gnats on the dishes and flying around. Cook C revealed she had served bacon, toast, and fruit for breakfast the morning of 07/20/18 and had to cook the bacon on a sheet pan that was not properly. She stated she knew she was not supposed to use cookware that had not been cleaned properly, but felt it was important to have a protein to serve the residents for breakfast. An observation revealed there was a pan in the kitchen with sausage and bacon in it. They both stated the facility's Dietary Manager was released from duty on 07/19/18. Interview with the Administrator on 07/20/18 at 9:15 a.m. revealed the facility's hot water had only been working intermittently for the last several weeks, but he did not know why it had not been fixed. Observation on 07/20/18 at 9:42 a.m. with Resident #15 revealed he was drinking milk from a disposable milk carton and had a banana, toast, and ground sausage for breakfast. The breakfast was served on a disposable plate with disposable utensils but was sitting on a non-disposable serving tray from the kitchen. Interview and observation on 07/20/18 at 9:55 a.m. and 10:30 a.m. with Cook D revealed on 07/19/18 Cook C tried to clean some of the dishes using boiled water. Cook D walked to the dish room and turned on the dish machine. She tested the water temperature and revealed it was only reaching 125 degrees Fahrenheit. She stated she did not know if the dish machine was a high temp or a low temp machine and tested the chlorine level in the dish machine using a chlorine testing the strip. The strip did not show any evidence of chlorine in the water. The water temperature in the 3-compartment sink was tested , and it only reached 90 degrees Fahrenheit. The only available sink dedicated to staff hand washing did not have soap available. Interview with the Administrator on 07/20/18 at 10:40 a.m. revealed the facility would be serving lunch on paper and plastic ware, and he was not aware the kitchen staff did not have hand soap available for use. Observation and interview on 07/20/18 at 11:17 a.m. with Cook [NAME] revealed the dish machine was a high temp machine and the machine had to reach 160 degrees Fahrenheit to wash the dishes effectively. Cook [NAME] tested the water of the dish machine using water temperature testing strips. The bottle indicated the strip color must turn black to show the water was at 160 degrees Fahrenheit. The strip color changed from white to a light gray color. She stated the kitchen's hot water supply had worked on and off for the past several weeks and she was instructed on 07/19/18 to stop using it. Cook [NAME] checked to see if the machine had dish detergent flowing to the dish machine and revealed it did not. Cook [NAME] removed the dish detergent bottle from the dispensing area. The bottle contained a watery, white, chunky fluid. Cook [NAME] stated the kitchen staff had to provide any cleaning materials used in the kitchen from their own money. Observation on 07/20/18 at 11:30 a.m. and 12:00 p.m. revealed kitchen staff were assembling sandwiches and chips for lunch. Gnats and flies were being swatted off the food by kitchen staff. The Administrator and Cook [NAME] brought a linen cart into the kitchen and stated they were going to use it to transport the food to residents. The cart was visibly dirty. Cook [NAME] took the linen cart to the food cart washing area, but could not find soap to clean it with, so she stated they would not be able to use it. Cook [NAME] returned to the food prep area and foil was observed laying on the counter surface. Cook [NAME] stated staff had cleaned the food prep area using germicidal wipes and would be serving lunch using paper and plastic products. Cook [NAME] stated kitchen staff did not start using paper products until after the City Fire Marshal arrived at the facility on 07/19/18. Interview with the DON on 07/20/18 at 1:00 p.m. revealed the plumber was able to repair plumbing for the kitchen and it was expected that the boiler would reach appropriate hot water temperatures by 5:00 p.m. on 07/20/18. She stated she did not know how long the kitchen had been without hot water. Observation and interview on 07/20/18 at 4:10 p.m. and 4:20 p.m. revealed staff were washing dishes in the dish machine. The Service technician stated he had provided soap for the machine and tested the water temperature. An observation of the water temperature test strip revealed the water was not at 160 degrees Fahrenheit and was a light gray color. He tested the sanitizer used at the 3-compartment sink and found the sanitizing supply tube was not functioning because it had a hole it. He replaced the supply tube and the sanitizer flowed into the 3-compartment sink without difficulty. Cook C was observed at the kitchen staff hand washing sink washing her hands with available soap. Interview with the Regional Vice President of Operations on 07/20/18 at 4:58 p.m. revealed she had interviewed kitchen staff and found that the 3-compartment sink had been out since 07/07/18, and the dish machine has been down intermittently since 07/07/18. She stated kitchen staff informed her previous to 07/20/18 they were using the 3-compartment sink to wash pots and pans, and then running them through the dishwasher. Observation on 07/20/18 at 7:08 p.m. revealed the water temperature of the 3-compartment sink was at 172 degrees Fahrenheit as tested by the Regional Director of Clinical Services. He tested the water temperature of the dish machine and stated it was not maintaining a temperature of 160 degrees Fahrenheit. He looked at the machine and turned a lever on top of the machine. After turning the lever, the water temperature in the dish machine reached 180 degrees Fahrenheit. He stated he did not know when the lever had been turned off and would have to instruct staff not to turn it off. Staff were instructed to re-wash the dishes. Interview and written statement received from the Maintenance Director on 07/23/18 at 8:40 a.m. revealed he was notified on 07/16/18 by the Maintenance Assistant that the boilers behind laundry were not working. He stated the laundry was receiving cold water only and water temperatures in the kitchen would fluctuate. On 07/17/18, he stated two boilers serviced laundry, but only one boiler was needed. He stated he successfully repaired the water issue in the laundry by taking parts from one boiler and adding them to the other boiler. He stated on 07/18/18, the water had to be shut off due to a water leak in the electrical room in the kitchen and he requested funds from the Administrator to fix the problem. He stated he did not receive approval for the funding and on 07/19/18, the City Fire Marshal inspected the problem and informed them they had to have a plumber get a city permit to make the repairs. The Maintenance Director stated the Administrator gave him his personal debit card to purchase the needed parts, so they would be on hand when a plumber was hired. The Maintenance Director stated he also purchased paper products for use in the kitchen after the City Fire Marshal inspected the kitchen. The Maintenance Director stated the water remained off to the building on 07/19/18. He stated the morning of 07/20/18, the plumber arrived, reviewed the work that had been completed and checked the kitchen boiler. The boiler and plumbing were turned back on and tested , and no leaks were found. The Maintenance Director stated he was told the laundry area water temperatures were not high enough and he turned up the boiler which raised the temperature in the washer to 135 degrees Fahrenheit. The Maintenance Director stated the Service Technician arrived at the facility to repair the dish machine and found the dish machine had sanitizing tubes that had been cut and no sanitizer was available for the dish machine. The Service Technician stated to him the dish machine would require a temperature of 160 degrees Fahrenheit to wash dishes. He stated the water temperature to the dish machine was at 180 degrees Fahrenheit. He stated he was informed by the Social Worker on 07/23/18 that the [MEDICAL CONDITION] Unit did not have hot water because someone had turned off the hot water valve that serviced that area. Interview with the Maintenance Assistant on 07/23/18 at 9:40 am revealed he had started employment with the facility four months prior. He stated a lady in the laundry department told him the hot water was not working, but he could not remember the date. He was first made aware that the hot water to the kitchen was not working properly on 07/05/18. He stated sometimes the water to the kitchen was hot, but sometimes it was not. He stated he had notified the Administrator and the Social Worker when he identified the issue and was told to fix it. He stated he tried but did not know how so he contacted a plumbing company to check the issue sometime around 07/07/18. He stated the plumber did not know what was wrong and recommended a boiler expert be called. He stated the boiler expert checked the boiler, unknown date, and stated the issue might be a metering valve in the boiler. He stated he told the Administrator and Social Worker about the results and was instructed to do what he needed to do to fix it. He informed them he did not know how to fix it but did try opening and closing valves on the boiler to get it to work. Interview with the Social Worker/AIT on 07/23/18 at 10:30 a.m. revealed he was also the Administrator In-Training at the facility. He stated on 07/06/18 he was told the hot water in the kitchen was going out and a plumber was called to fix the issue. He stated the previous Dietary Manager informed him the following day that the kitchen had hot water. He stated he was out of the facility 07/09/18 - 07/16/18 and when he returned he was told the 3-compartment sink did not have hot water. On 07/17/18, he stated the Maintenance Director informed him he needed to order a part to fix the plumbing and on 07/19/18 the Dietary Manager informed him that areas of the kitchen still did not have hot water. He stated on 07/19/18, the Maintenance Director got the part to fix the issue but was not able to do the repair because he did not have a city permit to work with the plumbing. He stated he purchased paper products for the kitchen to use on 07/19/18 but was told prior to that the kitchen did not need to use paper products. He revealed the facility had a disaster in plan in place for water issues, but the facility had not followed the disaster plan. He stated in-services would need to be completed with staff to make sure they knew what to do if the issue happened again. He stated he was not aware of laundry not having hot water available until the City Fire Marshal arrived at the facility. He stated there was a resident on isolation, but he did not know how their laundry was cleaned. Interview with the former Dietary Manager on 07/23/18 at 11:40 a.m. revealed she first identified issues with the hot water in the kitchen on 06/25/18 and notified both the Administrator and Social Worker. She stated sometimes the kitchen had hot water and sometimes it did not. She stated she arrived to work early on 07/19/18 and found the hot water was still not fixed and discussed the issue with the Maintenance Director and was told the part to fix the plumbing had been ordered. She stated she was concerned the residents were going to be sick because they had been eating off dirty dishes for almost 30 days. She stated she told Administration the residents could not keep eating off dirty dishes and the Social Worker purchased paper products for kitchen use. She stated the kitchen was out of dish machine detergent because she had ordered it but received a different product instead of dish detergent and had to return it. She stated she had contacted the Service Technician about the dish machine because it was not functioning well and was told the machine needed to be replaced. She stated she had been purchasing dishwashing soap for the kitchen out of her own pocket and when the City Fire Marshal entered the facility on 07/19/18, he found the facility did not have hot water available. Interview with the Plumber on 07/23/18 at 2:45 p.m. revealed still needed a circulatory pump, a thermostat, and a mixing valve to ensure the facility had consistent hot water in the resident areas. He stated the parts were ordered and would be placed on 07/27/18. Interview with the Administrator on 07/24/18 at 11:45 a.m. revealed he was first notified about the kitchen hot water issue near the end of (MONTH) (YEAR) or early in (MONTH) (YEAR). He stated sometimes the kitchen had hot water and sometimes it did not, and maintenance would have to adjust it. He stated a plumber was at the facility to fix the plumbing problems on 07/07/18 and 07/12/18 but they were not able to fix the problems. He stated the plumber said he thought the issue at that time was the mixing valve. He stated the kitchen was instructed to use paper products starting on 07/12/18. He stated he was not made aware that the dish machine did not have dish detergent available until the City Fire Marshal arrived on 07/19/18 and stated to him the facility did not have hot water or soap available. He stated he was not aware the sanitizer to the 3-compartment sink was not functioning properly. He stated the facility had a disaster plan to address water issues, but it was not followed because he did not think it had been available for review and was not clearly directed to the staff. Interview with the City Fire Marshal on 07/26/18 at 12:45 p.m. revealed he visited the facility on 07/19/18 after receiving multiple reports that the facility did not have hot water. He stated when he arrived at the facility he found they did not have hot water and did not have dish detergent to clean the dishes. He stated he informed them they would need to use paper products because they did not have soap or hot water to clean their dishes. He stated to make plumbing repairs at the facility, the facility needed a master plumber and a permit from the city. Review of the City Fire Marshal's Report, dated 07/19/18, revealed the facility boiler had worked on and off since (MONTH) (YEAR). There was no hot water available in the kitchen. Review of the Plumber's Report, dated 07/09/18, revealed it was recommended that a boiler company look at the kitchen boiler. Review of the facility's current, undated Specification Information for the dish machine, not dated, revealed water temperatures had to reach 160 degrees Fahrenheit to wash and 180 degrees Fahrenheit to rinse the dishes. Review of the facility's current Dishwashing Temperature/Sanitizing Log, dated (MONTH) (YEAR), revealed dish machine water temperatures were taken 07/01/18 - 07/18/18 with temperatures ranging from 120 - 125 degrees Fahrenheit. Review of the facility's current, undated Dietary Policy and Procedure Manual revealed all facilities needed to be prepared for interruption of water services and had to keep janitorial supplies on hand. Review of the facility's current Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated (MONTH) (YEAR), revealed employees in the kitchen could not substitute alcohol-based hand rub for hand washing. 2. Review of Resident #17's MDS assessment, dated 05/28/18, revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #17's Nurse Notes revealed the following: 07/02/18 11:09 a.m. - Resident remains in contact isolation related to an ESBL (Extended spectrum beta lactamase) bacterial urine infection. 07/20/18 9:17 a.m. - Urine Analysis results revealed the resident had ESBL bacteria in her urine. The physician was contacted with the results and stated the resident was colonized with the bacteria and no longer required treatment or contact isolation precautions. Review of Resident #17's Lab Results revealed the following: 03/09/18 Urine Culture - ESBL positive with a colony count of greater than 100,000. 03/26/18 Blood - White Blood Cell (WBC) count of 11.0 High (Range 3.8 - 10.1) indicating infection. 07/16/18 - White Blood Cell (WBC) count of 7.7 (Range 3.8 - 10.1) indicating normal results. 07/18/18 Urine Culture - ESBL positive with a colony count of 20,000-49,000. Review of Resident #17's Physician Orders, dated 07/20/18 9:29 a.m., revealed the resident could be taken off contact isolation precautions. Observation on 07/20/18 at 3:45 p.m. revealed Resident #17 was not in her room. There were no isolation signs posted or personal protective equipment outside of her room. Interview with CNA L on 07/20/18 at 3:47 p.m. revealed the resident was no longer in isolation. Interview with LVN I on 07/20/18 at 3:50 p.m. revealed the resident was no longer in isolation. Interview with the DON on 07/20/18 at 1:00 p.m. revealed there were no residents in isolation. She stated Resident #17 was taken out of isolation per orders on 07/20/18. Observation and interview on 07/20/18 11:45 a.m. with Laundry Aide J revealed the washer was reaching 80 degrees Fahrenheit. She stated she had one resident in isolation and their clothing was washed separately in a sugar bag (bag that dissolves in water.) Interview with Laundry Aide K on 07/24/18 at 1:05 p.m. revealed they no longer had any residents on isolation, but during the (MONTH) (YEAR) they did. She stated the water to the washer was warm, but not hot. She stated she washed the sugar bags in the water that was available. Interview with the Laundry Supervisor on 07/25/18 at 11:25 a.m. revealed he did not have a policy for washing linen belonging to residents in isolation and stated the hot water to the laundry area was not functioning consistently during (MONTH) (YEAR). He stated sometimes the water was hot and sometimes it was not. He stated he tried to help the Maintenance Assistant fix the problem and adjust the temperature and sometimes it worked. He stated the issue was brought to the attention of the Administrator multiple times and was discussed in the morning meetings. He stated they had one resident in isolation prior to 07/20/18 and their laundry was placed in a sugar bag and washed in the water available. Review of the facility's current Laundry and Linen policy and procedure, dated (MONTH) (YEAR), revealed the following: .Laundry may be processed in either low temperature or high temperature cycles. [NAME] For high-temperature processing, wash linen in water that is at least 160 degrees Fahrenheit, for a minimum of 25 minutes. B. For low-temperature processing, wash linen in water that is at least 71-77 degrees Fahrenheit and use a 125 part-per-million chlorine bleach rinse . Review of the facility's Product Specification Documents, dated 02/13/13, revealed the facility detergent required a water temperature of 100 - 180 degrees Fahrenheit, the facility bleach required a water temperature of 80-160 degrees Fahrenheit, and the facility [MEDICATION NAME] required a water temperature of 80-110 degrees Fahrenheit. Review of the U.S. Food Code, dated 2013, revealed the following: Duties. The person in charge shall ensure that: employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, pH, temperature, and exposure time for chemical sanitizing. Review of the facility's current, undated Job Descriptions provided by the Administrator on 07/27/18 revealed the following: Administrator: Manages all business-related activity. Installs and manages facility procedures/systems consistent with Facility Healthcare Needs. Dietary Director: Directs and supervises staff within the dietary department. Manages sanitary food service environment by protecting food in all phases of preparation, handling, servicing, cooling, storage, and transportation. Prepares purchase specifications and orders for food, supplies, and equipment. Manages equipment and maintenance of that equipment. Laundry Supervisor: Responsible for the daily operations of the laundry department. Maintenance Director: Performs maintenance and repair of physical structures of buildings. Maintains all essential equipment (boiler room equipment and laundry room equipment) in safe operating condition. Tests the facility hot water system on a regular basis to evaluate water temperatures in essential locations of the facility. Monitors acceptable range of temperatures and immediately starts repairs to eliminate hazards for facility residents, staff, and others. An Immediate Jeopardy (IJ) was identified on 07/24/18 at 4:00 p.m The Administrator and DON were notified, and a plan of removal was requested at that time. The plan of removal was accepted on 07/23/18 at 4:40 p.m. and included: Dietary Services: 1. Provided education to staff regarding the 3-compartment sink disinfection process on 07/20/18. 2. The dish machine was repaired by (Service Company) on 07/20/18 at 3:15 p.m. 3. The residents would be served dinner on plastic ware on 07/20/18. 4. Appropriate water temperatures for the dish machine were reached on 07/20/18 at 3:20 p.m. Infection Control: 1. Water temperature checks every 30 minutes until the hot water tanks were working in accordance to policy and regulation. 2. Provide education to staff regarding temperatures needed for laundry and who to report to when temperatures are not in accordance to policy and regulation. 3. Initiate a temperature record log in laundry on 07/20/18 and submit daily to Administrator or designee. 4. All residents would be assessed for ill effects related to hot water failure. No ill effects were identified. 5. Monitoring to be completed by Quality Assurance daily, monthly, and quarterly starting on 07/20/18. Administration: 1. Education provided to the Administrator regarding facility needs and follow-up. 2. Administrator to review dietary disinfectant system process with the Dietary Manager daily. 3. Administrator to review with Laundry Director to follow up with temperatures of water and laundry requirements in accordance to policy and regulation. a. Laundry was in-serviced on proper temperatures and monitoring temperatures. b. Laundry Aide will check the temperatures upon loading the washing machine and will report any low temperatures. 4. Every dish was rewashed starting on 07/20/18 at 3:00 p.m. 5. Kitchen staff were instructed to check dish machine water temperatures and document them throughout the cleaning cycle. 6. Kitchen staff were instructed to stop the dish machine if it was out of temperature range and contact Administration. 7. The facility contacted a licensed plumber who arrived at the facility on 07/20/18. 8. The Maintenance Director checked the water temperatures in the kitchen and the water temperatures had been maintained. Interviews were started on 07/24/18 at 10:25 a.m. and continued through 07/24/18 at 1:10 p.m. with eight staff members. The kitchen staff interviewed were Cooks C, E, F, G, and H. The facility did not have a Dietary Manager. The interviews revealed the kitchen staff had been in-serviced on: 1. Checking water temperatures for the dish machine and 3-compartment sink. 2. Checking the soap dispenser on the soap machine. 3. Checking the sanitizer level in the 3-compartment sink. 4. The procedure to follow if the water temperatures were out of range, the dish detergent or hand soap was not available, and if there were issues with the hot water. The laundry staff interviewed were Laundry Aides J and K. The Facility Laundry Supervisor was also interviewed. The interviews revealed the laundry staff had been in-serviced on: 1. Checking water temperatures in the laundry. 2. The procedure to follow if the water temperatures were out of range. Interview with the Administrator on 07/27/18 at 5:10 p.m. revealed he thought the problems with the facility were a result of a breakdown in communication and because department heads were trying to take on too much responsibility. Review of the facility's accepted Plan of Removal Form, dated 07/20/18, revealed there were two residents who did not receive food from the kitchen. Review of the facility's census dated 07/20/18 revealed there were 92 residents in the facility.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #16) of four residents reviewed for elopements and one (Resident #17) of four residents reviewed for falls. 1. The facility failed to prevent Resident #16 from eloping from the men's secured unit on 06/10/18. The facility was unaware the resident had exited the unit, and as a result, the resident made it 3.7 miles to his family's home before the facility was contacted regarding his whereabouts. An Immediate Jeopardy was identified on 07/26/18 at 4:50 p.m. While the Immediate Jeopardy was removed on 07/30/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of isolated because the facility was still monitoring the Plan of Removal. 2. The facility failed to utilize adequate supervision and interventions to prevent Resident #13 from falling. As a result, Resident #13 suffered an unwitnessed fall on 07/02/18 with resulting femoral neck fracture. These failures have the potential to affect 42 residents on two secured units that were identified as elopement risks, and 23 residents identified as fall risks in the facility, and have the potential to result in serious bodily harm, [MEDICATION NAME] physical impairment, or death. Findings included: 1. Review of Resident #16's MDS assessment, dated 06/22/18, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He had severe cognitive impairment and no wandering behaviors identified. Resident #16's care plan revealed the following dates, focus areas, and interventions: Initiated 06/15/18 - Dementia - Interventions included monitoring, documenting and reporting any changes in cognitive function to the physician. Initiated 06/11/18 - Wandering - Interventions included attempting to determine patterns of wandering, maintaining a clutter-free environment, having direct supervision while off of the locked unit and informing staff and volunteers of elopement risk while supervised off of locked unit. There was no care plan or interventions available for elopement risk while on the secured unit or exit-seeking behaviors. Resident #16's Wandering Risk Assessment, dated 06/08/18, revealed the resident was receiving antipsychotics, antidepressants, and anti-anxiety/hypnotic medications. The assessment did not have selections made for sections involving cognitive orientation, behavior/mood disruptions, diagnosis (which included dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]), or history of wandering. The assessment was signed by LVN I. Resident #16's Progress Notes revealed the following dates and information: 06/08/18 at 6:38 p.m. - ADON M spoke with Resident #16's family and was advised the resident had one-to-one care due to attempt to leave and was advised resident was at risk for elopement. ADON M documented observing the Resident #16 wandering in the hallway, entering other rooms on the hall. ADON M obtained verbal consent to send the resident to the secure unit if resident attempted to elope or entered an occupied room. The resident was redirected and oriented to his room and its amenities. 06/09/18 at 3:10 p.m. - Resident #16 was observed going into another resident's room. He was redirected and assisted back to his room. 06/09/18 at 5:05 p.m. and 06/09/18 at 5:26 p.m. - Resident #16 was transferred from a hall within the facility to the secured unit due to wandering. Documentation revealed he appeared confused and forgetful. The next of kin and physician were notified and a verbal order was received for the transfer for resident safety. 06/10/18 (Sunday) at 6:34 p.m. - Resident #16 was in the dining room with his sister. No wandering, confusion or aggression was noted during the shift. The resident was ambulatory, able to make his needs known, and able to identify his room. The note was signed by LVN N. 06/10/18 at 9:54 p.m. - Resident #16 was identified as being back into the unit. The physician was notified and gave orders for the resident to be on a one-on-one observation. Weekend Supervisor said there was no need for 15-minute checks since resident was on one-on-one observation. The note was signed by LVN N. 06/10/18 at 10:01 p.m. - A note was drafted in the computer system and not entered by LVN I reflecting the resident ate his dinner and went to his room. His sister was visiting at the time. The next piece of information revealed the fire department brought Resident #16 back to the facility. There was no further information available. 06/10/18 at 10:17 p.m. - A note entered by weekend supervisor, RN O, revealed a Code White (missing resident) was announced around 8:30 p.m. over the intercom. The weekend supervisor rushed to the unit and determined Resident #16 was missing. A thorough search was conducted, but the resident could not be found. While searching, RN O got a call the resident was found in town. He then received a second call from a fire officer to confirm Resident #16's identity, and the resident was brought in by the police. The physician emphasized Resident #16 be put on one-on-one watch. Review of Progress Notes dated 06/11/18 at 6:26 a.m. and 06/11/18 at 9:24 p.m. for Resident #26 revealed continuing exit-seeking behaviors, and the resident remained on 15-minute checks. No further elopement attempts were documented. Review of Resident #16's Safety Check Log, dated 06/10/18, revealed 15-minute check documentation for the resident began at 9:15 p.m. on 06/10/18. Interview with Resident #16 on 07/24/18 at 8:45 a.m. revealed he remembered taking a walk outside the facility last month and called a bus to return him to the facility. He said he apparently passed out or something. When asked how he called for a bus to return if he passed out, Resident #16 said he called someone who told him everything he needed to know over the phone. He said he was made to go to the doctor afterwards because he was confused, but he was currently doing better. When asked if he knew where he went, he said he walked down the block to the department store. Resident #16 said he loved living at the facility and played basketball every day for an activity. Interview with the Social Worker/AIT on 07/24/18 at 2:32 p.m. revealed he had received a call one night that Resident #16 was missing. Resident #16 was a new admission and had been moved to the secured unit because they felt it would be better there. The resident had dinner with a family member because they had not seen each other for a while, and afterwards it was noticed the resident was missing. By the time the Social Worker got the call, Resident #16 was back to his room and had been assessed by the nurse. The Social Worker said it was his understanding that the police and fire department had found the resident and returned him to the facility. The report did not say how far the resident had gotten from the facility, but the Social Worker believed he was still in the vicinity of the facility and within primary city limits. The Social Worker explained the resident was trying to get to a housing area that was approximately two miles from the facility, and located across city lines. The Social Worker said the facility was only four blocks from the city line. The resident was returned by the police for the facility's city. The Social Worker said when he got to the facility and was able to interview Resident #16, the resident did not have a recollection of leaving. The resident could only say that he thought he was going to the housing area where his family resided, and he had decided to go home. The Social Worker said they had not determined which facility door the resident had exited from, but from his survey, believed the resident would have had to exit the back door of the building. The front exit required an automatic handicap button to be pressed in order for the doors to open from the inside, and the back door could be opened easily just by pushing, even if locked. The Social Worker said the staff who were on duty reported Resident #16 was at dinner, then they passed out snacks and the resident was talking with his family member. They did not notice the resident leaving. They said it was about 8:00 p.m. when he left and around 9:00 p.m. when he returned. The Social Worker said the staff were in-serviced on monitoring residents and elopement. Though the Social Worker believed the elopement occurred the day Resident #16 was admitted , he was informed about the resident's admitted and the transferring of rooms and units for the resident. The Social Worker said Resident #16's care plan should have addressed wandering, elopement, and the resident's monitoring needs. He also said that following the elopement, the CNAs were placed standing in or near the hallway and one in the dining room so the doors could be monitored. Observation of the men's secured unit on 07/25/18 at 10:03 a.m. revealed there were no staff in the hall. LVN B and CNA R were sitting in the nurses' station while CNA A was assisting a resident in the resident's room. Once finished with providing care, CNA A exited the resident's room and took waiting residents outside for a smoke break in the courtyard located off the secured unit's dining area. CNA R remained in the nurses' station. Two visitors were observed on the hallway. A television monitor in the nurse's station showed two views of the secured unit; one view showed the length of the hallway and the other showed a downward angle near the nurses' station in the hallway which was obscured by lines and blurs on the screen. Interview with Weekend Supervisor/RN O on 07/25/18 at 9:20 a.m. revealed he usually sat in the ADON's office or walked around passing supplies but was on the female secured unit when he heard a Code White called on the night of Resident #16's elopement. He said he did not see anyone walking around the halls on that evening. RN O said the code was called just after dinner when it was beginning to get dark. RN O said Resident #16 was confused and was on the secured unit because he wandered. He said he did not know if the resident had exit-seeking behaviors because he was a new admission. He stated he had been told the resident was transferred from one of the regular halls to the secured unit due to wandering and exit-seeking behaviors. RN O said he was aware of how Resident #16 got off the secured unit on that day, but he did assist in the search for the resident. He also said he spoke with the nurse on duty that evening who told him the police had the resident. RN O said he told the nurse to verify that the resident belonged to the facility and to let the police know the facility's address. RN O said he was not aware the resident was gone until he heard the Code White called, and his roll in elopement incidents was to help with the search, inform all of the administrative staff, and to make sure staff gave their statements and received in-services. RN O said he and the DON conducted the in-services together. RN O was able to confirm the staff on duty the evening of the elopement were LVN N, CNA P, and CNA Q. Review of time punch detail reports for RN O dated 06/10/18 revealed RN O clocked in from 8:07 a.m. to 12:02 a.m., and there were no clock out punches made during the shift. Interview with LVN N on 07/25/18 at 1:25 p.m. revealed he was a nurse on the male secure unit. He revealed the elopement incident with Resident #16 occurred on a weekend. He stated the resident had just eaten dinner, someone had visited, and the resident followed the visitor out of the unit. The staff then received a call from the family saying the resident had been found. Though LVN N was not sure, he thought it was a random visitor (not belonging to the resident directly) that Resident #16 followed out of the unit. LVN N said that at the time, he had taken a brief break, about 15 minutes, and had two CNAs on duty trying to help get residents ready for bed. LVN N said there was not a nurse covering for him while he was on break, and the CNAs were already working to get the residents to bed. He said he thought the resident was gone for 45 minutes to one hour. LVN N said the resident was on the secured unit wandering from one resident room to another. LVN N said he worked on double weekends, referring to double shifts. He said it was not standard or procedure to leave a unit without a nurse, and that since the incident he was to leave his keys with the weekend supervisor or someone who could provide coverage during a break. He said he had been trained since the elopement occurred, and that the codes had been changed. He said that though breaks used to be an hour long, they had been reduced to only 30 minutes. LVN N said Resident #16 did not currently try to exit-seek, but did verbalize that he was going home. The staff would redirect him and the resident would go back to his room. Review of time punch detail reports for LVN N dated 06/10/18 revealed LVN N clocked in from 11:47 a.m. to 10:30 p.m., and there were no clock out punches made in the evening. Interview with CNA P on 07/25/18 at 2:00 p.m. revealed at the time of the incident she was just coming back from a break. She said there was only one CNA actively on duty when she got back because the nurse had taken a break as well. She said that at the time, breaks were an hour long so it would often leave one person on the unit for an hour at a time. Once she returned, she and the other CNA were doing care rounds when one of Resident #16's family members called and said the resident was at their home. CNA P said she asked the family how the resident was at their home, but the family did not know. CNA P said she became aware Resident #16 had followed a visitor off the unit because when he returned to the facility, he told numerous staff members, I followed the man out. CNA P said there was a male family member visiting another resident that evening of which she was aware. CNA P said she could not remember if she took her break from 7:00 - 8:00 p.m. or from 8:00 - 9:00 p.m. since those were her usual break times, but she believed she had taken a break from 8:00 - 9:00 p.m. that night because she arrived back to the unit a little before 9:00 p.m. She said the family resided in a housing area previously identified as being over the city line. She was not sure how far away the location was from the facility. The staff called a Code White for a missing resident once they found out he was gone. The police were called and that was how the resident was returned. CNA P said they were not in-serviced after the incident regarding the issue. The nurse assessed the resident that evening, but administration did not come to the facility. CNA P said it had become normal practice to leave the unit without a nurse when working double weekends because breaks were an hour long. The nurse was just coming back to the unit when she received the phone call from the family. CNA P said the resident had been brought to the unit because he was trying to leave from the regular hallway. She said they were never instructed how to properly monitor residents to prevent them from getting out of the secured double doors. Review of time punch detail reports for CNA P dated 06/10/18 revealed CNA P clocked out from 7:12 p.m. to 8:17 p.m. with a final clock out at 10:06 p.m. Interview with LVN I on 07/27/18 at 3:51 p.m. revealed he had been working outside of the men's secured unit the day of the elopement incident with Resident #16. LVN I received the call from the resident's family saying that Resident #16 was with them and transferred the call to LVN N. He received the call after 8:00 p.m. that evening. Review of time punch detail reports for LVN I dated 06/10/18 revealed LVN I clocked out from 9:10 p.m. to 9:45 p.m. with a final clock out at 10:38 p.m. Interview with CNA Q, men's secured unit CNA, on 07/28/18 at 1:28 p.m. revealed he usually worked double shifts on weekends and was working the night Resident #16 eloped. He said the lead CNA and the nurse had taken a lunch break. The nurse, LVN N, took lunch at 7:00 p.m. The other aide took hers at approximately 6:30 p.m. and CNA Q was on the unit alone. Right after dinner, which was served at 5:00 p.m., CNA Q said he began laying residents down. He said he thought it was, roughly, 6:00 p.m. He said he remembered seeing Resident #16 right after dinner, and at the time the resident's room was right by the door. Another resident's family member had come in to visit, and that was the last time he saw Resident #16. CNA Q said he took his lunch break at 8:30 p.m., and when he came back at 9:30 p.m., he was told the police had just returned Resident #16 to the facility. CNA Q said he did not know the resident had eloped. He said he knew the resident had to have left through the secured unit doors because there was an alarm on the fire exit doors on the secured unit, and their courtyard was key coded. CNA Q said someone would have had to let Resident #16 off the secured unit in order for him to leave, but because he was laying residents down for the evening, he was unable to see what time the resident left. CNA Q said it was difficult for all three staff to squeeze in an hour lunch break when working double shifts, so it was normal for the nurse to leave the unit and not have anyone to relieve him on the secured unit. He said after dinner, most everyone would go to bed, so it did not matter that there was not a nurse or possibly only one staff member. He said everyone on the secured unit paced back and forth, and they had cameras that could see what the residents were doing. Many of them would go to bed on their own. However, CNA Q said that out of everyone on the men's secured unit, there were not any residents who would try to go out the door as Resident #16 had. CNA Q said the nurse from the regular hall Resident #16 had transferred from told the staff that she was transferring him to the secured unit because he was exit-seeking, trying to elope, and she could not watch him and do her work as well. Placing him on the secured unit would allow him to walk up and down the halls. CNA Q said people who were actively trying to get out of the doors on the secured unit were usually brought to the nurses' station to be monitored more closely, but Resident #16 would get up and walk around like clockwork. Review of time punch detail reports for CNA Q dated 06/10/18 revealed CNA Q clocked out from 8:33 p.m. to 9:30 p.m. with a final clock out at 10:08 p.m. Interview with the Administrator on 07/25/18 at 2:48 p.m. revealed the facility did not have a policy that dictated required staffing numbers. He stated the facility tried to have enough staff on the secured units to meet the residents' needs, but the staffing was based on the census. He said there should be a nurse on the unit at all times and another nurse should relieve him/her if a break was needed. Interview with Resident #16's family member on 07/25/18 at 3:37 p.m. revealed Resident #16 had previously been in the hospital before being transferred to the facility. The family member said the facility was always supposed to have had the resident in a secured unit, but when he was first admitted they did not, and he was not sure what the miscommunication was about his placement upon admission. He said the resident eloped on a Sunday from the facility. The resident came back to the family's home, which was located over the city line. The family member provided the exact address location for the home where Resident #16 was found. The family member said he was unsure how the resident made it so far as the home was a distance away from the facility. He said it was about 6:00 p.m. when he got the call that Resident #16 was at the house. The family member said he was not at the home when Resident #16 was there, but he instructed the rest of the family to contact 9-1-1 and explain the situation so the resident could be transported back to the facility. He said he was unsure if the facility had been made aware of Resident #16's need for a secured unit upon admission because he was not the one who handled the admission. Interview with LVN S on 07/26/18 at 1:53 p.m. revealed Resident #16 was originally admitted to her hall, but he was exit-seeking so she had to move the resident to the secured unit. She stated the facility did not have a WanderGuard system so residents with exit-seeking behaviors did not reside on the halls outside of the secure units. Interview with CNA R on 07/24/18 at 8:38 a.m. revealed Resident #16 needed to be watched because after lunch he would become exit-seeking, saying that it was time for him to go to work. Then after dinner, he would again go to the door and say that it was time for him to go home. She said Resident #16 could talk about the past but was not able to discuss the present. CNA R stated Resident #16 had not gotten off the secured unit that she was aware of, and she had received training on elopement last month. Follow-up interview with CNA R on 07/26/18 at 8:21 a.m. revealed she had not been given any special instructions for monitoring residents since Resident #16's elopement, of which she had become aware. CNA R said she was only instructed that if someone was missing staff were to take a head count, search everywhere, and inform the charge nurse. CNA R said there should be two people on the unit at all times. She said there used to be times when there was only one staff member on the secured unit, but there now had to be two. She said there needed to be one staff member sitting in the hall and one in the common area. She said if one staff member was in the common room, they watched the station monitor. She said the rule for positioning had been in place even before Resident #16's elopement, and that she had worked in the facility for four years. CNA R said no one instructed the staff to be positioned in the specific areas after Resident #16's elopement. Observation of the men's secured unit on 07/26/18 at 8:18 a.m. revealed one male resident was actively exit-seeking at that time. Resident #17 was attempting to press and open the coded and alarmed door leading off the unit and to the outside grounds of the facility. CNA R was sitting in the nurses' station, LVN B was standing at his medication cart by the nurses' station, and CNA A was around the corner in the kitchen area of the common room. Observation of the men's secured unit on 07/26/18 at 8:30 a.m. revealed LVN B was passing medications in the common area. There was no staff member sitting on or near the hallway. Two staff from outside the unit were observed exiting the unit at that time, and a housekeeping staff member was observed with a cleaning cart at the end of the hall near the unit doors. Interview with CNA A, men's secured unit CNA, on 07/26/18 at 8:37 a.m. revealed the staff was supposed to do 15-minute checks for Resident #16 since his elopement. She said the facility did not give them any instructions for any other exit-seeking residents to prevent elopement. She said the staff always walked the halls and watched the monitors. She said they were supposed to have two aides and a nurse on the hall. She also said the facility did not tell them to be physically posted anywhere specific on the unit, but if they were having problems with a particular resident, they were position themselves within range of the resident. CNA A said she had worked at the facility for four years. CNA A said they monitored Resident #16 now because he would get in moods where he thought he was going to the housing area where his family lived or that he was going to work. She said the staff would watch him on the television monitor. Interview with LVN B, men's unit nurse, on 07/25/18 at 10:05 a.m. revealed Resident #16 required supervision for the secured unit. He initially admitted on one of the hallways in the facility but was moved to the secured unit. LVN B said he was informed that Resident #16 had eloped over the weekend when he first admitted . Since the elopement, Resident #16 would sometimes take his belongings and say he was going to leave, but staff would then redirect him. LVN B said the staff had been in-serviced on counting residents, following the elopement procedures, and laying eyes on the residents. He also said that the staff would tell visitors to watch for residents who were close by the door when exiting to prevent someone from following them out. Follow-up interview with LVN B on 07/26/18 at 8:32 a.m. revealed the facility had given the staff on the men's secured unit no new procedures after Resident #16's elopement. No one had specified that staff should be positioned in specific locations, only that they should be conducting rounds and Resident #16 was to receive 15-minute checks. LVN B said two staff were to be on the unit at all times; however, the rule for two staff being on the unit was not a new procedure. LVN B specified that there was always supposed to be a nurse on the unit, and if he was to take a break, he needed to find another nurse to cover for him. LVN B said there were occasions he could not find another nurse and would have to stay on the unit. LVN B confirmed on 07/26/18 at 12:21 p.m. that Resident #16 did not require any evening medications and received only B12 and Amplodipine in the mornings. Interview with MA T on 07/26/18 at 5:06 p.m. revealed she was the medication aide for the men's secured unit, and she was aware of Resident #16's elopement. She stated she was not told to do anything new with regards to monitoring the resident once he was returned to the facility. MA T said the staff were told to redirect the resident and keep a close eye on him, but were never instructed that one staff had to be positioned on the hall and one needed to be positioned in the common room. MA T said the staff paid more attention to residents who were exit-seeking. If the staff were busy, residents who were exit-seeking would be brought to the nurse so that they could be watched. MA T said two staff should be on duty at all times. Interview with ADON M on 07/26/18 at 5:38 p.m. revealed elopement evaluations were completed on residents who were exit-seeking. She did not recall having an in-service after Resident #16 eloped. Interview with MDS Coordinator U on 07/26/18 at 6:18 p.m. revealed Resident #16 had exit-seeking behaviors, and she thought the resident had a care plan for the secured unit. MDS Coordinator U said the resident should have had supervision as an intervention. Resident #16 also required someone to be with him when coming off of the secured unit. She said the same requirement for monitoring should be in place while on the secured unit as well. MDS Coordinator U said staff needed to keep up with the resident while off of the unit because some of the doors only stayed shut for 15 seconds and then opened, so the resident could be harmed. That was why there were two aides on the unit to keep him from wandering outside and to assist with activities of daily living. MDS Coordinator U said the importance of having an exit-seeking care plan would be for monitoring of Resident #16 on and off the secured unit. Interview with the Medical Director on 07/30/18 at 11:40 a.m. revealed the layout of the facility was not conducive to good monitoring, and he wished the facility had more supervision. The Medical Director said there had been a lot of turnover at the building in the last six months, and it had been a difficult time for the facility. He said that there were a lot of rooms around the secured unit doors and the nurses' stations were far away, so unless the staff were proactive and vigilant, someone could get out the door. Interview with Resident #16's physician, Physician X, on 07/30/18 at 11:52 a.m. revealed Resident #16's real risk was wandering. Physician X said that Resident #16 could not manage his own affairs, and it was apparent to him that the family felt the same if they had called to get the resident returned to the facility. He said as long as Resident #16 was going to show wandering behaviors, he was going to have to be on a secured unit. The only way that could change is if the resident had a significant change in condition that would stop that behavior. Interview with the Administrator on 07/25/18 at 4:47 p.m. revealed there had been no other elopements from the facility since Resident #16's. The facility had put a plan in place once Resident #16 was returned to the facility where one staff member would be assigned to the hallway area and one would be assigned to the common room area. This plan would be in place for both the male and female secured units. The in-service for this plan was done informally and per shift, where each shift was informed only verbally about the incident and what they would be doing going forward. There was no other information that could be provided about this plan, including any written records of training. The Administrator said it was his understanding the fire department or police department had seen Resident #16 walking around, assumed he belonged to the facility, and brought him back. The Administrator said the facility did contact the police but did not believe they obtained a police report number. Telephone interview with the police records department for the city the resident's family resided in revealed two call records dated 06/10/18 at 8:53 p.m. from the family's address. The two calls were made within minutes of one another and there was no police report made. The records department stated that police responded but the fire department took over. Observation of the men's and women's secured unit doors on 07/26/18 at 12:05 p.m. revealed a sign on the door with instructions to make sure the doors were closed completely before walking away. Signs were posted on the inside and outside of the doors. Signs were also posted instructing visitors and family to make sure residents did not follow them out. Observation of the men's secured unit on 07/26/18 at 7:45 p.m. revealed Resident #16 walking towards the secured unit doors with some clothing items in his hand. When asked where he was going, the resident responded that he was going home. Resident #16 walked to the secured doors, pushed on them, then returned to his room upon realizing the doors were locked. No staff were observed in the hallway at the time Resident #16 attempted the secured doors, nor did any staff come to the hallway to redirect the resident away from the doors. Review of the facility's current Elopement policy and procedure, dated (MONTH) (YEAR), revealed it did not include preventative measures to avoid elopements from the facility; rather, the elopement policy addressed procedures to be followed once a resident was discovered missing. The Policy Statement dictates the intention is to safely and timely redirect patients/residents to a safe environment, and a prompt investigation and search would be conducted if a patient/resident was considered missing. An Immediate Jeopardy was identified on 07/26/18 at 4:50 p.m. The Administrator, Social Worker, New DON, and Regional QA Nurse were informed and a Plan of Removal was requested at that time. The Plan of Removal revealed the following: 1. The facility has placed signs by the entrance and exit doors of the secured units instructing visitors to make sure doors close before leaving area. 2. The emergency exit doors/exit fire doors at the end of stations 2, 3, 4, and the [MEDICAL CONDITION] suites have alarms placed on them. When someone opens the emergency exit door it will make a loud squealing sound, to alert staff. The staff member closest to the alarm, that is sounding, will respond by going to that area to ensure no one has exited the building. In-servicing was started on 7/27/18 and will conclude by 8/3/18 3. Staff was educated by Administration on the Elopement Policy and Procedure 7/27/18 and will have sta

Based on interview and record review, the facility failed to ensure each resident was free from neglect for one (Resident #1) of eight residents reviewed for neglect. The facility failed to ensure Resident #1 was provided CPR until EMS arrived when the resident was found unresponsive on [DATE]. CPR was discontinued after approximately two minutes once a completed Out-of-Hospital Do Not Resuscitate (OOHDNR) form was found on Resident #1's facility chart. The resident was pronounced dead. Approximately 45 minutes later, the facility discovered the OOHDNR found on Resident #1's chart was another resident's, and Resident #1 was a Full Code. Facility staff re-initiated CPR until EMS arrived. EMS continued CPR then transported the resident to the hospital where she was pronounced dead. This failure placed 22 residents who were a full code on the [MEDICAL CONDITION] unit by placing them at risk of not receiving CPR when medically necessary and/or having their advance directive followed potentially resulting in death. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status had a summary score of 15 which indicated she was cognitively intact. Review of an advanced directives form, completed by Social Services (Social Worker) D on [DATE], reflected Resident #1 did not have an advance directive in place, did not have a living will and did not have a Do Not Resuscitate order, which made her a Full Code in the event of a [MEDICAL CONDITION]. Review of Resident #1's Admission Record dated [DATE] reflected the resident was a Full Code, which indicated the resident wanted to be provided with CPR in the event of a [MEDICAL CONDITION]. Resident #1's Comprehensive Plan of Care dated [DATE] reflected the resident was a Full Code. The resident had a physician's orders [REDACTED]. A care-planned goal included Staff will administer CPR if resident has an arrest. The care-planned interventions included Ensure Full Code order on chart, ensure staff is aware of code status through designated systems .begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party . The facility's current Emergency Procedure - Cardiopulmonary Resuscitation policy and procedure, revised [DATE] reflected the following: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is known that a Do not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . Review of the Provider Self-Reporting of Incidents dated [DATE] revealed the following: .Around 8:10 am (on [DATE]) nurse was notified by aide that the resident (Resident #1) was unresponsive with no audible breath sounds, absence of vitals, cold to touch [MEDICAL CONDITION] out of her throat lying on the left side of her (Resident #1) chest. (RN A) arrived along with the respiratory therapists and a code blue was initiated. (LVN B) charge nurse was directed to get the patients chart, call the family and physician while resident was carefully transferred to the floor by nursing staff to initiate CPR. Compressions were initiated by the RT (Respiratory Therapists), vitals and heart sounds were being assessed by (RN A) and the Ambu bag (used to ventilate a resident) was being prepared for use by the other RT. The charge nurse (LVN B) then entered the room while CPR was in progress and stated the patient was a DNR. At that time, CPR was stopped. (RN A) then continued to check for heart rate, respirations, rise and fall of the chest, but there was none. Resident was pronounced to be expired at 8:12 am. Immediate Actions Taken & Entities Notified. Family was contacted twice but there was no answer. Resident was then transferred back to the bed, cleaned and prepared for family visitation. Family called back 15 minutes later and stated that she (resident's daughter) wanted the staff to call 911. (RN A) and (LVN B) went back to the chart to re-check and verify that the code status was DNR. While reviewing the chart together they indicated that she (Resident #1) in fact was a Full Code, and that the wrong information had been placed into the chart. (LVN E) was given instructions to call 911 at 8:40 am and to call the physician. CPR was re-initiated, by nursing and RT staff until the EMTs arrived to take over at 8:55 am. EMTs continued to perform CPR for 30 minutes, resident was given 3 shots of [MEDICATION NAME]. The resident was then transferred on to a stretcher being brought to the ambulance while an EMT was still actively performing CPR on the patient as she was being taken out the door. Resident was taken to (hospital). Nurse from ER called charge nurse to ask for attending physicians phone number. ER nurse declined to give patients status at that time. Facility immediately conducted code status audit facility wide and in-services were initiated to ensure all staff were aware of policy and procedure related to CPR, and code status An interview with LVN B on [DATE] at 3:30 p.m. revealed when he was trained he was taught a green sheet on the front of the resident's chart indicated the resident was a Full Code, and the green sheet had Full Code typed on it. If there was a red sheet of paper with DNR typed on it, the resident was not be resuscitated. He stated behind the red sheet of paper there would also be a copy of the resident's OOHDNR. An interview with the Weekend Supervisor on [DATE] at 3:00 p.m. revealed she arrived at the facility after Resident #1 was taken to the hospital. She stated she had no idea how the resident's [MEDICAL CONDITION] (trach) had come out. The CNA had seen the resident five minutes before the resident put her call light on. When the CNA entered the resident's room she found the resident's head slumped over and [MEDICAL CONDITION] lying on her chest. Review of Resident #1's Incident Form completed by the DON and dated [DATE] revealed the following: Resident noted to be unresponsive in her room. CNA alerted nursing staff regarding patients (sic) condition. Code Blue initiated. Nursing and RT staff rushed to patient's room to assist. Resident was noted to be unresponsive, no audible pulse was present, no rise and fall of chest noted.[MEDICAL CONDITION] noted out of patients (sic) throat lying on her chest. CPR initiated on resident. Charge nurse informed to go and get patient's chart while the RTs and other nurses worked on patient. Charge nurse returned and indicated the patient was a DNR. CPR was stopped. Family was contacted x 2 no answer. Family called back 15 minutes later and directed staff to call 911. CPR was re-initiated and continued until the EMTs arrived to take over. EMTs worked on patient in-house for 30 minutes, resident was given [MEDICATION NAME] x 3, resident was transferred to stretcher by EMTs and CPR continued to be done on resident as she was being rolled out the door by the EMTs. Resident was taken to the hospital. An interview with RN A on [DATE] at 9:42 a.m. revealed he was covering for the Weekend Supervisor, and he was in charge of the Code Blue for Resident #1 on [DATE]. He revealed the Code Blue was called between 8:05 a.m. and 8:10 a.m. Resident #1 was discovered by a CNA (not sure her name) who informed Resident #1's charge nurse LVN B. LVN B then called/paged a Code Blue giving the resident's room number. RN A stated Resident #1 was in bed, and the resident'[MEDICAL CONDITION] out and lying on her chest. RN A stated he and a RT transferred Resident #1 from her bed to the floor, due to the resident having an air mattress, which was too soft for successful CPR. He stated he told LVN B to get Resident #1's chart and verify her code status. RN A stated the RT put the resident'[MEDICAL CONDITION] in and then started chest compressions. RN A stated LVN B returned to Resident #1's room with the resident clinical record, and RN A stated he glanced at the OOHDNR in the record to make sure there were signatures to show that the form was complete. After verifying that the OOHDNR was completed, RN A stated he told the team to stop the code. He stated the code had gone for three to four minutes before he stopped it. RN A stated he then pronounced the resident dead. RN A stated he and the CNAs put Resident #1 back in her bed, and they proceeded to clean her up for family visitation. RN A stated LVN B called the resident's family twice, before the resident's family member called back, ten to fifteen minutes after the resident was pronounced dead. He stated LVN B told the family member he/she needed to come to the facility because the resident was not doing well. RN A said the family member said, What do you mean? Call 911 and send her to the hospital. RN A stated that did not sound right to him so he went back to Resident #1's chart. He stated he then noticed the OOHDNR had a different resident's name on the top of the form. RN A had LVN B check Resident #1's face sheet on the computer, and the face sheet reflected Resident #1 was a Full Code. RN A stated they initiated CPR again, and the AED was hooked up to the resident. and it shocked the resident three times. RN A said, We did compressions for approximately seven minutes before EMS showed up and took over CPR. I told LVN B to stay with the resident. EMS took the resident to the hospital after giving three rounds of [MEDICATION NAME] via the resident's existing PICC line. EMS left the facility doing compressions. An interview with LVN B on [DATE] at 3:30 p.m. revealed he was Resident #1's charge nurse on [DATE] and had seen her up in the chair in her room between 6:30 a.m. and 7:00 a.m. and had asked the RT to suction the resident. After 8:00 a.m., one of the CNAs called everyone into the resident's room. LVN B said, We all went. He stated the staff put Resident #1 on the floor, and he went to get the resident's chart, to verify her code status. He revealed he brought the resident's chart back to the resident's room and showed everyone the red sheet of paper with DNR typed on it and the OOHDNR form on the flip side. LVN B stated he called the resident's family member twice, and the family member called back and said to send the resident to the hospital. At that point, CPR had been stopped for ten to fifteen minutes. LVN B stated he wondered why the resident's family member wanted the resident sent to the hospital if she had an OOHDNR. He stated he checked Resident #1's chart again and realized the OOHDNR was for another resident (Resident #2). LVN B stated he showed it to RN A, and RN A said to restart CPR. LVN B stated Resident #1 was hooked up to the AED and someone called 911. LVN B said, Everyone was in shock. He stated EMS administered [MEDICATION NAME] three times and performed CPR for thirty minutes before they took the resident to the hospital. An interview with the DON on [DATE] at 12:25 p.m. revealed staff could initiate CPR on a resident and then stop if DNR paperwork was found. An interview with Physician R, Resident #1's attending physician, on [DATE] at 4:05 p.m. revealed the Medical Examiner had called her and said Resident #1 died of natural causes. An interview with RT C on [DATE] at 11:48 a.m. revealed on [DATE] at approximately 8:03 a.m. she was down the hall when she saw a gathering of staff and said they needed her help. RT C stated she entered Resident #1's room, and the resident was lying on the floor. She stated she asked what happened and was told Resident #1 pulled [MEDICAL CONDITION]. RT C stated she was getting an Ambu bag (resuscitator bag used to assist ventilation) when LVN B came into the resident's room with a red paper and said Resident #1 was a DNR. She stated RN A told them to stop CPR. She stated Resident #1 might have gotten one or two compressions. RT C stated RN A asked her to put the Resident #1'[MEDICAL CONDITION] in. RN A then hyperextended the resident's neck, and RT C stated she was able to put [MEDICAL CONDITION] in with ease. RT C stated she asked RN A if they should get the AED and get a rhythm strip, and RN A responded, No. RT C stated RN A pronounced the Resident #1 dead at 8:15 a.m. RT C said, It was actually 8:07 a.m. She stated she left the room, and she heard the phone ring at the nurses' station. RT C stated she answered the phone, and it was Resident #1's family member. The family member asked if 911 was called and if the ambulance there. RT C stated she told the family member she would get the nurse to speak to him/her, and she put the call on hold. RT C stated RN A told them he needed to look at the OOHDNR and verified the form was notarized, and signed by the doctor and noticed Resident #2's name on the top of the form. RT C stated she said, What? That patient was (Resident #1) correct? RN A then told everybody they needed to start CPR. She stated it was 9:00 a.m. when the CPR was restarted. She stated RN A did compressions, and she bagged (provided ventilations) while LVN B applied the AED to Resident #1. Then, EMS arrived and took over compressions and bagging the resident. An interview with the DON on [DATE] at 8:00 a.m. revealed once a resident was admitted to the facility the Social Worker had 72 hours to meet/speak with the resident/resident's responsible party to discuss advanced directives and put the appropriate paperwork on the resident's chart. The DON stated otherwise the resident would be considered a Full Code. She stated the resident had to have an OOHDNR to be considered a DNR, and they would need to have the OOHDNR completely filled out. She stated they could do an OOHDNR in one day. An interview with Social Worker D on [DATE] at 10:22 a.m. revealed she reviewed advanced directives and resident wishes regarding their code status within 72 hours of a resident's admission to the facility. She stated she did not work on Friday, Saturday or Sundays, so if the resident was admitted on a Friday she would not be able to do their assessment within 72 hours. Social Worker D also stated advanced directives were reviewed during a resident's quarterly care plan meetings. Social Worker D said, Residents will be a Full Code unless otherwise indicated. If the Social Worker gets an OOHDNR (for a resident) she will change the green sheet (Full Code) to a red sheet (DNR) and get a doctor's order. (She puts copy of OOHDNR in the chart and gets a verbal order for DNR from the doctor. Social Worker D stated she was not sure who put the green or red sheet of paper on a resident's chart during the admission process. Social Worker D revealed the previous Social Worker audited all the resident charts for advanced directives in October or [DATE], but she could not find actual audit forms. The facility's current Abuse-Reportable Events policy and procedure dated [DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm . On [DATE] at 4:30 p.m., the Administrator and DON were notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and DON stated since Resident #1's death they had trained the majority of nursing staff on abuse/neglect. They had also conducted mock Code Blues, and they had verified all current residents' advanced directives were accurate and filed correctly. They stated the audit of all resident charts for accuracy of Full Code and DNR physician orders [REDACTED]. were found. All of this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted with nurses and respiratory therapists between [DATE] at 3:00 p.m. through [DATE] at 11:00 a.m. with the following staff: RN A, LVN B, RT C, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, RT K, RT L and RT M. All nurses and RTs who were interviewed stated they received in-services on Code Blues which included identifying who was in charge and the various roles. They stated they had also received additional in-service training regarding the use of the AED, DNR status of residents, verifying the DNR status of a resident, and abuse/neglect. Interviews were conducted with CNAs between [DATE] at 12:48 p.m. through [DATE] at 12:20 p.m. with the following staff: CNA N, CNA O, CNA P and CNA Q. These CNAs all stated they received in-service training on Code Blues and their role, verifying a resident's code status, and abuse/neglect. A list dated [DATE], provided by the DON, reflected 22 residents resided on the [MEDICAL CONDITION] unit that were a Full Code.

Based on interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for one (Resident #1) of eight residents reviewed for advanced directives. The facility failed to ensure Resident #1 had the correct Full Code paperwork on the front of her facility chart. CPR was discontinued after approximately two minutes once a completed Out-of-Hospital Do Not Resuscitate (OOHDNR) form was found on Resident #1's facility chart. The resident was pronounced dead. Approximately 45 minutes later, the facility discovered the OOHDNR found on Resident #1's chart was another resident's, and Resident #1 was a full code. CPR was re-initiated. The resident was pronounced dead at the hospital. This failure placed 22 residents who were a full code on the [MEDICAL CONDITION] unit by placing them at risk of not receiving CPR when medically necessary and/or having their advance directive followed potentially resulting in death. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status had a summary score of 15 which indicated she was cognitively intact. Review of an advanced directives form, completed by Social Services (Social Worker) D on [DATE], reflected Resident #1 did not have an advance directive in place, did not have a living will and did not have a Do Not Resuscitate order, which made her a Full Code in the event of a [MEDICAL CONDITION]. Review of Resident #1's Admission Record dated [DATE] reflected the resident was a Full Code, which indicated the resident wanted to be provided with CPR in the event of a [MEDICAL CONDITION]. Resident #1's Comprehensive Plan of Care dated [DATE] reflected the resident was a Full Code. The resident had a physician's orders [REDACTED]. A care-planned goal included Staff will administer CPR if resident has an arrest. The care-planned interventions included Ensure Full Code order on chart, ensure staff is aware of code status through designated systems .begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party . The facility's current Emergency Procedure - Cardiopulmonary Resuscitation policy and procedure, revised [DATE] reflected the following: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is known that a Do not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . Review of the Provider Self-Reporting of Incidents dated [DATE] revealed the following: .Around 8:10 am (on [DATE]) nurse was notified by aide that the resident (Resident #1) was unresponsive with no audible breath sounds, absence of vitals, cold to touch [MEDICAL CONDITION] out of her throat lying on the left side of her (Resident #1) chest. (RN A) arrived along with the respiratory therapists and a code blue was initiated. (LVN B) charge nurse was directed to get the patients chart, call the family and physician while resident was carefully transferred to the floor by nursing staff to initiate CPR. Compressions were initiated by the RT (Respiratory Therapists), vitals and heart sounds were being assessed by (RN A) and the Ambu bag (used to ventilate a resident) was being prepared for use by the other RT. The charge nurse (LVN B) then entered the room while CPR was in progress and stated the patient was a DNR. At that time, CPR was stopped. (RN A) then continued to check for heart rate, respirations, rise and fall of the chest, but there was none. Resident was pronounced to be expired at 8:12 am. Immediate Actions Taken & Entities Notified. Family was contacted twice but there was no answer. Resident was then transferred back to the bed, cleaned and prepared for family visitation. Family called back 15 minutes later and stated that she (resident's daughter) wanted the staff to call 911. (RN A) and (LVN B) went back to the chart to re-check and verify that the code status was DNR. While reviewing the chart together they indicated that she (Resident #1) in fact was a Full Code, and that the wrong information had been placed into the chart. (LVN E) was given instructions to call 911 at 8:40 am and to call the physician. CPR was re-initiated, by nursing and RT staff until the EMTs arrived to take over at 8:55 am. EMTs continued to perform CPR for 30 minutes, resident was given 3 shots of [MEDICATION NAME]. The resident was then transferred on to a stretcher being brought to the ambulance while an EMT was still actively performing CPR on the patient as she was being taken out the door. Resident was taken to (hospital). Nurse from ER called charge nurse to ask for attending physicians phone number. ER nurse declined to give patients status at that time. Facility immediately conducted code status audit facility wide and in-services were initiated to ensure all staff were aware of policy and procedure related to CPR, and code status An interview with LVN B on [DATE] at 3:30 p.m. revealed when he was trained he was taught a green sheet on the front of the resident's chart indicated the resident was a Full Code, and the green sheet had Full Code typed on it. If there was a red sheet of paper with DNR typed on it, the resident was not be resuscitated. He stated behind the red sheet of paper there would also be a copy of the resident's OOHDNR. An interview with the Weekend Supervisor on [DATE] at 3:00 p.m. revealed she arrived at the facility after Resident #1 was taken to the hospital. She stated she had no idea how the resident's [MEDICAL CONDITION] (trach) had come out. The CNA had seen the resident five minutes before the resident put her call light on. When the CNA entered the resident's room she found the resident's head slumped over and [MEDICAL CONDITION] lying on her chest. Review of Resident #1's Incident Form completed by the DON and dated [DATE] revealed the following: Resident noted to be unresponsive in her room. CNA alerted nursing staff regarding patients (sic) condition. Code Blue initiated. Nursing and RT staff rushed to patient's room to assist. Resident was noted to be unresponsive, no audible pulse was present, no rise and fall of chest noted.[MEDICAL CONDITION] noted out of patients (sic) throat lying on her chest. CPR initiated on resident. Charge nurse informed to go and get patient's chart while the RTs and other nurses worked on patient. Charge nurse returned and indicated the patient was a DNR. CPR was stopped. Family was contacted x 2 no answer. Family called back 15 minutes later and directed staff to call 911. CPR was re-initiated and continued until the EMTs arrived to take over. EMTs worked on patient in-house for 30 minutes, resident was given [MEDICATION NAME] x 3, resident was transferred to stretcher by EMTs and CPR continued to be done on resident as she was being rolled out the door by the EMTs. Resident was taken to the hospital. An interview with RN A on [DATE] at 9:42 a.m. revealed he was covering for the Weekend Supervisor, and he was in charge of the Code Blue for Resident #1 on [DATE]. He revealed the Code Blue was called between 8:05 a.m. and 8:10 a.m. Resident #1 was discovered by a CNA (not sure her name) who informed Resident #1's charge nurse LVN B. LVN B then called/paged a Code Blue giving the resident's room number. RN A stated Resident #1 was in bed, and the resident'[MEDICAL CONDITION] out and lying on her chest. RN A stated he and a RT transferred Resident #1 from her bed to the floor, due to the resident having an air mattress, which was too soft for successful CPR. He stated he told LVN B to get Resident #1's chart and verify her code status. RN A stated the RT put the resident'[MEDICAL CONDITION] in and then started chest compressions. RN A stated LVN B returned to Resident #1's room with the resident clinical record, and RN A stated he glanced at the OOHDNR in the record to make sure there were signatures to show that the form was complete. After verifying that the OOHDNR was completed, RN A stated he told the team to stop the code. He stated the code had gone for three to four minutes before he stopped it. RN A stated he then pronounced the resident dead. RN A stated he and the CNAs put Resident #1 back in her bed, and they proceeded to clean her up for family visitation. RN A stated LVN B called the resident's family twice, before the resident's family member called back, ten to fifteen minutes after the resident was pronounced dead. He stated LVN B told the family member he/she needed to come to the facility because the resident was not doing well. RN A said the family member said, What do you mean? Call 911 and send her to the hospital. RN A stated that did not sound right to him so he went back to Resident #1's chart. He stated he then noticed the OOHDNR had a different resident's name on the top of the form. RN A had LVN B check Resident #1's face sheet on the computer, and the face sheet reflected Resident #1 was a Full Code. RN A stated they initiated CPR again, and the AED was hooked up to the resident. and it shocked the resident three times. RN A said, We did compressions for approximately seven minutes before EMS showed up and took over CPR. I told LVN B to stay with the resident. EMS took the resident to the hospital after giving three rounds of [MEDICATION NAME] via the resident's existing PICC line. EMS left the facility doing compressions. An interview with LVN B on [DATE] at 3:30 p.m. revealed he was Resident #1's charge nurse on [DATE] and had seen her up in the chair in her room between 6:30 a.m. and 7:00 a.m. and had asked the RT to suction the resident. After 8:00 a.m., one of the CNAs called everyone into the resident's room. LVN B said, We all went. He stated the staff put Resident #1 on the floor, and he went to get the resident's chart, to verify her code status. He revealed he brought the resident's chart back to the resident's room and showed everyone the red sheet of paper with DNR typed on it and the OOHDNR form on the flip side. LVN B stated he called the resident's family member twice, and the family member called back and said to send the resident to the hospital. At that point, CPR had been stopped for ten to fifteen minutes. LVN B stated he wondered why the resident's family member wanted the resident sent to the hospital if she had an OOHDNR. He stated he checked Resident #1's chart again and realized the OOHDNR was for another resident (Resident #2). LVN B stated he showed it to RN A, and RN A said to restart CPR. LVN B stated Resident #1 was hooked up to the AED and someone called 911. LVN B said, Everyone was in shock. He stated EMS administered [MEDICATION NAME] three times and performed CPR for thirty minutes before they took the resident to the hospital. An interview with the DON on [DATE] at 12:25 p.m. revealed staff could initiate CPR on a resident and then stop if DNR paperwork was found. An interview with Physician R, Resident #1's attending physician, on [DATE] at 4:05 p.m. revealed the Medical Examiner had called her and said Resident #1 died of natural causes. An interview with RT C on [DATE] at 11:48 a.m. revealed on [DATE] at approximately 8:03 a.m. she was down the hall when she saw a gathering of staff and said they needed her help. RT C stated she entered Resident #1's room, and the resident was lying on the floor. She stated she asked what happened and was told Resident #1 pulled [MEDICAL CONDITION]. RT C stated she was getting an Ambu bag (resuscitator bag used to assist ventilation) when LVN B came into the resident's room with a red paper and said Resident #1 was a DNR. She stated RN A told them to stop CPR. She stated Resident #1 might have gotten one or two compressions. RT C stated RN A asked her to put the Resident #1'[MEDICAL CONDITION] in. RN A then hyperextended the resident's neck, and RT C stated she was able to put [MEDICAL CONDITION] in with ease. RT C stated she asked RN A if they should get the AED and get a rhythm strip, and RN A responded, No. RT C stated RN A pronounced the Resident #1 dead at 8:15 a.m. RT C said, It was actually 8:07 a.m. She stated she left the room, and she heard the phone ring at the nurses' station. RT C stated she answered the phone, and it was Resident #1's family member. The family member asked if 911 was called and if the ambulance there. RT C stated she told the family member she would get the nurse to speak to him/her, and she put the call on hold. RT C stated RN A told them he needed to look at the OOHDNR and verified the form was notarized, and signed by the doctor and noticed Resident #2's name on the top of the form. RT C stated she said, What? That patient was (Resident #1) correct? RN A then told everybody they needed to start CPR. She stated it was 9:00 a.m. when the CPR was restarted. She stated RN A did compressions, and she bagged (provided ventilations) while LVN B applied the AED to Resident #1. Then, EMS arrived and took over compressions and bagging the resident. An interview with the DON on [DATE] at 8:00 a.m. revealed once a resident was admitted to the facility the Social Worker had 72 hours to meet/speak with the resident/resident's responsible party to discuss advanced directives and put the appropriate paperwork on the resident's chart. The DON stated otherwise the resident would be considered a Full Code. She stated the resident had to have an OOHDNR to be considered a DNR, and they would need to have the OOHDNR completely filled out. She stated they could do an OOHDNR in one day. An interview with Social Worker D on [DATE] at 10:22 a.m. revealed she reviewed advanced directives and resident wishes regarding their code status within 72 hours of a resident's admission to the facility. She stated she did not work on Friday, Saturday or Sundays, so if the resident was admitted on a Friday she would not be able to do their assessment within 72 hours. Social Worker D also stated advanced directives were reviewed during a resident's quarterly care plan meetings. Social Worker D said, Residents will be a Full Code unless otherwise indicated. If the SW gets an OOHDNR (for a resident) she will change the green sheet (Full Code) to a red sheet (DNR) and get a doctor's order. (She puts copy of OOHDNR in the chart and gets a verbal order for DNR from the doctor. Social Worker D stated she was not sure who put the green or red sheet of paper on a resident's chart during the admission process. Social Worker D revealed the previous Social Worker audited all the resident charts for advanced directives in October or [DATE], but she could not find actual audit forms. On [DATE] at 4:30 p.m., the Administrator and DON were notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and DON stated since Resident #1's death they had trained the majority of nursing staff on abuse/neglect. They had also conducted mock Code Blues, and they had verified all current residents' advanced directives were accurate and filed correctly. They stated the audit of all resident charts for accuracy of Full Code and DNR physician orders [REDACTED]. were found. All of this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted with nurses and respiratory therapists between [DATE] at 3:00 p.m. through [DATE] at 11:00 a.m. with the following staff: RN A, LVN B, RT C, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, RT K, RT L and RT M. All nurses and RTs who were interviewed stated they received in-services on Code Blues which included identifying who was in charge and the various roles. They stated they had also received additional in-service training regarding the use of the AED, DNR status of residents, verifying the DNR status of a resident, and abuse/neglect. Interviews were conducted with CNAs between [DATE] at 12:48 p.m. through [DATE] at 12:20 p.m. with the following staff: CNA N, CNA O, CNA P and CNA Q. These CNAs all stated they received in-service training on Code Blues and their role, verifying a resident's code status, and abuse/neglect. A list dated [DATE], provided by the DON, reflected 22 residents resided on the [MEDICAL CONDITION] unit that were a Full Code.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of eight residents reviewed for neglect. The facility failed to ensure Resident #1 was provided CPR until EMS arrived when the resident was found unresponsive on [DATE]. CPR was discontinued after approximately two minutes once a completed Out-of-Hospital Do Not Resuscitate (OOHDNR) form was found on Resident #1's facility chart. The resident was pronounced dead. Approximately 45 minutes later, the facility discovered the OOHDNR found on Resident #1's chart was another resident's, and Resident #1 was a Full Code. Facility staff re-initiated CPR until EMS arrived. EMS continued CPR then transported the resident to the hospital where she was pronounced dead. This failure placed 22 residents who were a full code on the [MEDICAL CONDITION] unit by placing them at risk of not receiving CPR when medically necessary and/or having their advance directive followed potentially resulting in death. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. Findings included: The facility's current Abuse-Reportable Events policy and procedure dated [DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm . Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status had a summary score of 15 which indicated she was cognitively intact. Review of an advanced directives form, completed by Social Services (Social Worker) D on [DATE], reflected Resident #1 did not have an advance directive in place, did not have a living will and did not have a Do Not Resuscitate order, which made her a Full Code in the event of a [MEDICAL CONDITION]. Review of Resident #1's Admission Record dated [DATE] reflected the resident was a Full Code, which indicated the resident wanted to be provided with CPR in the event of a [MEDICAL CONDITION]. Resident #1's Comprehensive Plan of Care dated [DATE] reflected the resident was a Full Code. The resident had a physician's orders [REDACTED]. A care-planned goal included Staff will administer CPR if resident has an arrest. The care-planned interventions included Ensure Full Code order on chart, ensure staff is aware of code status through designated systems .begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party . The facility's current Emergency Procedure - Cardiopulmonary Resuscitation policy and procedure, revised [DATE] reflected the following: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is known that a Do not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . Review of the Provider Self-Reporting of Incidents dated [DATE] revealed the following: .Around 8:10 am (on [DATE]) nurse was notified by aide that the resident (Resident #1) was unresponsive with no audible breath sounds, absence of vitals, cold to touch [MEDICAL CONDITION] out of her throat lying on the left side of her (Resident #1) chest. (RN A) arrived along with the respiratory therapists and a code blue was initiated. (LVN B) charge nurse was directed to get the patients chart, call the family and physician while resident was carefully transferred to the floor by nursing staff to initiate CPR. Compressions were initiated by the RT (Respiratory Therapists), vitals and heart sounds were being assessed by (RN A) and the Ambu bag (used to ventilate a resident) was being prepared for use by the other RT. The charge nurse (LVN B) then entered the room while CPR was in progress and stated the patient was a DNR. At that time, CPR was stopped. (RN A) then continued to check for heart rate, respirations, rise and fall of the chest, but there was none. Resident was pronounced to be expired at 8:12 am. Immediate Actions Taken & Entities Notified. Family was contacted twice but there was no answer. Resident was then transferred back to the bed, cleaned and prepared for family visitation. Family called back 15 minutes later and stated that she (resident's daughter) wanted the staff to call 911. (RN A) and (LVN B) went back to the chart to re-check and verify that the code status was DNR. While reviewing the chart together they indicated that she (Resident #1) in fact was a Full Code, and that the wrong information had been placed into the chart. (LVN E) was given instructions to call 911 at 8:40 am and to call the physician. CPR was re-initiated, by nursing and RT staff until the EMTs arrived to take over at 8:55 am. EMTs continued to perform CPR for 30 minutes, resident was given 3 shots of [MEDICATION NAME]. The resident was then transferred on to a stretcher being brought to the ambulance while an EMT was still actively performing CPR on the patient as she was being taken out the door. Resident was taken to (hospital). Nurse from ER called charge nurse to ask for attending physicians phone number. ER nurse declined to give patients status at that time. Facility immediately conducted code status audit facility wide and in-services were initiated to ensure all staff were aware of policy and procedure related to CPR, and code status An interview with LVN B on [DATE] at 3:30 p.m. revealed when he was trained he was taught a green sheet on the front of the resident's chart indicated the resident was a Full Code, and the green sheet had Full Code typed on it. If there was a red sheet of paper with DNR typed on it, the resident was not be resuscitated. He stated behind the red sheet of paper there would also be a copy of the resident's OOHDNR. An interview with the Weekend Supervisor on [DATE] at 3:00 p.m. revealed she arrived at the facility after Resident #1 was taken to the hospital. She stated she had no idea how the resident's [MEDICAL CONDITION] (trach) had come out. The CNA had seen the resident five minutes before the resident put her call light on. When the CNA entered the resident's room she found the resident's head slumped over and [MEDICAL CONDITION] lying on her chest. Review of Resident #1's Incident Form completed by the DON and dated [DATE] revealed the following: Resident noted to be unresponsive in her room. CNA alerted nursing staff regarding patients (sic) condition. Code Blue initiated. Nursing and RT staff rushed to patient's room to assist. Resident was noted to be unresponsive, no audible pulse was present, no rise and fall of chest noted.[MEDICAL CONDITION] noted out of patients (sic) throat lying on her chest. CPR initiated on resident. Charge nurse informed to go and get patient's chart while the RTs and other nurses worked on patient. Charge nurse returned and indicated the patient was a DNR. CPR was stopped. Family was contacted x 2 no answer. Family called back 15 minutes later and directed staff to call 911. CPR was re-initiated and continued until the EMTs arrived to take over. EMTs worked on patient in-house for 30 minutes, resident was given [MEDICATION NAME] x 3, resident was transferred to stretcher by EMTs and CPR continued to be done on resident as she was being rolled out the door by the EMTs. Resident was taken to the hospital. An interview with RN A on [DATE] at 9:42 a.m. revealed he was covering for the Weekend Supervisor, and he was in charge of the Code Blue for Resident #1 on [DATE]. He revealed the Code Blue was called between 8:05 a.m. and 8:10 a.m. Resident #1 was discovered by a CNA (not sure her name) who informed Resident #1's charge nurse LVN B. LVN B then called/paged a Code Blue giving the resident's room number. RN A stated Resident #1 was in bed, and the resident'[MEDICAL CONDITION] out and lying on her chest. RN A stated he and a RT transferred Resident #1 from her bed to the floor, due to the resident having an air mattress, which was too soft for successful CPR. He stated he told LVN B to get Resident #1's chart and verify her code status. RN A stated the RT put the resident'[MEDICAL CONDITION] in and then started chest compressions. RN A stated LVN B returned to Resident #1's room with the resident clinical record, and RN A stated he glanced at the OOHDNR in the record to make sure there were signatures to show that the form was complete. After verifying that the OOHDNR was completed, RN A stated he told the team to stop the code. He stated the code had gone for three to four minutes before he stopped it. RN A stated he then pronounced the resident dead. RN A stated he and the CNAs put Resident #1 back in her bed, and they proceeded to clean her up for family visitation. RN A stated LVN B called the resident's family twice, before the resident's family member called back, ten to fifteen minutes after the resident was pronounced dead. He stated LVN B told the family member he/she needed to come to the facility because the resident was not doing well. RN A said the family member said, What do you mean? Call 911 and send her to the hospital. RN A stated that did not sound right to him so he went back to Resident #1's chart. He stated he then noticed the OOHDNR had a different resident's name on the top of the form. RN A had LVN B check Resident #1's face sheet on the computer, and the face sheet reflected Resident #1 was a Full Code. RN A stated they initiated CPR again, and the AED was hooked up to the resident. and it shocked the resident three times. RN A said, We did compressions for approximately seven minutes before EMS showed up and took over CPR. I told LVN B to stay with the resident. EMS took the resident to the hospital after giving three rounds of [MEDICATION NAME] via the resident's existing PICC line. EMS left the facility doing compressions. An interview with LVN B on [DATE] at 3:30 p.m. revealed he was Resident #1's charge nurse on [DATE] and had seen her up in the chair in her room between 6:30 a.m. and 7:00 a.m. and had asked the RT to suction the resident. After 8:00 a.m., one of the CNAs called everyone into the resident's room. LVN B said, We all went. He stated the staff put Resident #1 on the floor, and he went to get the resident's chart, to verify her code status. He revealed he brought the resident's chart back to the resident's room and showed everyone the red sheet of paper with DNR typed on it and the OOHDNR form on the flip side. LVN B stated he called the resident's family member twice, and the family member called back and said to send the resident to the hospital. At that point, CPR had been stopped for ten to fifteen minutes. LVN B stated he wondered why the resident's family member wanted the resident sent to the hospital if she had an OOHDNR. He stated he checked Resident #1's chart again and realized the OOHDNR was for another resident (Resident #2). LVN B stated he showed it to RN A, and RN A said to restart CPR. LVN B stated Resident #1 was hooked up to the AED and someone called 911. LVN B said, Everyone was in shock. He stated EMS administered [MEDICATION NAME] three times and performed CPR for thirty minutes before they took the resident to the hospital. An interview with the DON on [DATE] at 12:25 p.m. revealed staff could initiate CPR on a resident and then stop if DNR paperwork was found. An interview with Physician R, Resident #1's attending physician, on [DATE] at 4:05 p.m. revealed the Medical Examiner had called her and said Resident #1 died of natural causes. An interview with RT C on [DATE] at 11:48 a.m. revealed on [DATE] at approximately 8:03 a.m. she was down the hall when she saw a gathering of staff and said they needed her help. RT C stated she entered Resident #1's room, and the resident was lying on the floor. She stated she asked what happened and was told Resident #1 pulled [MEDICAL CONDITION]. RT C stated she was getting an Ambu bag (resuscitator bag used to assist ventilation) when LVN B came into the resident's room with a red paper and said Resident #1 was a DNR. She stated RN A told them to stop CPR. She stated Resident #1 might have gotten one or two compressions. RT C stated RN A asked her to put the Resident #1'[MEDICAL CONDITION] in. RN A then hyperextended the resident's neck, and RT C stated she was able to put [MEDICAL CONDITION] in with ease. RT C stated she asked RN A if they should get the AED and get a rhythm strip, and RN A responded, No. RT C stated RN A pronounced the Resident #1 dead at 8:15 a.m. RT C said, It was actually 8:07 a.m. She stated she left the room, and she heard the phone ring at the nurses' station. RT C stated she answered the phone, and it was Resident #1's family member. The family member asked if 911 was called and if the ambulance there. RT C stated she told the family member she would get the nurse to speak to him/her, and she put the call on hold. RT C stated RN A told them he needed to look at the OOHDNR and verified the form was notarized, and signed by the doctor and noticed Resident #2's name on the top of the form. RT C stated she said, What? That patient was (Resident #1) correct? RN A then told everybody they needed to start CPR. She stated it was 9:00 a.m. when the CPR was restarted. She stated RN A did compressions, and she bagged (provided ventilations) while LVN B applied the AED to Resident #1. Then, EMS arrived and took over compressions and bagging the resident. An interview with the DON on [DATE] at 8:00 a.m. revealed once a resident was admitted to the facility the Social Worker had 72 hours to meet/speak with the resident/resident's responsible party to discuss advanced directives and put the appropriate paperwork on the resident's chart. The DON stated otherwise the resident would be considered a Full Code. She stated the resident had to have an OOHDNR to be considered a DNR, and they would need to have the OOHDNR completely filled out. She stated they could do an OOHDNR in one day. An interview with Social Worker D on [DATE] at 10:22 a.m. revealed she reviewed advanced directives and resident wishes regarding their code status within 72 hours of a resident's admission to the facility. She stated she did not work on Friday, Saturday or Sundays, so if the resident was admitted on a Friday she would not be able to do their assessment within 72 hours. Social Worker D also stated advanced directives were reviewed during a resident's quarterly care plan meetings. Social Worker D said, Residents will be a Full Code unless otherwise indicated. If the Social Worker gets an OOHDNR (for a resident) she will change the green sheet (Full Code) to a red sheet (DNR) and get a doctor's order. (She puts copy of OOHDNR in the chart and gets a verbal order for DNR from the doctor. Social Worker D stated she was not sure who put the green or red sheet of paper on a resident's chart during the admission process. Social Worker D revealed the previous Social Worker audited all the resident charts for advanced directives in October or [DATE], but she could not find actual audit forms. On [DATE] at 4:30 p.m., the Administrator and DON were notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and DON stated since Resident #1's death they had trained the majority of nursing staff on abuse/neglect. They had also conducted mock Code Blues, and they had verified all current residents' advanced directives were accurate and filed correctly. They stated the audit of all resident charts for accuracy of Full Code and DNR physician orders [REDACTED]. were found. All of this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted with nurses and respiratory therapists between [DATE] at 3:00 p.m. through [DATE] at 11:00 a.m. with the following staff: RN A, LVN B, RT C, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, RT K, RT L and RT M. All nurses and RTs who were interviewed stated they received in-services on Code Blues which included identifying who was in charge and the various roles. They stated they had also received additional in-service training regarding the use of the AED, DNR status of residents, verifying the DNR status of a resident, and abuse/neglect. Interviews were conducted with CNAs between [DATE] at 12:48 p.m. through [DATE] at 12:20 p.m. with the following staff: CNA N, CNA O, CNA P and CNA Q. These CNAs all stated they received in-service training on Code Blues and their role, verifying a resident's code status, and abuse/neglect. A list dated [DATE], provided by the DON, reflected 22 residents resided on the [MEDICAL CONDITION] unit that were a Full Code.

Based on interview and record review, the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical well-being, consistent with the resident's comprehensive assessment and plan of care for one (Resident #1) of eight residents reviewed for CPR. The facility failed to ensure Resident #1 was provided CPR until EMS arrived when the resident was found unresponsive on [DATE]. CPR was discontinued after approximately two minutes once a completed Out-of-Hospital Do Not Resuscitate (OOHDNR) form was found on Resident #1's facility chart. The resident was pronounced dead. Approximately 45 minutes later, the facility discovered the OOHDNR found on Resident #1's chart was another resident's, and Resident #1 was a Full Code. Facility staff re-initiated CPR until EMS arrived. EMS continued CPR then transported the resident to the hospital where she was pronounced dead. This failure placed 22 residents who were a full code on the [MEDICAL CONDITION] unit by placing them at risk of not receiving CPR when medically necessary and/or having their advance directive followed potentially resulting in death. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status had a summary score of 15 which indicated she was cognitively intact. Review of an advanced directives form, completed by Social Services (Social Worker) D on [DATE], reflected Resident #1 did not have an advance directive in place, did not have a living will and did not have a Do Not Resuscitate order, which made her a Full Code in the event of a [MEDICAL CONDITION]. Review of Resident #1's Admission Record dated [DATE] reflected the resident was a Full Code, which indicated the resident wanted to be provided with CPR in the event of a [MEDICAL CONDITION]. Resident #1's Comprehensive Plan of Care dated [DATE] reflected the resident was a Full Code. The resident had a physician's orders [REDACTED]. A care-planned goal included Staff will administer CPR if resident has an arrest. The care-planned interventions included Ensure Full Code order on chart, ensure staff is aware of code status through designated systems .begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party . The facility's current Emergency Procedure - Cardiopulmonary Resuscitation policy and procedure, revised [DATE] reflected the following: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is known that a Do not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . Review of the Provider Self-Reporting of Incidents dated [DATE] revealed the following: .Around 8:10 am (on [DATE]) nurse was notified by aide that the resident (Resident #1) was unresponsive with no audible breath sounds, absence of vitals, cold to touch [MEDICAL CONDITION] out of her throat lying on the left side of her (Resident #1) chest. (RN A) arrived along with the respiratory therapists and a code blue was initiated. (LVN B) charge nurse was directed to get the patients chart, call the family and physician while resident was carefully transferred to the floor by nursing staff to initiate CPR. Compressions were initiated by the RT (Respiratory Therapists), vitals and heart sounds were being assessed by (RN A) and the Ambu bag (used to ventilate a resident) was being prepared for use by the other RT. The charge nurse (LVN B) then entered the room while CPR was in progress and stated the patient was a DNR. At that time, CPR was stopped. (RN A) then continued to check for heart rate, respirations, rise and fall of the chest, but there was none. Resident was pronounced to be expired at 8:12 am. Immediate Actions Taken & Entities Notified. Family was contacted twice but there was no answer. Resident was then transferred back to the bed, cleaned and prepared for family visitation. Family called back 15 minutes later and stated that she (resident's daughter) wanted the staff to call 911. (RN A) and (LVN B) went back to the chart to re-check and verify that the code status was DNR. While reviewing the chart together they indicated that she (Resident #1) in fact was a Full Code, and that the wrong information had been placed into the chart. (LVN E) was given instructions to call 911 at 8:40 am and to call the physician. CPR was re-initiated, by nursing and RT staff until the EMTs arrived to take over at 8:55 am. EMTs continued to perform CPR for 30 minutes, resident was given 3 shots of [MEDICATION NAME]. The resident was then transferred on to a stretcher being brought to the ambulance while an EMT was still actively performing CPR on the patient as she was being taken out the door. Resident was taken to (hospital). Nurse from ER called charge nurse to ask for attending physicians phone number. ER nurse declined to give patients status at that time. Facility immediately conducted code status audit facility wide and in-services were initiated to ensure all staff were aware of policy and procedure related to CPR, and code status An interview with LVN B on [DATE] at 3:30 p.m. revealed when he was trained he was taught a green sheet on the front of the resident's chart indicated the resident was a Full Code, and the green sheet had Full Code typed on it. If there was a red sheet of paper with DNR typed on it, the resident was not be resuscitated. He stated behind the red sheet of paper there would also be a copy of the resident's OOHDNR. An interview with the Weekend Supervisor on [DATE] at 3:00 p.m. revealed she arrived at the facility after Resident #1 was taken to the hospital. She stated she had no idea how the resident's [MEDICAL CONDITION] (trach) had come out. The CNA had seen the resident five minutes before the resident put her call light on. When the CNA entered the resident's room she found the resident's head slumped over and [MEDICAL CONDITION] lying on her chest. Review of Resident #1's Incident Form completed by the DON and dated [DATE] revealed the following: Resident noted to be unresponsive in her room. CNA alerted nursing staff regarding patients (sic) condition. Code Blue initiated. Nursing and RT staff rushed to patient's room to assist. Resident was noted to be unresponsive, no audible pulse was present, no rise and fall of chest noted.[MEDICAL CONDITION] noted out of patients (sic) throat lying on her chest. CPR initiated on resident. Charge nurse informed to go and get patient's chart while the RTs and other nurses worked on patient. Charge nurse returned and indicated the patient was a DNR. CPR was stopped. Family was contacted x 2 no answer. Family called back 15 minutes later and directed staff to call 911. CPR was re-initiated and continued until the EMTs arrived to take over. EMTs worked on patient in-house for 30 minutes, resident was given [MEDICATION NAME] x 3, resident was transferred to stretcher by EMTs and CPR continued to be done on resident as she was being rolled out the door by the EMTs. Resident was taken to the hospital. An interview with RN A on [DATE] at 9:42 a.m. revealed he was covering for the Weekend Supervisor, and he was in charge of the Code Blue for Resident #1 on [DATE]. He revealed the Code Blue was called between 8:05 a.m. and 8:10 a.m. Resident #1 was discovered by a CNA (not sure her name) who informed Resident #1's charge nurse LVN B. LVN B then called/paged a Code Blue giving the resident's room number. RN A stated Resident #1 was in bed, and the resident'[MEDICAL CONDITION] out and lying on her chest. RN A stated he and a RT transferred Resident #1 from her bed to the floor, due to the resident having an air mattress, which was too soft for successful CPR. He stated he told LVN B to get Resident #1's chart and verify her code status. RN A stated the RT put the resident'[MEDICAL CONDITION] in and then started chest compressions. RN A stated LVN B returned to Resident #1's room with the resident clinical record, and RN A stated he glanced at the OOHDNR in the record to make sure there were signatures to show that the form was complete. After verifying that the OOHDNR was completed, RN A stated he told the team to stop the code. He stated the code had gone for three to four minutes before he stopped it. RN A stated he then pronounced the resident dead. RN A stated he and the CNAs put Resident #1 back in her bed, and they proceeded to clean her up for family visitation. RN A stated LVN B called the resident's family twice, before the resident's family member called back, ten to fifteen minutes after the resident was pronounced dead. He stated LVN B told the family member he/she needed to come to the facility because the resident was not doing well. RN A said the family member said, What do you mean? Call 911 and send her to the hospital. RN A stated that did not sound right to him so he went back to Resident #1's chart. He stated he then noticed the OOHDNR had a different resident's name on the top of the form. RN A had LVN B check Resident #1's face sheet on the computer, and the face sheet reflected Resident #1 was a Full Code. RN A stated they initiated CPR again, and the AED was hooked up to the resident. and it shocked the resident three times. RN A said, We did compressions for approximately seven minutes before EMS showed up and took over CPR. I told LVN B to stay with the resident. EMS took the resident to the hospital after giving three rounds of [MEDICATION NAME] via the resident's existing PICC line. EMS left the facility doing compressions. An interview with LVN B on [DATE] at 3:30 p.m. revealed he was Resident #1's charge nurse on [DATE] and had seen her up in the chair in her room between 6:30 a.m. and 7:00 a.m. and had asked the RT to suction the resident. After 8:00 a.m., one of the CNAs called everyone into the resident's room. LVN B said, We all went. He stated the staff put Resident #1 on the floor, and he went to get the resident's chart, to verify her code status. He revealed he brought the resident's chart back to the resident's room and showed everyone the red sheet of paper with DNR typed on it and the OOHDNR form on the flip side. LVN B stated he called the resident's family member twice, and the family member called back and said to send the resident to the hospital. At that point, CPR had been stopped for ten to fifteen minutes. LVN B stated he wondered why the resident's family member wanted the resident sent to the hospital if she had an OOHDNR. He stated he checked Resident #1's chart again and realized the OOHDNR was for another resident (Resident #2). LVN B stated he showed it to RN A, and RN A said to restart CPR. LVN B stated Resident #1 was hooked up to the AED and someone called 911. LVN B said, Everyone was in shock. He stated EMS administered [MEDICATION NAME] three times and performed CPR for thirty minutes before they took the resident to the hospital. An interview with the DON on [DATE] at 12:25 p.m. revealed staff could initiate CPR on a resident and then stop if DNR paperwork was found. An interview with Physician R, Resident #1's attending physician, on [DATE] at 4:05 p.m. revealed the Medical Examiner had called her and said Resident #1 died of natural causes. An interview with RT C on [DATE] at 11:48 a.m. revealed on [DATE] at approximately 8:03 a.m. she was down the hall when she saw a gathering of staff and said they needed her help. RT C stated she entered Resident #1's room, and the resident was lying on the floor. She stated she asked what happened and was told Resident #1 pulled [MEDICAL CONDITION]. RT C stated she was getting an Ambu bag (resuscitator bag used to assist ventilation) when LVN B came into the resident's room with a red paper and said Resident #1 was a DNR. She stated RN A told them to stop CPR. She stated Resident #1 might have gotten one or two compressions. RT C stated RN A asked her to put the Resident #1'[MEDICAL CONDITION] in. RN A then hyperextended the resident's neck, and RT C stated she was able to put [MEDICAL CONDITION] in with ease. RT C stated she asked RN A if they should get the AED and get a rhythm strip, and RN A responded, No. RT C stated RN A pronounced the Resident #1 dead at 8:15 a.m. RT C said, It was actually 8:07 a.m. She stated she left the room, and she heard the phone ring at the nurses' station. RT C stated she answered the phone, and it was Resident #1's family member. The family member asked if 911 was called and if the ambulance there. RT C stated she told the family member she would get the nurse to speak to him/her, and she put the call on hold. RT C stated RN A told them he needed to look at the OOHDNR and verified the form was notarized, and signed by the doctor and noticed Resident #2's name on the top of the form. RT C stated she said, What? That patient was (Resident #1) correct? RN A then told everybody they needed to start CPR. She stated it was 9:00 a.m. when the CPR was restarted. She stated RN A did compressions, and she bagged (provided ventilations) while LVN B applied the AED to Resident #1. Then, EMS arrived and took over compressions and bagging the resident. An interview with the DON on [DATE] at 8:00 a.m. revealed once a resident was admitted to the facility the Social Worker had 72 hours to meet/speak with the resident/resident's responsible party to discuss advanced directives and put the appropriate paperwork on the resident's chart. The DON stated otherwise the resident would be considered a Full Code. She stated the resident had to have an OOHDNR to be considered a DNR, and they would need to have the OOHDNR completely filled out. She stated they could do an OOHDNR in one day. An interview with Social Worker D on [DATE] at 10:22 a.m. revealed she reviewed advanced directives and resident wishes regarding their code status within 72 hours of a resident's admission to the facility. She stated she did not work on Friday, Saturday or Sundays, so if the resident was admitted on a Friday she would not be able to do their assessment within 72 hours. Social Worker D also stated advanced directives were reviewed during a resident's quarterly care plan meetings. Social Worker D said, Residents will be a Full Code unless otherwise indicated. If the Social Worker gets an OOHDNR (for a resident) she will change the green sheet (Full Code) to a red sheet (DNR) and get a doctor's order. (She puts copy of OOHDNR in the chart and gets a verbal order for DNR from the doctor. Social Worker D stated she was not sure who put the green or red sheet of paper on a resident's chart during the admission process. Social Worker D revealed the previous Social Worker audited all the resident charts for advanced directives in October or [DATE], but she could not find actual audit forms. The facility's current Abuse-Reportable Events policy and procedure dated [DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm . On [DATE] at 4:30 p.m., the Administrator and DON were notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and DON stated since Resident #1's death they had trained the majority of nursing staff on abuse/neglect. They had also conducted mock Code Blues, and they had verified all current residents' advanced directives were accurate and filed correctly. They stated the audit of all resident charts for accuracy of Full Code and DNR physician orders [REDACTED]. were found. All of this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted with nurses and respiratory therapists between [DATE] at 3:00 p.m. through [DATE] at 11:00 a.m. with the following staff: RN A, LVN B, RT C, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, RT K, RT L and RT M. All nurses and RTs who were interviewed stated they received in-services on Code Blues which included identifying who was in charge and the various roles. They stated they had also received additional in-service training regarding the use of the AED, DNR status of residents, verifying the DNR status of a resident, and abuse/neglect. Interviews were conducted with CNAs between [DATE] at 12:48 p.m. through [DATE] at 12:20 p.m. with the following staff: CNA N, CNA O, CNA P and CNA Q. These CNAs all stated they received in-service training on Code Blues and their role, verifying a resident's code status, and abuse/neglect. A list dated [DATE], provided by the DON, reflected 22 residents resided on the [MEDICAL CONDITION] unit that were a Full Code.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures, which prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. Facility failures included: The doors to Terrace Unit had been malfunctioning since [DATE]. Staff, including the ADM and Maintenance Supervisor, were aware the doors were malfunctioning, because staff were notifying them. There was no evidence of increased supervision of Resident #1, who exhibited exit-seeking behaviors on a daily basis and had eloped on [DATE], when staff were aware the doors were malfunctioning. There were no follow-up repairs despite the door to Terrace Unit continuing to malfunction until [DATE], the date of the incident. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised February 2008, revealed: "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, and when required, the release of information to those agencies, pursuant to applicable federal and/or stat law. (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds." Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The [MEDICAL CONDITION] Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the [MEDICAL CONDITION] Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/reside

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. Facility failures included: The doors to Terrace Unit had been malfunctioning since [DATE]. Staff, including the ADM and Maintenance Supervisor, were aware the doors were malfunctioning, because staff were notifying them. There was no evidence of increased supervision of Resident #1, who exhibited exit-seeking behaviors on a daily basis and had eloped on [DATE], when staff were aware the doors were malfunctioning. There were no follow-up repairs despite the door to Terrace Unit continuing to malfunction until [DATE], the date of the incident. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised February 2008, revealed: "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, and when required, the release of information to those agencies, pursuant to applicable federal and/or stat law. (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds." An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The [MEDICAL CONDITION] Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the [MEDICAL CONDITION] Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was fou

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. Facility failures included: The doors to Terrace Unit had been malfunctioning since [DATE]. Staff, including the ADM and Maintenance Supervisor, were aware the doors were malfunctioning, because staff were notifying them. There was no evidence of increased supervision of Resident #1, who exhibited exit-seeking behaviors on a daily basis and had eloped on [DATE], when staff were aware the doors were malfunctioning. There were no follow-up repairs despite the door to Terrace Unit continuing to malfunction until [DATE], the date of the incident. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised February 2008, revealed: "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, and when required, the release of information to those agencies, pursuant to applicable federal and/or stat law. (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds." An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The [MEDICAL CONDITION] Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the [MEDICAL CONDITION] Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was fou

Based on observation, interview and record review, the Administrator failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #1) of seven residents reviewed for a elopement. 1) The Administrator failed to implement the facility's Abuse (and Neglect) Policy to ensure there was adequate supervision when the Terrace Unit (male secured unit) entrance/exit doors were malfunctioning. 2) The Administrator failed to supervise the Maintenance Supervisor, who failed to ensure the entrance/exit doors to the Terrace Unit were repaired when they continued to malfunction. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised February 2008, revealed: "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, and when required, the release of information to those agencies, pursuant to applicable federal and/or stat law. (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds." An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The [MEDICAL CONDITION] Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the [MEDICAL CONDITION] Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was found to be missing, the ADM and/or designee will contact the appro

Based on observation, interview and record review, the Administrator failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #1) of seven residents reviewed for a elopement. 1) The Administrator failed to implement the facility's Abuse (and Neglect) Policy to ensure there was adequate supervision when the Terrace Unit (male secured unit) entrance/exit doors were malfunctioning. 2) The Administrator failed to supervise the Maintenance Supervisor, who failed to ensure the entrance/exit doors to the Terrace Unit were repaired when they continued to malfunction. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised February 2008, revealed: "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, and when required, the release of information to those agencies, pursuant to applicable federal and/or stat law. (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds." An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The [MEDICAL CONDITION] Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the [MEDICAL CONDITION] Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was found to be missing, the ADM and/or designee will contact the appro

Based on observation, interview and record review, the facility failed to provide a safe and functional environment for one (Resident #1) of seven residents reviewed for exit-seeking behaviors from eloping from the facility. Facility failures included: The doors to Terrace Unit had been malfunctioning since August 2013. Staff, including the ADM and Maintenance Supervisor, were aware the doors were malfunctioning, because staff were notifying them. There was no evidence of increased supervision of Resident #1, who exhibited exit-seeking behaviors on a daily basis and had eloped on 08/24/13, when staff were aware the doors were malfunctioning. There were no follow-up repairs despite the door to Terrace Unit continuing to malfunction until 10/03/13, the date of the incident. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on 10/03/13 from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on 10/03/13. While the IJ was removed on 10/07/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated 09/10/13, reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated 01/22/13, reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on 04/19/13, 07/08/13, and 09/10/13 as "Goals Being Met." Resident #1's History and Physical, dated 05/08/13, reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on 01/14/13, 04/15/13, and 08/28/13. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On 08/28/13, the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated 10/03/13 reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on 10/09/13, regarding Resident #1's elopement on 10/03/13, reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on 10/3 (10/03/13) at 9 AM and stayed in place until 10/7 (10/07/13) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift 10/3 - 10/5 (10/03/13 - 10/05/13). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on 10/07/13 at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on 10/03/13 at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on 10/03/13 at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday (10/02/13). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on 10/03/13 at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on 10/04/13 at 12:45 AM with CNA B, revealed she worked on 10/03/13 from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on 10/04/13 at 10:30 AM with CNA G, revealed she worked (a double shift) on 10/03/13 from 10:00 PM (10/02/13) to 2:00 PM (10/03/13). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on 10/03/13 at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on 10/03/13 at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on 10/03/13 at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on 10/04/13 at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on 10/04/13 at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on 10/02/13. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on 10/05/13 at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated 10/11/12, reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on 10/10/12. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated 12/05/12. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on 10/03/13 at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on 10/03/13 at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on 09/03/13, they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" (10/03/13) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on 10/03/13 at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day (10/03/13). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on 10/04/13 at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on 10/03/13). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" (10/03/13). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on 10/03/13 with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on 09/01/13, an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on 09/13/13, "Found no problem with door." Interview on 10/04/13 at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated 09/03/13, provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated 10/03/13, reflected the following: "Adjusted door closure/shaved 1/8" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated 08/05/13, reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for July 2013 through September 2013 revealed on 08/24/13, Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated 08/24/13 revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on 10/03/13 at 2:30 PM with the ADM, she was queried about Resident #1's elopement on 08/24/13. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on 10/03/13 at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on 08/24/13. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on 08/24/13. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on 10/03/13 at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. An Immediate Jeopardy was identified on 10/03/13. On 10/03/13 at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On 10/04/13 at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The [MEDICAL CONDITION] Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the [MEDICAL CONDITION] Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on 10/04/13 at 3:45 PM, reflected: On 10/03/13 at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On 10/03/13, Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on 10/03/13, designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On 10/03/13, all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on 10/03/13. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on 10/03/13 through 10/05/13. Education on the elopement policy was initiated 10/03/13, and will be completed by 10/05/13 by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was found to be missing, the ADM and/or designee will contact the appropriate community agencies (Police, Local Health Department) and Administration, the resident's legal representative and attending physician. Staff will provide the police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex and clothing, if known. The search will be continued. Two staff members will search the surrounding streets by car for a two (2) mile radius around the facility. When the resident is located, the Charge Nurse will complete a head to toe assessment. The Social Service Designee will assess the resident for emotional distress. The Charge Nurse will report any findings to the DON/designee. The DON/designee will notify the appropriate community agencies, attending physician and resident's legal representative. The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences. The Staff Development Coordinator will also reeducate all staff to monitor the doors to validate no one follows them out upon exit. Education was initiated 10/03/13 to be completed by 10/05/13. Elopement drill will be performed every shift to validate all staff have been reeducated by 10/05/13. This was started 10/03/13. Elopement drills will be performed by th

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent one (Resident #1) of seven residents reviewed for exit-seeking behaviors from eloping from the facility. Facility failures included: The doors to Terrace Unit had been malfunctioning since [DATE]. Staff, including the ADM and Maintenance Supervisor, were aware the doors were malfunctioning, because staff were notifying them. There was no evidence of increased supervision of Resident #1, who exhibited exit-seeking behaviors on a daily basis and had eloped on [DATE], when staff were aware the doors were malfunctioning. There were no follow-up repairs despite the door to Terrace Unit continuing to malfunction until [DATE], the date of the incident. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The Pulmonary Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the Pulmonary Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was found to be missing, the ADM and/or designee will contact the appropriate community agencies (Police, Local Health Department) and Administration, the resident's legal representative and attending physician. Staff will provide the police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex and clothing, if known. The search will be continued. Two staff members will search the surrounding streets by car for a two (2) mile radius around the facility. When the resident is located, the Charge Nurse will complete a head to toe assessment. The Social Service Designee will assess the resident for emotional distress. The Charge Nurse will report any findings to the DON/designee. The DON/designee will notify the appropriate community agencies, attending physician and resident's legal representative. The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrence

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent one (Resident #1) of seven residents reviewed for exit-seeking behaviors from eloping from the facility. Facility failures included: The doors to Terrace Unit had been malfunctioning since [DATE]. Staff, including the ADM and Maintenance Supervisor, were aware the doors were malfunctioning, because staff were notifying them. There was no evidence of increased supervision of Resident #1, who exhibited exit-seeking behaviors on a daily basis and had eloped on [DATE], when staff were aware the doors were malfunctioning. There were no follow-up repairs despite the door to Terrace Unit continuing to malfunction until [DATE], the date of the incident. The facility failed to supervise a resident with a history of elopement and to ensure exit doors from a locked unit were operational. Resident #1 eloped on [DATE] from the facility and was found by the Motel Manager outside the motel, which was one-half mile from the facility; the resident was drooling, became rigid, turning purple, was unable to speak, and appeared to be having a stroke; CPR was initiated and the resident expired at 8:15 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," because the facility was still inservicing staff and monitoring the Plan of Removal. These failures could affect the 28 residents on Terrace Unit, who were identified as elopement risks, placing them at risk for being able to elope from the facility, which could result in a resident never being found, falls, injuries, other serious mental/physical harm and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE]. The MDS assessment reflected Resident #1 was able to understand and be understood by others. Resident #1's BIMS score was a "3" out of 15, which indicated he had severe cognitive impairment and had disorganized thinking, which was continuously present. The MDS assessment reflected Resident #1 exhibited wandering behavior. Resident #1 was independent with ambulation, transfers, locomotion, dressing, eating, and personal hygiene. Resident #1 required limited assistance with toilet use, and total assistance with bathing. Resident #1's care plan, dated [DATE], reflected: "Resident experiences wandering and exit seeking." The goal was, "Resident will wander safely within specified boundaries." The approaches were the following: "Approach from the front, walk in step with resident first before redirecting, Maintain a calm environment and approach to the resident, Remove resident from other resident's rooms and unsafe situations." The care plan was stamped on [DATE], [DATE], and [DATE] as "Goals Being Met." Resident #1's History and Physical, dated [DATE], reflected Resident #1 had [DIAGNOSES REDACTED]. The History and Physical reflected Resident #1 was confused and ambulated with a shuffle. Resident #1's "Risk of Elopement/Wandering Review" form reflected evaluations were completed on [DATE], [DATE], and [DATE]. Potential risk factors/resident status reflected the following: The resident was cognitively impaired with poor decision-making skills, had a pertinent [DIAGNOSES REDACTED]. The resident ambulated independently, had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door. He wandered aimlessly or non-goal directed (i.e. confused, moved without purpose, may have entered others' rooms and explored others' belongings). The family/responsible party voiced concerns, which indicated Resident #1 may have had wandering tendencies or try to leave. On [DATE], the evaluation reflected "yes" was marked for the question, "Is the wandering behavior a pattern, goal-directed or routine tied to resident's past...?" The Summary reflected Resident #1 was at risk for elopement/wandering as evidenced by, "wanders, dementia." Potential interventions included: "secured unit, frequent monitoring, keep behavior logs, review medications, recreational activities, music, exercise, personalization of room with familiar objects and photographs, staff aware of resident's wander risk." Resident #1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note dated [DATE] reflected LVN A documented: "Visual contact by this nurse after coming from shower went to his room to put on socks/shoes around 655 AM. Around 740 AM looking for resident to give routine meds and eat breakfast - not on unit - code white called around 745 AM. Copies of picture made - staff searching facility - call received by facility that resident was @ (name of motel) - this nurse reached motel site around 8 AM - police/(EMS name) present (with) CPR being performed. Administrator @ scene contacted RP. CPR stopped around 815 AM. Upon Returning to facility - NP (with) (Physician II) ((NP's name)) notified of Incident." The facility's Provider Investigation Report, which was faxed to the State agency on [DATE], regarding Resident #1's elopement on [DATE], reflected the following: Description of the Allegation: "Resident received a shower by C.N.A. (B) at 6:50 AM. He was last seen at 7 AM in his room by Nurse (LVN A). At 7:40 AM, Nurse (LVN A) reports she realized the resident was not in the dining room for breakfast and went to his room to locate. Resident was not in his room. Nurse (LVN A) along with the C.N.A.'s then began a room to room search. Code White was called at 7:45 AM by Nurse (LVN A). Facility staff followed elopement policy and procedure at this time. Resident was then located about ? mile from the facility by motel staff (see attached statement from Motel Manager; (Manager JJ)). ...Injury/Adverse Effect?... Description of Injury Resident coded on site and expired. ...Description of Assessment EMS was called to the scene and performed CPR. Resident was pronounced at the scene. ...Provider Response ...Physician, Medical Director and Guardian of this resident were notified. Room to room search completed. Door monitoring in place. Elopement procedures were implemented. ...Investigation Summary... Facility staff on duty were interviewed in an attempt to identify how the resident eloped from the facility. Doors were checked by maintenance. Door monitor put in place on ,[DATE] ([DATE]) at 9 AM and stayed in place until ,[DATE] ([DATE]) 2 PM. Outside contractor was called to check door for proper functioning and minor adjustments were made that day. Facility was unable to determine how the resident eloped from the unit... ...Provider Action Taken Post-Investigation Facility staff was re-educated on our elopement policy and using caution when entering and exiting the secured units. Elopement assessments were completed on all residents that are at risk for elopement and care plans were updated accordinally (sic), Elopement risk books were placed at each nurses station with face sheets and pictures of residents from the Terrace Unit and Veranda Unit. Elopement drills were completed ever shift ,[DATE] - ,[DATE] ([DATE] - [DATE]). Staff who has not received the education are required to complete before working. Verification is validated by a post test. SW contacted families and vendors regarding using caution will (sic) entering and exiting the secured units." Interview on [DATE] at 9:25 AM with the motel manager, Manager JJ, revealed he arrived at the motel around 7:38 AM. He said Resident #1 was sitting on a rail behind the motel's dumpster. Manager JJ said he asked the desk clerk if the resident was a guest at the motel. Manager JJ said he then went to the resident and asked, "Sir, can I help you? Do you need any help?" He said the resident opened his mouth but did not say anything. Manager JJ said he then went inside to call 911. He also retrieved a pillow for the resident. He said when he returned, Resident #1's eyes were open, he was turning purple, and appeared to have had a stroke. Manager JJ said the police then arrived. Interview on [DATE] at 2:30 PM with the ADM, revealed the last time Resident #1 was seen was 7:00 AM. The ADM said it was unknown what door the resident exited from. She said some exit doors had alarms and some did not. The ADM said Resident #1 was found at the motel on the other side of the facility parking lot by the Motel Manager, Manager JJ. She said Manager JJ noticed Resident #1 around 7:45 AM sitting on the railing on the service road. She said Manager JJ asked the resident if he was okay and then Resident #1 became rigid, started drooling and turned blue. The ADM said they did not know how the resident died . When the ADM was asked about the facility's doors having alarms, the ADM stated not all the facility doors were alarmed considering it was not a regulation. During an interview on [DATE] at 2:45 PM, LVN A described Resident #1 as being independently ambulatory. LVN A said he received therapy services off the secured unit (Terrace Unit). She told the surveyor Resident #1 had exit-seeking behaviors but not on a daily basis, although he would stand around the exit doors. She said Resident #1 talked about the past and going to Weatherford. LVN A said the resident's family member visited him every week, and had just visited him Wednesday ([DATE]). LVN A further said Resident #1 got to leave Terrace Unit to participate in activities. She said Resident #1 knew where he was going and what he was going to do when he got to leave the unit: activities. The surveyor asked LVN A why residents were placed on the Terrace Unit. LVN A responded the residents were predominately exit-seeking. During the interview on [DATE] at 2:45 PM with LVN A, she told the surveyor she was on duty at 5:45 AM that morning, and when she arrived on the secured unit, she normally checked the residents and she had that morning. LVN A said she usually received reports from the off-going shift and started treatments. LVN A said she would normally stopped treatments around 7:00 AM and began medication pass. LVN A said Resident #1 received a shower around 6:50 AM and then CNA B took Resident #1 to his room to get him dry socks. LVN A said she would pass medications standing between the dining room and the hall. She said she had a visual of the hall and could see the exit door from Terrace Hall to the courtyard and the door to the outside of the facility was a few feet behind her. LVN A said the kitchen announced the unit's breakfast trays were ready at 7:30 AM and one of the CNAs left Terrace Unit to retrieve the trays. LVN A said the residents were in the dining room being served when she noticed Resident #1 was not in the dining room. She said she started looking for him at approximately 7:40 AM and went to his room, but he was not there. She said she began searching in the other residents' rooms and told the CNAs so they could help her look for him. CNA B left the unit to search for Resident #1. LVN A said she called a "code white" (for elopement) around 7:45 AM and made copies of the resident's picture for other staff. LVN A said someone told her Resident #1 was at the motel near the facility. She said she left Terrace Unit and got to the motel around 8:00 AM. LVN A said the police department and EMTs were already there and CPR had been started. LVN A said CPR was stopped at 8:15 AM. Interview on [DATE] at 12:45 AM with CNA B, revealed she worked on [DATE] from 6:00 AM to 2:00 PM. CNA B said Resident #1 was a "bad exit seeker" and was always exit-seeking. She said he would go to any door and shake it. She said he would say he needed to get out of the facility or had to get his truck. CNA B said she arrived at work at 6:03 AM. She said she checked her resident rooms. CNA B said Resident #1 was in bed. She said she prepared the shower room and showered another resident. CNA B said she then gave Resident #1 a shower. She said after his shower, his feet got wet, so they went to his room to change his socks. CNA B said she told Resident #1 to finish putting on his socks, and she went to the shower room to clean it. CNA B said she went to get the breakfast trays from the kitchen at 7:30 AM. She said when she left to get the breakfast trays, she pushed the Terrace Unit door shut. She said when she returned with the trays, LVN A asked where Resident #1 was. CNA B said the residents were in the dining room except for two, who were still in bed. The surveyor asked CNA B if she happened to look into Resident #1's room as she returned to the unit. CNA B said she did not glance into Resident #1's room, because she was attempting to redirect another resident. CNA B said three people, an aide from the female secured unit and two therapists had come onto the unit. CNA B said the Terrace Unit doors had been malfunctioning since August (2013). She said Resident #1 had gotten off the unit in the past. She said she noticed the unit door was not catching (the magnets) and reported it to her supervisor. CNA B said CNA I and she were always letting maintenance know about the Terrace Unit doors malfunctioning. She said she had never seen the maintenance staff working on the doors. She said they said they were trying to get the doors fixed. CNA B said LVN H had made and put a sign on the unit doors to inform staff and visitors to ensure the doors were latched. She said the sign had been put on the doors in August (2013). CNA B said the ADM and the DON were aware the doors had issues. Interview on [DATE] at 10:30 AM with CNA G, revealed she worked (a double shift) on [DATE] from 10:00 PM ([DATE]) to 2:00 PM ([DATE]). CNA G said Resident #1 was in bed when she arrived at Terrace Unit for her shift. She said nothing unusual occurred overnight. She said she did not know what time he got up, because she was assisting other residents. She said CNA B started giving resident showers around 6:00 AM. She added, "at six something (time)," two therapists and a lab tech entered the unit. CNA G said she felt Resident #2 left prior to CNA B retrieving the breakfast trays from the kitchen (at 7:30 AM). CNA G said LVN A asked, "Where is (Resident #1)? Is (Resident #1) not coming down?" CNA G said LVN A called a code white. Interview on [DATE] at 4:25 PM with CNA D, revealed she had worked on the unit for three weeks. She said Resident #1 was always walking around. She said he would stand at the doors and push on them. She said he looked to her like he was trying to figure out how to get out, but she had never heard him say he needed to leave. When queried about problems with the Terrace Unit doors, CNA D said there was a sign on the Terrace Unit doors requesting people to make sure the door closed. During an interview on [DATE] at 4:35 PM, CNA E said Resident #1 liked to try to get out. She said he would go from door to door and push on them. She said she had not heard him make comments about wanting to leave the unit. When asked the doors on Terrace Unit, CNA E stated the Terrace Unit doors had a sign to make sure the doors were closed. Interview on [DATE] at 4:38 PM with Activity Aide F revealed she took Resident #1 to activities, because he got to leave Terrace Unit for activities. She said Resident #1 would say he needed to go to his car. When she was asked about problems with the Terrace Unit doors, Activity Aide F said the Terrace Unit doors would latch, but if you rushed in, the door would not always latch. Interview on [DATE] at 10:30 AM with CNA G revealed Resident #1 was always trying to get out, but his exit-seeking behaviors usually started after lunch. She said he would say he had to go to school or had to go outside to his truck. CNA G said Resident #1 would attempt any door to see if it was unlocked. CNA G said Terrace Unit's doors started to malfunction in August (2013). She said staff noticed the door was not "sticking (latching)." CNA G said when they realized the door was malfunctioning, LVN H put a sign on the door. The surveyor inquired how staff notified the maintenance department of issues. She said the staff would put the issue in the maintenance log and they would notify maintenance. The surveyor asked what interventions were put into place since Resident #1 eloped. CNA G said the doors were fixed. Interview on [DATE] at 1:08 PM with MA J, revealed she worked 2:00 PM to 10:00 PM on [DATE]. MA J said she did not notice anything unusual about Resident #1. She said Resident #1 was always friendly and pleasant, but he never gave up looking for an exit and trying to get out every door. She said he would say he needed to get his truck. MA J said Resident #1 was easily redirected at times, but he attempted to open any door. The surveyor inquired about Resident #1's verbal behaviors regarding exit-seeking. MA J said the resident felt he was still in school and had tests to do. MA J said there had been a sign on the Terrace Unit doors. She said the sign addressed the issue that both doors were not functioning properly and to be careful regarding the residents. MA J said when she entered and exited the unit, she would make sure the doors latched. She said staff, visitors, and vendors would be on and off the unit. Interview on [DATE] at 1:20 PM with CNA I, revealed Resident #1 was sometimes easily redirected. She said he would try to get out any door he could push. She said he would tell her he felt he was still in school and still had tests to do. A Notification of Room Change, dated [DATE], reflected Resident #1 was being moved to the Terrace Unit, a secured male unit. Resident #1's family member signed the notification on [DATE]. No reason for the transfer was documented. Resident #1's Secured Unit Placement, Admission Evaluation and Authorization form was signed by the resident's family member and dated [DATE]. It reflected Resident #1 was "at risk for wandering away from a familiar setting with the inability to find his way home." During an interview on [DATE] at 3:30 PM with Resident #1's family member, he/she was asked about the resident's placement at the facility. He/she said the resident was put into the nursing home and then placed on Terrace Unit (the secured unit) due to wandering. He/she said Resident #1 would talk about things that did not happen and was very confused. The surveyor asked the family member if Resident #1 knew he was in a nursing home. He/she said he/she did know, but the resident knew he was not in Weatherford. When Resident #1's family member was asked about a sign on the Terrace Unit door, he/she said he/she had noticed it for about two weeks and had asked the DON about it. When asked about the incident with Resident #1 that morning, the family member said he/she was called by the ADM at about 8:00 - 8:15 AM. He/she told the surveyor he was a physician and felt this was a "preventable death situation." During an interview on [DATE] at 4:45 PM with the ADM, she said Terrace Unit's doors had been having problems for about a month with shutting and latching securely. The ADM said staff reported the unit doors not working properly and on [DATE], they had an outside company check the doors and the magnets on the doors were adjusted. The ADM said they had the same company out "today" ([DATE]) at 11:00 AM and fixed the doors to Terrace Unit. She then said according to the staff, the doors were working intermittently. The ADM added the Maintenance Director said all doors were all checked routinely every morning. When the ADM was asked about the sign on the Terrace Unit door, "Attention due to not working please check doors," the ADM stated they took the sign off the door because they had someone monitoring the door. Interview on [DATE] at 4:20 PM with MA C revealed she was monitoring Terrace Unit's doors. She said she had been monitoring the unit doors since 3:20 PM that day ([DATE]). She said she was making sure the door latched when it was closing, and residents were not trying to leave. Interview on [DATE] at 2:55 PM with the Maintenance Director, revealed he found out about the Terrace Unit doors a couple of weeks prior to the incident (with Resident #1 on [DATE]). The surveyor inquired if he only knew about it for a few weeks or since August (2013). The Maintenance Director said it might have been in August when he learned about the doors. The Maintenance Director said the doors had to be sanded down due to foundation problems. He said they were working properly after sanding them down "today" ([DATE]). The Maintenance Director said the locks on the doors had a five-second delay. He said staff would squeeze through the opening of the door, which affected the door locking. The Maintenance Director said when the maintenance staff checked the doors, they were locking. He said they checked the maintenance logs twice a day. He said the doors were checked every morning. He said after the incident (on [DATE] with Resident #1), the doors were being checked every hour. The surveyor inquired about documentation from checking the doors in the past. No documentation was provided. Review of the Terrace Unit maintenance log revealed on [DATE], an entry was made regarding the unit door. The entry reflected: "Main entrance door not locked properly." Maintenance documented on [DATE], "Found no problem with door." Interview on [DATE] at 3:20 PM with LVN H, revealed approximately a month ago, he documented in the maintenance log, the Terrace Unit doors were not functioning properly. He said he also put a sign on the door coming into Terrace Unit letting people know the door would not automatically lock and needed to be given a push. A company's Work Sign-Off Sheet, dated [DATE], provided to the surveyor by the ADM, reflected the work requested was to "check door to Terrace (Unit)." The work performed reflected: "Adjusted door, adjusted door closure to Terrace (Unit)." The same company's Work Sign-Off Sheet, dated [DATE], reflected the following: "Adjusted door closure/shaved ,[DATE]" off top of door(.) Realigned magnetic striker plate on door/lowered door striker away from frame. The door has been tested and now is locking securley (sic)." Resident #1's Psychiatric Progress Notes, dated [DATE], reflected Resident #1's Dementia symptoms continued. Resident #1 was repeating certain words, stories, or behaviors. Resident #1's poor judgment created safety issues when the resident was left alone and was wandering. The resident was unable to organize his thoughts or follow logical explanations. Resident #1 had difficulty naming objects. Psychotic or borderline psychotic process appeared to be present. Delusional ideas were expressed. Resident #1's associations were loose. Insight into problems and social judgment was poor. Review of the Facility Incident Detail Report for [DATE] through [DATE] revealed on [DATE], Resident #1 eloped. Review of the Patient/Resident Incident/Accident Investigation Report dated [DATE] revealed Resident #1 left Terrace Hall after eating lunch. It reflected the Staff Development Coordinator returned Resident #1 to Terrace Hall. The Report reflected the exit door on Terrace Unit was checked for correct locking. The Maintenance Director was notified. Safety checks for Resident #1 were put into place. The facility's plan was for staff and visitors to ensure the door locked/closed securely when they were going off and on Terrace Unit. During an interview on [DATE] at 2:30 PM with the ADM, she was queried about Resident #1's elopement on [DATE]. The ADM said Resident #1 got off the secured unit by following another resident's family member out. She said the Staff Development Coordinator intervened at that time. During an interview on [DATE] at 4:48 PM with the Staff Development Coordinator, she was asked about Resident #1's elopement on [DATE]. She said Resident #1 followed another resident's family member out of the door from Terrace Unit on [DATE]. She said he technically did not get off the unit. The Staff Development Coordinator said she took Resident #1 to the game room and conducted an elopement drill. Observation of Terrace Unit on [DATE] at 4:25 PM, revealed Resident #1's room was the first room on the left near the unit's entrance/exit doors, which had been malfunctioning. The facility's current policy and procedure for Elopement dated [DATE] reflected the following: POLICY: To safely and timely redirect residents to a safe environment.... PROCEDURES: ...10. The facility's Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences.... An Immediate Jeopardy was identified on [DATE]. On [DATE] at 5:37 PM, the ADM was notified of the Immediate Jeopardy (IJ). A Plan of Removal for the IJ was requested. On [DATE] at 3:00 PM, the surveyor toured the facility with the Maintenance Director. The exit doors from the Terrace Unit provided access to the rest of the facility. The Pulmonary Unit was observed with an automatic entrance door, which had a large square button, which had to be pushed in order to exit. The surveyor exited and re-entered through the Pulmonary Unit door several times. The door did not immediately close after a person walked through the door. Further observation revealed an exit door next to the kitchen, where the employee time clock was kept, which was unlocked from 8:00 AM to 5:00 PM; the Sun Room had a keypad, which required a code to exit and the code was posted on the door; an exit door on Hall 300 was kept unlocked, had no alarm and led to the facility's main courtyard; and an exit door on Hall 400 was kept unlocked, had no alarm, and led to the facility's main courtyard. The surveyor and Maintenance Director observed the main courtyard. The Maintenance Director informed the surveyor the gate to exit the courtyard was kept locked. The surveyor approached the fencing on the north side of the courtyard. The gate with the barrier was approximately five and half feet tall. The fencing was a metal scalloped fence built into a concrete base, which was approximately one foot tall and could be used to provide a step up to climb over the fence. The facility's Plan of Removal, which was accepted on [DATE] at 3:45 PM, reflected: On [DATE] at 6:50 AM, Resident #1 received a shower by CNA B. He was last seen at 7:00 AM in his room by LVN A. At 7:40 AM, LVN A reported she realized the resident was not in the dining room for breakfast and went to his room to locate resident, but he was not there. LVN A and CNAs B and G began a room-to-room search, but Resident #1 was not found. At 7:45 AM, LVN A called a code white, which was a signal to indicate an elopement had occurred. Using pictures of the resident, staff began searching the inside and outside perimeter of the facility. At 7:50 AM, the police called the facility informing them they had found an elderly male in the parking lot of a nearby motel, which was less than a mile from the facility. CNA BB and CNA B went to the site. CNA BB called the facility at 7:58 AM and reported to LVN CC to inform the DON and Administrator Resident #1 was at the motel. EMS was present performing CPR on Resident #1 when the ADM arrived. Resident #1 was pronounced at 8:16 AM. Resident did have a documented DNR with order. Resident's Guardian and Physician II were notified. A full head count of all residents was done by the Charge Nurses and CNAs on all stations - no other residents were missing. On [DATE], Maintenance Assistant DD checked all doors on the Terrace Unit at 8:13 AM - all doors were properly functioning at that time. Beginning on [DATE], designated staff members have been assigned to monitor the main door of the Terrace Unit, by station two, 24 hours a day for the next 72 hours, until education of the facility's elopement policy has been completed and unit exits are deemed secured without incident. A log was being completed hourly to report findings of the staff members assigned to monitor this door. The ADM/designee will verify a Door Monitor remains in place during business hours; after hours Charge Nurses on 200 hall will monitor to verify a Door Monitor remains in place. The Maintenance Director and Maintenance Assistant DD will monitor the working function of specific doors throughout the facility, including the secured unit's doors, on a monthly basis and daily Monday thru Friday. Upon finding issues, they will be corrected immediately or outside contractors will be brought in within 24 hours as needed. If the door cannot be repaired by Maintenance, a Door Monitor will be put in place until contractors are able to complete repairs. On [DATE], all doors on the Terrace Unit were inspected by Maintenance Assistant DD and in addition, an outside contractor was also brought in to inspect and make any needed adjustments to the door. The Contractor reported per work order the door was working securely after they adjusted the door closure and shaved an eighth of an inch off top of door. Realigned magnetic striker plate on the door/lowered door striker away from frame. Identified issues are to be addressed and reported to the Administrator and/or Assistant Administrator in a timely (within 24 hours) manner. Terrace ADON M reviewed all secured unit residents charts for a current elopement evaluation; those needing to be updated were reevaluated and current elopement evaluation was completed on [DATE]. List of residents and elopement risk cues included. Elopement Care Plans were reviewed by ADON M and LVNs FF and GG and were updated with appropriate interventions and elopement risk cues as needed on [DATE] through [DATE]. Education on the elopement policy was initiated [DATE], and will be completed by [DATE] by 11:00 PM. The Staff Development Coordinator will reeducate all facility staff on elopement policy: Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Code White. The DON/Charge Nurse will complete a missing resident profile. The DON or Charge Nurse will organize and institute an immediate and thorough search of the center and surrounding grounds, including but not limited to a search of the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resided or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident was found to be missing, the ADM and/or designee will contact the appropriate community agencies (Police, Local Health Department) and Administration, the resident's legal representative and attending physician. Staff will provide the police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex and clothing, if known. The search will be continued. Two staff members will search the surrounding streets by car for a two (2) mile radius around the facility. When the resident is located, the Charge Nurse will complete a head to toe assessment. The Social Service Designee will assess the resident for emotional distress. The Charge Nurse will report any findings to the DON/designee. The DON/designee will notify the appropriate community agencies, attending physician and resident's legal representative. The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrence

Based on observation, interview and record review, the facility's Administrator, the DON and LVN F failed to use the facility's resources effectively and efficiently to maintain the highes practicable physical well-being for one (Resident #1) of four residents reviewed for quality of care, assessment, neglect, consulting with the physician and the facility's physical environment. 1) The Administrator failed to implement the facility's Abuse (and Neglect) Policy when the Administrator failed to provide oversight of an investigation conducted by the DON. This resulted in a failure to identify the DON's inadequate investigation of an incident of neglect. 2) The Administrator failed to ensure the nursing facility was physically maintained in a manner to protect the health and safety of residents and ensured the facility had an effective pest control program. 3) The DON failed to complete a thorough investigation and thus failed to identify training needs of LVN F. The DON conducted the investigation regarding Resident #1 sustaining multiple ant bites, but failed to identify the following: When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: -- conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. -- notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours. On 09/26/13 an Immediate Jeopardy (IJ) was identified in the area of quality of care and accurate assessments. While the IJ was removed on 09/30/13, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and at a potential for more than minimal harm and scope of "pattern." because staff were still being inserviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 152 residents, including Residents #1, #2, #3 and #4, at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: On 09/26/13, based on administrative review, the investigation was reopened for further investigation of a current Immediate Jeopardy situation. Resident #1's MDS assessment, dated 08/25/13, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment, received nourishment via tube feeding, and required total dependence on staff for activities of daily living to include bed mobility and personal hygiene. Resident #1's care plan with a current review date of 08/11/13, reflected the following: a) ADL functions reflected she was totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches included to provide Resident #1 with assistance as needed. b) [DIAGNOSES REDACTED]. Approaches included following safety measures and implementing [MEDICAL CONDITION] precautions. c) Resident had difficulty making self understood related to her [DIAGNOSES REDACTED]. Approaches included to observe for non-verbal signs of distress (guarding, moaning, restlessness, grimacing, withdrawal, etc.). Turn/reposition, communicate, provide pericare, assess for pain, and provide liquids/food as needed. Staff must anticipate needs. Resident unable to communicate. d) Resident is at risk for skin breakdown related to bowel and bladder incontinence. The goal was for the resident's skin to remain intact. Approaches included to assess the resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident's room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident's room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and "covered" in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death. Resident #1's nurse's notes dated 09/01/13 and timed both at 5:30 AM and 11:40 PM (start of shift was on 08/31/13), reflected ants were on the resident's dresser and some on her bed. The nurse conducted an assessment of the resident and noted she had no ant bites and had no signs and symptoms of pain. The resident's MD was notified and an order was received to move the resident to another room, and the family was notified of the resident's transfer to a different room due to the presence of ants. An entry at 8:30 AM, reflected the resident was resting comfortably and there were no signs of ants or ant bites in the new room (which shared a wall with Resident #1's old room). The next nurse's notes entry for Resident #1, dated 09/03/13 at 9:30 AM, reflected the nurse heard a nurse aide calling "come STAT (immediately) to room (Resident #1's room). The nurse entered the room and observed two nurse aides and the resident's mother striping her bed. Resident #1's mother was "yelling" that her daughter had ants all on her. The resident had bites on both arms, along her collar bone and the front of her legs, and that the areas were slightly swollen and red. The physician's NP was consulted and gave orders for 50 mg of [MEDICATION NAME] and 7.5 mg of Loratab via her feeding tube, and to apply [MEDICATION NAME] cream to her body. The resident's mother wanted her transferred to a hospital, at 10:00 AM, and at 4:00 PM, Resident #1 returned from the hospital via ambulance. A Patient/Resident Incident/Accident Investigation Worksheet, completed by LVN F on 09/01/13, documented on 09/01/13 at 9:20 AM, Resident #1 was found to have ant bites. At 9:20 AM, the resident's mother came and found ants in the resident's bed and room. Staff then cleaned the ants off the resident and applied cream with medication given per [DEVICE]. On 09/13/13 at 9:15 AM, during an interview with CNA E, she confirmed she worked on 09/01/13, and that she had been assigned the hall where Resident #1 resided. She stated her shift began at 6:00 AM. She stated she was not informed about ants being found in Resident #1's room and bed during the previous shift. She stated she checked on Resident #1 briefly, but did not pull back her sheet to check for ants or perform any incontinence care. She stated around 9:00 AM, she saw Resident #1's family member enter the resident's room and then heard the resident's family member yelling for help. She stated when she arrived at Resident #1's room, "hundreds of ants" were on Resident #1, as well as on her bed and under the resident. CNA E stated she had previously seen ants on the 200 and 300 halls, but denied seeing them on any resident. CNA E stated staff now report any sightings of ants to the charge nurse and maintenance. On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1's family member call for help and went to assist. He stated Resident #1 was "covered from head-to-toe in ants." He stated he focused on helping get the ants off her. He added there were "too many ants to count." During a confidential staff interview, he/she stated he/she had assisted with removing ants from Resident #1 on 09/01/13, and had provided care for the resident when the resident returned from the hospital. The confidential interviewee (CI) stated he/she was present when Resident #1's family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1's brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1's sheets had not been changed the night before when the ants where initially found in the resident's bed. The CI stated Resident #1's brief was "filled with ants," and there were "hundreds" of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being "covered in bites." The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready. The CI stated Resident #1 was then moved to another unit. The CI stated he/she went to check on the resident and she was wrapped in a sheet and when he/she removed the sheet from the resident, he/she observed three to four ants. The CI stated he/she knew the sheets and the mattress were clean and free of ants, so he/she checked Resident #1's wheelchair. The CI stated he/she discovered the pad in the seat of the wheelchair had a hole with food in it as well as food under the pad. The CI shook the pad and approximately eight to nine ants came out of the pad. The CI stated this incident was reported to the DON and Administrator. On 09/16/13 at approximately 11:15 AM, during an interview with LVN F, she confirmed she worked on 09/01/13, and her shift was 6:00 AM to 2:00 PM. She stated she had been the charge nurse for the 200 and 300 halls, which included Resident #1. She stated the night nurse told her ants had been found in Resident #1's room and the resident was moved to a new room. She stated she did a "quick check" of Resident #1 during walking rounds at approximately 6:00 AM, and then did a complete check of Resident #1 at approximately 8:30 AM. She stated the complete check included pulling back Resident #1's covers and checking her body for ant bites and did not find any. During the interview with LVN F, she further stated that at approximately 9:20 AM, she was called by a nurse aide to Resident #1's room. She stated she did not see "a great deal of ants;" no more than 30 ants. LVN F stated she observed ant bites around Resident #1's collarbone and the front of her chest. She stated she did not observe any ant bites on Resident #1's trunk or vaginal area. She stated the bites did not have "blisters" and Resident #1 did not have any facial expression indicating she was in pain. (Note: CNA E and the CI both stated they saw "hundreds of ants," and MA G stated he saw "too many (ants) to count.") LVN F further stated she contacted Resident #1's physician's answering service and then spoke with the physician's NP regarding the incident. She stated the NP who prescribed Resident #1 [MEDICATION NAME] and Loritab, said if Resident #1's family member wanted her sent to the hospital to go ahead and send her. Resident #1's family member requested the resident be sent to the hospital so she contacted a non-emergency transport company and was told that due to Resident #1 being total care, they would be unable to transport the resident. She stated she then contacted an ambulance service for a non-emergency transport. LVN F stated she was not sure if she had notified Resident #1's physician about Resident #1 being sent to the hospital, but did notify the physician upon the resident's return to the facility. (Note: LVN F's nurse's notes for 09/01/13, provided no evidence the physician or his NP were consulted prior to the resident being transferred to a local hospital or upon the resident's return to the facility.) On 09/17/13 at 3:30 PM, during an interview with the DON, she stated that on 09/01/13, between 9:30 AM to 10:00 AM, she was notified of the incident involving Resident #1 and the ants. She recalled that Resident #1 was sent out to the hospital due to the family member's request. The DON stated she arrived at the facility shortly after she was notified of the incident but she did not observe Resident #1 until she had returned from the hospital. The DON stated she conducted the investigation of the incident. she could ot explain why LVN F's nurse's notes did not provide and accurate assessment of the number of Resident #1's number of ant bites. She stated she did not interview LVN F regarding her statement that Resident #1 only received 30 ant bites. She stated she was not aware LVN F had not disclosed the severity of Resident #1's ant bites when she consulted with the physician's NP. She was not aware that neither the physician nor the physician's NP had been consulted regarding Resident #1's transfer to the hospital. She was not aware that neither the physician nor his NP were notified when Resident #1 returned to the facility from the hospital. Nurse's notes, dated 09/01/13 at 4:00 PM, reflected the hospital's physician gave orders for the resident to receive 500 mg of Keflex four times a day for seven days, 4 mg of [MEDICATION NAME][MEDICATION NAME] to take as directed on the package, and [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg/167 mg per 5 ml solution, take 10 ml (two teasponns) every 6 hours as needed for pain. The nurses' notes provided no documented evidence the resident's physician or the physician's PA were notified of the request to transfer the resident to the hospital or of the resident's return from the hospital with new orders. On 09/13/13 at 10:15 AM, during an interview with the physician's NP, she stated she was first notified around midnight (12:00 AM) on 09/01/13, of the ants in Resident #1's room. She stated she received another telephone call later that morning, but was uncertain of the time, and was told the resident had been moved to another room. She stated a third telephone call was received from the facility on 09/01/13, saying Resident #1's family member was worried about Resident #1 being in pain from "some ant bites." She stated she prescribed a topical cream, pain medication, and [MEDICATION NAME]. She stated she was not informed of the number of ant bites or seriousness of the incident. The NP stated she received another telephone call from the facility on 09/02/13 at around midnight to inform her that Resident #1's family member did not want Resident #1 to take the steroids prescribed by the emergency room physician. The NP stated she had been unaware Resident #1 had transferred to a hospital emergency room or of Resident #1's return to the facility. The NP stated she did not see Resident #1 until Tuesday (09/03/13), but could tell that she would have sent Resident #1 to the hospital at the time of the incident if the seriousness of the incident had been conveyed. The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1's physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the "worst case scenario" would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a "massive infection." The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, "There had to be hundreds of ants to have caused the extent of (Resident #1's) injuries." Resident #1's nurse's notes reflected the following entries regarding her ant bites: Entry dated 09/03/13 on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected Resident #1 was "small and frail in stature and unable to make needs known." The resident had contractures to "knees, hips, and elbows bilaterally." Ant bites are noted to Resident #1's "entire body from dense to sparse concentrations." The densest concentrations of ant bites are in the following areas: the base of the back of the neck, the right posterior flank area, left posterior thigh, and left posterior lateral calf. The ants bites are "cluster of fluid filled pustules, too numerous to count." Entry dated 09/06/13 (5 days after the incident) on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected a skin assessment was performed due to the incident of multiple ant bites. The densest concentrations of ant bites are the left posterior thigh and left posterior lateral calf. The ant bites in these areas are "very red and irritated" with a decrease in the fluid filled pustules. The ant bites to the neck, bilateral arms, and right flack are "red and angry, but the concentration of redness has decreased." Observation on 09/13/13 at 12:29 PM, of Resident #1 in her room, revealed she was in bed with socks on her hand. Resident #1's family member was present and stated the socks were used to prevent Resident #1 from scratching herself. Ant bites were observed on all of Resident #1's limbs, neck, shoulders, back, right rib cage, and left inner thigh. Several of the ant bites were observed to have pustules. The family member removed the socks and Resident #1 immediately began scratching her neck and shoulder area. Resident #1 had several dark red scratch marks on both her upper arms and shoulder area. Resident #1's facial expression indicated she was distressed. Resident #1 made slight groaning noises and continued to attempt to scratch at areas with ant bites. Review of the Provider Investigation Report, signed by the DON and dated 09/06/13, identified the category of the incident involving Resident #1 as "Other: Ant Bites." It reflected the incident occurred on 09/01/13, and was reported to the State Agency on 09/01/13. The summary of the investigation reflected: A nurse observed ants on the resident's dresser and on her bed on 08/31/13 at approximately 11:40 PM. The resident and her roommate were moved to another room and both residents were assessed and no observations of ants were noted on either resident. Staff continued to monitor throughout the shift. On 09/01/13 at 9:30 AM, the resident's mother observed ants on the resident. A nurse assessed Resident #1 and observed multiple ant bits on Resident #1 and the areas were closed and slightly swollen. The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms. Resident #1 was moved to another room, and her previous room was deep cleaned, and she was provided with a new wheelchair cushion. A head-to-toe assessment was conducted every shift. A pest control provider treated the interior and exterior of the facility. (The copies of billing from the pest control provider were for 08/09/13, 08/13/13, 08/16/13, 08/20/13, 08/21/13, 08/26/13, 08/27/13, and 09/06/13.) Staff, including nursing staff, maintenance, housekeeping and administration, were educated on monitoring rooms for ant activity, implementing safety checks for ants, who to notify in the event of finding ants, and how to respond if ants were observed on residents or beds/linens. Daily monitoring continued for observation of ants. The plan did not address ensuring nurses conduct accurate assessments of residents and ensuring nurses provide complete and accurate information when consulting with a resident's physician. It furthermore did not provide information regarding how they addressed ensuring nurses consult/notify a physician when a resident is being transferred to a hospital and again when they return with an order to review the treatment orders from the hospital to allow the attending physician to determine if he wants to approve the new treatment plan or change it. Review of the facility's Patient/Resident Incident/Accident Investigation Worksheets revealed on 08/31/13 at 11:49 PM, Resident #3 was found in her room with ants on her dresser. The nurse conducted a head-to-toe assessment of the resident and found no ant bites. (Note: This incident occurred the day before Resident #1 was found in the same room covered with ants.) Review of the facility's Service Request Log for the contract exterminator revealed the following: 08/20/13 at 2:30 p.m. - Entire unit needs to be sprayed. Bugs and ants in every room. On 08/21/13 (no time) - Entire room [ROOM NUMBER] and bed B have ants. On 08/21/13 (no time) - Ants in closet in room [ROOM NUMBER] on clothes. On 09/01/13 (no time) - Ants in resident room [ROOM NUMBER] and restroom. On 09/03/13 (no time) - Ants at nurses' station (station not specified). Review of the pest control service provider's receipts for treatment revealed the following: 08/13/13: room [ROOM NUMBER] was treated. The facility's exterior was treated. Ants were the targeted pest. Ants were noted during service. A Fire Ant mound was noted near an exit door. Ants were noted in room [ROOM NUMBER]. 08/16/13: this visit was in regard to cockroaches in the kitchen and the treatment of [REDACTED]. 08/20/13: The facility's exterior area was treated. Ants were noted during service. The courtyard of the secured unit, 200 hall, was treated. rooms [ROOM NUMBERS] were treated for [REDACTED]. 08/21/13: Patient/guest rooms were treated. The targeted pest was ants. rooms [ROOM NUMBERS] were treated. Ants were noted during service under cold base in rooms [ROOM NUMBERS]. 08/25/13: The facility's exterior area and patient/guest rooms were treated. The targeted pest was ants. The areas were inspected and treated and rooms were serviced. room [ROOM NUMBER], baseboards, was treated. Ants were noted during services; baseboards around bed. 08/27/13: The facility's perimeter was treated and ants were the target. Ants were noted during service; several ants near building on exterior of building. Trees/shrubs were contacting the facility creating a path for pests to enter. The service provider suggested the facility trim back vegetation to eliminate contact. 09/06/13: The exterior of the widnoew and ground near room [ROOM NUMBER]. On 09/13/13 at 3:20 PM, interview with the Pest Control Service Provider revealed only one fire ant mound was found after the incident that occurred on 09/01/13. The service provider completed a "power spray" approximately two weeks ago. It will sometimes drive the insects into the facility where they will ingest the poison and then die. The service provider and the facility are working on controlling the issue. On 09/13/13 at 2:28 PM, interview with the Administrator revealed the facility did not have a specific policy regarding ants, just the statement written for the in-service conducted after the incident on 09/01/13. On 09/13/13 at 2:50 PM, interview with the Maintenance Director revealed prior to the incident on 09/01/13, the facility had been calling the exterminator when ants were found in the facility. The Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The identified repairs were completed following the compilation of the list of repairs needed, however completion dates were not provided at that time. Any ants seen in the facility are logged by staff in a maintenance log book located at each nurses' station. The log books are check twice a day. Insect sightings are also logged in a pest control book located at the nurses' station that is monitored by the pest control service provider on a monthly basis. If only a couple of ants are sighted the maintenance staff will treat the area himself. If it is a resident room he will also treat outside near the exterior wall of the room. Maintenance staff also monitor outside for ant mounds on a daily basis. Review of an undated, untitled document attached to the Facility's Provider Investigation Report involving Resident #1 revealed a list of resident rooms in the facility with environmental issues. On 09/13/13 at 2:50 PM, the Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The list included a total of 82 resident rooms that needed "caulk around the windows." The following are the rooms identified: 1, 3, 11, 18, 20-22, 24-25, 28-30, 33-34, 38-39, 41-42, 45, 59-60, 200-213, 215-226, 228, 301-309, 311-313, 315, 401-408, 412-415, 418-420, 422-424, 426-427, and 429. The list also included 20 rooms that needed "caulk around the windows" and in the bathroom. The identified rooms were: 4, 23, 26, 31-32, 35-36, 40, 44, 48-49, 51-58, and 310. Also identified on the list were the following five rooms that needed caulking in the bathroom only: 9, 10, 12, 19, and 411. The list identified seven rooms where ants were found, the rooms were: 5, 9, 11, 20, 53, 55, and 406. The list also identified other environmental issues in resident rooms. In room [ROOM NUMBER] a hole in the widow screen was identified. In room [ROOM NUMBER] the "window doesn't shut all the way," and the frame was "rotten." In room [ROOM NUMBER] the window was "still broken," and room [ROOM NUMBER] had "broken window trim." The window in room [ROOM NUMBER] was described as being in "bad shape." room [ROOM NUMBER] had a hole by the bathroom door, and room [ROOM NUMBER] had a broken baseboard. A total of 107 resident rooms of the 120 resident rooms in the facility were identified as needing some type of repair. On 09/13/13 at approximately 4:00 PM, the Administrator and Assistant Administrator revealed the plan to address the ants in the facility included the following: One hour checks of total care residents by direct care staff, daily checks on residents' rooms by clinical staff and housekeeping, and daily checks by maintenance outside the facility for ant mounds. Logs of the resident and room checks were kept at each nurses' station, one for direct care staff and one for housekeeping. Staff documents any sightings of ants in the maintenance log as well as the other identified logs. The Assistant Administrator stated he has begun marking rooms where ants were sited on a floor plan so he can monitor which rooms are impacted. The Administrator stated the monitoring began on 08/28/13, but some of the nurses' stations did not begin their logs until 09/02/13. Maintenance staff is monitoring the maintenance logs kept at the nursing stations at least once a day. Maintenance treats any sightings of insects immediately and coordinates further treatments with the pest control service providers. Review of the facility's "Daily Ant Inspection" logs revealed rooms on the 200 Hall, 300 Hall, 400 Hall, The Terrace, and The Verandah were monitored once a day for ants from 08/28/13 to 09/14/13. Ants were noted on 09/01/13 in Rooms 211, 213, 310, and the 300 Hall Shower Room. Ants were noted on 09/01/13 in room [ROOM NUMBER], and the 300 Hall. Ants were noted on 09/04/13 in rooms [ROOM NUMBERS]. Ants were noted on 09/04/13 in Rooms 310, and 417, and 400 Hall Shower Room. Ants were noted on 09/05/13 in room [ROOM NUMBER]. Ants were noted on 09/06/13 in room [ROOM NUMBER]. Ants were noted on 09/10/13 in room [ROOM NUMBER]. Ants were noted on 09/12/13 in room [ROOM NUMBER]. Ants were noted on 09/14/13 in rooms [ROOM NUMBERS]. Review of the in-service regarding "ants/residents," conducted on 09/04/13, revealed the following: "If a resident is found to have ants in the room the following should be done; head-to-toe assessment done on the resident, shower the resident, change gown and linens. If the resident is needed to change rooms the bed must be changed as well. One hour ant round logs are to be completed by each shift." The facility's current Nursing Policies and Procedures included: Physician Communication/Change in Condition, revised September 2011 and reflected the following: "POLICY: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition. PROCEDURES: 1. Complete assessment of the patient/resident which may include but is not limited to: ...B. Current physical condition C. Patient's/resident's previous condition (declining, improving, stable) ...E. Vital signs, TPR (temperature), BP (blood pressure)...Lung Sounds, N/V Abdominal Assessment, Pain... ...H. allergies [REDACTED]. ...L. Any interventions/first aide (sic) provided to the patient/resident... 2. Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified... 4. The patient's/resident's family member/legal representative will be notified of any change in condition requiring an emergent transfer to the hospital...." A Physician Communication Grid was provided as guidelines for notifying the physician and reflected: "These guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event...." Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised on February 2008, revealed the following: "1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, when requ

Based on observation, interview and record review, the facility failed to maintain an effective pest control program as evidenced by an infestation of fire ants. When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: -- conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. -- notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours. On 09/26/13 an Immediate Jeopardy (IJ) was identified in the area of quality of care and accurate assessments. While the IJ was removed on 09/30/13, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and at a potential for more than minimal harm and scope of "pattern." because staff were still being inserviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 152 residents, including Residents #1, #2, #3 and #4, at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: On 09/26/13, based on administrative review, the investigation was reopened for further investigation of a current Immediate Jeopardy situation. Resident #1's MDS assessment, dated 08/25/13, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment, received nourishment via tube feeding, and required total dependence on staff for activities of daily living to include bed mobility and personal hygiene. Resident #1's care plan with a current review date of 08/11/13, reflected the following: a) ADL functions reflected she was totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches included to provide Resident #1 with assistance as needed. b) [DIAGNOSES REDACTED]. Approaches included following safety measures and implementing [MEDICAL CONDITION] precautions. c) Resident had difficulty making self understood related to her [DIAGNOSES REDACTED]. Approaches included to observe for non-verbal signs of distress (guarding, moaning, restlessness, grimacing, withdrawal, etc.). Turn/reposition, communicate, provide pericare, assess for pain, and provide liquids/food as needed. Staff must anticipate needs. Resident unable to communicate. d) Resident is at risk for skin breakdown related to bowel and bladder incontinence. The goal was for the resident's skin to remain intact. Approaches included to assess the resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident's room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident's room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and "covered" in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death. Resident #1's nurse's notes dated 09/01/13 and timed both at 5:30 AM and 11:40 PM (start of shift was on 08/31/13), reflected ants were on the resident's dresser and some on her bed. The nurse conducted an assessment of the resident and noted she had no ant bites and had no signs and symptoms of pain. The resident's MD was notified and an order was received to move the resident to another room, and the family was notified of the resident's transfer to a different room due to the presence of ants. An entry at 8:30 AM, reflected the resident was resting comfortably and there were no signs of ants or ant bites in the new room (which shared a wall with Resident #1's old room). The next nurse's notes entry for Resident #1, dated 09/03/13 at 9:30 AM, reflected the nurse heard a nurse aide calling "come STAT (immediately) to room (Resident #1's room). The nurse entered the room and observed two nurse aides and the resident's mother striping her bed. Resident #1's mother was "yelling" that her daughter had ants all on her. The resident had bites on both arms, along her collar bone and the front of her legs, and that the areas were slightly swollen and red. The physician's NP was consulted and gave orders for 50 mg of [MEDICATION NAME] and 7.5 mg of Loratab via her feeding tube, and to apply [MEDICATION NAME] cream to her body. The resident's mother wanted her transferred to a hospital, at 10:00 AM, and at 4:00 PM, Resident #1 returned from the hospital via ambulance. A Patient/Resident Incident/Accident Investigation Worksheet, completed by LVN F on 09/01/13, documented on 09/01/13 at 9:20 AM, Resident #1 was found to have ant bites. At 9:20 AM, the resident's mother came and found ants in the resident's bed and room. Staff then cleaned the ants off the resident and applied cream with medication given per [DEVICE]. On 09/13/13 at 9:15 AM, during an interview with CNA E, she confirmed she worked on 09/01/13, and that she had been assigned the hall where Resident #1 resided. She stated her shift began at 6:00 AM. She stated she was not informed about ants being found in Resident #1's room and bed during the previous shift. She stated she checked on Resident #1 briefly, but did not pull back her sheet to check for ants or perform any incontinence care. She stated around 9:00 AM, she saw Resident #1's family member enter the resident's room and then heard the resident's family member yelling for help. She stated when she arrived at Resident #1's room, "hundreds of ants" were on Resident #1, as well as on her bed and under the resident. CNA E stated she had previously seen ants on the 200 and 300 halls, but denied seeing them on any resident. CNA E stated staff now report any sightings of ants to the charge nurse and maintenance. On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1's family member call for help and went to assist. He stated Resident #1 was "covered from head-to-toe in ants." He stated he focused on helping get the ants off her. He added there were "too many ants to count." During a confidential staff interview, he/she stated he/she had assisted with removing ants from Resident #1 on 09/01/13, and had provided care for the resident when the resident returned from the hospital. The confidential interviewee (CI) stated he/she was present when Resident #1's family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1's brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1's sheets had not been changed the night before when the ants where initially found in the resident's bed. The CI stated Resident #1's brief was "filled with ants," and there were "hundreds" of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being "covered in bites." The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready. The CI stated Resident #1 was then moved to another unit. The CI stated he/she went to check on the resident and she was wrapped in a sheet and when he/she removed the sheet from the resident, he/she observed three to four ants. The CI stated he/she knew the sheets and the mattress were clean and free of ants, so he/she checked Resident #1's wheelchair. The CI stated he/she discovered the pad in the seat of the wheelchair had a hole with food in it as well as food under the pad. The CI shook the pad and approximately eight to nine ants came out of the pad. The CI stated this incident was reported to the DON and Administrator. On 09/16/13 at approximately 11:15 AM, during an interview with LVN F, she confirmed she worked on 09/01/13, and her shift was 6:00 AM to 2:00 PM. She stated she had been the charge nurse for the 200 and 300 halls, which included Resident #1. She stated the night nurse told her ants had been found in Resident #1's room and the resident was moved to a new room. She stated she did a "quick check" of Resident #1 during walking rounds at approximately 6:00 AM, and then did a complete check of Resident #1 at approximately 8:30 AM. She stated the complete check included pulling back Resident #1's covers and checking her body for ant bites and did not find any. During the interview with LVN F, she further stated that at approximately 9:20 AM, she was called by a nurse aide to Resident #1's room. She stated she did not see "a great deal of ants;" no more than 30 ants. LVN F stated she observed ant bites around Resident #1's collarbone and the front of her chest. She stated she did not observe any ant bites on Resident #1's trunk or vaginal area. She stated the bites did not have "blisters" and Resident #1 did not have any facial expression indicating she was in pain. (Note: CNA E and the CI both stated they saw "hundreds of ants," and MA G stated he saw "too many (ants) to count.") LVN F further stated she contacted Resident #1's physician's answering service and then spoke with the physician's NP regarding the incident. She stated the NP who prescribed Resident #1 [MEDICATION NAME] and Loritab, said if Resident #1's family member wanted her sent to the hospital to go ahead and send her. Resident #1's family member requested the resident be sent to the hospital so she contacted a non-emergency transport company and was told that due to Resident #1 being total care, they would be unable to transport the resident. She stated she then contacted an ambulance service for a non-emergency transport. LVN F stated she was not sure if she had notified Resident #1's physician about Resident #1 being sent to the hospital, but did notify the physician upon the resident's return to the facility. (Note: LVN F's nurse's notes for 09/01/13, provided no evidence the physician or his NP were consulted prior to the resident being transferred to a local hospital or upon the resident's return to the facility.) On 09/17/13 at 3:30 PM, during an interview with the DON, she stated that on 09/01/13, between 9:30 AM to 10:00 AM, she was notified of the incident involving Resident #1 and the ants. She recalled that Resident #1 was sent out to the hospital due to the family member's request. The DON stated she arrived at the facility shortly after she was notified of the incident but she did not observe Resident #1 until she had returned from the hospital. The DON stated she conducted the investigation of the incident. she could ot explain why LVN F's nurse's notes did not provide and accurate assessment of the number of Resident #1's number of ant bites. She stated she did not interview LVN F regarding her statement that Resident #1 only received 30 ant bites. She stated she was not aware LVN F had not disclosed the severity of Resident #1's ant bites when she consulted with the physician's NP. She was not aware that neither the physician nor the physician's NP had been consulted regarding Resident #1's transfer to the hospital. She was not aware that neither the physician nor his NP were notified when Resident #1 returned to the facility from the hospital. Nurse's notes, dated 09/01/13 at 4:00 PM, reflected the hospital's physician gave orders for the resident to receive 500 mg of Keflex four times a day for seven days, 4 mg of [MEDICATION NAME][MEDICATION NAME] to take as directed on the package, and [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg/167 mg per 5 ml solution, take 10 ml (two teasponns) every 6 hours as needed for pain. The nurses' notes provided no documented evidence the resident's physician or the physician's PA were notified of the request to transfer the resident to the hospital or of the resident's return from the hospital with new orders. On 09/13/13 at 10:15 AM, during an interview with the physician's NP, she stated she was first notified around midnight (12:00 AM) on 09/01/13, of the ants in Resident #1's room. She stated she received another telephone call later that morning, but was uncertain of the time, and was told the resident had been moved to another room. She stated a third telephone call was received from the facility on 09/01/13, saying Resident #1's family member was worried about Resident #1 being in pain from "some ant bites." She stated she prescribed a topical cream, pain medication, and [MEDICATION NAME]. She stated she was not informed of the number of ant bites or seriousness of the incident. The NP stated she received another telephone call from the facility on 09/02/13 at around midnight to inform her that Resident #1's family member did not want Resident #1 to take the steroids prescribed by the emergency room physician. The NP stated she had been unaware Resident #1 had transferred to a hospital emergency room or of Resident #1's return to the facility. The NP stated she did not see Resident #1 until Tuesday (09/03/13), but could tell that she would have sent Resident #1 to the hospital at the time of the incident if the seriousness of the incident had been conveyed. The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1's physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the "worst case scenario" would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a "massive infection." The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, "There had to be hundreds of ants to have caused the extent of (Resident #1's) injuries." Resident #1's nurse's notes reflected the following entries regarding her ant bites: Entry dated 09/03/13 on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected Resident #1 was "small and frail in stature and unable to make needs known." The resident had contractures to "knees, hips, and elbows bilaterally." Ant bites are noted to Resident #1's "entire body from dense to sparse concentrations." The densest concentrations of ant bites are in the following areas: the base of the back of the neck, the right posterior flank area, left posterior thigh, and left posterior lateral calf. The ants bites are "cluster of fluid filled pustules, too numerous to count." Entry dated 09/06/13 (5 days after the incident) on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected a skin assessment was performed due to the incident of multiple ant bites. The densest concentrations of ant bites are the left posterior thigh and left posterior lateral calf. The ant bites in these areas are "very red and irritated" with a decrease in the fluid filled pustules. The ant bites to the neck, bilateral arms, and right flack are "red and angry, but the concentration of redness has decreased." Observation on 09/13/13 at 12:29 PM, of Resident #1 in her room, revealed she was in bed with socks on her hand. Resident #1's family member was present and stated the socks were used to prevent Resident #1 from scratching herself. Ant bites were observed on all of Resident #1's limbs, neck, shoulders, back, right rib cage, and left inner thigh. Several of the ant bites were observed to have pustules. The family member removed the socks and Resident #1 immediately began scratching her neck and shoulder area. Resident #1 had several dark red scratch marks on both her upper arms and shoulder area. Resident #1's facial expression indicated she was distressed. Resident #1 made slight groaning noises and continued to attempt to scratch at areas with ant bites. Review of the Provider Investigation Report, signed by the DON and dated 09/06/13, identified the category of the incident involving Resident #1 as "Other: Ant Bites." It reflected the incident occurred on 09/01/13, and was reported to the State Agency on 09/01/13. The summary of the investigation reflected: A nurse observed ants on the resident's dresser and on her bed on 08/31/13 at approximately 11:40 PM. The resident and her roommate were moved to another room and both residents were assessed and no observations of ants were noted on either resident. Staff continued to monitor throughout the shift. On 09/01/13 at 9:30 AM, the resident's mother observed ants on the resident. A nurse assessed Resident #1 and observed multiple ant bits on Resident #1 and the areas were closed and slightly swollen. The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms. Resident #1 was moved to another room, and her previous room was deep cleaned, and she was provided with a new wheelchair cushion. A head-to-toe assessment was conducted every shift. A pest control provider treated the interior and exterior of the facility. (The copies of billing from the pest control provider were for 08/09/13, 08/13/13, 08/16/13, 08/20/13, 08/21/13, 08/26/13, 08/27/13, and 09/06/13.) Staff, including nursing staff, maintenance, housekeeping and administration, were educated on monitoring rooms for ant activity, implementing safety checks for ants, who to notify in the event of finding ants, and how to respond if ants were observed on residents or beds/linens. Daily monitoring continued for observation of ants. The plan did not address ensuring nurses conduct accurate assessments of residents and ensuring nurses provide complete and accurate information when consulting with a resident's physician. It furthermore did not provide information regarding how they addressed ensuring nurses consult/notify a physician when a resident is being transferred to a hospital and again when they return with an order to review the treatment orders from the hospital to allow the attending physician to determine if he wants to approve the new treatment plan or change it. Review of the facility's Patient/Resident Incident/Accident Investigation Worksheets revealed on 08/31/13 at 11:49 PM, Resident #3 was found in her room with ants on her dresser. The nurse conducted a head-to-toe assessment of the resident and found no ant bites. (Note: This incident occurred the day before Resident #1 was found in the same room covered with ants.) Review of the facility's Service Request Log for the contract exterminator revealed the following: 08/20/13 at 2:30 p.m. - Entire unit needs to be sprayed. Bugs and ants in every room. On 08/21/13 (no time) - Entire Room 424 and bed B have ants. On 08/21/13 (no time) - Ants in closet in Room 426 on clothes. On 09/01/13 (no time) - Ants in resident Room 427 and restroom. On 09/03/13 (no time) - Ants at nurses' station (station not specified). Review of the pest control service provider's receipts for treatment revealed the following: 08/13/13: Room 426 was treated. The facility's exterior was treated. Ants were the targeted pest. Ants were noted during service. A Fire Ant mound was noted near an exit door. Ants were noted in Room 426. 08/16/13: this visit was in regard to cockroaches in the kitchen and the treatment of [REDACTED]. 08/20/13: The facility's exterior area was treated. Ants were noted during service. The courtyard of the secured unit, 200 hall, was treated. Rooms 223 and 225 were treated for [REDACTED]. 08/21/13: Patient/guest rooms were treated. The targeted pest was ants. Rooms 424 and 426 were treated. Ants were noted during service under cold base in Rooms 424 and 426. 08/25/13: The facility's exterior area and patient/guest rooms were treated. The targeted pest was ants. The areas were inspected and treated and rooms were serviced. Room 40, baseboards, was treated. Ants were noted during services; baseboards around bed. 08/27/13: The facility's perimeter was treated and ants were the target. Ants were noted during service; several ants near building on exterior of building. Trees/shrubs were contacting the facility creating a path for pests to enter. The service provider suggested the facility trim back vegetation to eliminate contact. 09/06/13: The exterior of the widnoew and ground near Room 417. On 09/13/13 at 3:20 PM, interview with the Pest Control Service Provider revealed only one fire ant mound was found after the incident that occurred on 09/01/13. The service provider completed a "power spray" approximately two weeks ago. It will sometimes drive the insects into the facility where they will ingest the poison and then die. The service provider and the facility are working on controlling the issue. On 09/13/13 at 2:28 PM, interview with the Administrator revealed the facility did not have a specific policy regarding ants, just the statement written for the in-service conducted after the incident on 09/01/13. On 09/13/13 at 2:50 PM, interview with the Maintenance Director revealed prior to the incident on 09/01/13, the facility had been calling the exterminator when ants were found in the facility. The Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The identified repairs were completed following the compilation of the list of repairs needed, however completion dates were not provided at that time. Any ants seen in the facility are logged by staff in a maintenance log book located at each nurses' station. The log books are check twice a day. Insect sightings are also logged in a pest control book located at the nurses' station that is monitored by the pest control service provider on a monthly basis. If only a couple of ants are sighted the maintenance staff will treat the area himself. If it is a resident room he will also treat outside near the exterior wall of the room. Maintenance staff also monitor outside for ant mounds on a daily basis. Review of an undated, untitled document attached to the Facility's Provider Investigation Report involving Resident #1 revealed a list of resident rooms in the facility with environmental issues. On 09/13/13 at 2:50 PM, the Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The list included a total of 82 resident rooms that needed "caulk around the windows." The following are the rooms identified: 1, 3, 11, 18, 20-22, 24-25, 28-30, 33-34, 38-39, 41-42, 45, 59-60, 200-213, 215-226, 228, 301-309, 311-313, 315, 401-408, 412-415, 418-420, 422-424, 426-427, and 429. The list also included 20 rooms that needed "caulk around the windows" and in the bathroom. The identified rooms were: 4, 23, 26, 31-32, 35-36, 40, 44, 48-49, 51-58, and 310. Also identified on the list were the following five rooms that needed caulking in the bathroom only: 9, 10, 12, 19, and 411. The list identified seven rooms where ants were found, the rooms were: 5, 9, 11, 20, 53, 55, and 406. The list also identified other environmental issues in resident rooms. In Room 3 a hole in the widow screen was identified. In Room 13 the "window doesn't shut all the way," and the frame was "rotten." In Room 301 the window was "still broken," and Room 307 had "broken window trim." The window in Room 311 was described as being in "bad shape." Room 409 had a hole by the bathroom door, and Room 413 had a broken baseboard. A total of 107 resident rooms of the 120 resident rooms in the facility were identified as needing some type of repair. On 09/13/13 at approximately 4:00 PM, the Administrator and Assistant Administrator revealed the plan to address the ants in the facility included the following: One hour checks of total care residents by direct care staff, daily checks on residents' rooms by clinical staff and housekeeping, and daily checks by maintenance outside the facility for ant mounds. Logs of the resident and room checks were kept at each nurses' station, one for direct care staff and one for housekeeping. Staff documents any sightings of ants in the maintenance log as well as the other identified logs. The Assistant Administrator stated he has begun marking rooms where ants were sited on a floor plan so he can monitor which rooms are impacted. The Administrator stated the monitoring began on 08/28/13, but some of the nurses' stations did not begin their logs until 09/02/13. Maintenance staff is monitoring the maintenance logs kept at the nursing stations at least once a day. Maintenance treats any sightings of insects immediately and coordinates further treatments with the pest control service providers. Review of the facility's "Daily Ant Inspection" logs revealed rooms on the 200 Hall, 300 Hall, 400 Hall, The Terrace, and The Verandah were monitored once a day for ants from 08/28/13 to 09/14/13. Ants were noted on 09/01/13 in Rooms 211, 213, 310, and the 300 Hall Shower Room. Ants were noted on 09/01/13 in Room 310, and the 300 Hall. Ants were noted on 09/04/13 in Rooms 414 and 417. Ants were noted on 09/04/13 in Rooms 310, and 417, and 400 Hall Shower Room. Ants were noted on 09/05/13 in Room 417. Ants were noted on 09/06/13 in Room 417. Ants were noted on 09/10/13 in Room 301. Ants were noted on 09/12/13 in Room 403. Ants were noted on 09/14/13 in Rooms 301 and 310. Review of the in-service regarding "ants/residents," conducted on 09/04/13, revealed the following: "If a resident is found to have ants in the room the following should be done; head-to-toe assessment done on the resident, shower the resident, change gown and linens. If the resident is needed to change rooms the bed must be changed as well. One hour ant round logs are to be completed by each shift." An Immediate Jeopardy was identified on 09/26/13 in the area of Quality of Care and accurate assessments. On 09/26/13 at 1:00 PM, the Assistant Administrator and DON were informed an Immediate Jeopardy (IJ) had been identified. A Plan of Removal for the IJ was requested. . The Plan of Removal for the IJ was accepted on 09/27/13 at 7:30 PM, and reflected the following: Resident #1's bed was found with ants on 08/31/13 at 11:49 PM. Assessment of the resident revealed there were no ant bites. The resident was moved to another room, which shared a wall with her first room. On 09/01/13 at 8:30 AM, ants were found on Resident #1. LVN F was informed, but her documentation in the resident's clinical record was not an accurate description of the number of ants. MA G and CNA E, along with Resident #1's family member were stripping the bed and wiping ants off the resident. LVN F documented ants were under the resident as well as having been bitten on both arms, collar bone and front of the legs. There was no evidence of a comprehensive clinical assessment. Information provided to the NP was unknown. Orders were received to give [MEDICATION NAME] 50 mg and [MEDICATION NAME] 7.5 mg per [DEVICE] and to apply [MEDICATION NAME] cream. Resident #1 was transferred to the ER for treatment at the insistence of the resident's family member. LVN F provided no other reason for Resident #1 being sent to the ER. Resident #1 returned to the facility the same day and was taken to a room on the Suites station. There was no evidence to indicate Resident #1's physician or NP was notified of the resident going to the ER or what treatment and medication was ordered for the resident for two and one-half hours following her return to the facility. On 09/01/13, nursing staff, Weekend Supervisor, LVN N and the SW began making rounds of every occupied room in the facility looking for ants. Residents unable to make their needs known were given head-to-toe assessments. There were no additional ant bites identified. The Assistant Administrator, the Maintenance Supervisor and Maintenance Man O walked the entire inside of the facility and the exterior assessing for evidence of ants on 09/01/13 and 09/02/13. Housekeeping deep cleaned the two rooms Resident #1 was in. No other residents were found to be affected. The Maintenance Director contacted the facility's contracted pest control company on 09/01/13, to treat and exterminate the outside of the facility. On 09/01/13, the pest control company treated/exterminated the outside and the inside affected areas. Previous treatment had been done on 08/27/13. Maintenance staff made daily rounds outside the facility at the start of shift, treating identified areas. If an increase in ant activity did not respond to treatment, the Maintenance Supervisor will call the pest control company, who will respond within a four hour time frame to treat the affected area. Nursing staff started making hourly checks of resident rooms on 09/01/13. Housekeeping completed daily rounds and documented ant sightings in their log beginning 08/28/13. Facility protocol, effective 09/01/13, was in place for CNAs to visually monitor the resident rooms hourly and notify findings to the charge nurses. Charge nurses are to document on every room. If a resident has ants in the room, the following should be done: -- Remove any ants off the resident wiping them o

Based on observation, interview and record review, the facility failed to ensure one (Resident #1) of four (Residents #1, #2, #3, and #4) residents reviewed for quality of care was provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: -- conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. -- notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours. On 09/26/13 an Immediate Jeopardy (IJ) was identified in the area of quality of care and accurate assessments. While the IJ was removed on 09/30/13, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and at a potential for more than minimal harm and scope of "pattern." because staff were still being inserviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 152 residents, including Residents #1, #2, #3 and #4, at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: On 09/26/13, based on administrative review, the investigation was reopened for further investigation of a current Immediate Jeopardy situation. Resident #1's MDS assessment, dated 08/25/13, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment, received nourishment via tube feeding, and required total dependence on staff for activities of daily living to include bed mobility and personal hygiene. Resident #1's care plan with a current review date of 08/11/13, reflected the following: a) ADL functions reflected she was totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches included to provide Resident #1 with assistance as needed. b) [DIAGNOSES REDACTED]. Approaches included following safety measures and implementing [MEDICAL CONDITION] precautions. c) Resident had difficulty making self understood related to her [DIAGNOSES REDACTED]. Approaches included to observe for non-verbal signs of distress (guarding, moaning, restlessness, grimacing, withdrawal, etc.). Turn/reposition, communicate, provide pericare, assess for pain, and provide liquids/food as needed. Staff must anticipate needs. Resident unable to communicate. d) Resident is at risk for skin breakdown related to bowel and bladder incontinence. The goal was for the resident's skin to remain intact. Approaches included to assess the resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident's room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident's room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and "covered" in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death. Resident #1's nurse's notes dated 09/01/13 and timed both at 5:30 AM and 11:40 PM (start of shift was on 08/31/13), reflected ants were on the resident's dresser and some on her bed. The nurse conducted an assessment of the resident and noted she had no ant bites and had no signs and symptoms of pain. The resident's MD was notified and an order was received to move the resident to another room, and the family was notified of the resident's transfer to a different room due to the presence of ants. An entry at 8:30 AM, reflected the resident was resting comfortably and there were no signs of ants or ant bites in the new room (which shared a wall with Resident #1's old room). The next nurse's notes entry for Resident #1, dated 09/03/13 at 9:30 AM, reflected the nurse heard a nurse aide calling "come STAT (immediately) to room (Resident #1's room). The nurse entered the room and observed two nurse aides and the resident's mother striping her bed. Resident #1's mother was "yelling" that her daughter had ants all on her. The resident had bites on both arms, along her collar bone and the front of her legs, and that the areas were slightly swollen and red. The physician's NP was consulted and gave orders for 50 mg of [MEDICATION NAME] and 7.5 mg of Loratab via her feeding tube, and to apply [MEDICATION NAME] cream to her body. The resident's mother wanted her transferred to a hospital, at 10:00 AM, and at 4:00 PM, Resident #1 returned from the hospital via ambulance. A Patient/Resident Incident/Accident Investigation Worksheet, completed by LVN F on 09/01/13, documented on 09/01/13 at 9:20 AM, Resident #1 was found to have ant bites. At 9:20 AM, the resident's mother came and found ants in the resident's bed and room. Staff then cleaned the ants off the resident and applied cream with medication given per [DEVICE]. On 09/13/13 at 9:15 AM, during an interview with CNA E, she confirmed she worked on 09/01/13, and that she had been assigned the hall where Resident #1 resided. She stated her shift began at 6:00 AM. She stated she was not informed about ants being found in Resident #1's room and bed during the previous shift. She stated she checked on Resident #1 briefly, but did not pull back her sheet to check for ants or perform any incontinence care. She stated around 9:00 AM, she saw Resident #1's family member enter the resident's room and then heard the resident's family member yelling for help. She stated when she arrived at Resident #1's room, "hundreds of ants" were on Resident #1, as well as on her bed and under the resident. CNA E stated she had previously seen ants on the 200 and 300 halls, but denied seeing them on any resident. CNA E stated staff now report any sightings of ants to the charge nurse and maintenance. On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1's family member call for help and went to assist. He stated Resident #1 was "covered from head-to-toe in ants." He stated he focused on helping get the ants off her. He added there were "too many ants to count." During a confidential staff interview, he/she stated he/she had assisted with removing ants from Resident #1 on 09/01/13, and had provided care for the resident when the resident returned from the hospital. The confidential interviewee (CI) stated he/she was present when Resident #1's family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1's brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1's sheets had not been changed the night before when the ants where initially found in the resident's bed. The CI stated Resident #1's brief was "filled with ants," and there were "hundreds" of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being "covered in bites." The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready. The CI stated Resident #1 was then moved to another unit. The CI stated he/she went to check on the resident and she was wrapped in a sheet and when he/she removed the sheet from the resident, he/she observed three to four ants. The CI stated he/she knew the sheets and the mattress were clean and free of ants, so he/she checked Resident #1's wheelchair. The CI stated he/she discovered the pad in the seat of the wheelchair had a hole with food in it as well as food under the pad. The CI shook the pad and approximately eight to nine ants came out of the pad. The CI stated this incident was reported to the DON and Administrator. On 09/16/13 at approximately 11:15 AM, during an interview with LVN F, she confirmed she worked on 09/01/13, and her shift was 6:00 AM to 2:00 PM. She stated she had been the charge nurse for the 200 and 300 halls, which included Resident #1. She stated the night nurse told her ants had been found in Resident #1's room and the resident was moved to a new room. She stated she did a "quick check" of Resident #1 during walking rounds at approximately 6:00 AM, and then did a complete check of Resident #1 at approximately 8:30 AM. She stated the complete check included pulling back Resident #1's covers and checking her body for ant bites and did not find any. During the interview with LVN F, she further stated that at approximately 9:20 AM, she was called by a nurse aide to Resident #1's room. She stated she did not see "a great deal of ants;" no more than 30 ants. LVN F stated she observed ant bites around Resident #1's collarbone and the front of her chest. She stated she did not observe any ant bites on Resident #1's trunk or vaginal area. She stated the bites did not have "blisters" and Resident #1 did not have any facial expression indicating she was in pain. (Note: CNA E and the CI both stated they saw "hundreds of ants," and MA G stated he saw "too many (ants) to count.") LVN F further stated she contacted Resident #1's physician's answering service and then spoke with the physician's NP regarding the incident. She stated the NP who prescribed Resident #1 [MEDICATION NAME] and Loritab, said if Resident #1's family member wanted her sent to the hospital to go ahead and send her. Resident #1's family member requested the resident be sent to the hospital so she contacted a non-emergency transport company and was told that due to Resident #1 being total care, they would be unable to transport the resident. She stated she then contacted an ambulance service for a non-emergency transport. LVN F stated she was not sure if she had notified Resident #1's physician about Resident #1 being sent to the hospital, but did notify the physician upon the resident's return to the facility. (Note: LVN F's nurse's notes for 09/01/13, provided no evidence the physician or his NP were consulted prior to the resident being transferred to a local hospital or upon the resident's return to the facility.) On 09/17/13 at 3:30 PM, during an interview with the DON, she stated that on 09/01/13, between 9:30 AM to 10:00 AM, she was notified of the incident involving Resident #1 and the ants. She recalled that Resident #1 was sent out to the hospital due to the family member's request. The DON stated she arrived at the facility shortly after she was notified of the incident but she did not observe Resident #1 until she had returned from the hospital. The DON stated she conducted the investigation of the incident. she could ot explain why LVN F's nurse's notes did not provide and accurate assessment of the number of Resident #1's number of ant bites. She stated she did not interview LVN F regarding her statement that Resident #1 only received 30 ant bites. She stated she was not aware LVN F had not disclosed the severity of Resident #1's ant bites when she consulted with the physician's NP. She was not aware that neither the physician nor the physician's NP had been consulted regarding Resident #1's transfer to the hospital. She was not aware that neither the physician nor his NP were notified when Resident #1 returned to the facility from the hospital. Nurse's notes, dated 09/01/13 at 4:00 PM, reflected the hospital's physician gave orders for the resident to receive 500 mg of Keflex four times a day for seven days, 4 mg of [MEDICATION NAME][MEDICATION NAME] to take as directed on the package, and [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg/167 mg per 5 ml solution, take 10 ml (two teasponns) every 6 hours as needed for pain. The nurses' notes provided no documented evidence the resident's physician or the physician's PA were notified of the request to transfer the resident to the hospital or of the resident's return from the hospital with new orders. On 09/13/13 at 10:15 AM, during an interview with the physician's NP, she stated she was first notified around midnight (12:00 AM) on 09/01/13, of the ants in Resident #1's room. She stated she received another telephone call later that morning, but was uncertain of the time, and was told the resident had been moved to another room. She stated a third telephone call was received from the facility on 09/01/13, saying Resident #1's family member was worried about Resident #1 being in pain from "some ant bites." She stated she prescribed a topical cream, pain medication, and [MEDICATION NAME]. She stated she was not informed of the number of ant bites or seriousness of the incident. The NP stated she received another telephone call from the facility on 09/02/13 at around midnight to inform her that Resident #1's family member did not want Resident #1 to take the steroids prescribed by the emergency room physician. The NP stated she had been unaware Resident #1 had transferred to a hospital emergency room or of Resident #1's return to the facility. The NP stated she did not see Resident #1 until Tuesday (09/03/13), but could tell that she would have sent Resident #1 to the hospital at the time of the incident if the seriousness of the incident had been conveyed. The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1's physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the "worst case scenario" would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a "massive infection." The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, "There had to be hundreds of ants to have caused the extent of (Resident #1's) injuries." Resident #1's nurse's notes reflected the following entries regarding her ant bites: Entry dated 09/03/13 on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected Resident #1 was "small and frail in stature and unable to make needs known." The resident had contractures to "knees, hips, and elbows bilaterally." Ant bites are noted to Resident #1's "entire body from dense to sparse concentrations." The densest concentrations of ant bites are in the following areas: the base of the back of the neck, the right posterior flank area, left posterior thigh, and left posterior lateral calf. The ants bites are "cluster of fluid filled pustules, too numerous to count." Entry dated 09/06/13 (5 days after the incident) on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected a skin assessment was performed due to the incident of multiple ant bites. The densest concentrations of ant bites are the left posterior thigh and left posterior lateral calf. The ant bites in these areas are "very red and irritated" with a decrease in the fluid filled pustules. The ant bites to the neck, bilateral arms, and right flack are "red and angry, but the concentration of redness has decreased." Observation on 09/13/13 at 12:29 PM, of Resident #1 in her room, revealed she was in bed with socks on her hand. Resident #1's family member was present and stated the socks were used to prevent Resident #1 from scratching herself. Ant bites were observed on all of Resident #1's limbs, neck, shoulders, back, right rib cage, and left inner thigh. Several of the ant bites were observed to have pustules. The family member removed the socks and Resident #1 immediately began scratching her neck and shoulder area. Resident #1 had several dark red scratch marks on both her upper arms and shoulder area. Resident #1's facial expression indicated she was distressed. Resident #1 made slight groaning noises and continued to attempt to scratch at areas with ant bites. Review of the Provider Investigation Report, signed by the DON and dated 09/06/13, identified the category of the incident involving Resident #1 as "Other: Ant Bites." It reflected the incident occurred on 09/01/13, and was reported to the State Agency on 09/01/13. The summary of the investigation reflected: A nurse observed ants on the resident's dresser and on her bed on 08/31/13 at approximately 11:40 PM. The resident and her roommate were moved to another room and both residents were assessed and no observations of ants were noted on either resident. Staff continued to monitor throughout the shift. On 09/01/13 at 9:30 AM, the resident's mother observed ants on the resident. A nurse assessed Resident #1 and observed multiple ant bits on Resident #1 and the areas were closed and slightly swollen. The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms. Resident #1 was moved to another room, and her previous room was deep cleaned, and she was provided with a new wheelchair cushion. A head-to-toe assessment was conducted every shift. A pest control provider treated the interior and exterior of the facility. (The copies of billing from the pest control provider were for 08/09/13, 08/13/13, 08/16/13, 08/20/13, 08/21/13, 08/26/13, 08/27/13, and 09/06/13.) Staff, including nursing staff, maintenance, housekeeping and administration, were educated on monitoring rooms for ant activity, implementing safety checks for ants, who to notify in the event of finding ants, and how to respond if ants were observed on residents or beds/linens. Daily monitoring continued for observation of ants. The plan did not address ensuring nurses conduct accurate assessments of residents and ensuring nurses provide complete and accurate information when consulting with a resident's physician. It furthermore did not provide information regarding how they addressed ensuring nurses consult/notify a physician when a resident is being transferred to a hospital and again when they return with an order to review the treatment orders from the hospital to allow the attending physician to determine if he wants to approve the new treatment plan or change it. Review of the facility's Patient/Resident Incident/Accident Investigation Worksheets revealed on 08/31/13 at 11:49 PM, Resident #3 was found in her room with ants on her dresser. The nurse conducted a head-to-toe assessment of the resident and found no ant bites. (Note: This incident occurred the day before Resident #1 was found in the same room covered with ants.) Review of the facility's Service Request Log for the contract exterminator revealed the following: 08/20/13 at 2:30 p.m. - Entire unit needs to be sprayed. Bugs and ants in every room. On 08/21/13 (no time) - Entire room [ROOM NUMBER] and bed B have ants. On 08/21/13 (no time) - Ants in closet in room [ROOM NUMBER] on clothes. On 09/01/13 (no time) - Ants in resident room [ROOM NUMBER] and restroom. On 09/03/13 (no time) - Ants at nurses' station (station not specified). Review of the pest control service provider's receipts for treatment revealed the following: 08/13/13: room [ROOM NUMBER] was treated. The facility's exterior was treated. Ants were the targeted pest. Ants were noted during service. A Fire Ant mound was noted near an exit door. Ants were noted in room [ROOM NUMBER]. 08/16/13: this visit was in regard to cockroaches in the kitchen and the treatment of [REDACTED]. 08/20/13: The facility's exterior area was treated. Ants were noted during service. The courtyard of the secured unit, 200 hall, was treated. rooms [ROOM NUMBERS] were treated for [REDACTED]. 08/21/13: Patient/guest rooms were treated. The targeted pest was ants. rooms [ROOM NUMBERS] were treated. Ants were noted during service under cold base in rooms [ROOM NUMBERS]. 08/25/13: The facility's exterior area and patient/guest rooms were treated. The targeted pest was ants. The areas were inspected and treated and rooms were serviced. room [ROOM NUMBER], baseboards, was treated. Ants were noted during services; baseboards around bed. 08/27/13: The facility's perimeter was treated and ants were the target. Ants were noted during service; several ants near building on exterior of building. Trees/shrubs were contacting the facility creating a path for pests to enter. The service provider suggested the facility trim back vegetation to eliminate contact. 09/06/13: The exterior of the widnoew and ground near room [ROOM NUMBER]. On 09/13/13 at 3:20 PM, interview with the Pest Control Service Provider revealed only one fire ant mound was found after the incident that occurred on 09/01/13. The service provider completed a "power spray" approximately two weeks ago. It will sometimes drive the insects into the facility where they will ingest the poison and then die. The service provider and the facility are working on controlling the issue. On 09/13/13 at 2:28 PM, interview with the Administrator revealed the facility did not have a specific policy regarding ants, just the statement written for the in-service conducted after the incident on 09/01/13. On 09/13/13 at 2:50 PM, interview with the Maintenance Director revealed prior to the incident on 09/01/13, the facility had been calling the exterminator when ants were found in the facility. The Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The identified repairs were completed following the compilation of the list of repairs needed, however completion dates were not provided at that time. Any ants seen in the facility are logged by staff in a maintenance log book located at each nurses' station. The log books are check twice a day. Insect sightings are also logged in a pest control book located at the nurses' station that is monitored by the pest control service provider on a monthly basis. If only a couple of ants are sighted the maintenance staff will treat the area himself. If it is a resident room he will also treat outside near the exterior wall of the room. Maintenance staff also monitor outside for ant mounds on a daily basis. Review of an undated, untitled document attached to the Facility's Provider Investigation Report involving Resident #1 revealed a list of resident rooms in the facility with environmental issues. On 09/13/13 at 2:50 PM, the Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The list included a total of 82 resident rooms that needed "caulk around the windows." The following are the rooms identified: 1, 3, 11, 18, 20-22, 24-25, 28-30, 33-34, 38-39, 41-42, 45, 59-60, 200-213, 215-226, 228, 301-309, 311-313, 315, 401-408, 412-415, 418-420, 422-424, 426-427, and 429. The list also included 20 rooms that needed "caulk around the windows" and in the bathroom. The identified rooms were: 4, 23, 26, 31-32, 35-36, 40, 44, 48-49, 51-58, and 310. Also identified on the list were the following five rooms that needed caulking in the bathroom only: 9, 10, 12, 19, and 411. The list identified seven rooms where ants were found, the rooms were: 5, 9, 11, 20, 53, 55, and 406. The list also identified other environmental issues in resident rooms. In room [ROOM NUMBER] a hole in the widow screen was identified. In room [ROOM NUMBER] the "window doesn't shut all the way," and the frame was "rotten." In room [ROOM NUMBER] the window was "still broken," and room [ROOM NUMBER] had "broken window trim." The window in room [ROOM NUMBER] was described as being in "bad shape." room [ROOM NUMBER] had a hole by the bathroom door, and room [ROOM NUMBER] had a broken baseboard. A total of 107 resident rooms of the 120 resident rooms in the facility were identified as needing some type of repair. On 09/13/13 at approximately 4:00 PM, the Administrator and Assistant Administrator revealed the plan to address the ants in the facility included the following: One hour checks of total care residents by direct care staff, daily checks on residents' rooms by clinical staff and housekeeping, and daily checks by maintenance outside the facility for ant mounds. Logs of the resident and room checks were kept at each nurses' station, one for direct care staff and one for housekeeping. Staff documents any sightings of ants in the maintenance log as well as the other identified logs. The Assistant Administrator stated he has begun marking rooms where ants were sited on a floor plan so he can monitor which rooms are impacted. The Administrator stated the monitoring began on 08/28/13, but some of the nurses' stations did not begin their logs until 09/02/13. Maintenance staff is monitoring the maintenance logs kept at the nursing stations at least once a day. Maintenance treats any sightings of insects immediately and coordinates further treatments with the pest control service providers. Review of the facility's "Daily Ant Inspection" logs revealed rooms on the 200 Hall, 300 Hall, 400 Hall, The Terrace, and The Verandah were monitored once a day for ants from 08/28/13 to 09/14/13. Ants were noted on 09/01/13 in Rooms 211, 213, 310, and the 300 Hall Shower Room. Ants were noted on 09/01/13 in room [ROOM NUMBER], and the 300 Hall. Ants were noted on 09/04/13 in rooms [ROOM NUMBERS]. Ants were noted on 09/04/13 in Rooms 310, and 417, and 400 Hall Shower Room. Ants were noted on 09/05/13 in room [ROOM NUMBER]. Ants were noted on 09/06/13 in room [ROOM NUMBER]. Ants were noted on 09/10/13 in room [ROOM NUMBER]. Ants were noted on 09/12/13 in room [ROOM NUMBER]. Ants were noted on 09/14/13 in rooms [ROOM NUMBERS]. Review of the in-service regarding "ants/residents," conducted on 09/04/13, revealed the following: "If a resident is found to have ants in the room the following should be done; head-to-toe assessment done on the resident, shower the resident, change gown and linens. If the resident is needed to change rooms the bed must be changed as well. One hour ant round logs are to be completed by each shift." The facility's current Nursing Policies and Procedures included: Physician Communication/Change in Condition, revised September 2011 and reflected the following: "POLICY: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition. PROCEDURES: 1. Complete assessment of the patient/resident which may include but is not limited to: ...B. Current physical condition C. Patient's/resident's previous condition (declining, improving, stable) ...E. Vital signs, TPR (temperature), BP (blood pressure)...Lung Sounds, N/V Abdominal Assessment, Pain... ...H. allergies [REDACTED]. ...L. Any interventions/first aide (sic) provided to the patient/resident... 2. Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified... 4. The patient's/resident's family member/legal representative will be notified of any change in condition requiring an emergent transfer to the hospital...." A Physician Communication Grid was provided as guidelines for notifying the physician and reflected: "These guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event...." An Immediate Jeopardy was identified on 09/26/13 in the area of Quality of Care and accurate assessments. On 09/26/13 at 1:00 PM, the Assistant Administrator and DON were informed an Immediate Jeopardy (IJ) had been identified. A Plan of Removal for the IJ was requested. . The Plan of Removal for the IJ was accepted on 09/27/13 at 7:30 PM, and reflected the following: Resident #1's bed was found with ants on 08/31/13 at 11:49 PM. Assessment of the resident revealed there were no ant bites. The resident was moved to another room, which shared a wall with her first room. On 09/01/13 at 8:30 AM, ants were found on Resident #1. LVN F was informed, but her documentation in the resident's clinical record was not an accurate description of the number of ants. MA G and CNA E, along with Resident #1's family member were stripping the bed and wiping ants off the resident. LVN F documented ants were under the resident as well as having been bitten on both arms, collar bone and front of the legs. There was no evidence of a comprehensive clinical assessment. Information provided to the NP was unknown. Orders were received to give [MEDICATION NAME] 50 mg and [MEDICATION NAME] 7.5 mg per [DEVICE] and to apply [MEDICATION NAME] cream. Resident #1 was transferred to the ER for treatment at the insistence of the resident's family member.

Based on interview and record review, the facility failed to implement its written policies and procedures, which prohibit neglect, for one (Resident #1) of four residents reviewed for neglect. When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: -- conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. -- notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours. On 09/26/13 an Immediate Jeopardy (IJ) was identified in the area of quality of care and accurate assessments. While the IJ was removed on 09/30/13, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and at a potential for more than minimal harm and scope of "pattern." because staff were still being inserviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 152 residents, including Residents #1, #2, #3 and #4, at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: On 09/26/13, based on administrative review, the investigation was reopened for further investigation of a current Immediate Jeopardy situation. Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised on February 2008, revealed the following: "1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds. Guidelines for investigation reflected the following: "A. Immediately assess resident/patient at the time if discovery of alleged abuse. B. Document assessment in the medical record. C. Maintain resident's/patient's protection during the investigation. D. Notify the attending physician and resident's/patient's legally responsible party. E. Notify the Administrator, Director of Nursing, and Social Worker regardless of the times of day. F. Conduct/make arrangements for physical/mental examination. DO NOT CLEAN, SHOWER OR BATHE Resident in allegations of physical/sexual assault, rape, molestation or coercion prior to any such examination. G. Complete the Suspected Abuse Reporting Tool and begin the Investigation Reporting Tool. H. Notify per Component VII. I. Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated Facility staff and the interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. J. Social Service to provide support services to resident/patient and implement an interdisciplinary care plan. K. Depending on the incident, other residents in the facility may be interviewed. DON or designee will review the resident's medical record. L. Unless otherwise directed by the Legal Department, all investigations are to be in writing and kept on file in the administrator's office. M. Complete the Abuse Investigation Checklist. " Resident #1's MDS assessment, dated 08/25/13, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment, received nourishment via tube feeding, and required total dependence on staff for activities of daily living to include bed mobility and personal hygiene. Resident #1's care plan with a current review date of 08/11/13, reflected the following: a) ADL functions reflected she was totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches included to provide Resident #1 with assistance as needed. b) [DIAGNOSES REDACTED]. Approaches included following safety measures and implementing [MEDICAL CONDITION] precautions. c) Resident had difficulty making self understood related to her [DIAGNOSES REDACTED]. Approaches included to observe for non-verbal signs of distress (guarding, moaning, restlessness, grimacing, withdrawal, etc.). Turn/reposition, communicate, provide pericare, assess for pain, and provide liquids/food as needed. Staff must anticipate needs. Resident unable to communicate. d) Resident is at risk for skin breakdown related to bowel and bladder incontinence. The goal was for the resident's skin to remain intact. Approaches included to assess the resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident's room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident's room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and "covered" in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death. Resident #1's nurse's notes dated 09/01/13 and timed both at 5:30 AM and 11:40 PM (start of shift was on 08/31/13), reflected ants were on the resident's dresser and some on her bed. The nurse conducted an assessment of the resident and noted she had no ant bites and had no signs and symptoms of pain. The resident's MD was notified and an order was received to move the resident to another room, and the family was notified of the resident's transfer to a different room due to the presence of ants. An entry at 8:30 AM, reflected the resident was resting comfortably and there were no signs of ants or ant bites in the new room (which shared a wall with Resident #1's old room). The next nurse's notes entry for Resident #1, dated 09/03/13 at 9:30 AM, reflected the nurse heard a nurse aide calling "come STAT (immediately) to room (Resident #1's room). The nurse entered the room and observed two nurse aides and the resident's mother striping her bed. Resident #1's mother was "yelling" that her daughter had ants all on her. The resident had bites on both arms, along her collar bone and the front of her legs, and that the areas were slightly swollen and red. The physician's NP was consulted and gave orders for 50 mg of [MEDICATION NAME] and 7.5 mg of Loratab via her feeding tube, and to apply [MEDICATION NAME] cream to her body. The resident's mother wanted her transferred to a hospital, at 10:00 AM, and at 4:00 PM, Resident #1 returned from the hospital via ambulance. A Patient/Resident Incident/Accident Investigation Worksheet, completed by LVN F on 09/01/13, documented on 09/01/13 at 9:20 AM, Resident #1 was found to have ant bites. At 9:20 AM, the resident's mother came and found ants in the resident's bed and room. Staff then cleaned the ants off the resident and applied cream with medication given per [DEVICE]. On 09/13/13 at 9:15 AM, during an interview with CNA E, she confirmed she worked on 09/01/13, and that she had been assigned the hall where Resident #1 resided. She stated her shift began at 6:00 AM. She stated she was not informed about ants being found in Resident #1's room and bed during the previous shift. She stated she checked on Resident #1 briefly, but did not pull back her sheet to check for ants or perform any incontinence care. She stated around 9:00 AM, she saw Resident #1's family member enter the resident's room and then heard the resident's family member yelling for help. She stated when she arrived at Resident #1's room, "hundreds of ants" were on Resident #1, as well as on her bed and under the resident. CNA E stated she had previously seen ants on the 200 and 300 halls, but denied seeing them on any resident. CNA E stated staff now report any sightings of ants to the charge nurse and maintenance. On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1's family member call for help and went to assist. He stated Resident #1 was "covered from head-to-toe in ants." He stated he focused on helping get the ants off her. He added there were "too many ants to count." During a confidential staff interview, he/she stated he/she had assisted with removing ants from Resident #1 on 09/01/13, and had provided care for the resident when the resident returned from the hospital. The confidential interviewee (CI) stated he/she was present when Resident #1's family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1's brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1's sheets had not been changed the night before when the ants where initially found in the resident's bed. The CI stated Resident #1's brief was "filled with ants," and there were "hundreds" of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being "covered in bites." The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready. The CI stated Resident #1 was then moved to another unit. The CI stated he/she went to check on the resident and she was wrapped in a sheet and when he/she removed the sheet from the resident, he/she observed three to four ants. The CI stated he/she knew the sheets and the mattress were clean and free of ants, so he/she checked Resident #1's wheelchair. The CI stated he/she discovered the pad in the seat of the wheelchair had a hole with food in it as well as food under the pad. The CI shook the pad and approximately eight to nine ants came out of the pad. The CI stated this incident was reported to the DON and Administrator. On 09/16/13 at approximately 11:15 AM, during an interview with LVN F, she confirmed she worked on 09/01/13, and her shift was 6:00 AM to 2:00 PM. She stated she had been the charge nurse for the 200 and 300 halls, which included Resident #1. She stated the night nurse told her ants had been found in Resident #1's room and the resident was moved to a new room. She stated she did a "quick check" of Resident #1 during walking rounds at approximately 6:00 AM, and then did a complete check of Resident #1 at approximately 8:30 AM. She stated the complete check included pulling back Resident #1's covers and checking her body for ant bites and did not find any. During the interview with LVN F, she further stated that at approximately 9:20 AM, she was called by a nurse aide to Resident #1's room. She stated she did not see "a great deal of ants;" no more than 30 ants. LVN F stated she observed ant bites around Resident #1's collarbone and the front of her chest. She stated she did not observe any ant bites on Resident #1's trunk or vaginal area. She stated the bites did not have "blisters" and Resident #1 did not have any facial expression indicating she was in pain. (Note: CNA E and the CI both stated they saw "hundreds of ants," and MA G stated he saw "too many (ants) to count.") LVN F further stated she contacted Resident #1's physician's answering service and then spoke with the physician's NP regarding the incident. She stated the NP who prescribed Resident #1 [MEDICATION NAME] and Loritab, said if Resident #1's family member wanted her sent to the hospital to go ahead and send her. Resident #1's family member requested the resident be sent to the hospital so she contacted a non-emergency transport company and was told that due to Resident #1 being total care, they would be unable to transport the resident. She stated she then contacted an ambulance service for a non-emergency transport. LVN F stated she was not sure if she had notified Resident #1's physician about Resident #1 being sent to the hospital, but did notify the physician upon the resident's return to the facility. (Note: LVN F's nurse's notes for 09/01/13, provided no evidence the physician or his NP were consulted prior to the resident being transferred to a local hospital or upon the resident's return to the facility.) On 09/17/13 at 3:30 PM, during an interview with the DON, she stated that on 09/01/13, between 9:30 AM to 10:00 AM, she was notified of the incident involving Resident #1 and the ants. She recalled that Resident #1 was sent out to the hospital due to the family member's request. The DON stated she arrived at the facility shortly after she was notified of the incident but she did not observe Resident #1 until she had returned from the hospital. The DON stated she conducted the investigation of the incident. she could ot explain why LVN F's nurse's notes did not provide and accurate assessment of the number of Resident #1's number of ant bites. She stated she did not interview LVN F regarding her statement that Resident #1 only received 30 ant bites. She stated she was not aware LVN F had not disclosed the severity of Resident #1's ant bites when she consulted with the physician's NP. She was not aware that neither the physician nor the physician's NP had been consulted regarding Resident #1's transfer to the hospital. She was not aware that neither the physician nor his NP were notified when Resident #1 returned to the facility from the hospital. Nurse's notes, dated 09/01/13 at 4:00 PM, reflected the hospital's physician gave orders for the resident to receive 500 mg of Keflex four times a day for seven days, 4 mg of [MEDICATION NAME][MEDICATION NAME] to take as directed on the package, and [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg/167 mg per 5 ml solution, take 10 ml (two teasponns) every 6 hours as needed for pain. The nurses' notes provided no documented evidence the resident's physician or the physician's PA were notified of the request to transfer the resident to the hospital or of the resident's return from the hospital with new orders. On 09/13/13 at 10:15 AM, during an interview with the physician's NP, she stated she was first notified around midnight (12:00 AM) on 09/01/13, of the ants in Resident #1's room. She stated she received another telephone call later that morning, but was uncertain of the time, and was told the resident had been moved to another room. She stated a third telephone call was received from the facility on 09/01/13, saying Resident #1's family member was worried about Resident #1 being in pain from "some ant bites." She stated she prescribed a topical cream, pain medication, and [MEDICATION NAME]. She stated she was not informed of the number of ant bites or seriousness of the incident. The NP stated she received another telephone call from the facility on 09/02/13 at around midnight to inform her that Resident #1's family member did not want Resident #1 to take the steroids prescribed by the emergency room physician. The NP stated she had been unaware Resident #1 had transferred to a hospital emergency room or of Resident #1's return to the facility. The NP stated she did not see Resident #1 until Tuesday (09/03/13), but could tell that she would have sent Resident #1 to the hospital at the time of the incident if the seriousness of the incident had been conveyed. The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1's physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the "worst case scenario" would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a "massive infection." The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, "There had to be hundreds of ants to have caused the extent of (Resident #1's) injuries." Resident #1's nurse's notes reflected the following entries regarding her ant bites: Entry dated 09/03/13 on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected Resident #1 was "small and frail in stature and unable to make needs known." The resident had contractures to "knees, hips, and elbows bilaterally." Ant bites are noted to Resident #1's "entire body from dense to sparse concentrations." The densest concentrations of ant bites are in the following areas: the base of the back of the neck, the right posterior flank area, left posterior thigh, and left posterior lateral calf. The ants bites are "cluster of fluid filled pustules, too numerous to count." Entry dated 09/06/13 (5 days after the incident) on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected a skin assessment was performed due to the incident of multiple ant bites. The densest concentrations of ant bites are the left posterior thigh and left posterior lateral calf. The ant bites in these areas are "very red and irritated" with a decrease in the fluid filled pustules. The ant bites to the neck, bilateral arms, and right flack are "red and angry, but the concentration of redness has decreased." Observation on 09/13/13 at 12:29 PM, of Resident #1 in her room, revealed she was in bed with socks on her hand. Resident #1's family member was present and stated the socks were used to prevent Resident #1 from scratching herself. Ant bites were observed on all of Resident #1's limbs, neck, shoulders, back, right rib cage, and left inner thigh. Several of the ant bites were observed to have pustules. The family member removed the socks and Resident #1 immediately began scratching her neck and shoulder area. Resident #1 had several dark red scratch marks on both her upper arms and shoulder area. Resident #1's facial expression indicated she was distressed. Resident #1 made slight groaning noises and continued to attempt to scratch at areas with ant bites. Review of the Provider Investigation Report, signed by the DON and dated 09/06/13, identified the category of the incident involving Resident #1 as "Other: Ant Bites." It reflected the incident occurred on 09/01/13, and was reported to the State Agency on 09/01/13. The summary of the investigation reflected: A nurse observed ants on the resident's dresser and on her bed on 08/31/13 at approximately 11:40 PM. The resident and her roommate were moved to another room and both residents were assessed and no observations of ants were noted on either resident. Staff continued to monitor throughout the shift. On 09/01/13 at 9:30 AM, the resident's mother observed ants on the resident. A nurse assessed Resident #1 and observed multiple ant bits on Resident #1 and the areas were closed and slightly swollen. The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms. Resident #1 was moved to another room, and her previous room was deep cleaned, and she was provided with a new wheelchair cushion. A head-to-toe assessment was conducted every shift. A pest control provider treated the interior and exterior of the facility. (The copies of billing from the pest control provider were for 08/09/13, 08/13/13, 08/16/13, 08/20/13, 08/21/13, 08/26/13, 08/27/13, and 09/06/13.) Staff, including nursing staff, maintenance, housekeeping and administration, were educated on monitoring rooms for ant activity, implementing safety checks for ants, who to notify in the event of finding ants, and how to respond if ants were observed on residents or beds/linens. Daily monitoring continued for observation of ants. The plan did not address ensuring nurses conduct accurate assessments of residents and ensuring nurses provide complete and accurate information when consulting with a resident's physician. It furthermore did not provide information regarding how they addressed ensuring nurses consult/notify a physician when a resident is being transferred to a hospital and again when they return with an order to review the treatment orders from the hospital to allow the attending physician to determine if he wants to approve the new treatment plan or change it. Review of the facility's Patient/Resident Incident/Accident Investigation Worksheets revealed on 08/31/13 at 11:49 PM, Resident #3 was found in her room with ants on her dresser. The nurse conducted a head-to-toe assessment of the resident and found no ant bites. (Note: This incident occurred the day before Resident #1 was found in the same room covered with ants.) Review of the facility's Service Request Log for the contract exterminator revealed the following: 08/20/13 at 2:30 p.m. - Entire unit needs to be sprayed. Bugs and ants in every room. On 08/21/13 (no time) - Entire room [ROOM NUMBER] and bed B have ants. On 08/21/13 (no time) - Ants in closet in room [ROOM NUMBER] on clothes. On 09/01/13 (no time) - Ants in resident room [ROOM NUMBER] and restroom. On 09/03/13 (no time) - Ants at nurses' station (station not specified). Review of the pest control service provider's receipts for treatment revealed the following: 08/13/13: room [ROOM NUMBER] was treated. The facility's exterior was treated. Ants were the targeted pest. Ants were noted during service. A Fire Ant mound was noted near an exit door. Ants were noted in room [ROOM NUMBER]. 08/16/13: this visit was in regard to cockroaches in the kitchen and the treatment of [REDACTED]. 08/20/13: The facility's exterior area was treated. Ants were noted during service. The courtyard of the secured unit, 200 hall, was treated. rooms [ROOM NUMBERS] were treated for [REDACTED]. 08/21/13: Patient/guest rooms were treated. The targeted pest was ants. rooms [ROOM NUMBERS] were treated. Ants were noted during service under cold base in rooms [ROOM NUMBERS]. 08/25/13: The facility's exterior area and patient/guest rooms were treated. The targeted pest was ants. The areas were inspected and treated and rooms were serviced. room [ROOM NUMBER], baseboards, was treated. Ants were noted during services; baseboards around bed. 08/27/13: The facility's perimeter was treated and ants were the target. Ants were noted during service; several ants near building on exterior of building. Trees/shrubs were contacting the facility creating a path for pests to enter. The service provider suggested the facility trim back vegetation to eliminate contact. 09/06/13: The exterior of the widnoew and ground near room [ROOM NUMBER]. On 09/13/13 at 3:20 PM, interview with the Pest Control Service Provider revealed only one fire ant mound was found after the incident that occurred on 09/01/13. The service provider completed a "power spray" approximately two weeks ago. It will sometimes drive the insects into the facility where they will ingest the poison and then die. The service provider and the facility are working on controlling the issue. On 09/13/13 at 2:28 PM, interview with the Administrator revealed the facility did not have a specific policy regarding ants, just the statement written for the in-service conducted after the incident on 09/01/13. On 09/13/13 at 2:50 PM, interview with the Maintenance Director revealed prior to the incident on 09/01/13, the facility had been calling the exterminator when ants were found in the facility. The Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The identified repairs were completed following the compilation of the list of repairs needed, however completion dates were not provided at that time. Any ants seen in the facility are logged by staff in a maintenance log book located at each nurses' station. The log books are check twice a day. Insect sightings are also logged in a pest control book located at the nurses' station that is monitored by the pest control service provider on a monthly basis. If only a couple of ants are sighted the maintenance staff will treat the area himself. If it is a resident room he will also treat outside near the exterior wall of the room. Maintenance staff also monitor outside for ant mounds on a daily basis. Review of an undated, untitled document attached to the Facility's Provider Investigation Report involving Resident #1 revealed a list of resident rooms in the facility with environmental issues. On 09/13/13 at 2:50 PM, the Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The list included a total of 82 resident rooms that needed "caulk around the windows." The following are the rooms identified: 1, 3, 11, 18, 20-22, 24-25, 28-30, 33-34, 38-39, 41-42, 45, 59-60, 200-213, 215-226, 228, 301-309, 311-313, 315, 401-408, 412-415, 418-420, 422-424, 426-427, and 429. The list also included 20 rooms that needed "caulk around the windows" and in the bathroom. The identified rooms were: 4, 23, 26, 31-32, 35-36, 40, 44, 48-49, 51-58, and 310. Also identified on the list were the following five rooms that needed caulking in the bathroom only: 9, 10, 12, 19, and 411. The list identified seven rooms where ants were found, the rooms were: 5, 9, 11, 20, 53, 55, and 406. The list also identified other environmental issues in resident rooms. In room [ROOM NUMBER] a hole in the widow screen was identified. In room [ROOM NUMBER] the "window doesn't shut all the way," and the frame was "rotten." In room [ROOM NUMBER] the window was "still broken," and room [ROOM NUMBER] had "broken window trim." The window in room [ROOM NUMBER] was described as being in "bad shape." room [ROOM NUMBER] had a hole by the bathroom door, and room [ROOM NUMBER] had a broken baseboard. A total of 107 resident rooms of the 120 resident rooms in the facility were identified as needing some type of repair. On 09/13/13 at approximately 4:00 PM, the Administrator and Assistant Administrator revealed the plan to address the ants in the facility included the following: One hour checks of total care residents by direct care staff, daily checks on residents' rooms by clinical staff and housekeeping, and daily checks by maintenance outside the facility for ant mounds. Logs of the resident and room checks were kept at each nurses' station, one for direct care staff and one for housekeeping. Staff documents any sightings of ants in the maintenance log as well as the other identified logs. The Assistant Administrator stated he has begun marking rooms where ants were sited on a floor plan so he can monitor which rooms are impacted. The Administrator stated the monitoring began on 08/28/13, but some of the nurses' stations did not begin their logs until 09/02/13. Maintenance staff is monitoring the maintenance logs kept at the nursing stations at least once a day. Maintenance treats any sightings of insects immediately and coordinates further treatments with the pest control service providers. Review of the facility's "Daily Ant Inspection" logs revealed rooms on the 200 Hall, 300 Hall, 400 Hall, The Terrace, and The Verandah were monitored once a day for ants from 08/28/13 to 09/14/13. Ants were noted on 09/01/13 in Rooms 211, 213, 310, and the 300 Hall Shower Room. Ants were noted on 09/01/13 in room [ROOM NUMBER], and the 300 Hall. Ants were noted on 09/04/13 in rooms [ROOM NUMBERS]. Ants were noted on 09/04/13 in Rooms 310, and 417, and 400 Hall Shower Room. Ants were noted on 09/05/13 in room [ROOM NUMBER]. Ants were noted on 09/06/13 in room [ROOM NUMBER]. Ants were noted on 09/10/13 in room [ROOM NUMBER]. Ants were noted on 09/12/13 in room [ROOM NUMBER]. Ants were noted on 09/14/13 in rooms [ROOM NUMBERS]. Review of the in-service regarding "ants/residents," conducted on 09/04/13, revealed the following: "If a resident is found to have ants in the room the following should be done; head-to-toe assessment done on the resident, shower the resident, change gown and linens. If the resident is needed to change rooms the bed must be changed as well. One hour ant round logs are to be completed by each shift." The facility's current Nursing Policies and Procedures included: Physician Communication/Change in Condition, revised September 2011 and reflected the following: "POLICY: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition. PROCEDURES: 1. Complete assessment of the patient/resident which may include but is not limited to: ...B. Current physical condition C. Patient's/resident's previous condition (declining, improving, stable) ...E. Vital signs, TPR (temperature), BP (blood pressure)ZXXXZ

Based on observation, interview and record review, the facility failed to implement the policies and procedures, which prohibit neglect for one (Resident #1) of four residents reviewed for neglect. When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: -- conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. -- notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours. On 09/26/13 an Immediate Jeopardy (IJ) was identified in the area of quality of care and accurate assessments. While the IJ was removed on 09/30/13, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and at a potential for more than minimal harm and scope of "pattern." because staff were still being inserviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 152 residents, including Residents #1, #2, #3 and #4, at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: On 09/26/13, based on administrative review, the investigation was reopened for further investigation of a current Immediate Jeopardy situation. Resident #1's MDS assessment, dated 08/25/13, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment, received nourishment via tube feeding, and required total dependence on staff for activities of daily living to include bed mobility and personal hygiene. Resident #1's care plan with a current review date of 08/11/13, reflected the following: a) ADL functions reflected she was totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches included to provide Resident #1 with assistance as needed. b) [DIAGNOSES REDACTED]. Approaches included following safety measures and implementing [MEDICAL CONDITION] precautions. c) Resident had difficulty making self understood related to her [DIAGNOSES REDACTED]. Approaches included to observe for non-verbal signs of distress (guarding, moaning, restlessness, grimacing, withdrawal, etc.). Turn/reposition, communicate, provide pericare, assess for pain, and provide liquids/food as needed. Staff must anticipate needs. Resident unable to communicate. d) Resident is at risk for skin breakdown related to bowel and bladder incontinence. The goal was for the resident's skin to remain intact. Approaches included to assess the resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident's room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident's room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and "covered" in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death. Resident #1's nurse's notes dated 09/01/13 and timed both at 5:30 AM and 11:40 PM (start of shift was on 08/31/13), reflected ants were on the resident's dresser and some on her bed. The nurse conducted an assessment of the resident and noted she had no ant bites and had no signs and symptoms of pain. The resident's MD was notified and an order was received to move the resident to another room, and the family was notified of the resident's transfer to a different room due to the presence of ants. An entry at 8:30 AM, reflected the resident was resting comfortably and there were no signs of ants or ant bites in the new room (which shared a wall with Resident #1's old room). The next nurse's notes entry for Resident #1, dated 09/03/13 at 9:30 AM, reflected the nurse heard a nurse aide calling "come STAT (immediately) to room (Resident #1's room). The nurse entered the room and observed two nurse aides and the resident's mother striping her bed. Resident #1's mother was "yelling" that her daughter had ants all on her. The resident had bites on both arms, along her collar bone and the front of her legs, and that the areas were slightly swollen and red. The physician's NP was consulted and gave orders for 50 mg of [MEDICATION NAME] and 7.5 mg of Loratab via her feeding tube, and to apply [MEDICATION NAME] cream to her body. The resident's mother wanted her transferred to a hospital, at 10:00 AM, and at 4:00 PM, Resident #1 returned from the hospital via ambulance. A Patient/Resident Incident/Accident Investigation Worksheet, completed by LVN F on 09/01/13, documented on 09/01/13 at 9:20 AM, Resident #1 was found to have ant bites. At 9:20 AM, the resident's mother came and found ants in the resident's bed and room. Staff then cleaned the ants off the resident and applied cream with medication given per [DEVICE]. On 09/13/13 at 9:15 AM, during an interview with CNA E, she confirmed she worked on 09/01/13, and that she had been assigned the hall where Resident #1 resided. She stated her shift began at 6:00 AM. She stated she was not informed about ants being found in Resident #1's room and bed during the previous shift. She stated she checked on Resident #1 briefly, but did not pull back her sheet to check for ants or perform any incontinence care. She stated around 9:00 AM, she saw Resident #1's family member enter the resident's room and then heard the resident's family member yelling for help. She stated when she arrived at Resident #1's room, "hundreds of ants" were on Resident #1, as well as on her bed and under the resident. CNA E stated she had previously seen ants on the 200 and 300 halls, but denied seeing them on any resident. CNA E stated staff now report any sightings of ants to the charge nurse and maintenance. On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1's family member call for help and went to assist. He stated Resident #1 was "covered from head-to-toe in ants." He stated he focused on helping get the ants off her. He added there were "too many ants to count." During a confidential staff interview, he/she stated he/she had assisted with removing ants from Resident #1 on 09/01/13, and had provided care for the resident when the resident returned from the hospital. The confidential interviewee (CI) stated he/she was present when Resident #1's family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1's brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1's sheets had not been changed the night before when the ants where initially found in the resident's bed. The CI stated Resident #1's brief was "filled with ants," and there were "hundreds" of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being "covered in bites." The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready. The CI stated Resident #1 was then moved to another unit. The CI stated he/she went to check on the resident and she was wrapped in a sheet and when he/she removed the sheet from the resident, he/she observed three to four ants. The CI stated he/she knew the sheets and the mattress were clean and free of ants, so he/she checked Resident #1's wheelchair. The CI stated he/she discovered the pad in the seat of the wheelchair had a hole with food in it as well as food under the pad. The CI shook the pad and approximately eight to nine ants came out of the pad. The CI stated this incident was reported to the DON and Administrator. On 09/16/13 at approximately 11:15 AM, during an interview with LVN F, she confirmed she worked on 09/01/13, and her shift was 6:00 AM to 2:00 PM. She stated she had been the charge nurse for the 200 and 300 halls, which included Resident #1. She stated the night nurse told her ants had been found in Resident #1's room and the resident was moved to a new room. She stated she did a "quick check" of Resident #1 during walking rounds at approximately 6:00 AM, and then did a complete check of Resident #1 at approximately 8:30 AM. She stated the complete check included pulling back Resident #1's covers and checking her body for ant bites and did not find any. During the interview with LVN F, she further stated that at approximately 9:20 AM, she was called by a nurse aide to Resident #1's room. She stated she did not see "a great deal of ants;" no more than 30 ants. LVN F stated she observed ant bites around Resident #1's collarbone and the front of her chest. She stated she did not observe any ant bites on Resident #1's trunk or vaginal area. She stated the bites did not have "blisters" and Resident #1 did not have any facial expression indicating she was in pain. (Note: CNA E and the CI both stated they saw "hundreds of ants," and MA G stated he saw "too many (ants) to count.") LVN F further stated she contacted Resident #1's physician's answering service and then spoke with the physician's NP regarding the incident. She stated the NP who prescribed Resident #1 [MEDICATION NAME] and Loritab, said if Resident #1's family member wanted her sent to the hospital to go ahead and send her. Resident #1's family member requested the resident be sent to the hospital so she contacted a non-emergency transport company and was told that due to Resident #1 being total care, they would be unable to transport the resident. She stated she then contacted an ambulance service for a non-emergency transport. LVN F stated she was not sure if she had notified Resident #1's physician about Resident #1 being sent to the hospital, but did notify the physician upon the resident's return to the facility. (Note: LVN F's nurse's notes for 09/01/13, provided no evidence the physician or his NP were consulted prior to the resident being transferred to a local hospital or upon the resident's return to the facility.) On 09/17/13 at 3:30 PM, during an interview with the DON, she stated that on 09/01/13, between 9:30 AM to 10:00 AM, she was notified of the incident involving Resident #1 and the ants. She recalled that Resident #1 was sent out to the hospital due to the family member's request. The DON stated she arrived at the facility shortly after she was notified of the incident but she did not observe Resident #1 until she had returned from the hospital. The DON stated she conducted the investigation of the incident. she could ot explain why LVN F's nurse's notes did not provide and accurate assessment of the number of Resident #1's number of ant bites. She stated she did not interview LVN F regarding her statement that Resident #1 only received 30 ant bites. She stated she was not aware LVN F had not disclosed the severity of Resident #1's ant bites when she consulted with the physician's NP. She was not aware that neither the physician nor the physician's NP had been consulted regarding Resident #1's transfer to the hospital. She was not aware that neither the physician nor his NP were notified when Resident #1 returned to the facility from the hospital. Nurse's notes, dated 09/01/13 at 4:00 PM, reflected the hospital's physician gave orders for the resident to receive 500 mg of Keflex four times a day for seven days, 4 mg of [MEDICATION NAME][MEDICATION NAME] to take as directed on the package, and [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg/167 mg per 5 ml solution, take 10 ml (two teasponns) every 6 hours as needed for pain. The nurses' notes provided no documented evidence the resident's physician or the physician's PA were notified of the request to transfer the resident to the hospital or of the resident's return from the hospital with new orders. On 09/13/13 at 10:15 AM, during an interview with the physician's NP, she stated she was first notified around midnight (12:00 AM) on 09/01/13, of the ants in Resident #1's room. She stated she received another telephone call later that morning, but was uncertain of the time, and was told the resident had been moved to another room. She stated a third telephone call was received from the facility on 09/01/13, saying Resident #1's family member was worried about Resident #1 being in pain from "some ant bites." She stated she prescribed a topical cream, pain medication, and [MEDICATION NAME]. She stated she was not informed of the number of ant bites or seriousness of the incident. The NP stated she received another telephone call from the facility on 09/02/13 at around midnight to inform her that Resident #1's family member did not want Resident #1 to take the steroids prescribed by the emergency room physician. The NP stated she had been unaware Resident #1 had transferred to a hospital emergency room or of Resident #1's return to the facility. The NP stated she did not see Resident #1 until Tuesday (09/03/13), but could tell that she would have sent Resident #1 to the hospital at the time of the incident if the seriousness of the incident had been conveyed. The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1's physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the "worst case scenario" would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a "massive infection." The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, "There had to be hundreds of ants to have caused the extent of (Resident #1's) injuries." Resident #1's nurse's notes reflected the following entries regarding her ant bites: Entry dated 09/03/13 on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected Resident #1 was "small and frail in stature and unable to make needs known." The resident had contractures to "knees, hips, and elbows bilaterally." Ant bites are noted to Resident #1's "entire body from dense to sparse concentrations." The densest concentrations of ant bites are in the following areas: the base of the back of the neck, the right posterior flank area, left posterior thigh, and left posterior lateral calf. The ants bites are "cluster of fluid filled pustules, too numerous to count." Entry dated 09/06/13 (5 days after the incident) on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected a skin assessment was performed due to the incident of multiple ant bites. The densest concentrations of ant bites are the left posterior thigh and left posterior lateral calf. The ant bites in these areas are "very red and irritated" with a decrease in the fluid filled pustules. The ant bites to the neck, bilateral arms, and right flack are "red and angry, but the concentration of redness has decreased." Observation on 09/13/13 at 12:29 PM, of Resident #1 in her room, revealed she was in bed with socks on her hand. Resident #1's family member was present and stated the socks were used to prevent Resident #1 from scratching herself. Ant bites were observed on all of Resident #1's limbs, neck, shoulders, back, right rib cage, and left inner thigh. Several of the ant bites were observed to have pustules. The family member removed the socks and Resident #1 immediately began scratching her neck and shoulder area. Resident #1 had several dark red scratch marks on both her upper arms and shoulder area. Resident #1's facial expression indicated she was distressed. Resident #1 made slight groaning noises and continued to attempt to scratch at areas with ant bites. Review of the Provider Investigation Report, signed by the DON and dated 09/06/13, identified the category of the incident involving Resident #1 as "Other: Ant Bites." It reflected the incident occurred on 09/01/13, and was reported to the State Agency on 09/01/13. The summary of the investigation reflected: A nurse observed ants on the resident's dresser and on her bed on 08/31/13 at approximately 11:40 PM. The resident and her roommate were moved to another room and both residents were assessed and no observations of ants were noted on either resident. Staff continued to monitor throughout the shift. On 09/01/13 at 9:30 AM, the resident's mother observed ants on the resident. A nurse assessed Resident #1 and observed multiple ant bits on Resident #1 and the areas were closed and slightly swollen. The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms. Resident #1 was moved to another room, and her previous room was deep cleaned, and she was provided with a new wheelchair cushion. A head-to-toe assessment was conducted every shift. A pest control provider treated the interior and exterior of the facility. (The copies of billing from the pest control provider were for 08/09/13, 08/13/13, 08/16/13, 08/20/13, 08/21/13, 08/26/13, 08/27/13, and 09/06/13.) Staff, including nursing staff, maintenance, housekeeping and administration, were educated on monitoring rooms for ant activity, implementing safety checks for ants, who to notify in the event of finding ants, and how to respond if ants were observed on residents or beds/linens. Daily monitoring continued for observation of ants. The plan did not address ensuring nurses conduct accurate assessments of residents and ensuring nurses provide complete and accurate information when consulting with a resident's physician. It furthermore did not provide information regarding how they addressed ensuring nurses consult/notify a physician when a resident is being transferred to a hospital and again when they return with an order to review the treatment orders from the hospital to allow the attending physician to determine if he wants to approve the new treatment plan or change it. Review of the facility's Patient/Resident Incident/Accident Investigation Worksheets revealed on 08/31/13 at 11:49 PM, Resident #3 was found in her room with ants on her dresser. The nurse conducted a head-to-toe assessment of the resident and found no ant bites. (Note: This incident occurred the day before Resident #1 was found in the same room covered with ants.) Review of the facility's Service Request Log for the contract exterminator revealed the following: 08/20/13 at 2:30 p.m. - Entire unit needs to be sprayed. Bugs and ants in every room. On 08/21/13 (no time) - Entire room [ROOM NUMBER] and bed B have ants. On 08/21/13 (no time) - Ants in closet in room [ROOM NUMBER] on clothes. On 09/01/13 (no time) - Ants in resident room [ROOM NUMBER] and restroom. On 09/03/13 (no time) - Ants at nurses' station (station not specified). Review of the pest control service provider's receipts for treatment revealed the following: 08/13/13: room [ROOM NUMBER] was treated. The facility's exterior was treated. Ants were the targeted pest. Ants were noted during service. A Fire Ant mound was noted near an exit door. Ants were noted in room [ROOM NUMBER]. 08/16/13: this visit was in regard to cockroaches in the kitchen and the treatment of [REDACTED]. 08/20/13: The facility's exterior area was treated. Ants were noted during service. The courtyard of the secured unit, 200 hall, was treated. rooms [ROOM NUMBERS] were treated for [REDACTED]. 08/21/13: Patient/guest rooms were treated. The targeted pest was ants. rooms [ROOM NUMBERS] were treated. Ants were noted during service under cold base in rooms [ROOM NUMBERS]. 08/25/13: The facility's exterior area and patient/guest rooms were treated. The targeted pest was ants. The areas were inspected and treated and rooms were serviced. room [ROOM NUMBER], baseboards, was treated. Ants were noted during services; baseboards around bed. 08/27/13: The facility's perimeter was treated and ants were the target. Ants were noted during service; several ants near building on exterior of building. Trees/shrubs were contacting the facility creating a path for pests to enter. The service provider suggested the facility trim back vegetation to eliminate contact. 09/06/13: The exterior of the widnoew and ground near room [ROOM NUMBER]. On 09/13/13 at 3:20 PM, interview with the Pest Control Service Provider revealed only one fire ant mound was found after the incident that occurred on 09/01/13. The service provider completed a "power spray" approximately two weeks ago. It will sometimes drive the insects into the facility where they will ingest the poison and then die. The service provider and the facility are working on controlling the issue. On 09/13/13 at 2:28 PM, interview with the Administrator revealed the facility did not have a specific policy regarding ants, just the statement written for the in-service conducted after the incident on 09/01/13. On 09/13/13 at 2:50 PM, interview with the Maintenance Director revealed prior to the incident on 09/01/13, the facility had been calling the exterminator when ants were found in the facility. The Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The identified repairs were completed following the compilation of the list of repairs needed, however completion dates were not provided at that time. Any ants seen in the facility are logged by staff in a maintenance log book located at each nurses' station. The log books are check twice a day. Insect sightings are also logged in a pest control book located at the nurses' station that is monitored by the pest control service provider on a monthly basis. If only a couple of ants are sighted the maintenance staff will treat the area himself. If it is a resident room he will also treat outside near the exterior wall of the room. Maintenance staff also monitor outside for ant mounds on a daily basis. Review of an undated, untitled document attached to the Facility's Provider Investigation Report involving Resident #1 revealed a list of resident rooms in the facility with environmental issues. On 09/13/13 at 2:50 PM, the Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The list included a total of 82 resident rooms that needed "caulk around the windows." The following are the rooms identified: 1, 3, 11, 18, 20-22, 24-25, 28-30, 33-34, 38-39, 41-42, 45, 59-60, 200-213, 215-226, 228, 301-309, 311-313, 315, 401-408, 412-415, 418-420, 422-424, 426-427, and 429. The list also included 20 rooms that needed "caulk around the windows" and in the bathroom. The identified rooms were: 4, 23, 26, 31-32, 35-36, 40, 44, 48-49, 51-58, and 310. Also identified on the list were the following five rooms that needed caulking in the bathroom only: 9, 10, 12, 19, and 411. The list identified seven rooms where ants were found, the rooms were: 5, 9, 11, 20, 53, 55, and 406. The list also identified other environmental issues in resident rooms. In room [ROOM NUMBER] a hole in the widow screen was identified. In room [ROOM NUMBER] the "window doesn't shut all the way," and the frame was "rotten." In room [ROOM NUMBER] the window was "still broken," and room [ROOM NUMBER] had "broken window trim." The window in room [ROOM NUMBER] was described as being in "bad shape." room [ROOM NUMBER] had a hole by the bathroom door, and room [ROOM NUMBER] had a broken baseboard. A total of 107 resident rooms of the 120 resident rooms in the facility were identified as needing some type of repair. On 09/13/13 at approximately 4:00 PM, the Administrator and Assistant Administrator revealed the plan to address the ants in the facility included the following: One hour checks of total care residents by direct care staff, daily checks on residents' rooms by clinical staff and housekeeping, and daily checks by maintenance outside the facility for ant mounds. Logs of the resident and room checks were kept at each nurses' station, one for direct care staff and one for housekeeping. Staff documents any sightings of ants in the maintenance log as well as the other identified logs. The Assistant Administrator stated he has begun marking rooms where ants were sited on a floor plan so he can monitor which rooms are impacted. The Administrator stated the monitoring began on 08/28/13, but some of the nurses' stations did not begin their logs until 09/02/13. Maintenance staff is monitoring the maintenance logs kept at the nursing stations at least once a day. Maintenance treats any sightings of insects immediately and coordinates further treatments with the pest control service providers. Review of the facility's "Daily Ant Inspection" logs revealed rooms on the 200 Hall, 300 Hall, 400 Hall, The Terrace, and The Verandah were monitored once a day for ants from 08/28/13 to 09/14/13. Ants were noted on 09/01/13 in Rooms 211, 213, 310, and the 300 Hall Shower Room. Ants were noted on 09/01/13 in room [ROOM NUMBER], and the 300 Hall. Ants were noted on 09/04/13 in rooms [ROOM NUMBERS]. Ants were noted on 09/04/13 in Rooms 310, and 417, and 400 Hall Shower Room. Ants were noted on 09/05/13 in room [ROOM NUMBER]. Ants were noted on 09/06/13 in room [ROOM NUMBER]. Ants were noted on 09/10/13 in room [ROOM NUMBER]. Ants were noted on 09/12/13 in room [ROOM NUMBER]. Ants were noted on 09/14/13 in rooms [ROOM NUMBERS]. Review of the in-service regarding "ants/residents," conducted on 09/04/13, revealed the following: "If a resident is found to have ants in the room the following should be done; head-to-toe assessment done on the resident, shower the resident, change gown and linens. If the resident is needed to change rooms the bed must be changed as well. One hour ant round logs are to be completed by each shift." The facility's current Nursing Policies and Procedures included: Physician Communication/Change in Condition, revised September 2011 and reflected the following: "POLICY: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition. PROCEDURES: 1. Complete assessment of the patient/resident which may include but is not limited to: ...B. Current physical condition C. Patient's/resident's previous condition (declining, improving, stable) ...E. Vital signs, TPR (temperature), BP (blood pressure)...Lung Sounds, N/V Abdominal Assessment, Pain... ...H. allergies [REDACTED]. ...L. Any interventions/first aide (sic) provided to the patient/resident... 2. Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified... 4. The patient's/resident's family member/legal representative will be notified of any change in condition requiring an emergent transfer to the hospital...." A Physician Communication Grid was provided as guidelines for notifying the physician and reflected: "These guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event...." Review of the facility's current Abuse, Neglect and Misappropriation of Property policy, revised on February 2008, revealed the following: "1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law (F223, F224, F225, and F226). 4. The facility's Leadership will designate a staff member to oversee the abuse prohibition policy (Facility Abuse Coordinator). 5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds. Guidelines for investigation reflected the following: "A. Immediately assess resident/patient at the time if discovery of alleged abuse. B. Document assessment in the medical record. C. Maintain resident's/patient's protection during the investigation. D. Notify the attending physician and resident's/patient's legally responsible party. E. Notify the Administrator, Director of Nursing, and Social Worker regardless of the times of da

Based on observation, interview and record review, the facility failed to immediately consult one (Resident #1) of four residents' physician when there is a signifiant change in the resident's physical status. When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: -- conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. -- provide Resident #1's physician/NP with an accurate assessment of Resident #1's status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. -- notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours. On 09/26/13 an Immediate Jeopardy (IJ) was identified in the area of quality of care and accurate assessments. While the IJ was removed on 09/30/13, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and at a potential for more than minimal harm and scope of "pattern." because staff were still being inserviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 152 residents, including Residents #1, #2, #3 and #4, at risk for not being adequately assessed with [REDACTED]. in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: On 09/26/13, based on administrative review, the investigation was reopened for further investigation of a current Immediate Jeopardy situation. Resident #1's MDS assessment, dated 08/25/13, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had severe cognitive impairment, received nourishment via tube feeding, and required total dependence on staff for activities of daily living to include bed mobility and personal hygiene. Resident #1's care plan with a current review date of 08/11/13, reflected the following: a) ADL functions reflected she was totally dependent for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches included to provide Resident #1 with assistance as needed. b) [DIAGNOSES REDACTED]. Approaches included following safety measures and implementing [MEDICAL CONDITION] precautions. c) Resident had difficulty making self understood related to her [DIAGNOSES REDACTED]. Approaches included to observe for non-verbal signs of distress (guarding, moaning, restlessness, grimacing, withdrawal, etc.). Turn/reposition, communicate, provide pericare, assess for pain, and provide liquids/food as needed. Staff must anticipate needs. Resident unable to communicate. d) Resident is at risk for skin breakdown related to bowel and bladder incontinence. The goal was for the resident's skin to remain intact. Approaches included to assess the resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident's room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident's room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and "covered" in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death. Resident #1's nurse's notes dated 09/01/13 and timed both at 5:30 AM and 11:40 PM (start of shift was on 08/31/13), reflected ants were on the resident's dresser and some on her bed. The nurse conducted an assessment of the resident and noted she had no ant bites and had no signs and symptoms of pain. The resident's MD was notified and an order was received to move the resident to another room, and the family was notified of the resident's transfer to a different room due to the presence of ants. An entry at 8:30 AM, reflected the resident was resting comfortably and there were no signs of ants or ant bites in the new room (which shared a wall with Resident #1's old room). The next nurse's notes entry for Resident #1, dated 09/03/13 at 9:30 AM, reflected the nurse heard a nurse aide calling "come STAT (immediately) to room (Resident #1's room). The nurse entered the room and observed two nurse aides and the resident's mother striping her bed. Resident #1's mother was "yelling" that her daughter had ants all on her. The resident had bites on both arms, along her collar bone and the front of her legs, and that the areas were slightly swollen and red. The physician's NP was consulted and gave orders for 50 mg of [MEDICATION NAME] and 7.5 mg of Loratab via her feeding tube, and to apply [MEDICATION NAME] cream to her body. The resident's mother wanted her transferred to a hospital, at 10:00 AM, and at 4:00 PM, Resident #1 returned from the hospital via ambulance. A Patient/Resident Incident/Accident Investigation Worksheet, completed by LVN F on 09/01/13, documented on 09/01/13 at 9:20 AM, Resident #1 was found to have ant bites. At 9:20 AM, the resident's mother came and found ants in the resident's bed and room. Staff then cleaned the ants off the resident and applied cream with medication given per [DEVICE]. On 09/13/13 at 9:15 AM, during an interview with CNA E, she confirmed she worked on 09/01/13, and that she had been assigned the hall where Resident #1 resided. She stated her shift began at 6:00 AM. She stated she was not informed about ants being found in Resident #1's room and bed during the previous shift. She stated she checked on Resident #1 briefly, but did not pull back her sheet to check for ants or perform any incontinence care. She stated around 9:00 AM, she saw Resident #1's family member enter the resident's room and then heard the resident's family member yelling for help. She stated when she arrived at Resident #1's room, "hundreds of ants" were on Resident #1, as well as on her bed and under the resident. CNA E stated she had previously seen ants on the 200 and 300 halls, but denied seeing them on any resident. CNA E stated staff now report any sightings of ants to the charge nurse and maintenance. On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1's family member call for help and went to assist. He stated Resident #1 was "covered from head-to-toe in ants." He stated he focused on helping get the ants off her. He added there were "too many ants to count." During a confidential staff interview, he/she stated he/she had assisted with removing ants from Resident #1 on 09/01/13, and had provided care for the resident when the resident returned from the hospital. The confidential interviewee (CI) stated he/she was present when Resident #1's family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1's brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1's sheets had not been changed the night before when the ants where initially found in the resident's bed. The CI stated Resident #1's brief was "filled with ants," and there were "hundreds" of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being "covered in bites." The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready. The CI stated Resident #1 was then moved to another unit. The CI stated he/she went to check on the resident and she was wrapped in a sheet and when he/she removed the sheet from the resident, he/she observed three to four ants. The CI stated he/she knew the sheets and the mattress were clean and free of ants, so he/she checked Resident #1's wheelchair. The CI stated he/she discovered the pad in the seat of the wheelchair had a hole with food in it as well as food under the pad. The CI shook the pad and approximately eight to nine ants came out of the pad. The CI stated this incident was reported to the DON and Administrator. On 09/16/13 at approximately 11:15 AM, during an interview with LVN F, she confirmed she worked on 09/01/13, and her shift was 6:00 AM to 2:00 PM. She stated she had been the charge nurse for the 200 and 300 halls, which included Resident #1. She stated the night nurse told her ants had been found in Resident #1's room and the resident was moved to a new room. She stated she did a "quick check" of Resident #1 during walking rounds at approximately 6:00 AM, and then did a complete check of Resident #1 at approximately 8:30 AM. She stated the complete check included pulling back Resident #1's covers and checking her body for ant bites and did not find any. During the interview with LVN F, she further stated that at approximately 9:20 AM, she was called by a nurse aide to Resident #1's room. She stated she did not see "a great deal of ants;" no more than 30 ants. LVN F stated she observed ant bites around Resident #1's collarbone and the front of her chest. She stated she did not observe any ant bites on Resident #1's trunk or vaginal area. She stated the bites did not have "blisters" and Resident #1 did not have any facial expression indicating she was in pain. (Note: CNA E and the CI both stated they saw "hundreds of ants," and MA G stated he saw "too many (ants) to count.") LVN F further stated she contacted Resident #1's physician's answering service and then spoke with the physician's NP regarding the incident. She stated the NP who prescribed Resident #1 [MEDICATION NAME] and Loritab, said if Resident #1's family member wanted her sent to the hospital to go ahead and send her. Resident #1's family member requested the resident be sent to the hospital so she contacted a non-emergency transport company and was told that due to Resident #1 being total care, they would be unable to transport the resident. She stated she then contacted an ambulance service for a non-emergency transport. LVN F stated she was not sure if she had notified Resident #1's physician about Resident #1 being sent to the hospital, but did notify the physician upon the resident's return to the facility. (Note: LVN F's nurse's notes for 09/01/13, provided no evidence the physician or his NP were consulted prior to the resident being transferred to a local hospital or upon the resident's return to the facility.) On 09/17/13 at 3:30 PM, during an interview with the DON, she stated that on 09/01/13, between 9:30 AM to 10:00 AM, she was notified of the incident involving Resident #1 and the ants. She recalled that Resident #1 was sent out to the hospital due to the family member's request. The DON stated she arrived at the facility shortly after she was notified of the incident but she did not observe Resident #1 until she had returned from the hospital. The DON stated she conducted the investigation of the incident. she could ot explain why LVN F's nurse's notes did not provide and accurate assessment of the number of Resident #1's number of ant bites. She stated she did not interview LVN F regarding her statement that Resident #1 only received 30 ant bites. She stated she was not aware LVN F had not disclosed the severity of Resident #1's ant bites when she consulted with the physician's NP. She was not aware that neither the physician nor the physician's NP had been consulted regarding Resident #1's transfer to the hospital. She was not aware that neither the physician nor his NP were notified when Resident #1 returned to the facility from the hospital. Nurse's notes, dated 09/01/13 at 4:00 PM, reflected the hospital's physician gave orders for the resident to receive 500 mg of Keflex four times a day for seven days, 4 mg of [MEDICATION NAME][MEDICATION NAME] to take as directed on the package, and [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg/167 mg per 5 ml solution, take 10 ml (two teasponns) every 6 hours as needed for pain. The nurses' notes provided no documented evidence the resident's physician or the physician's PA were notified of the request to transfer the resident to the hospital or of the resident's return from the hospital with new orders. On 09/13/13 at 10:15 AM, during an interview with the physician's NP, she stated she was first notified around midnight (12:00 AM) on 09/01/13, of the ants in Resident #1's room. She stated she received another telephone call later that morning, but was uncertain of the time, and was told the resident had been moved to another room. She stated a third telephone call was received from the facility on 09/01/13, saying Resident #1's family member was worried about Resident #1 being in pain from "some ant bites." She stated she prescribed a topical cream, pain medication, and [MEDICATION NAME]. She stated she was not informed of the number of ant bites or seriousness of the incident. The NP stated she received another telephone call from the facility on 09/02/13 at around midnight to inform her that Resident #1's family member did not want Resident #1 to take the steroids prescribed by the emergency room physician. The NP stated she had been unaware Resident #1 had transferred to a hospital emergency room or of Resident #1's return to the facility. The NP stated she did not see Resident #1 until Tuesday (09/03/13), but could tell that she would have sent Resident #1 to the hospital at the time of the incident if the seriousness of the incident had been conveyed. The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1's physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the "worst case scenario" would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a "massive infection." The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, "There had to be hundreds of ants to have caused the extent of (Resident #1's) injuries." Resident #1's nurse's notes reflected the following entries regarding her ant bites: Entry dated 09/03/13 on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected Resident #1 was "small and frail in stature and unable to make needs known." The resident had contractures to "knees, hips, and elbows bilaterally." Ant bites are noted to Resident #1's "entire body from dense to sparse concentrations." The densest concentrations of ant bites are in the following areas: the base of the back of the neck, the right posterior flank area, left posterior thigh, and left posterior lateral calf. The ants bites are "cluster of fluid filled pustules, too numerous to count." Entry dated 09/06/13 (5 days after the incident) on the 6:00 AM to 2:00 PM shift (no specific time provided), reflected a skin assessment was performed due to the incident of multiple ant bites. The densest concentrations of ant bites are the left posterior thigh and left posterior lateral calf. The ant bites in these areas are "very red and irritated" with a decrease in the fluid filled pustules. The ant bites to the neck, bilateral arms, and right flack are "red and angry, but the concentration of redness has decreased." Observation on 09/13/13 at 12:29 PM, of Resident #1 in her room, revealed she was in bed with socks on her hand. Resident #1's family member was present and stated the socks were used to prevent Resident #1 from scratching herself. Ant bites were observed on all of Resident #1's limbs, neck, shoulders, back, right rib cage, and left inner thigh. Several of the ant bites were observed to have pustules. The family member removed the socks and Resident #1 immediately began scratching her neck and shoulder area. Resident #1 had several dark red scratch marks on both her upper arms and shoulder area. Resident #1's facial expression indicated she was distressed. Resident #1 made slight groaning noises and continued to attempt to scratch at areas with ant bites. Review of the Provider Investigation Report, signed by the DON and dated 09/06/13, identified the category of the incident involving Resident #1 as "Other: Ant Bites." It reflected the incident occurred on 09/01/13, and was reported to the State Agency on 09/01/13. The summary of the investigation reflected: A nurse observed ants on the resident's dresser and on her bed on 08/31/13 at approximately 11:40 PM. The resident and her roommate were moved to another room and both residents were assessed and no observations of ants were noted on either resident. Staff continued to monitor throughout the shift. On 09/01/13 at 9:30 AM, the resident's mother observed ants on the resident. A nurse assessed Resident #1 and observed multiple ant bits on Resident #1 and the areas were closed and slightly swollen. The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms. Resident #1 was moved to another room, and her previous room was deep cleaned, and she was provided with a new wheelchair cushion. A head-to-toe assessment was conducted every shift. A pest control provider treated the interior and exterior of the facility. (The copies of billing from the pest control provider were for 08/09/13, 08/13/13, 08/16/13, 08/20/13, 08/21/13, 08/26/13, 08/27/13, and 09/06/13.) Staff, including nursing staff, maintenance, housekeeping and administration, were educated on monitoring rooms for ant activity, implementing safety checks for ants, who to notify in the event of finding ants, and how to respond if ants were observed on residents or beds/linens. Daily monitoring continued for observation of ants. The plan did not address ensuring nurses conduct accurate assessments of residents and ensuring nurses provide complete and accurate information when consulting with a resident's physician. It furthermore did not provide information regarding how they addressed ensuring nurses consult/notify a physician when a resident is being transferred to a hospital and again when they return with an order to review the treatment orders from the hospital to allow the attending physician to determine if he wants to approve the new treatment plan or change it. Review of the facility's Patient/Resident Incident/Accident Investigation Worksheets revealed on 08/31/13 at 11:49 PM, Resident #3 was found in her room with ants on her dresser. The nurse conducted a head-to-toe assessment of the resident and found no ant bites. (Note: This incident occurred the day before Resident #1 was found in the same room covered with ants.) Review of the facility's Service Request Log for the contract exterminator revealed the following: 08/20/13 at 2:30 p.m. - Entire unit needs to be sprayed. Bugs and ants in every room. On 08/21/13 (no time) - Entire room [ROOM NUMBER] and bed B have ants. On 08/21/13 (no time) - Ants in closet in room [ROOM NUMBER] on clothes. On 09/01/13 (no time) - Ants in resident room [ROOM NUMBER] and restroom. On 09/03/13 (no time) - Ants at nurses' station (station not specified). Review of the pest control service provider's receipts for treatment revealed the following: 08/13/13: room [ROOM NUMBER] was treated. The facility's exterior was treated. Ants were the targeted pest. Ants were noted during service. A Fire Ant mound was noted near an exit door. Ants were noted in room [ROOM NUMBER]. 08/16/13: this visit was in regard to cockroaches in the kitchen and the treatment of [REDACTED]. 08/20/13: The facility's exterior area was treated. Ants were noted during service. The courtyard of the secured unit, 200 hall, was treated. rooms [ROOM NUMBERS] were treated for [REDACTED]. 08/21/13: Patient/guest rooms were treated. The targeted pest was ants. rooms [ROOM NUMBERS] were treated. Ants were noted during service under cold base in rooms [ROOM NUMBERS]. 08/25/13: The facility's exterior area and patient/guest rooms were treated. The targeted pest was ants. The areas were inspected and treated and rooms were serviced. room [ROOM NUMBER], baseboards, was treated. Ants were noted during services; baseboards around bed. 08/27/13: The facility's perimeter was treated and ants were the target. Ants were noted during service; several ants near building on exterior of building. Trees/shrubs were contacting the facility creating a path for pests to enter. The service provider suggested the facility trim back vegetation to eliminate contact. 09/06/13: The exterior of the widnoew and ground near room [ROOM NUMBER]. On 09/13/13 at 3:20 PM, interview with the Pest Control Service Provider revealed only one fire ant mound was found after the incident that occurred on 09/01/13. The service provider completed a "power spray" approximately two weeks ago. It will sometimes drive the insects into the facility where they will ingest the poison and then die. The service provider and the facility are working on controlling the issue. On 09/13/13 at 2:28 PM, interview with the Administrator revealed the facility did not have a specific policy regarding ants, just the statement written for the in-service conducted after the incident on 09/01/13. On 09/13/13 at 2:50 PM, interview with the Maintenance Director revealed prior to the incident on 09/01/13, the facility had been calling the exterminator when ants were found in the facility. The Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The identified repairs were completed following the compilation of the list of repairs needed, however completion dates were not provided at that time. Any ants seen in the facility are logged by staff in a maintenance log book located at each nurses' station. The log books are check twice a day. Insect sightings are also logged in a pest control book located at the nurses' station that is monitored by the pest control service provider on a monthly basis. If only a couple of ants are sighted the maintenance staff will treat the area himself. If it is a resident room he will also treat outside near the exterior wall of the room. Maintenance staff also monitor outside for ant mounds on a daily basis. Review of an undated, untitled document attached to the Facility's Provider Investigation Report involving Resident #1 revealed a list of resident rooms in the facility with environmental issues. On 09/13/13 at 2:50 PM, the Maintenance Director identified the undated handwritten document as a list compiled by staff members after the incident on 09/01/13, of areas in the facility where repairs were needed to address ants in the building. The list included a total of 82 resident rooms that needed "caulk around the windows." The following are the rooms identified: 1, 3, 11, 18, 20-22, 24-25, 28-30, 33-34, 38-39, 41-42, 45, 59-60, 200-213, 215-226, 228, 301-309, 311-313, 315, 401-408, 412-415, 418-420, 422-424, 426-427, and 429. The list also included 20 rooms that needed "caulk around the windows" and in the bathroom. The identified rooms were: 4, 23, 26, 31-32, 35-36, 40, 44, 48-49, 51-58, and 310. Also identified on the list were the following five rooms that needed caulking in the bathroom only: 9, 10, 12, 19, and 411. The list identified seven rooms where ants were found, the rooms were: 5, 9, 11, 20, 53, 55, and 406. The list also identified other environmental issues in resident rooms. In room [ROOM NUMBER] a hole in the widow screen was identified. In room [ROOM NUMBER] the "window doesn't shut all the way," and the frame was "rotten." In room [ROOM NUMBER] the window was "still broken," and room [ROOM NUMBER] had "broken window trim." The window in room [ROOM NUMBER] was described as being in "bad shape." room [ROOM NUMBER] had a hole by the bathroom door, and room [ROOM NUMBER] had a broken baseboard. A total of 107 resident rooms of the 120 resident rooms in the facility were identified as needing some type of repair. On 09/13/13 at approximately 4:00 PM, the Administrator and Assistant Administrator revealed the plan to address the ants in the facility included the following: One hour checks of total care residents by direct care staff, daily checks on residents' rooms by clinical staff and housekeeping, and daily checks by maintenance outside the facility for ant mounds. Logs of the resident and room checks were kept at each nurses' station, one for direct care staff and one for housekeeping. Staff documents any sightings of ants in the maintenance log as well as the other identified logs. The Assistant Administrator stated he has begun marking rooms where ants were sited on a floor plan so he can monitor which rooms are impacted. The Administrator stated the monitoring began on 08/28/13, but some of the nurses' stations did not begin their logs until 09/02/13. Maintenance staff is monitoring the maintenance logs kept at the nursing stations at least once a day. Maintenance treats any sightings of insects immediately and coordinates further treatments with the pest control service providers. Review of the facility's "Daily Ant Inspection" logs revealed rooms on the 200 Hall, 300 Hall, 400 Hall, The Terrace, and The Verandah were monitored once a day for ants from 08/28/13 to 09/14/13. Ants were noted on 09/01/13 in Rooms 211, 213, 310, and the 300 Hall Shower Room. Ants were noted on 09/01/13 in room [ROOM NUMBER], and the 300 Hall. Ants were noted on 09/04/13 in rooms [ROOM NUMBERS]. Ants were noted on 09/04/13 in Rooms 310, and 417, and 400 Hall Shower Room. Ants were noted on 09/05/13 in room [ROOM NUMBER]. Ants were noted on 09/06/13 in room [ROOM NUMBER]. Ants were noted on 09/10/13 in room [ROOM NUMBER]. Ants were noted on 09/12/13 in room [ROOM NUMBER]. Ants were noted on 09/14/13 in rooms [ROOM NUMBERS]. Review of the in-service regarding "ants/residents," conducted on 09/04/13, revealed the following: "If a resident is found to have ants in the room the following should be done; head-to-toe assessment done on the resident, shower the resident, change gown and linens. If the resident is needed to change rooms the bed must be changed as well. One hour ant round logs are to be completed by each shift." The facility's current Nursing Policies and Procedures included: Physician Communication/Change in Condition, revised September 2011 and reflected the following: "POLICY: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition. PROCEDURES: 1. Complete assessment of the patient/resident which may include but is not limited to: ...B. Current physical condition C. Patient's/resident's previous condition (declining, improving, stable) ...E. Vital signs, TPR (temperature), BP (blood pressure)...Lung Sounds, N/V Abdominal Assessment, Pain... ...H. allergies [REDACTED]. ...L. Any interventions/first aide (sic) provided to the patient/resident... 2. Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified... 4. The patient's/resident's family member/legal representative will be notified of any change in condition requiring an emergent transfer to the hospital...." A Physician Communication Grid was provided as guidelines for notifying the physician and reflected: "These guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event...." An Immediate Jeopardy was identified on 09/26/13 in the area of Quality of Care and accurate assessments. On 09/26/13 at 1:00 PM, the Assistant Administrator and DON were informed an Immediate Jeopardy (IJ) had been identified. A Plan of Removal for the IJ was requested. . The Plan of Removal for the IJ was accepted on 09/27/13 at 7:30 PM, and reflected the following: Resident #1's bed was found with ants on 08/31/13 at 11:49 PM. Assessment of the resident revealed there were no ant bites. The resident was moved to another room, which shared a wall with her first room. On 09/01/13 at 8:30 AM, ants were found on Resident #1. LVN F was informed, but her documentation in the resident's clinical record was not an accurate description of the number of ants. MA G and CNA E, along with Resident #1's family member were stripping the bed and wiping ants off the resident. LVN F documented ants were under the resident as well as having been bitten on both arms, collar bone and front of the legs. There was no evidence of a comprehensive clinical assessment. Information provided to the NP was unknown. Orders were received to give [MEDICATION NAME] 50 mg and [MEDICATION NAME] 7.5 mg per [DEVICE] and to apply [MEDICATION NAME] cream. Resident #1 was transferred to the ER for treatment at the insistence of the resident's family member. LVN F provided no other reason for Resident #1 being sent to the ER. Resident #1 returned to the facility the same day and was taken to a ro

Based on interview and record review, it was determined the facility failed to promptly notify the attending physician of a critical laboratory result for one (Resident #1) of six residents reviewed for lab results. LVN C failed to notify Resident #1's physician of a a critical hemoglobin level on 07/29/13. The physician ordered another hemoglobin test, and the level was still critical on 07/31/13. Resident #1's physician was notified on 07/31/13 of the critical level, and he ordered the resident to be sent to the hospital. Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. He also received a blood transfusion. An Immediate Jeopardy (IJ) was identified on 08/16/13. While the IJ was removed on 08/17/13, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 18 residents, who resided on the [MEDICAL CONDITION] Unit, by placing them at risk for bleeding, heart failure, [MEDICAL CONDITION] and delayed medical care and intervention. Findings included: After Administrative Review, it was determined an IJ existed and a surveyor re-entered the facility on 08/16/13 to notify the facility of the IJ and request a Plan of Removal. Resident #1's Discharge Summary, dated 08/03/13, reflected the resident was transferred from the hospital to another facility, which was approximately two hours away, that day. The surveyor was unable to observe or interview the resident in the hospital or in a facility. Review of Resident #1's Admission Record revealed the resident was a [AGE] year-old male with an admission date of [DATE]. Resident #1's History and Physical, dated 06/18/13, reflected, "...He is known to have a history of [MEDICAL CONDITIONS] embolism (blood clot in the lung) and is on chronic anticoagulation, currently in [MEDICATION NAME] (blood thinner)...LABORATORY...Hemoglobin 9.0 (normal for men is 14 to 18 g/dL)...ASSESSMENT: 1. [MEDICAL CONDITION]...5. status [REDACTED]..9. [MEDICAL CONDITION]. PLAN: 1. We will need to convert [MEDICATION NAME] to [MEDICATION NAME] (blood thinner); will check daily INRs (laboratory test to check for blood clotting time) 2. Initiate anticoagulation (illegible) [MEDICATION NAME] at this point...6. We will also need [MEDICAL CONDITION] workup in the near future." Taber's Cyclopedic Medical Dictionary 21st Edition on page 1046 reflected Hemoglobin was "...the iron-containing pigment of red blood cells that carries oxygen from the lungs to the tissues...In the tissues where oxygen concentration is low and carbon [MEDICATION NAME] is high (low pH), hemoglobin releases its oxygen...." Taber's Cyclopedic Medical Dictionary 21st Edition on page 115 reflected [MEDICAL CONDITION] was "...reduction in the mass of circulating red blood cells. Generally, people are considered anemic when their hemoglobin levels are more more than two standard deviations from below the mean level in their hospital's [MEDICAL CONDITION] may be caused by bleeding...." Lippincott, Williams & Wilkins Nursing 2013 Drug Handbook on page 1409, regarding [MEDICATION NAME], reflected, "...NURSING CONSIDERATIONS Black Box Warning [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients Consider more frequent INR monitoring in those at high risk for bleeding...Elderly patients...are especially sensitive to drugs effect...." http://labtestsonline.org/understanding/analytes/pt/tab/test reflected, "Most laboratories report PT ([MEDICATION NAME] time) results that have been adjusted to the INR for people on [MEDICATION NAME] ([MEDICATION NAME]). These people should have an INR of 2.0 - 3.0 for basic 'blood-thinning' needs." (retrieved on 09/03/13). Resident #1's Care Plan, dated 06/26/13, did not address his low Hemoglobin or the potential for bleeding due to [MEDICATION NAME]. Resident #1's NP's Progress Note, dated 07/10/13, reflected his INR on 07/09/13 was 2.6. Resident #1's MDS assessment, dated 07/12/13, reflected [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was severely impaired, he was totally dependent on staff for bed mobility, transfers, locomotion, eating, and bathing, and he needed extensive staff assistance with dressing, toileting, and personal hygiene. Further review of Resident #1's MDS assessment revealed he had an indwelling catheter and ostomy, he received an anticoagulant on four of the last seven days, and he received oxygen, suctioning, and [MEDICAL CONDITION] care in the last 14 days. Resident #1's NP's Progress Note, dated 07/15/13, reflected an elevated INR of 4.2 on 07/12/13 with his [MEDICATION NAME] held until his INR was less than 3.0. an order for [REDACTED]. Resident #1's NP's Progress Note, dated 07/19/13, reflected his INR was 1.2 due to holding [MEDICATION NAME]. The Note also reflected he had a low grade temperature. Resident #1's CBC laboratory results, dated 07/22/13, reflected his hemoglobin was 7.5 g/dL with a reference range of 13.8 - 17.2 g/dL. A Physician's Progress Note, dated 07/23/13, reflected, "...He does remain on anticoagulation...Most recent INR was 2.2. Today's CBC reveals...Hemoglobin: 7.5...6. Significant [MEDICAL CONDITION] will need to monitor BMP closely over the next few days...Continue to monitor INR. Continue to monitor CBC closely." Resident #1's CBC laboratory results, dated 07/25/13, reflected his hemoglobin was low at 7.5 g/dL. Resident #1's Physician's Progress Note, dated 07/25/13, reflected, "...His BMP requested on the 24th and 25th have not yet made their way to the chart. We will request Nursing to gather such. Most recent INR was therapeutic...1. Low-grade fever, questionable source...4. Chronic anticoagulation with [MEDICATION NAME] need to monitor for further temperature elevation...The patient appears to be declining...We will ask that staff obtain the most immediate pressing lab, repeat CBC in the morning." Physician's Telephone Order, dated 07/25/13, reflected a CBC to be obtained from Resident #1 the morning of 07/26/13 and again on Monday 07/29/13. Resident #1's NP's Progress Note, dated 07/26/13, reflected to hold [MEDICATION NAME] that day and check his INR in the morning. The Note also reflected his current INR was 4.9. Lab results, dated 07/26/13, reflected Resident #1's hemoglobin was low at 7.7 g/dL. According to documentation on the lab report, dated 07/26/13, the physician was notified of the results. Resident #1's NP's Progress Note, dated 07/27/13, reflected a critical INR of 5.6 which was reported to the NP. The NP's order was to continue to hold [MEDICATION NAME]. Resident #1's NP's Progress Note, dated 07/29/13, reflected his INR was 5.7 on 07/27/13. Lab results, dated 07/29/13, reflected Resident #1's hemoglobin was at a critically low level of 6.9 g/dL. According to the lab report, LVN C was notified by telephone of the critical level on 07/29/13 at 3:41 p.m. However, there was no documented evidence in the clinical record Resident #1's physician was notified of the critical results. http://www.surgeryencyclopedia.com/Fi-La/Hemoglobin-Test.html reflected, "Dangerously low hemoglobin levels put a person at risk of a [MEDICAL CONDITIONS], or stroke...Critically high or low levels should be immediately called to the attention of the patient's doctor." (retrieved on 09/03/13). Resident #1's physician's Progress Note, dated 07/30/13 reflected, the resident's INR was "markedly elevated...ASSESSMENT...6. Subtherapeutic INR...PLAN: 1. Check INR in the morning. Give Vitamin K if it remains elevated...We will repeat BMP in the morning...." A Physician's Telephone Order, dated 07/30/13, reflected another CBC to be obtained from Resident #1 the morning of 07/31/13. The lab result, dated 07/31/13, reflected Resident #1's hemoglobin remained at a critical level of 6.9 g/dL. A Nurse's Note, dated 07/31/13 and timed 1:45 p.m., reflected Resident #1's physician was notified on 07/31/13 of the critical hemoglobin level. An order was received at that time to transfer the resident to the hospital. A telephone interview with the NP on 08/03/13 at 5:40 p.m. revealed she was at the facility on 07/29/13, but neither she nor the physician were notified of a critical 6.9 hemoglobin level until 07/31/13. The NP stated Physician K's protocol was to transfer a resident to the hospital for a hemoglobin below 7.0. The NP further stated if she had been aware of the critical hemoglobin on 07/29/13, she would have sent Resident #1 to the hospital on [DATE]. An interview with Resident #1's primary physician,Physician K on 08/16/13 at 10:58 a.m. revealed he had experienced difficulties in the past with receiving lab results from facility nursing staff. Resident #1's NP's Progress Note, dated 07/31/13, reflected his hemoglobin continued to be less than 6.9 g/dL, and the physician was contacted who wanted the resident sent to the hospital. The Note also reflected his INR was low at 1.2 due to his [MEDICATION NAME] being held since 07/25/13 because his INR was high. Nurse's Notes, dated 07/31/13 and timed 2:00 p.m., reflected Resident #1 was transferred from the [MEDICAL CONDITION] Unit to the hospital. An interview was conducted with the DON on 08/03/13 at 5:30 p.m. in the presence of the Administrator, Corporate Nurse, and the facility's only Treatment Nurse. During this time, the DON stated she had communicated with LVN C, who was the nurse contacted by the lab and informed of Resident #1's critical hemoglobin on 07/29/13. The DON further stated the nurse was unable to recall being notified of the critical hemoglobin on 07/29/13. The surveyor's attempts to contact LVN C were unsuccessful. Resident #1's hospital History and Physical, dated 07/31/13 reflected, "...He was transferred here because of low h/h (hemoglobin and hematocrit). On the floor pt (patient) is hypotensive (low blood pressure) and rapid response was called...Physical Exam...Pulse: 105... BP (blood pressure): 101/52 mmHg...." Resident #1's hospital records, dated 08/01/13, reflected, "PROBLEMS: [MEDICAL CONDITION] due to acute blood loss...PLANS: ...6. Transfuse...." Resident #1's hospital records, dated 08/01/13, reflected, "...notified as requested after first unit of blood completed...Heart rate [MEDICAL CONDITION], no temp. Blood Pressure beginning to sustain > 100...Order received that if blood pressure remains > 100 post transfusion of 2nd unit...." Resident #1's hospital's Renal Daily Progress Note, dated 08/02/13, reflected, "[MEDICAL CONDITION] due to blood loss...2. Hospice reasonable alternative as quality of life will be impossible to restore in my opinion." Resident #1's hospital's Daily Progress Note, dated 08/02/13, reflected, "Awake today. Does not feel comfortable...Looks like (family member) will arrange hospice at new NH (Nursing Home)...Will transfer to NH today with hospice to be arranged at the facility." Resident #1's hospital Daily Progress Note, dated 08/03/13, reflected, "...3. If NH has a bariatric bed, will transfer today and hospice to be arranged at facility." Resident #1's hospital Discharge Summary, dated 08/03/13, reflected he was discharged to another nursing facility on 08/03/13. On 08/03/13 at 6:00 p.m., the DON and Corporate Nurse stated problems with lab reports was identified and staff training was initiated after communicating with the hospital and initiating their own investigation on 08/01/13. She further stated the investigation was ongoing and quality assurance measures were being implemented to address the identified problems including notifying physicians of abnormal lab/test results. On 08/03/13 the Corporate nurse provided undated training records related to reporting and documenting abnormal test results. The training information reflected any abnormal test result required notification of the physician. Tests included lab and radiology reports. The training information further reflected nurses were expected to document the date and the time they notified the physician, the physician's response and any new orders received. An IJ was identified on 08/16/13. The Administrator and DON were notified on 08/16/13 at 10:25 a.m. of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, dated 08/16/13, was accepted on 08/16/13 and reflected, "... (LVN C) working during this incident was immediately suspended on 08/03/13 pending investigation of this incident and was subsequently terminated... All current Licensed Nurses has (sic) been educated to notify physician/nurse practitioner upon receipt of abnormal test results and to document notification with response from Physician. Facility Licensed Nursing staff has been reeducated on use of the 24 hr report with post test as validation. ....Education was completed 08/10/13 with the exception of prn or part-time staff she (the Staff Development Coordinator) has been unable to reach; this staff will not be allowed to work until education is completed. Lab Tracker form was initiated by Assistant Director of Nurses on 08/05/13. This Assistant Director of Nurses educated the [MEDICAL CONDITION] Rehab Suites staff at the time of initiation, 08/05/13. Lab Tracker form consists of Room number, Resident Name, Date ordered, date sent, lab ordered, results back, date, physician notified and new orders. The system that is used on the Long Term Care Stations - routine labs is data entered into the computer and printed on Medication Administration Records for tracking. Assistant Director of Nurses/director of Nurses will monitor Lab tracker daily. Assistant Directors of Nurses/Director of Nurses will monitor daily by taking the 24 hr report to stand-up and 'scrubbing' the 24 hr report (comparing orders/test results to documentation on report and documentation in chart). The Director of Nurses/Assistant Director of Nurses will address deficient practices with the individual nurse by calling them in and providing 1:1 education and/or disciplinary actions if indicated. Newly hired Licensed staff will be educated on all items above during classroom orientation. This will be included in Annual Orientation. Staff Development Coordinator (name) will monitor to ensure all Licensed Nurses have received this training - initially and annually. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting. 08/2/13 (Resident #1's physician), the attending Physician was notified of the concerns by the Administrator and due to the Medical Director was unavailable (out of the country). 08/16/13 (name) Medical Director was notified of issues in the facility to schedule a meeting with the Administrator. 08/16/13 (medical director) was notified at 11:14 a.m. of IJ...." Interviews were conducted with staff on the [MEDICAL CONDITION] Unit representing all three shifts as follows: On 08/16/13 interviews were conducted with RN D, LVN E, LVN F, LVN G, and LVN H between 12:20 p.m. and 12:45 p.m. and 3:15 p.m. and 3:35 p.m. On 08/17/13 interviews were conducted with LVN I and LVN J between 10:50 a.m. and 11:05 a.m. All of the nurses interviewed revealed they received training that included a post-test related to documenting and follow-up of lab results. The nurses further stated they were aware of the Lab Tracker system and were able to explain the system in detail. The nurses provided lab books for their assigned rooms that included resident names, room numbers, labs ordered, date collected, results and documentation of physician notification. On 08/17/13 the IJ was removed. On 08/17/13 at 12:45 p.m., the Administrator and DON were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. A resident room roster provided by the Administrator on 08/17/13 reflected 18 residents resided on the [MEDICAL CONDITION] Unit.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of six residents reviewed for laboratory results. LVN C failed to notify Resident #1's physician of a critical hemoglobin level on 07/29/13. The physician ordered another hemoglobin test, and the level was still critical on 07/31/13. Resident #1's physician was notified on 07/31/13 of the critical level, and he ordered the resident to be sent to the hospital. Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. He also received a blood transfusion. An Immediate Jeopardy (IJ) was identified on 08/16/13. While the IJ was removed on 08/17/13, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 18 residents, who resided on the [MEDICAL CONDITION] Unit, by placing them at risk for bleeding, heart failure, [MEDICAL CONDITION] and delayed medical care and intervention. Findings included: After Administrative Review, it was determined an IJ existed and a surveyor re-entered the facility on 08/16/13 to notify the facility of the IJ and request a Plan of Removal. Resident #1's hospital Discharge Summary, dated 08/03/13, reflected the resident was transferred from the hospital to another facility, which was approximately two hours away, that day. The surveyor was unable to observe or interview the resident in the hospital or in a facility. Review of Resident #1's Admission Record revealed the resident was a [AGE] year-old male with an admission date of [DATE]. Resident #1's History and Physical, dated 06/18/13, reflected, "...He is known to have a history of [MEDICAL CONDITIONS] embolism (blood clot in the lung) and is on chronic anticoagulation, currently in [MEDICATION NAME] (blood thinner)...LABORATORY...Hemoglobin 9.0 (normal for men is 14 to 18 g/dL)...ASSESSMENT: 1. [MEDICAL CONDITION]...5. status [REDACTED]..9. [MEDICAL CONDITION]. PLAN: 1. We will need to convert [MEDICATION NAME] to [MEDICATION NAME] (blood thinner); will check daily INRs (laboratory test to check for blood clotting time) 2. Initiate anticoagulation (illegible) [MEDICATION NAME] at this point...6. We will also need [MEDICAL CONDITION] workup in the near future." Taber's Cyclopedic Medical Dictionary 21st Edition on page 1046 reflected Hemoglobin was "...the iron-containing pigment of red blood cells that carries oxygen from the lungs to the tissues...In the tissues where oxygen concentration is low and carbon [MEDICATION NAME] is high (low pH), hemoglobin releases its oxygen...." Taber's Cyclopedic Medical Dictionary 21st Edition on page 115 reflected [MEDICAL CONDITION] was "...reduction in the mass of circulating red blood cells. Generally, people are considered anemic when their hemoglobin levels are more more than two standard deviations from below the mean level in their hospital's [MEDICAL CONDITION] may be caused by bleeding...." Lippincott, Williams & Wilkins Nursing 2013 Drug Handbook on page 1409, regarding [MEDICATION NAME], reflected, "...NURSING CONSIDERATIONS Black Box Warning [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients Consider more frequent INR monitoring in those at high risk for bleeding...Elderly patients...are especially sensitive to drugs effect...." http://labtestsonline.org/understanding/analytes/pt/tab/test reflected, "Most laboratories report PT ([MEDICATION NAME] time) results that have been adjusted to the INR for people on [MEDICATION NAME] ([MEDICATION NAME]). These people should have an INR of 2.0 - 3.0 for basic 'blood-thinning' needs." (retrieved on 09/03/13). Resident #1's Care Plan, dated 06/26/13, did not address his low Hemoglobin or the potential for bleeding due to [MEDICATION NAME]. Resident #1's NP's Progress Note, dated 07/10/13, reflected his INR on 07/09/13 was 2.6. Resident #1's MDS assessment, dated 07/12/13, reflected [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was severely impaired, he was totally dependent on staff for bed mobility, transfers, locomotion, eating, and bathing, and he needed extensive staff assistance with dressing, toileting, and personal hygiene. Further review of Resident #1's MDS assessment revealed he had an indwelling catheter and ostomy, he received an anticoagulant on four of the last seven days, and he received oxygen, suctioning, and [MEDICAL CONDITION] care in the last 14 days. Resident #1's NP's Progress Note, dated 07/15/13, reflected an elevated INR of 4.2 on 07/12/13 with his [MEDICATION NAME] held until his INR was less than 3.0. an order for [REDACTED]. Resident #1's NP's Progress Note, dated 07/19/13, reflected his INR was 1.2 due to holding [MEDICATION NAME]. The Note also reflected he had a low grade temperature. Resident #1's CBC laboratory results, dated 07/22/13, reflected his hemoglobin was 7.5 g/dL with a reference range of 13.8 - 17.2 g/dL. A Physician's Progress Note, dated 07/23/13, reflected, "...He does remain on anticoagulation...Most recent INR was 2.2. Today's CBC reveals...Hemoglobin: 7.5...6. Significant [MEDICAL CONDITION] will need to monitor BMP closely over the next few days...Continue to monitor INR. Continue to monitor CBC closely." Resident #1's CBC laboratory results, dated 07/25/13, reflected his hemoglobin was low at 7.5 g/dL. Resident #1's Physician's Progress Note, dated 07/25/13, reflected, "...His BMP requested on the 24th and 25th have not yet made their way to the chart. We will request Nursing to gather such. Most recent INR was therapeutic...1. Low-grade fever, questionable source...4. Chronic anticoagulation with [MEDICATION NAME] need to monitor for further temperature elevation...The patient appears to be declining...We will ask that staff obtain the most immediate pressing lab, repeat CBC in the morning." Physician's Telephone Order, dated 07/25/13, reflected a CBC to be obtained from Resident #1 the morning of 07/26/13 and again on Monday 07/29/13. Resident #1's NP's Progress Note, dated 07/26/13, reflected to hold [MEDICATION NAME] that day and check his INR in the morning. The Note also reflected his current INR was 4.9. Lab results, dated 07/26/13, reflected Resident #1's hemoglobin was low at 7.7 g/dL. According to documentation on the lab report, dated 07/26/13, the physician was notified of the results. Resident #1's NP's Progress Note, dated 07/27/13, reflected a critical INR of 5.6 which was reported to the NP. The NP's order was to continue to hold [MEDICATION NAME]. Resident #1's NP's Progress Note, dated 07/29/13, reflected his INR was 5.7 on 07/27/13. Lab results, dated 07/29/13, reflected Resident #1's hemoglobin was at a critically low level of 6.9 g/dL. According to the lab report, LVN C was notified by telephone of the critical level on 07/29/13 at 3:41 p.m. However, there was no documented evidence in the clinical record Resident #1's physician was notified of the critical results. http://www.surgeryencyclopedia.com/Fi-La/Hemoglobin-Test.html reflected, "Dangerously low hemoglobin levels put a person at risk of a [MEDICAL CONDITIONS], or stroke...Critically high or low levels should be immediately called to the attention of the patient's doctor." (retrieved on 09/03/13). Resident #1's physician's Progress Note, dated 07/30/13 reflected, the resident's INR was "markedly elevated...ASSESSMENT...6. Subtherapeutic INR...PLAN: 1. Check INR in the morning. Give Vitamin K if it remains elevated...We will repeat BMP in the morning...." A Physician's Telephone Order, dated 07/30/13, reflected another CBC to be obtained from Resident #1 the morning of 07/31/13. The lab result, dated 07/31/13, reflected Resident #1's hemoglobin remained at a critical level of 6.9 g/dL. A Nurse's Note, dated 07/31/13 and timed 1:45 p.m., reflected Resident #1's physician was notified on 07/31/13 of the critical hemoglobin level. An order was received at that time to transfer the resident to the hospital. A telephone interview with the NP on 08/03/13 at 5:40 p.m. revealed she was at the facility on 07/29/13, but neither she nor the physician were notified of a critical 6.9 hemoglobin level until 07/31/13. The NP stated Physician K's protocol was to transfer a resident to the hospital for a hemoglobin below 7.0. The NP further stated if she had been aware of the critical hemoglobin on 07/29/13, she would have sent Resident #1 to the hospital on [DATE]. An interview with Resident #1's primary physician,Physician K on 08/16/13 at 10:58 a.m. revealed he had experienced difficulties in the past with receiving lab results from facility nursing staff. Resident #1's NP's Progress Note, dated 07/31/13, reflected his hemoglobin was continued to be less than 6.9 g/dL, and the physician was contacted who wanted the resident sent to the hospital. The Note also reflected his INR was low at 1.2 due to his [MEDICATION NAME] being held since 07/25/13 because his INR was high. Nurse's Notes, dated 07/31/13 and timed 2:00 p.m., reflected Resident #1 was transferred from the [MEDICAL CONDITION] Unit to the hospital. An interview was conducted with the DON on 08/03/13 at 5:30 p.m. in the presence of the Administrator, Corporate Nurse, and the facility's only Treatment Nurse. During this time, the DON stated she had communicated with LVN C, who was the nurse contacted by the lab and informed of Resident #1's critical hemoglobin on 07/29/13. The DON further stated the nurse was unable to recall being notified of the critical hemoglobin on 07/29/13. The surveyor's attempts to contact LVN C were unsuccessful. Resident #1's hospital History and Physical, dated 07/31/13 reflected, "...He was transferred here because of low h/h (hemoglobin and hematocrit). On the floor pt (patient) is hypotensive (low blood pressure) and rapid response was called...Physical Exam...Pulse: 105... BP (blood pressure): 101/52 mmHg...." Resident #1's hospital records, dated 08/01/13, reflected, "PROBLEMS: [MEDICAL CONDITION] due to acute blood loss...PLANS: ...6. Transfuse...." Resident #1's hospital records, dated 08/01/13, reflected, "...notified as requested after first unit of blood completed...Heart rate [MEDICAL CONDITION], no temp. Blood Pressure beginning to sustain > 100...Order received that if blood pressure remains > 100 post transfusion of 2nd unit...." Resident #1's hospital's Renal Daily Progress Note, dated 08/02/13, reflected, "[MEDICAL CONDITION] due to blood loss...2. Hospice reasonable alternative as quality of life will be impossible to restore in my opinion." Resident #1's hospital's Daily Progress Note, dated 08/02/13, reflected, "Awake today. Does not feel comfortable...Looks like (family member) will arrange hospice at new NH (Nursing Home)...Will transfer to NH today with hospice to be arranged at the facility." Resident #1's hospital Daily Progress Note, dated 08/03/13, reflected, "...3. If NH has a bariatric bed, will transfer today and hospice to be arranged at facility." Resident #1's hospital Discharge Summary, dated 08/03/13, reflected he was discharged to another nursing facility on 08/03/13. On 08/03/13 at 6:00 p.m., the DON and Corporate Nurse stated problems with lab reports was identified and staff training was initiated after communicating with the hospital and initiating their own investigation on 08/01/13. She further stated the investigation was ongoing and quality assurance measures were being implemented to address the identified problems including notifying physicians of abnormal lab/test results. On 08/03/13 the Corporate nurse provided undated training records related to reporting and documenting abnormal test results. The training information reflected any abnormal test result required notification of the physician. Tests included lab and radiology reports. The training information further reflected nurses were expected to document the date and the time they notified the physician, the physician's response and any new orders received. An IJ was identified on 08/16/13. The Administrator and DON were notified on 08/16/13 at 10:25 a.m. of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, dated 08/16/13, was accepted on 08/16/13 and reflected, "... (LVN C) working during this incident was immediately suspended on 08/03/13 pending investigation of this incident and was subsequently terminated... All current Licensed Nurses has (sic) been educated to notify physician/nurse practitioner upon receipt of abnormal test results and to document notification with response from Physician. Facility Licensed Nursing staff has been reeducated on use of the 24 hr report with post test as validation. ....Education was completed 08/10/13 with the exception of prn or part-time staff she (the Staff Development Coordinator) has been unable to reach; this staff will not be allowed to work until education is completed. Lab Tracker form was initiated by Assistant Director of Nurses on 08/05/13. This Assistant Director of Nurses educated the [MEDICAL CONDITION] Rehab Suites staff at the time of initiation, 08/05/13. Lab Tracker form consists of Room number, Resident Name, Date ordered, date sent, lab ordered, results back, date, physician notified and new orders. The system that is used on the Long Term Care Stations - routine labs is data entered into the computer and printed on Medication Administration Records for tracking. Assistant Director of Nurses/director of Nurses will monitor Lab tracker daily. Assistant Directors of Nurses/Director of Nurses will monitor daily by taking the 24 hr report to stand-up and 'scrubbing' the 24 hr report (comparing orders/test results to documentation on report and documentation in chart). The Director of Nurses/Assistant Director of Nurses will address deficient practices with the individual nurse by calling them in and providing 1:1 education and/or disciplinary actions if indicated. Newly hired Licensed staff will be educated on all items above during classroom orientation. This will be included in Annual Orientation. Staff Development Coordinator (name) will monitor to ensure all Licensed Nurses have received this training - initially and annually. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting. 08/2/13 (Resident #1's physician), the attending Physician was notified of the concerns by the Administrator and due to the Medical Director was unavailable (out of the country). 08/16/13 (name) Medical Director was notified of issues in the facility to schedule a meeting with the Administrator. 08/16/13 (medical director) was notified at 11:14 a.m. of IJ...." Interviews were conducted with staff on the [MEDICAL CONDITION] Unit representing all three shifts as follows: On 08/16/13 interviews were conducted with RN D, LVN E, LVN F, LVN G, and LVN H between 12:20 p.m. and 12:45 p.m. and 3:15 p.m. and 3:35 On 08/17/13 interviews were conducted with LVN I and LVN J between 10:50 a.m. and 11:05 a.m.

Based on interview and record review, the facility failed to implement its written policies and procedures that prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. Resident #1, whose desire was to receive CPR and life-saving interventions (full code), was found by CNA A without respirations at approximately 8:00 PM. She immediately reported to LVN B and then LVN C. CPR was initiated at approximately 8:20 PM. RN D pronounced Resident #1 as expired at 8:25 PM on [DATE]. The following facility failures occurred: Resident #1, whose desire was to receive CPR and life-saving interventions (full code), was found by CNA A without respirations at approximately 8:00 PM. She immediately reported to LVN B and then LVN C. CPR was initiated at approximately 8:20 PM. RN D pronounced Resident #1 as expired at 8:25 PM on [DATE]. The following facility failures occurred: CNA A was not aware she could call 911 and "code blue" when a resident was found nonresponsive. LVN B found Resident #1 warm to touch, but initially decided not to initiate CPR because he thought Resident #1 was without respiration and pulse for 20 minutes. When he found Resident #1 was a full code (CPR and life-saving interventions), he went to start CPR at approximately 8:20 PM. LVN C called the weekend supervisor and the DON reporting LVN B's hesitation in initiating CPR, and did not call 911. RN D pronounced Resident #1 as expired at 8:25 PM as instructed by the DON via the phone even though Resident #1 was still warm to touch, had no mottling (discoloring of areas on the skin) and no pooling of blood. RN D did not document her assessment of the resident or the pronouncement of death in the resident's chart. The DON did not report the incident to the State agency or investigate LVN C's allegation of neglect until [DATE], when LVN B did not immediately provide Resident #1 CPR on [DATE]. LVN B, LVN C and RN D continued to work at the facility providing care for the residents without any retraining until [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. Even though the IJ was removed on [DATE], the facility remained out of compliance at a level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" due to facility staff still being inserviced and the facility was monitoring the plan of removal. These failures placed the facility's 68 residents identified with a full code status at risk for the potential of staff failing to provide their end of life desire for CPR and life-saving interventions and being pronounced without signs of death prior to discontinuing CPR. Findings included: The facility's current Administrative Policies and Procedures reflected: Section III: Organizational Ethics Subject: Abuse, Neglect and Misappropriation of Property (revised February 2008) "POLICY: 1. The facility's Leadership prohibits neglect... 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected ...neglect... 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. ...5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit... neglect... PROCEDURES: Component III; Prevention ...6. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: ...C. Ignoring the patient's/resident's needs requests, etc.... Component IV: Identification 1. Staff members identify and assess suspected or alleged reports of ...neglect, focusing on objective and observable evidence, such as... patterns or trends of potential... neglect... ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness. Component V: Reporting/Response 1. All alleged violations concerning... neglect... are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency... ...3. An analysis is completed to determine what changed are needed, if appropriate, to prevent further occurrences... Component VI: Investigation 1. The facility maintains that all allegations of... neglect are thoroughly investigated and appropriate action taken... 2. The facility conducts an internal investigation... and reports the results... within five (5) working days... 3. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting." 1. Review of Resident #1's closed clinical record revealed on the Resident Admission Record (no date) he was admitted to the facility on [DATE] and "there are no Advanced Directives selected for this resident." The Resident Admission Record reflected a primary [DIAGNOSES REDACTED]. The facility's Investigation Report, completed by the DON and dated [DATE] reflected the following in regard to Resident #1. Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses, which included: [MEDICAL CONDITIONS] with Acute [MEDICAL CONDITION] and Hypertension. Resident #1 had a [MEDICAL CONDITION] r/t his [MEDICAL CONDITION] and a PEG tube for feedings. He also had a recent history of a [MEDICAL CONDITION]. Resident #1 was alert and able to respond when questions were asked but not with 100% accuracy. He required total care, was dependent on staff for ADLs and was incontinent of bowel and bladder. Resident #1 required skilled care from Respiratory Therapy as well as nursing. The resident was also a full code. 2. The facility's Investigation Report then included a description of the incident when CNA A found Resident #1 without respirations and/or pulse at approximately 8:00 PM on [DATE]. "The nurse (LVN B) went down to room and the Respiratory therapist joined the nurse. The LVN on duty ____ (LVN B) performed an assessment on the resident and found resident pulse less (sic) and without a heart beat. The investigation revealed the nurse (LVN B) in his nursing judgment felt the resident had been without a pulse or heartbeat for at least 20 minutes. The nurse (LVN B) explained in his statement the resident was mottled on the face and neck, extremities were very cool to touch, the residents (sic) pupils were fixed and dilated and the resident appeared to have expired at lease (sic) 20 to 25 minutes before staff was aware as staff (CNA A) had given (Resident #1) bed bath earlier in shift around 7:30 (PM) and had not checked on resident since that time period as his next round by staff was due at 9:30 PM. The nurse (LVN B) went to the station and looked at chart and found documentation resident was a full code, the nurse and Respiratory therapist then went back to (Resident #1's) room and began CPR. The resident was bagged and the AED used. The resident did not respond to treatment. The resident was then pronounced by the RN on duty, the family was notified as well as the attending physician...." The Investigation Report reflected on [DATE] (sic), Resident #1's family member called and made "accusations" about the event and asked why EMS was not called. The DON explained "the nurse (LVN B) felt the resident had been without a pulse or respirations for over 20 minutes and after CPR was performed, it was over half hour that the resident had been down. The nurse had called the weekend supervisor who then called (the DON)." The Report reflected the DON called the facility and "informed staff if more than 30 minutes had passed since resident had been found and post CPR and no change in resident's condition, there was no reason to call 911 as too much time had passed." The Investigation Report reflected following Resident #1's family member's phone call on [DATE], the DON conducted an inservice on [DATE] regarding the need to call 911 when a code was called and CPR had been initiated. It further reflected LVN B was suspended on [DATE] pending the investigation and returned to work on [DATE]. The DON was interviewed by the surveyor on [DATE] at 9:30 AM in regard to Resident #1. The DON stated she had received a call from the House Supervisor on the evening of [DATE]. The DON denied knowledge of the concerns expressed by LVN C regarding LVN B delaying to initiate CPR. She confirmed the information she documented in her investigation of the incident. The DON stated when LVN B was told by CNA A about Resident #1, he went and checked the resident. He said the resident was blue in the face and was "cool to touch." She said she was aware 911 was not called "because the resident appeared deceased ," but CPR was started. She stated staff worked on the resident for about 20 - 25 minutes with no response from the resident. She stated she "wrote up" LVN B because of his lack of documentation and had him complete a late entry regarding the events. She confirmed she had provided no additional staff training regarding who could call a "code blue" and call 911, as per their policy, when a resident with a full code status was found not breathing. When questioned about RN D not documenting her assessment or pronouncement of death of Resident #1, the DON stated RN D was not required to document Resident #1's death, because she was assigned to another unit. During this interview, the DON told the surveyor she had not investigated this situation or reported it to the State agency until Resident #1's family member called the facility on [DATE] asking why EMS was not called for Resident #1. The DON said she later informed the family member the State had been notified due to the family's concerns of neglect (on [DATE]). The DON stated the investigation was started at that time and it was when LVN B was suspended for three days beginning [DATE]. 3. Resident #1's Daily Skilled Nurse's Notes, dated [DATE] at 8:20 PM and completed by LVN B, reflected CNA A reported Resident #1 was unresponsive, the crash cart was brought to the resident's room, a code was called, and CPR was started. According to the Note, at 8:23 PM, RN D came to the room. LVN C then came and said the DON "expressed to call the code" (to stop CPR) at 8:25 PM. The Note reflected Resident #1 had no pulse and "extremities W.T.T. (warm to touch)." According to this note, CPR was provided for five minutes. An undated Late Entry nurse's notes written by LVN B for [DATE] provided additional details. At 7:40 PM, LVN B gave the resident his medications and at 7:50 PM, the CNA (CNA A) was giving him a bed bath. At approximately 8:20 PM, CNA A came and "hurried me" to Resident #1's room. When LVN B entered the room, he found the resident unresponsive, without a pulse or breath sounds, his face was mottled, his pupils were without dilation, and his gums were pale. LVN B wrote he "estimated" Resident #1 was "expired for about 20 mins." LVN B checked the chart and found Resident #1 was a "full-code. I grabbed crash cart, the other staff nurse (not identified) called the code overhead." An interview with LVN B on [DATE] at 11:55 AM, confirmed he was on duty on [DATE] at the time of Resident #1's change of condition. He said CNA A had given Resident #1 a bed bath at approximately 8:00 PM. He confirmed CNA A notified him Resident #1 was not breathing at around 8:20 PM, but he was unable to immediately respond. He said when he entered Resident #1's room, he assessed the resident. He stated the resident's extremities were warm to touch with no rigor, his face was mottled, and his eyes were fixed and dilated and he had no pulse. He said he checked his left carotid artery and groin and could find no pulse. He said he made a "nursing judgment call" since he estimated the resident had been "down" approximately 20 minutes. He said he did not call 911, but did start CPR. LVN B told the surveyor when he was in CPR class, he was told "if a person is without a pulse for seven minutes, it is not certain they will come back." CNA A was interviewed on [DATE] at 1:15 PM regarding Resident #1. CNA A stated she had given Resident #1 a bed bath approximately 30 minutes before she found him not breathing. She said during the bed bath, she had not noted any change in his condition. She stated she was walking down the hall at approximately 8:00 PM and realized she did not hear Resident #1's usual heavy breathing sounds. CNA A said the resident "normally breathed real heavy-like and this time he was not." She said she went to his room and saw he was not breathing. She stated she then went across the hall two doors down where LVN B was providing care for a resident's gastrostomy tube (a feeding tube located on the abdominal region). She stated she told him she believed the resident was dead, but LVN B was unable to immediately help Resident #1, so she went down the hall and located LVN C and told her about Resident #1. She said LVN C returned with her down the hall when they saw LVN B entering the resident's room. She stated she (CNA A) did not remain in the resident's room once the nurses arrived. She added she did not call 911 or "code blue" and did not know she could. An interview with LVN C on [DATE] at 12:30 PM confirmed she was on duty on [DATE] at the time of Resident #1's change of condition. She confirmed CNA A notified her of the resident's change of condition. LVN C stated CNA A asked her to come to the resident's room at the beginning of the "incident." The LVN said when she and the CNA arrived at Resident #1's room, LVN B and the RT were already in the room. LVN C said she did not touch Resident #1 and she did not know if he was breathing or not. She said he looked unresponsive. She said LVN B came to the nurses' station to check the resident's code status and even though the resident was a full code, he delayed returning to the resident's room and initiating CPR. She stated LVN B told her that in his judgment Resident #1 had been deceased approximately 20 minutes and was already dead. She added she was not CPR certified and did not know how to perform CPR. She further stated she did not call 911, but instead called the weekend supervisor and then the DON to report her concern with LVN B's delay in initiating CPR. On [DATE] at approximately 1:30 PM, during a phone interview with LVN C, she was asked why she did not call 911. LVN C said she did not call 911 because LVN B told her the resident was deceased . An interview with RN D on [DATE] at 7:25 PM, confirmed she was on duty on [DATE] and pronounced Resident #1's death. She said she had responded to a code blue alert. She said when she arrived on the unit, LVN C was at the nurses' station talking to the DON on the telephone. She said when she arrived at Resident #1's room, LVN B and an RT were performing CPR. The RT was doing chest compressions and using the ambu bag. She said LVN C came and told her the DON said to pronounce the resident's death, so she did. When asked about her assessment of Resident #1, she stated he was warm to touch, had no mottling and no pooling of blood. When asked if these signs were signs of death, she responded the DON had said to pronounce Resident #1's death and added, "(The DON) knew him better than me and he was already sick." When asked if the DON pronounced his death or if she did, RN D agreed she (RN D) had pronounced the resident's death. She then added she knew the resident had expired, because his eyes were fixed and "you just know." She concluded by saying she did not know why she failed to document her assessment of the resident and the fact she pronounced his death. During this interview, RN D told the surveyor she had received training from ADON I in regard to calling a code and 911, who can pronounce death, the signs and symptoms of death and follow-up documentation of the event. 4. The Texas Board of Nurse Examiner's (BON) position statements 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death and 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility both documented the following presumptive or conclusive signs of death: Presumptive Signs of Death: the patient is unresponsive, has no respirations, no pulse, pupils are fixed and dilated, body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature, and has generalized cyanosis, and Conclusive Sign of Death: There is presence of liver mortis (pooling of blood in dependent body parts causing purple discoloration). Note: Resident #1 was warm to touch and had no pooling of blood. In addition, the BON's position statement regarding the role of the LVN noted "LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas." The position statement regarding the role of the RN noted "documentation of the circumstances and the assessment of the resident in the resident record are a requirement . . . Documentation should be adequate to give a clear picture of the situation and all the actions that were taken or not taken on behalf of the resident." Note: RN D did not document the circumstances and the assessment of Resident #1 or the fact she pronounced his death. 5. Policy: The staff will call 911 for emergency situations. This policy only applies to resident who have been determined to be a full code. Procedures: 1. Qualified staff initiates the appropriate emergency procedures, i.e., oxygen, suction, CPR . . ., as appropriate, etc in accordance with a resident's Advance Directives. 2. Call 911 when the resident's condition is life threatening, unless the resident is coding and staff have determined the resident is a DNR... ...5. Document the occurrence in the medical record. Nursing Policies and Procedures, Subject: Physician Communication/Change in Condition (revised [DATE]) Policy: ...2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition. Procedures: ...7. In the event of a life threatening event - contact 911 immediately. 6. An IJ was identified in the area of Resident Behavior/Facility Practice and Administration on [DATE]. The ADM and DON were notified of the IJ on [DATE] at 6:00 PM. At that time, they were requested to provide a Plan of Removal for the IJ. 7. The facility's Plan of Removal was accepted on [DATE] at 8:55 AM and included the following: 1. All facility CNAs will be educated to notify the charge nurse and call code blue upon identification of an unresponsive resident. Upon completion of the education, a post test will be administered to monitor all nursing staff regarding their knowledge of education. Identified deficient knowledge will result in being re-educated immediately. Newly hired Certified Nurse Aide staff will be educated during classroom orientation prior to their first assigned duty by LVN E, the Staff Development Coordinator. Notification of Charge Nurse and calling a Code Blue upon finding a resident unresponsive will be included in Annual Orientation. LVN E, Staff Development Coordinator will monitor to ensure all Certified Nurse Aides have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Certified Nurse Aide staff members who cannot be reached will not be allowed to work until the education is completed. The Nurse Management Team (including LVN E, ADON F, ADON G, LVN H, ADON I, ADON J and LVN K) will be in-servicing the CNAs. Initiated in-service on [DATE] with completion date of [DATE]. 2. All LVN and RN staff will be in-serviced regarding the initiation of code blue and calling 911. (See attached NP-E-17 Policy). All Facility Licensed Nurses will be re-educated to respond immediately to a report of a resident being unresponsive. All Facility Licensed Nurses will be reeducated on the Texas Board of Nursing Position Statement 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death, which includes "Presumptive Signs of Death" - The patient is unresponsive - The patient has no respirations - The patient has no pulse - The Patient's pupils are fixed and dilated - The patient's body temperature indicates hypothermia: skin is cold relative to the patients baseline skin temperature - The patient has generalized cyanosis And Conclusive Sign of Death - There is presence of livor mortis (venous pooling of blood in the dependent body parts causing purple discoloration of the skin which does blanch with pressure). Upon completion of the education a post test will be administered to monitor all nursing staff regarding their knowledge of education identified deficient knowledge will be re-educated immediately. Education will be by the Nurse Management Team. Initiated [DATE] and will be completed by [DATE]. Newly hired Licensed staff will be educated on all items above, Pronouncement of Death, Code Status and Response to a code including calling 911 during classroom orientation prior to their first assigned duty by the Staff Development Coordinator, LVN. The above will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members who cannot be reached will not be allowed to work until the education is completed. 3. This will be monitored as events occur: Effective immediately ([DATE]) all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting by the QAPI committee members, who include: the ADM, the Interim DON, the Medical Director, LVN E, ADON F, ADON G, LVN H, ADON I, ADON J, Social Services L, Nurse Case Manager M, Medical Records N, Environmental O, Maintenance P, Central Supply Q and the Food Services Director. Education by the Nurse Management Team. 4. All Staff Nurses will be re-educated in process of promptly calling 911 upon notification of a resident that is unresponsive prior to notification of house supervisor or director of nurses. They will follow NP-E-17 and NP-E-14 policies related to Emergency - Code Blue Initiation and Emergency 911 policies to ensure the needs of the resident are met. In service the staff to notify the Abuse Coordinator about concerns with the implementation of protocol. Upon completion of the education, a post test will be administered to monitor all nursing staff regarding their knowledge of education. Identified deficient knowledge will be re-educated immediately. The Nurse Management Team will be educating staff. Initiated [DATE] and will be completed by [DATE]. Newly hired Licensed staff will be educated on all items above during classroom orientation prior to their first assigned duty. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be monitored as events occur: Effective immediately all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure facility policy was followed. Identified deficient practices will be corrected immediately and reported to the ADM as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting by the QAPI committee members. 5. Upon notification of the allegation of neglect by Resident #1's family, LVN B was suspended pending outcome of the investigation. Staff education was started regarding the initiation of code blue and calling 911. Initiated inservice [DATE] for all staff with completion date of [DATE] by the Nurse Management Team. 6. A review of residents who expired or were discharged between [DATE] and [DATE] was conducted on [DATE] to ensure the facility staff responded appropriately to end of life situations. This was done by the Interim DON. 7. All Staff will be educated that the Abuse Coordinator has changed to the ADM. Newly hired Licensed staff will be educated on all items during classroom orientation prior to first assigned duty by LVN E. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be done by the Nurse Management Team. This will be monitored as events occur: Effective immediately all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting attended by the QAPI committee members. 8. RN D was re-educated on [DATE] by the ADM and ADON I about the policy of documentation in the charts related pronouncement of death of a resident and received verbal warning. 9. All current Licensed Nursing staff will be re-educated on the policy of documentation in the charts related to the pronouncement of death of a resident by the Nurse Management Team. Initiated inservice [DATE] for all staff with completion date of [DATE]. All newly hired Licensed staff will be educated on the policy of documentation in the charts related pronouncement of death of a resident. Newly hired Licensed staff will be educated on all items above during classroom orientation prior to first assigned duty by LVN E. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be monitored as events occur: Effective immediately all code blue situations and residents who expire within 24 hours of transfer to hospital will be reviewed next business day by the DON and/or designee to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting. 10. The process for immediately reporting and investigating abuse/ neglect/ exploitation of a resident has been assigned to the ADM, effective [DATE]. The ADM has verbalized understanding of the policy and procedures related to abuse of a resident and will be monitored by CSD R and/or the Interim DON, who starts on [DATE]. 11. The facility's Medical Director was notified at 7:00 PM regarding the IJ and the plan for removal on [DATE]. 8. Inservice records reflected the following subjects were covered: determination of an unresponsive resident and calling code blue and 911, documentation in the clinical records when a resident is found unresponsive and the change of the ADM now being the Abuse Coordinator. The inservice records reflected the majority of licensed nurses, CNAs and RTs from each shift had received the above noted training. Interviews beginning on [DATE] through [DATE], with 11 nurses, one MA, one RT and seven CNAs, representing staff from all three shifts and staff who worked strictly weekdays or weekends, confirmed the staff had received training regarding timely notification of a code blue, timely contact with 911, the fact a CNA can call a code blue alert and 911, if needed and the ADM as the Abuse Coordinator. The interviews were obtained on the following dates/times from the following staff - On [DATE] - LVN S, LVN T, RN D, CNA U, MA V, CNA LL, CNA X, LVN Y, LVN/RT Z, at 7:00 PM, 7:15 PM, 7:25 PM, 7:43 PM, 7:52 PM, 8:00 PM, 8:24 PM, 8:40 PM, and 8:50 PM, respectively. On [DATE] - LVN AA, CNA BB, CNA CC, LVN DD, RT EE, LVN FF at 11:15 PM, 11:23 PM, 11:30 PM, 11:38 PM, 11:45 PM, and 11:47 PM, respectively. On [DATE] - CNA GG, LVN HH, LVN II, CNA JJ, LVN KK at 2:30 PM, 2:40 PM, 2:45 PM, 2:55 PM, and 3:05 PM, respectively. The Administrator was notified the IJ was removed on [DATE] at 4:59 PM. The facility remained out of compliance at a level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" due to staff still being inserviced and the facility still monitoring the plan of removal. The facility's Advanced Directives and Code Status Report, dated [DATE], reflected 68 current residents had a full code status.

Based on interview and record review, the facility failed to ensure all alleged violations of neglect were reported immediately to the State agency, were thoroughly investigated and prevented the potential for 68 residents, who had a full code status, being subject to further neglect . Resident #1, whose desire was to receive CPR and life-saving interventions (full code), was found by CNA A without respirations at approximately 8:00 PM. She immediately reported to LVN B and then LVN C. CPR was initiated at approximately 8:20 PM. RN D pronounced Resident #1 as expired at 8:25 PM on [DATE]. The following facility failures occurred: Resident #1, whose desire was to receive CPR and life-saving interventions (full code), was found by CNA A without respirations at approximately 8:00 PM. She immediately reported to LVN B and then LVN C. CPR was initiated at approximately 8:20 PM. RN D pronounced Resident #1 as expired at 8:25 PM on [DATE]. The following facility failures occurred: CNA A was not aware she could call 911 and "code blue" when a resident was found nonresponsive. LVN B found Resident #1 warm to touch, but initially decided not to initiate CPR because he thought Resident #1 was without respiration and pulse for 20 minutes. When he found Resident #1 was a full code (CPR and life-saving interventions), he went to start CPR at approximately 8:20 PM. LVN C called the weekend supervisor and the DON reporting LVN B's hesitation in initiating CPR, and did not call 911. RN D pronounced Resident #1 as expired at 8:25 PM as instructed by the DON via the phone even though Resident #1 was still warm to touch, had no mottling (discoloring of areas on the skin) and no pooling of blood. RN D did not document her assessment of the resident or the pronouncement of death in the resident's chart. The DON did not report the incident to the State agency or investigate LVN C's allegation of neglect until [DATE], when LVN B did not immediately provide Resident #1 CPR on [DATE]. LVN B, LVN C and RN D continued to work at the facility providing care for the residents without any retraining until [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. Even though the IJ was removed on [DATE], the facility remained out of compliance at a level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" due to facility staff still being inserviced and the facility still monitoring the plan of removal. These failures placed the facility's 68 residents identified with a full code status at risk for the potential of staff failing to provide their end-of-life desire for CPR and life-saving interventions and being pronounced without signs of death prior to discontinuing CPR. Findings included: 1. Review of Resident #1's closed clinical record revealed on the Resident Admission Record (no date) he was admitted to the facility on [DATE] and "there are no Advanced Directives selected for this resident." The Resident Admission Record reflected a primary [DIAGNOSES REDACTED]. The facility's Investigation Report, completed by the DON and dated [DATE] reflected the following in regard to Resident #1. Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses, which included: [MEDICAL CONDITIONS] with Acute [MEDICAL CONDITION] and Hypertension. Resident #1 had a [MEDICAL CONDITION] r/t his [MEDICAL CONDITION] and a PEG tube for feedings. He also had a recent history of a [MEDICAL CONDITION]. Resident #1 was alert and able to respond when questions were asked but not with 100% accuracy. He required total care, was dependent on staff for ADLs and was incontinent of bowel and bladder. Resident #1 required skilled care from Respiratory Therapy as well as nursing. The resident was also a full code. 2. The facility's Investigation Report then included a description of the incident when CNA A found Resident #1 without respirations and/or pulse at approximately 8:00 PM on [DATE]. "The nurse (LVN B) went down to room and the Respiratory therapist joined the nurse. The LVN on duty ____ (LVN B) performed an assessment on the resident and found resident pulse less (sic) and without a heart beat. The investigation revealed the nurse (LVN B) in his nursing judgment felt the resident had been without a pulse or heartbeat for at least 20 minutes. The nurse (LVN B) explained in his statement the resident was mottled on the face and neck, extremities were very cool to touch, the residents (sic) pupils were fixed and dilated and the resident appeared to have expired at lease (sic) 20 to 25 minutes before staff was aware as staff (CNA A) had given (Resident #1) bed bath earlier in shift around 7:30 (PM) and had not checked on resident since that time period as his next round by staff was due at 9:30 PM. The nurse (LVN B) went to the station and looked at chart and found documentation resident was a full code, the nurse and Respiratory therapist then went back to (Resident #1's) room and began CPR. The resident was bagged and the AED used. The resident did not respond to treatment. The resident was then pronounced by the RN on duty, the family was notified as well as the attending physician...." The Investigation Report reflected on [DATE] (sic), Resident #1's family member called and made "accusations" about the event and asked why EMS was not called. The DON explained "the nurse (LVN B) felt the resident had been without a pulse or respirations for over 20 minutes and after CPR was performed, it was over half hour that the resident had been down. The nurse had called the weekend supervisor who then called (the DON)." The Report reflected the DON called the facility and "informed staff if more than 30 minutes had passed since resident had been found and post CPR and no change in resident's condition, there was no reason to call 911 as too much time had passed." The Investigation Report reflected following Resident #1's family member's phone call on [DATE], the DON conducted an inservice on [DATE] regarding the need to call 911 when a code was called and CPR had been initiated. It further reflected LVN B was suspended on [DATE] pending the investigation and returned to work on [DATE]. The DON was interviewed by the surveyor on [DATE] at 9:30 AM in regard to Resident #1. The DON stated she had received a call from the House Supervisor on the evening of [DATE]. The DON denied knowledge of the concerns expressed by LVN C regarding LVN B delaying to initiate CPR. She confirmed the information she documented in her investigation of the incident. The DON stated when LVN B was told by CNA A about Resident #1, he went and checked the resident. He said the resident was blue in the face and was "cool to touch." She said she was aware 911 was not called "because the resident appeared deceased ," but CPR was started. She stated staff worked on the resident for about 20 - 25 minutes with no response from the resident. She stated she "wrote up" LVN B because of his lack of documentation and had him complete a late entry regarding the events. She confirmed she had provided no additional staff training regarding who could call a "code blue" and call 911, as per their policy, when a resident with a full code status was found not breathing. When questioned about RN D not documenting her assessment or pronouncement of death of Resident #1, the DON stated RN D was not required to document Resident #1's death, because she was assigned to another unit. During this interview, the DON told the surveyor she had not investigated this situation or reported it to the State agency until Resident #1's family member called the facility on [DATE] asking why EMS was not called for Resident #1. The DON said she later informed the family member the State had been notified due to the family's concerns of neglect (on [DATE]). The DON stated the investigation was started at that time and it was when LVN B was suspended for three days beginning [DATE]. 3. Resident #1's Daily Skilled Nurse's Notes, dated [DATE] at 8:20 PM and completed by LVN B, reflected CNA A reported Resident #1 was unresponsive, the crash cart was brought to the resident's room, a code was called, and CPR was started. According to the Note, at 8:23 PM, RN D came to the room. LVN C then came and said the DON "expressed to call the code" (to stop CPR) at 8:25 PM. The Note reflected Resident #1 had no pulse and "extremities W.T.T. (warm to touch)." According to this note, CPR was provided for five minutes. An undated Late Entry nurse's notes written by LVN B for [DATE] provided additional details. At 7:40 PM, LVN B gave the resident his medications and at 7:50 PM, the CNA (CNA A) was giving him a bed bath. At approximately 8:20 PM, CNA A came and "hurried me" to Resident #1's room. When LVN B entered the room, he found the resident unresponsive, without a pulse or breath sounds, his face was mottled, his pupils were without dilation, and his gums were pale. LVN B wrote he "estimated" Resident #1 was "expired for about 20 mins." LVN B checked the chart and found Resident #1 was a "full-code. I grabbed crash cart, the other staff nurse (not identified) called the code overhead." An interview with LVN B on [DATE] at 11:55 AM, confirmed he was on duty on [DATE] at the time of Resident #1's change of condition. He said CNA A had given Resident #1 a bed bath at approximately 8:00 PM. He confirmed CNA A notified him Resident #1 was not breathing at around 8:20 PM, but he was unable to immediately respond. He said when he entered Resident #1's room, he assessed the resident. He stated the resident's extremities were warm to touch with no rigor, his face was mottled, and his eyes were fixed and dilated and he had no pulse. He said he checked his left carotid artery and groin and could find no pulse. He said he made a "nursing judgment call" since he estimated the resident had been "down" approximately 20 minutes. He said he did not call 911, but did start CPR. LVN B told the surveyor when he was in CPR class, he was told "if a person is without a pulse for seven minutes, it is not certain they will come back." CNA A was interviewed on [DATE] at 1:15 PM regarding Resident #1. CNA A stated she had given Resident #1 a bed bath approximately 30 minutes before she found him not breathing. She said during the bed bath, she had not noted any change in his condition. She stated she was walking down the hall at approximately 8:00 PM and realized she did not hear Resident #1's usual heavy breathing sounds. CNA A said the resident "normally breathed real heavy-like and this time he was not." She said she went to his room and saw he was not breathing. She stated she then went across the hall two doors down where LVN B was providing care for a resident's gastrostomy tube (a feeding tube located on the abdominal region). She stated she told him she believed the resident was dead, but LVN B was unable to immediately help Resident #1, so she went down the hall and located LVN C and told her about Resident #1. She said LVN C returned with her down the hall when they saw LVN B entering the resident's room. She stated she (CNA A) did not remain in the resident's room once the nurses arrived. She added she did not call 911 or "code blue" and did not know she could. An interview with LVN C on [DATE] at 12:30 PM confirmed she was on duty on [DATE] at the time of Resident #1's change of condition. She confirmed CNA A notified her of the resident's change of condition. LVN C stated CNA A asked her to come to the resident's room at the beginning of the "incident." The LVN said when she and the CNA arrived at Resident #1's room, LVN B and the RT were already in the room. LVN C said she did not touch Resident #1 and she did not know if he was breathing or not. She said he looked unresponsive. She said LVN B came to the nurses' station to check the resident's code status and even though the resident was a full code, he delayed returning to the resident's room and initiating CPR. She stated LVN B told her that in his judgment Resident #1 had been deceased approximately 20 minutes and was already dead. She added she was not CPR certified and did not know how to perform CPR. She further stated she did not call 911, but instead called the weekend supervisor and then the DON to report her concern with LVN B's delay in initiating CPR. On [DATE] at approximately 1:30 PM, during a phone interview with LVN C, she was asked why she did not call 911. LVN C said she did not call 911 because LVN B told her the resident was deceased . An interview with RN D on [DATE] at 7:25 PM, confirmed she was on duty on [DATE] and pronounced Resident #1's death. She said she had responded to a code blue alert. She said when she arrived on the unit, LVN C was at the nurses' station talking to the DON on the telephone. She said when she arrived at Resident #1's room, LVN B and an RT were performing CPR. The RT was doing chest compressions and using the ambu bag. She said LVN C came and told her the DON said to pronounce the resident's death, so she did. When asked about her assessment of Resident #1, she stated he was warm to touch, had no mottling and no pooling of blood. When asked if these signs were signs of death, she responded the DON had said to pronounce Resident #1's death and added, "(The DON) knew him better than me and he was already sick." When asked if the DON pronounced his death or if she did, RN D agreed she (RN D) had pronounced the resident's death. She then added she knew the resident had expired, because his eyes were fixed and "you just know." She concluded by saying she did not know why she failed to document her assessment of the resident and the fact she pronounced his death. During this interview, RN D told the surveyor she had received training from ADON I in regard to calling a code and 911, who can pronounce death, the signs and symptoms of death and follow-up documentation of the event. 4. The Texas Board of Nurse Examiner's (BON) position statements 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death and 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility both documented the following presumptive or conclusive signs of death: Presumptive Signs of Death: the patient is unresponsive, has no respirations, no pulse, pupils are fixed and dilated, body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature, and has generalized cyanosis, and Conclusive Sign of Death: There is presence of liver mortis (pooling of blood in dependent body parts causing purple discoloration). Note: Resident #1 was warm to touch and had no pooling of blood. In addition, the BON's position statement regarding the role of the LVN noted "LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas." The position statement regarding the role of the RN noted "documentation of the circumstances and the assessment of the resident in the resident record are a requirement . . . Documentation should be adequate to give a clear picture of the situation and all the actions that were taken or not taken on behalf of the resident." Note: RN D did not document the circumstances and the assessment of Resident #1 or the fact she pronounced his death. 5. The facility's current Administrative Policies and Procedures reflected: Section III: Organizational Ethics Subject: Abuse, Neglect and Misappropriation of Property (revised February 2008) "POLICY: 1. The facility's Leadership prohibits neglect... 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected ...neglect... 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. ...5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit... neglect... PROCEDURES: Component III: Prevention ...6. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: ...C. Ignoring the patient's/resident's needs requests, etc.... Component IV: Identification 1. Staff members identify and assess suspected or alleged reports of ...neglect, focusing on objective and observable evidence, such as... patterns or trends of potential... neglect... ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness. Component V: Reporting/Response 1. All alleged violations concerning... neglect... are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency... ...3. An analysis is completed to determine what changed are needed, if appropriate, to prevent further occurrences... Component VI: Investigation 1. The facility maintains that all allegations of... neglect are thoroughly investigated and appropriate action taken... 2. The facility conducts an internal investigation... and reports the results... within five (5) working days... 3. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting." Nursing Polices and Procedures, Subject: Emergency - 911, (revised [DATE]) reflected: Policy: The staff will call 911 for emergency situations. This policy only applies to resident who have been determined to be a full code. Procedures: 1. Qualified staff initiates the appropriate emergency procedures, i.e., oxygen, suction, CPR . . ., as appropriate, etc in accordance with a resident's Advance Directives. 2. Call 911 when the resident's condition is life threatening, unless the resident is coding and staff have determined the resident is a DNR... ...5. Document the occurrence in the medical record. Nursing Policies and Procedures, Subject: Physician Communication/Change in Condition (revised [DATE]) Policy: ...2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition. Procedures: ...7. In the event of a life threatening event - contact 911 immediately. 6. An IJ was identified in the area of Resident Behavior/Facility Practice and Administration on [DATE]. The ADM and DON were notified of the IJ on [DATE] at 6:00 PM. At that time, they were requested to provide a Plan of Removal for the IJ. 7. The facility's Plan of Removal was accepted on [DATE] at 8:55 AM and included the following: 1. All facility CNAs will be educated to notify the charge nurse and call code blue upon identification of an unresponsive resident. Upon completion of the education, a post test will be administered to monitor all nursing staff regarding their knowledge of education. Identified deficient knowledge will result in being re-educated immediately. Newly hired Certified Nurse Aide staff will be educated during classroom orientation prior to their first assigned duty by LVN E, the Staff Development Coordinator. Notification of Charge Nurse and calling a Code Blue upon finding a resident unresponsive will be included in Annual Orientation. LVN E, Staff Development Coordinator will monitor to ensure all Certified Nurse Aides have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Certified Nurse Aide staff members who cannot be reached will not be allowed to work until the education is completed. The Nurse Management Team (including LVN E, ADON F, ADON G, LVN H, ADON I, ADON J and LVN K) will be in-servicing the CNAs. Initiated in-service on [DATE] with completion date of [DATE]. 2. All LVN and RN staff will be in-serviced regarding the initiation of code blue and calling 911. (See attached NP-E-17 Policy). All Facility Licensed Nurses will be re-educated to respond immediately to a report of a resident being unresponsive. All Facility Licensed Nurses will be reeducated on the Texas Board of Nursing Position Statement 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death, which includes "Presumptive Signs of Death" - The patient is unresponsive - The patient has no respirations - The patient has no pulse - The Patient's pupils are fixed and dilated - The patient's body temperature indicates hypothermia: skin is cold relative to the patients baseline skin temperature - The patient has generalized cyanosis And Conclusive Sign of Death - There is presence of livor mortis (venous pooling of blood in the dependent body parts causing purple discoloration of the skin which does blanch with pressure). Upon completion of the education a post test will be administered to monitor all nursing staff regarding their knowledge of education identified deficient knowledge will be re-educated immediately. Education will be by the Nurse Management Team. Initiated [DATE] and will be completed by [DATE]. Newly hired Licensed staff will be educated on all items above, Pronouncement of Death, Code Status and Response to a code including calling 911 during classroom orientation prior to their first assigned duty by the Staff Development Coordinator, LVN. The above will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members who cannot be reached will not be allowed to work until the education is completed. 3. This will be monitored as events occur: Effective immediately ([DATE]) all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting by the QAPI committee members, who include: the ADM, the Interim DON, the Medical Director, LVN E, ADON F, ADON G, LVN H, ADON I, ADON J, Social Services L, Nurse Case Manager M, Medical Records N, Environmental O, Maintenance P, Central Supply Q and the Food Services Director. Education by the Nurse Management Team. 4. All Staff Nurses will be re-educated in process of promptly calling 911 upon notification of a resident that is unresponsive prior to notification of house supervisor or director of nurses. They will follow NP-E-17 and NP-E-14 policies related to Emergency - Code Blue Initiation and Emergency 911 policies to ensure the needs of the resident are met. In service the staff to notify the Abuse Coordinator about concerns with the implementation of protocol. Upon completion of the education, a post test will be administered to monitor all nursing staff regarding their knowledge of education. Identified deficient knowledge will be re-educated immediately. The Nurse Management Team will be educating staff. Initiated [DATE] and will be completed by [DATE]. Newly hired Licensed staff will be educated on all items above during classroom orientation prior to their first assigned duty. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be monitored as events occur: Effective immediately all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure facility policy was followed. Identified deficient practices will be corrected immediately and reported to the ADM as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting by the QAPI committee members. 5. Upon notification of the allegation of neglect by Resident #1's family, LVN B was suspended pending outcome of the investigation. Staff education was started regarding the initiation of code blue and calling 911. Initiated inservice [DATE] for all staff with completion date of [DATE] by the Nurse Management Team. 6. A review of residents who expired or were discharged between [DATE] and [DATE] was conducted on [DATE] to ensure the facility staff responded appropriately to end of life situations. This was done by the Interim DON. 7. All Staff will be educated that the Abuse Coordinator has changed to the ADM. Newly hired Licensed staff will be educated on all items during classroom orientation prior to first assigned duty by LVN E. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be done by the Nurse Management Team. This will be monitored as events occur: Effective immediately all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting attended by the QAPI committee members. 8. RN D was re-educated on [DATE] by the ADM and ADON I about the policy of documentation in the charts related pronouncement of death of a resident and received verbal warning. 9. All current Licensed Nursing staff will be re-educated on the policy of documentation in the charts related to the pronouncement of death of a resident by the Nurse Management Team. Initiated inservice [DATE] for all staff with completion date of [DATE]. All newly hired Licensed staff will be educated on the policy of documentation in the charts related pronouncement of death of a resident. Newly hired Licensed staff will be educated on all items above during classroom orientation prior to first assigned duty by LVN E. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be monitored as events occur: Effective immediately all code blue situations and residents who expire within 24 hours of transfer to hospital will be reviewed next business day by the DON and/or designee to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting. 10. The process for immediately reporting and investigating abuse/ neglect/ exploitation of a resident has been assigned to the ADM, effective [DATE]. The ADM has verbalized understanding of the policy and procedures related to abuse of a resident and will be monitored by CSD R and/or the Interim DON, who starts on [DATE]. 11. The facility's Medical Director was notified at 7:00 PM regarding the IJ and the plan for removal on [DATE]. 8. Inservice records reflected the following subjects were covered: determination of an unresponsive resident and calling code blue and 911, documentation in the clinical records when a resident is found unresponsive and the change of the ADM now being the Abuse Coordinator. The inservice records reflected the majority of licensed nurses, CNAs and RTs from each shift had received the above noted training. Interviews beginning on [DATE] through [DATE], with 11 nurses, one MA, one RT and seven CNAs, representing staff from all three shifts and staff who worked strictly weekdays or weekends, confirmed the staff had received training regarding timely notification of a code blue, timely contact with 911, the fact a CNA can call a code blue alert and 911, if needed and the ADM as the Abuse Coordinator. The interviews were obtained on the following dates/times from the following staff - On [DATE] - LVN S, LVN T, RN D, CNA U, MA V, CNA LL, CNA X, LVN Y, LVN/RT Z, at 7:00 PM, 7:15 PM, 7:25 PM, 7:43 PM, 7:52 PM, 8:00 PM, 8:24 PM, 8:40 PM, and 8:50 PM, respectively. On [DATE] - LVN AA, CNA BB, CNA CC, LVN DD, RT EE, LVN FF at 11:15 PM, 11:23 PM, 11:30 PM, 11:38 PM, 11:45 PM, and 11:47 PM, respectively. On [DATE] - CNA GG, LVN HH, LVN II, CNA JJ, LVN KK at 2:30 PM, 2:40 PM, 2:45 PM, 2:55 PM, and 3:05 PM, respectively. The Administrator was notified the IJ was removed on [DATE] at 4:59 PM. The facility remained out of compliance at a level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" due to staff still being inserviced and the facility still monitoring the plan of removal. The facility's Advanced Directives and Code Status Report, dated [DATE], reflected 68 current residents had a full code status.

Based on interview and record review, the facility failed to implement its written policies and procedures that prohibit neglect for one (Resident #1) of seven residents reviewed for neglect. Resident #1, whose desire was to receive CPR and life-saving interventions (full code), was found by CNA A without respirations at approximately 8:00 PM. She immediately reported to LVN B and then LVN C. CPR was initiated at approximately 8:20 PM. RN D pronounced Resident #1 as expired at 8:25 PM on [DATE]. The following facility failures occurred: CNA A was not aware she could call 911 and "code blue" when a resident was found nonresponsive. LVN B found Resident #1 warm to touch, but initially decided not to initiate CPR because he thought Resident #1 was without respiration and pulse for 20 minutes. When he found Resident #1 was a full code (CPR and life-saving interventions), he went to start CPR at approximately 8:20 PM. LVN C called the weekend supervisor and the DON reporting LVN B's hesitation in initiating CPR, and did not call 911. RN D pronounced Resident #1 as expired at 8:25 PM as instructed by the DON via the phone even though Resident #1 was still warm to touch, had no mottling (discoloring of areas on the skin) and no pooling of blood. RN D did not document her assessment of the resident or the pronouncement of death in the resident's chart. LVN B, LVN C and RN D continued to work at the facility providing care for the residents without any retraining until [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. Even though the IJ was removed on [DATE], the facility remained out of compliance at a level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" due to facility staff still being inserviced and the facility still monitoring the plan of removal. These failures placed the facility's 68 residents identified with a full code status at risk for the potential of staff failing to provide their end-of-life desire for CPR and life-saving interventions and being pronounced without signs of death prior to discontinuing CPR. Findings included: 1. Review of Resident #1's closed clinical record revealed on the Resident Admission Record (no date) he was admitted to the facility on [DATE] and "there are no Advanced Directives selected for this resident." The Resident Admission Record reflected a primary [DIAGNOSES REDACTED]. The facility's Investigation Report, completed by the DON and dated [DATE] reflected the following in regard to Resident #1. Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses, which included: [MEDICAL CONDITIONS] with Acute [MEDICAL CONDITION] and Hypertension. Resident #1 had a [MEDICAL CONDITION] r/t his [MEDICAL CONDITION] and a PEG tube for feedings. He also had a recent history of a [MEDICAL CONDITION]. Resident #1 was alert and able to respond when questions were asked but not with 100% accuracy. He required total care, was dependent on staff for ADLs and was incontinent of bowel and bladder. Resident #1 required skilled care from Respiratory Therapy as well as nursing. The resident was also a full code. 2. The facility's Investigation Report then included a description of the incident when CNA A found Resident #1 without respirations and/or pulse at approximately 8:00 PM on [DATE]. "The nurse (LVN B) went down to room and the Respiratory therapist joined the nurse. The LVN on duty ____ (LVN B) performed an assessment on the resident and found resident pulse less (sic) and without a heart beat. The investigation revealed the nurse (LVN B) in his nursing judgment felt the resident had been without a pulse or heartbeat for at least 20 minutes. The nurse (LVN B) explained in his statement the resident was mottled on the face and neck, extremities were very cool to touch, the residents (sic) pupils were fixed and dilated and the resident appeared to have expired at lease (sic) 20 to 25 minutes before staff was aware as staff (CNA A) had given (Resident #1) bed bath earlier in shift around 7:30 (PM) and had not checked on resident since that time period as his next round by staff was due at 9:30 PM. The nurse (LVN B) went to the station and looked at chart and found documentation resident was a full code, the nurse and Respiratory therapist then went back to (Resident #1's) room and began CPR. The resident was bagged and the AED used. The resident did not respond to treatment. The resident was then pronounced by the RN on duty, the family was notified as well as the attending physician...." The Investigation Report reflected on [DATE] (sic), Resident #1's family member called and made "accusations" about the event and asked why EMS was not called. The DON explained "the nurse (LVN B) felt the resident had been without a pulse or respirations for over 20 minutes and after CPR was performed, it was over half hour that the resident had been down. The nurse had called the weekend supervisor who then called (the DON)." The Report reflected the DON called the facility and "informed staff if more than 30 minutes had passed since resident had been found and post CPR and no change in resident's condition, there was no reason to call 911 as too much time had passed." The Investigation Report reflected following Resident #1's family member's phone call on [DATE], the DON conducted an inservice on [DATE] regarding the need to call 911 when a code was called and CPR had been initiated. It further reflected LVN B was suspended on [DATE] pending the investigation and returned to work on [DATE]. The DON was interviewed by the surveyor on [DATE] at 9:30 AM in regard to Resident #1. The DON stated she had received a call from the House Supervisor on the evening of [DATE]. The DON denied knowledge of the concerns expressed by LVN C regarding LVN B delaying to initiate CPR. She confirmed the information she documented in her investigation of the incident. The DON stated when LVN B was told by CNA A about Resident #1, he went and checked the resident. He said the resident was blue in the face and was "cool to touch." She said she was aware 911 was not called "because the resident appeared deceased ," but CPR was started. She stated staff worked on the resident for about 20 - 25 minutes with no response from the resident. She stated she "wrote up" LVN B because of his lack of documentation and had him complete a late entry regarding the events. She confirmed she had provided no additional staff training regarding who could call a "code blue" and call 911, as per their policy, when a resident with a full code status was found not breathing. When questioned about RN D not documenting her assessment or pronouncement of death of Resident #1, the DON stated RN D was not required to document Resident #1's death, because she was assigned to another unit. During this interview, the DON told the surveyor she had not investigated this situation or reported it to the State agency until Resident #1's family member called the facility on [DATE] asking why EMS was not called for Resident #1. The DON said she later informed the family member the State had been notified due to the family's concerns of neglect (on [DATE]). The DON stated the investigation was started at that time and it was when LVN B was suspended for three days beginning [DATE]. 3. Resident #1's Daily Skilled Nurse's Notes, dated [DATE] at 8:20 PM and completed by LVN B, reflected CNA A reported Resident #1 was unresponsive, the crash cart was brought to the resident's room, a code was called, and CPR was started. According to the Note, at 8:23 PM, RN D came to the room. LVN C then came and said the DON "expressed to call the code" (to stop CPR) at 8:25 PM. The Note reflected Resident #1 had no pulse and "extremities W.T.T. (warm to touch)." According to this note, CPR was provided for five minutes. An undated Late Entry nurse's notes written by LVN B for [DATE] provided additional details. At 7:40 PM, LVN B gave the resident his medications and at 7:50 PM, the CNA (CNA A) was giving him a bed bath. At approximately 8:20 PM, CNA A came and "hurried me" to Resident #1's room. When LVN B entered the room, he found the resident unresponsive, without a pulse or breath sounds, his face was mottled, his pupils were without dilation, and his gums were pale. LVN B wrote he "estimated" Resident #1 was "expired for about 20 mins." LVN B checked the chart and found Resident #1 was a "full-code. I grabbed crash cart, the other staff nurse (not identified) called the code overhead." An interview with LVN B on [DATE] at 11:55 AM, confirmed he was on duty on [DATE] at the time of Resident #1's change of condition. He said CNA A had given Resident #1 a bed bath at approximately 8:00 PM. He confirmed CNA A notified him Resident #1 was not breathing at around 8:20 PM, but he was unable to immediately respond. He said when he entered Resident #1's room, he assessed the resident. He stated the resident's extremities were warm to touch with no rigor, his face was mottled, and his eyes were fixed and dilated and he had no pulse. He said he checked his left carotid artery and groin and could find no pulse. He said he made a "nursing judgment call" since he estimated the resident had been "down" approximately 20 minutes. He said he did not call 911, but did start CPR. LVN B told the surveyor when he was in CPR class, he was told "if a person is without a pulse for seven minutes, it is not certain they will come back." CNA A was interviewed on [DATE] at 1:15 PM regarding Resident #1. CNA A stated she had given Resident #1 a bed bath approximately 30 minutes before she found him not breathing. She said during the bed bath, she had not noted any change in his condition. She stated she was walking down the hall at approximately 8:00 PM and realized she did not hear Resident #1's usual heavy breathing sounds. CNA A said the resident "normally breathed real heavy-like and this time he was not." She said she went to his room and saw he was not breathing. She stated she then went across the hall two doors down where LVN B was providing care for a resident's gastrostomy tube (a feeding tube located on the abdominal region). She stated she told him she believed the resident was dead, but LVN B was unable to immediately help Resident #1, so she went down the hall and located LVN C and told her about Resident #1. She said LVN C returned with her down the hall when they saw LVN B entering the resident's room. She stated she (CNA A) did not remain in the resident's room once the nurses arrived. She added she did not call 911 or "code blue" and did not know she could. An interview with LVN C on [DATE] at 12:30 PM confirmed she was on duty on [DATE] at the time of Resident #1's change of condition. She confirmed CNA A notified her of the resident's change of condition. LVN C stated CNA A asked her to come to the resident's room at the beginning of the "incident." The LVN said when she and the CNA arrived at Resident #1's room, LVN B and the RT were already in the room. LVN C said she did not touch Resident #1 and she did not know if he was breathing or not. She said he looked unresponsive. She said LVN B came to the nurses' station to check the resident's code status and even though the resident was a full code, he delayed returning to the resident's room and initiating CPR. She stated LVN B told her that in his judgment Resident #1 had been deceased approximately 20 minutes and was already dead. She added she was not CPR certified and did not know how to perform CPR. She further stated she did not call 911, but instead called the weekend supervisor and then the DON to report her concern with LVN B's delay in initiating CPR. On [DATE] at approximately 1:30 PM, during a phone interview with LVN C, she was asked why she did not call 911. LVN C said she did not call 911 because LVN B told her the resident was deceased . An interview with RN D on [DATE] at 7:25 PM, confirmed she was on duty on [DATE] and pronounced Resident #1's death. She said she had responded to a code blue alert. She said when she arrived on the unit, LVN C was at the nurses' station talking to the DON on the telephone. She said when she arrived at Resident #1's room, LVN B and an RT were performing CPR. The RT was doing chest compressions and using the ambu bag. She said LVN C came and told her the DON said to pronounce the resident's death, so she did. When asked about her assessment of Resident #1, she stated he was warm to touch, had no mottling and no pooling of blood. When asked if these signs were signs of death, she responded the DON had said to pronounce Resident #1's death and added, "(The DON) knew him better than me and he was already sick." When asked if the DON pronounced his death or if she did, RN D agreed she (RN D) had pronounced the resident's death. She then added she knew the resident had expired, because his eyes were fixed and "you just know." She concluded by saying she did not know why she failed to document her assessment of the resident and the fact she pronounced his death. During this interview, RN D told the surveyor she had received training from ADON I in regard to calling a code and 911, who can pronounce death, the signs and symptoms of death and follow-up documentation of the event. 4. The Texas Board of Nurse Examiner's (BON) position statements 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death and 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility both documented the following presumptive or conclusive signs of death: Presumptive Signs of Death: the patient is unresponsive, has no respirations, no pulse, pupils are fixed and dilated, body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature, and has generalized cyanosis, and Conclusive Sign of Death: There is presence of liver mortis (pooling of blood in dependent body parts causing purple discoloration). Note: Resident #1 was warm to touch and had no pooling of blood. In addition, the BON's position statement regarding the role of the LVN noted "LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas." The position statement regarding the role of the RN noted "documentation of the circumstances and the assessment of the resident in the resident record are a requirement . . . Documentation should be adequate to give a clear picture of the situation and all the actions that were taken or not taken on behalf of the resident." Note: RN D did not document the circumstances and the assessment of Resident #1 or the fact she pronounced his death. 5. The facility's current Administrative Policies and Procedures reflected: Section III: Organizational Ethics Subject: Abuse, Neglect and Misappropriation of Property (revised February 2008) "POLICY: 1. The facility's Leadership prohibits neglect... 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected ...neglect... 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law. ...5. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit... neglect... PROCEDURES: Component III: Prevention ...6. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: ...C. Ignoring the patient's/resident's needs requests, etc.... Component IV: Identification 1. Staff members identify and assess suspected or alleged reports of ...neglect, focusing on objective and observable evidence, such as... patterns or trends of potential... neglect... ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness. Component V: Reporting/Response 1. All alleged violations concerning... neglect... are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency... ...3. An analysis is completed to determine what changed are needed, if appropriate, to prevent further occurrences... Component VI: Investigation 1. The facility maintains that all allegations of... neglect are thoroughly investigated and appropriate action taken... 2. The facility conducts an internal investigation... and reports the results... within five (5) working days... 3. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting." Nursing Polices and Procedures, Subject: Emergency - 911, (revised [DATE]) reflected: Policy: The staff will call 911 for emergency situations. This policy only applies to resident who have been determined to be a full code. Procedures: 1. Qualified staff initiates the appropriate emergency procedures, i.e., oxygen, suction, CPR . . ., as appropriate, etc in accordance with a resident's Advance Directives. 2. Call 911 when the resident's condition is life threatening, unless the resident is coding and staff have determined the resident is a DNR... ...5. Document the occurrence in the medical record. Nursing Policies and Procedures, Subject: Physician Communication/Change in Condition (revised [DATE]) Policy: ...2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a resident's condition. Procedures: ...7. In the event of a life threatening event - contact 911 immediately. 6. An IJ was identified in the area of Resident Behavior/Facility Practice and Administration on [DATE]. The ADM and DON were notified of the IJ on [DATE] at 6:00 PM. At that time, they were requested to provide a Plan of Removal for the IJ. 7. The facility's Plan of Removal was accepted on [DATE] at 8:55 AM and included the following: 1. All facility CNAs will be educated to notify the charge nurse and call code blue upon identification of an unresponsive resident. Upon completion of the education, a post test will be administered to monitor all nursing staff regarding their knowledge of education. Identified deficient knowledge will result in being re-educated immediately. Newly hired Certified Nurse Aide staff will be educated during classroom orientation prior to their first assigned duty by LVN E, the Staff Development Coordinator. Notification of Charge Nurse and calling a Code Blue upon finding a resident unresponsive will be included in Annual Orientation. LVN E, Staff Development Coordinator will monitor to ensure all Certified Nurse Aides have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Certified Nurse Aide staff members who cannot be reached will not be allowed to work until the education is completed. The Nurse Management Team (including LVN E, ADON F, ADON G, LVN H, ADON I, ADON J and LVN K) will be in-servicing the CNAs. Initiated in-service on [DATE] with completion date of [DATE]. 2. All LVN and RN staff will be in-serviced regarding the initiation of code blue and calling 911. (See attached NP-E-17 Policy). All Facility Licensed Nurses will be re-educated to respond immediately to a report of a resident being unresponsive. All Facility Licensed Nurses will be reeducated on the Texas Board of Nursing Position Statement 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death, which includes "Presumptive Signs of Death" - The patient is unresponsive - The patient has no respirations - The patient has no pulse - The Patient's pupils are fixed and dilated - The patient's body temperature indicates hypothermia: skin is cold relative to the patients baseline skin temperature - The patient has generalized cyanosis And Conclusive Sign of Death - There is presence of livor mortis (venous pooling of blood in the dependent body parts causing purple discoloration of the skin which does blanch with pressure). Upon completion of the education a post test will be administered to monitor all nursing staff regarding their knowledge of education identified deficient knowledge will be re-educated immediately. Education will be by the Nurse Management Team. Initiated [DATE] and will be completed by [DATE]. Newly hired Licensed staff will be educated on all items above, Pronouncement of Death, Code Status and Response to a code including calling 911 during classroom orientation prior to their first assigned duty by the Staff Development Coordinator, LVN. The above will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members who cannot be reached will not be allowed to work until the education is completed. 3. This will be monitored as events occur: Effective immediately ([DATE]) all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting by the QAPI committee members, who include: the ADM, the Interim DON, the Medical Director, LVN E, ADON F, ADON G, LVN H, ADON I, ADON J, Social Services L, Nurse Case Manager M, Medical Records N, Environmental O, Maintenance P, Central Supply Q and the Food Services Director. Education by the Nurse Management Team. 4. All Staff Nurses will be re-educated in process of promptly calling 911 upon notification of a resident that is unresponsive prior to notification of house supervisor or director of nurses. They will follow NP-E-17 and NP-E-14 policies related to Emergency - Code Blue Initiation and Emergency 911 policies to ensure the needs of the resident are met. In service the staff to notify the Abuse Coordinator about concerns with the implementation of protocol. Upon completion of the education, a post test will be administered to monitor all nursing staff regarding their knowledge of education. Identified deficient knowledge will be re-educated immediately. The Nurse Management Team will be educating staff. Initiated [DATE] and will be completed by [DATE]. Newly hired Licensed staff will be educated on all items above during classroom orientation prior to their first assigned duty. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be monitored as events occur: Effective immediately all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure facility policy was followed. Identified deficient practices will be corrected immediately and reported to the ADM as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting by the QAPI committee members. 5. Upon notification of the allegation of neglect by Resident #1's family, LVN B was suspended pending outcome of the investigation. Staff education was started regarding the initiation of code blue and calling 911. Initiated inservice [DATE] for all staff with completion date of [DATE] by the Nurse Management Team. 6. A review of residents who expired or were discharged between [DATE] and [DATE] was conducted on [DATE] to ensure the facility staff responded appropriately to end of life situations. This was done by the Interim DON. 7. All Staff will be educated that the Abuse Coordinator has changed to the ADM. Newly hired Licensed staff will be educated on all items during classroom orientation prior to first assigned duty by LVN E. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be done by the Nurse Management Team. This will be monitored as events occur: Effective immediately all code blue situations and or all residents who expire within 24 hours of transferring to a hospital will be reviewed next business day by the Nurse Management Team to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting attended by the QAPI committee members. 8. RN D was re-educated on [DATE] by the ADM and ADON I about the policy of documentation in the charts related pronouncement of death of a resident and received verbal warning. 9. All current Licensed Nursing staff will be re-educated on the policy of documentation in the charts related to the pronouncement of death of a resident by the Nurse Management Team. Initiated inservice [DATE] for all staff with completion date of [DATE]. All newly hired Licensed staff will be educated on the policy of documentation in the charts related pronouncement of death of a resident. Newly hired Licensed staff will be educated on all items above during classroom orientation prior to first assigned duty by LVN E. This will be included in Annual Orientation. LVN E will monitor to ensure all Licensed Nurses have received this training. Because of the holiday weekend, staff that cannot come or not scheduled to work will be in-serviced over the telephone with two nurse managers as witnesses. All Licensed Nursing staff members that cannot be reached will not be allowed to work until the education is completed. This will be monitored as events occur: Effective immediately all code blue situations and residents who expire within 24 hours of transfer to hospital will be reviewed next business day by the DON and/or designee to ensure that facility policy was followed. Identified deficient practices will be corrected immediately and reported to the Administrator as part of the facility QAPI process. This process will be monitored monthly during the facility QAPI committee meeting. 10. The process for immediately reporting and investigating abuse/ neglect/ exploitation of a resident has been assigned to the ADM, effective [DATE]. The ADM has verbalized understanding of the policy and procedures related to abuse of a resident and will be monitored by CSD R and/or the Interim DON, who starts on [DATE]. 11. The facility's Medical Director was notified at 7:00 PM regarding the IJ and the plan for removal on [DATE]. 8. Inservice records reflected the following subjects were covered: determination of an unresponsive resident and calling code blue and 911, documentation in the clinical records when a resident is found unresponsive and the change of the ADM now being the Abuse Coordinator. The inservice records reflected the majority of licensed nurses, CNAs and RTs from each shift had received the above noted training. Interviews beginning on [DATE] through [DATE], with 11 nurses, one MA, one RT and seven CNAs, representing staff from all three shifts and staff who worked strictly weekdays or weekends, confirmed the staff had received training regarding timely notification of a code blue, timely contact with 911, the fact a CNA can call a code blue alert and 911, if needed and the ADM as the Abuse Coordinator. The interviews were obtained on the following dates/times from the following staff - On [DATE] - LVN S, LVN T, RN D, CNA U, MA V, CNA LL, CNA X, LVN Y, LVN/RT Z, at 7:00 PM, 7:15 PM, 7:25 PM, 7:43 PM, 7:52 PM, 8:00 PM, 8:24 PM, 8:40 PM, and 8:50 PM, respectively. On [DATE] - LVN AA, CNA BB, CNA CC, LVN DD, RT EE, LVN FF at 11:15 PM, 11:23 PM, 11:30 PM, 11:38 PM, 11:45 PM, and 11:47 PM, respectively. On [DATE] - CNA GG, LVN HH, LVN II, CNA JJ, LVN KK at 2:30 PM, 2:40 PM, 2:45 PM, 2:55 PM, and 3:05 PM, respectively. The Administrator was notified the IJ was removed on [DATE] at 4:59 PM. The facility remained out of compliance at a level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" due to staff still being inserviced and the facility still monitoring the plan of removal. The facility's Advanced Directives and Code Status Report, dated [DATE], reflected 68 current residents had a full code status.

Based on interview and record review, it was determined the facility failed to ensure residents were free of any significant medication errors for one (Resident #23) of 22 residents reviewed for medications. NP I failed to inform Resident #23's physician she ordered Cathflo [MEDICATION NAME] on [DATE], which was not appropriate for the resident's clinical situation, and LVN F administered it on [DATE]. Resident #23 expired at the facility on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 10 residents with PICC and central lines, residing on the [MEDICAL CONDITION] Suites Unit, by placing them at risk for a rupture of the catheter or the expulsion of a blood clot into the circulation causing a stroke or [MEDICAL CONDITION], bleeding, and/or death. Findings included: After Administrative Review, it was determined the IJ remained until NP I's status at the facility was ascertained. Resident #23's Record of admitted d [DATE] reflected she was a [AGE] year-old female, who was admitted to the facility's [MEDICAL CONDITION] Unit from the hospital on [DATE]. Resident #23's physician's orders [REDACTED]. Resident #23's History and Physical, dated [DATE] by Physician H (the resident's physician), reflected she had the following Diagnoses: [REDACTED]. The History and Physical reflected: "...CHRONIC SBO; NEED TO BE CORRECTED BY SURGERY. DEFERRED DUE TO SVC THROMBUS AND SUBSEQUENT ANTI-COAGULATION; WILL NEED TO F/U WITH SURGERY IN 1 MONTH." In addition, Physician H's History and Physical for Resident #23 reflected: "SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS." Resident #23's Physician's Progress Note, dated [DATE], reflected Physician H added the following Diagnoses: [REDACTED]...4. [MEDICAL CONDITION]: PLT COUNT WNL AT THE HOSPITAL; SEEMS TO BE TRENDING NOW; POSSIBLY ,[DATE] [MEDICATION NAME]; CONTINUE TO MONITOR AT THIS TIME AND SHE PROBABLY NEEDS TO BE SWITCHED TO [MEDICATION NAME] IF PLT CONTINUES TO GO DOWN....SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS BUT GIVEN #4 ([MEDICAL CONDITION]), WILL NEED TO CONTINUE MONITORING HER CBC Q 3 DAYS AT THIS TIME; [MEDICATION NAME] WAS NOT STARTED AT THE HOSPITAL GIVEN THAT IT MIGHT INTERACT WITH HER MEDICATIONS; WILL FOLLOW." Resident #23's chest x-ray report dated [DATE] reflected: "Impression: CHEST FOR PICC LINE PLACEMENT: LEFT PICC LINE IN POSITION. MILD CARDIOMEGALY AND SLIGHT CONGESTIVE FAILURE. Comment: CHEST FOR PICC LINE PLACEMENT: EXAMINATION REVEALS A PICC LINE IN POSITION EXTENDING FROM THE LEFT AXILLARY REGION INTO THE LEFT [MEDICATION NAME]. THE TIP IS APPROXIMATELY IN THE SUPERIOR VENA CAVA. THE HEART IS MILDLY ENLARGED. THE AORTA AND OTHER MEDIASTINAL STRUCTURES ARE IN THE MIDLINE. THE [MEDICAL CONDITION] VASCULATURE IS SLIGHTLY PROMINENT PROXIMALLY WITH PERIHILAR CONGESTION PERIPHERALLY." This report was initialed by NP I with a date of [DATE]. Resident #23's Nurse's Notes documented by LVN A on [DATE] reflected: 6:15 AM - "Initial A.M. assessment, finds this patient A & O, and in moderate distress. She is immediately given pain med, with (symbol used) the gt being clamped off. BSG WNL, no coverage. (L) upper (symbol used) PICC intact with (symbol used) TPN infusion in progress @ 75 cc/hr via pump, Liter bag N/S also infusing, via gravity @ 70 cc/hr. No (symbol used) Temp. this A.M. - patient drinking copious amts. of cold H2O. Nurse assisted patient OOB to the BSC, she voided QS with (symbol used) moderate loose stool noted. During the assessment, I observed skin wounds to her sacral upper (symbol used) buttock area, x2 areas. Will notify our facility tx. nurse." 11:30 AM - "Nurse Practioner (sic) (NP I) orders an IV be inserted to her rt. arm, I was unable to palpate a vein, nurse (RN C) attempted IV insertion x2, nurse (LVN D) attempted x2, & got an IV in, and the line infiltrated immediately. (NP I) has this nurse squeeze the N/S bag to speed up to N/S infusion rate, also she turns off the TPN infusion." On [DATE] at 12:45 PM, RN C, a charge nurse on the 6:00 AM-2:00 PM shift, was interviewed about her involvement with Resident #23 on [DATE]. RN C stated LVN A asked her to assist with inserting a peripheral line for Resident #23. She stated she heard the resident was experiencing low blood pressure, and they were trying to give the resident an IV [MEDICATION NAME]. RN C stated when she entered the room the IV lines were all tangled, and NP I told her she wanted to IV [MEDICATION NAME] the resident. RN C stated Resident #23's PICC line was patent, but it would not run really fast. She stated NP I was initially helping to trouble-shoot the issue with the PICC line. She stated LVN A flushed the line repeatedly with a 10 ml syringe. Resident #23's continued Nurse's Notes completed by LVN A on [DATE] reflected the following: An interview with LVN A on [DATE] at 8:48 AM, regarding her Nurse's Notes from [DATE], revealed Resident #23 had been sick up until [DATE] when she was able to work with PT. She stated after finishing PT, Resident #23 was able to work with the OT in her room. While working with the OT, NP I came onto the [MEDICAL CONDITION] Suites Unit. LVN A stated she gave report to NP I, and she shared her concern that Resident #23 was getting too much fluid. LVN A stated she and NP I then proceeded to enter Resident #23's room, and upon entering the room they discovered the resident was weak, dizzy, and was having a hypotensive episode. The resident was in the chair, at that time, and LVN A assisted her to the bed. LVN A stated NP I took over at that time, and she asked what the resident's rate of infusion was for the PICC line. LVN A stated the resident's PICC line ran slow. The next day, [DATE], LVN A learned the 2:00 PM to 10:00 PM charge nurse, LVN F, administered Cathflo [MEDICATION NAME] via Resident #23's PICC line per NP I's orders, and the resident died later that day after the medication was administered. Review of NP I's Progress Note, dated [DATE] for Resident #23, revealed there was no documented evidence the patency of the PICC line had been assessed prior to the administration of the Cathflo [MEDICATION NAME]. In the same Progress Note, NP I documented: "While assessing pt sitting @ BS awaiting a shower she c/o dizziness, she was pale. BP ,[DATE] P 51, profoundly weak assisted to bed. BP ,[DATE] P 59 attempted to run in fluid wide open thru PICC but to no avail...." In addition, NP I's Progress Notes also reflected the following lab values for Resident #23: White Blood Cells increased from 5.1 to 17.4 Platelet Count decreased from 113 to 79 H & H decreased from 10XXX,[DATE].3 to 9XXX,[DATE].0 Note: Platelets are blood cells needed in the body to promote blood clotting. A platelet count below 100 indicates someone has a higher risk for bleeding due to low platelet count. Also, a white blood cell count above 10 indicates a person has an infection On [DATE] at 10:15 AM, NP I was interviewed about her involvement with Resident #23 on [DATE]. NP I revealed, when she entered the room on [DATE], Resident #23 was sitting up in a chair. The resident was pale and sweating, and she complained of dizziness. When the nurse put her back to bed, her blood pressure was ,[DATE] with a heart rate of 59. NP I stated Resident #23 was volume depleted, and she needed to be [MEDICATION NAME] with IV fluids. She stated there was a good blood return on the catheter. She added the PICC line was a small caliber, and it was sluggish. NP I stated, "I ordered the Cathflo. I don't know who gave it." When queried as to whom was to give the Cathflo [MEDICATION NAME], NP I stated the protocol was the company, who handled the PICC lines, was responsible for coming to the facility and administering it. She further revealed, "I don't know anything about Cathflo, and I wouldn't give it myself." Resident #23's NP I's Order, dated [DATE], reflected: "Cathflo 2 mg as needed for PICC x 2 lumens per protocol." The manufacturer's website (<http://www.cathflo.com>, last accessed on [DATE]) for Cathflo [MEDICATION NAME] reflected: "INDICATIONS AND USAGE Cathflo [MEDICATION NAME] (Atleplase) is indicated for the restoration of function to central venous devices as assessed by the ability to withdraw blood. PRECAUTIONS General Catheter dysfuction may be caused by a variety of conditions rather than thrombus formation, such as catheter malposition, mechanical failure, [MEDICATION NAME] by a suture, and lipid deposits or drug precipitates within the catheter lumen. These types of conditions should be considered before treatment with Cathflo [MEDICATION NAME] Bleeding ...In addition, caution should be exercised with patients who have [MEDICAL CONDITION], other [MEDICATION NAME] defects (including those secondary to severe hepatic or [MEDICAL CONDITION]), or any condition for which bleeding constitutes a significant hazard or would be particluarly difficult to manage because of its location, or who are at high risk for embolic complications (e.g., venous [MEDICAL CONDITION] in the region of the catheter). Death and permanent disability have been reported in patients who have experienced stroke or other serious bleeding episodes when receiving pharmacologic doses of a [MEDICAL CONDITION] Infections Cathflo [MEDICATION NAME] should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo [MEDICATION NAME] in patients with infected catheters may release a localized infection into the systemic circulation (see ADVERSE REACTIONS). As with all catheterization procedures, care should be used to maintain aseptic technique... Geriatric Use ...In general, caution should be used in geriatric patients with conditions known to increase the risk of bleeding (see PRECAUTIONS, Bleeding)." An interview with LVN E, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:45 PM revealed he ordered the Cathflo [MEDICATION NAME] from the pharmacy, and LVN F administered it to Resident #23. Resident #23's [DATE] MAR indicated [REDACTED]. An interview with LVN F, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:30 PM revealed he administered Cathflo [MEDICATION NAME] to Resident #23 via her PICC line on [DATE] at 3:45 PM. LVN F provided a Witness Statement on [DATE], which reflected: "Reviewed order for Cathflo on (Resident #23). Got med out of refrigerator mixed according to mfg. Standards. Went to Pt room with (symbol used) her primary nurse, (LVN E), ID'd patient. Donned gloves, cleaned white hub with (symbol used) ETOH, injected 2 ml of med into PICC line. This was @ 1545 (3:45 PM). Returned to Pt room @ 1700 (5:00 PM). Cleaned white hub with (symbol used) ETOH. And with (symbol used) a new 10 ml syringe drew back 10 ml of blood. Then flushed with (symbol used) 10 ml NS. Cleaned clear hub with (symbol used) ETOH. With (symbol used) new 10 ml syringe, attempted to draw blood but was unsuccessful. Only got back the 2 ml of Cathflow. Primary nurse notified of outcome. This all occurred on [DATE]. Before admin of Cathflo assessed each hub by attempting to flush with (symbol used) 10 ml of ns & to draw blood from PICC. White hub flushed, but no blood return. Clear hub didn't flush or give blood return." LVN F's personnel file did not reflect a skills check-off list from the DON for IV competency. Resident #23's Nurse's Notes dated [DATE] reflected Resident #23 was found unresponsive and without a pulse at 5:45 PM. The Notes reflected LVN E called 911, and the paramedics came to the facility. The paramedics tried at length but were unsuccessful in resuscitating Resident #23. The Notes reflected the resident was pronounced dead at the facility by the DON at 8:00 PM. An interview with the MD, who was also Resident #23's attending physician (Physician H), on [DATE] at 9:20 AM revealed when asked about Resident #23's PICC line, he replied there was a [MEDICATION NAME] thrombus (blood clot) in the area of the PICC line. The MD was asked if the facility had notified him Resident #23's PICC line was occluded or sluggish, and he answered he was not notified. The MD stated he saw Resident #23 on [DATE] and [DATE]. When the MD was asked about an LVN administering Cathflo [MEDICATION NAME], he replied he thought an RN should administer the Cathflo [MEDICATION NAME]. When he was asked if he was aware NP I ordered Cathflo [MEDICATION NAME] on [DATE], the MD replied no. When asked what his expectation would be regarding documentation if Cathflo [MEDICATION NAME] was used, the MD responded, "The circumstances should be documented for giving the medication." He was then asked if he had standing orders for Cathflo [MEDICATION NAME], and he replied, "No." The MD was provided with Resident #23's clinical record, and he examined the resident's lab reports. The MD revealed he was not aware Resident #23's platelet count was 40. The MD stated he would not have used Cathflo [MEDICATION NAME] for this situation. Resident #23's preliminary lab report for a Blood Culture drawn on [DATE] reflected Gram Negative Rods were present, which indicated an infection. This Blood Culture report was initialed and dated by NP I on [DATE]. Resident #23's CBC results drawn on [DATE] at 4:51 AM reflected her HGB, HCT (H & H), and platelets had declined since her admission to the facility. The results reflected the following: [DATE] - HGB 11.5 g/dL reference range 12.0 -15.6 g/dL; HCT 34.5% reference range 35.0 - 46.0%; and PLT 160 reference range 130 - 400 K/mm3 [DATE] - HGB 10.7 g/dL; HCT 31.7%; and PLT 113 [DATE] - HGB 8.3 g/dL; HCT 25.0%; and PLT 40 Note: HCT is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. The decline of HGB and HCT could be a sign of bleeding. NP I initialed and dated this laboratory result on [DATE]. An IJ was identified on [DATE]. The Administrator, DON, and Assistant Administrator were notified of the IJ on [DATE] at 12:07 PM. A Plan of Removal was requested at that time. During the interview on [DATE] at 3:45 PM, the DON was asked to provide the facility's protocol for the use of Cathflo [MEDICATION NAME]. The DON stated the vendor pharmacy protocol, and the chapter regarding IV therapy in the Perry and Potter nursing textbook were the policies the facility used. The DON provided a copy of the seventh edition of the Perry and Potter nursing textbook, and she stated it was the facility's policy. The facility's policy and procedures for IV therapy reflected the facility had no IV therapy policies or procedure of their own. During the interview on [DATE] at 3:45 PM, the DON was asked what type of procedures there were to make sure the nursing needs of the residents were being met. The DON stated the facility followed physician orders [REDACTED]. The DON was asked how she monitored staff to ensure the systems they monitored were being done sufficiently. She stated she and the ADONs conducted rounds, and they observed medication passes and incontinent care. She also said they did follow-ups with nursing concerns brought to their attention in daily meetings and followed the standards of care. She said the ADONs would also review residents' clinical records to ensure proper care was being provided. The DON was asked how she thought the IJ came about, and she stated the facility had not done anything wrong. The facility's Plan of Removal was accepted on [DATE] and reflected: IV push medications requiring special monitoring will not be administered. On [DATE] at 10:56 AM, a telephone interview was conducted with the DON regarding how the facility addressed the role of the NP in the IJ. The DON stated the Administrator and she met with the Medical Director and the NP on the morning just prior to the survey team talking to them ([DATE]). They discussed the concerns, which were identified by the survey team. The Medical Director stated he would bring their concerns to his supervisor at the company, which employed him and the NP. The Medical Director told them (the Administrator and the DON) it would be up to the company to handle corrective actions regarding the NP. The DON further stated they had a Physician Dinner on [DATE], and they (the Administrator and the DON) again discussed their concerns regarding the NP. The DON then explained the facility planned to hire an NP on a full-time basis 8:00 AM - 5:00 PM Monday through Friday. The DON stated they had already met with a potential candidate on [DATE]. The DON stated the facility and staff were taking the situation seriously and would continue to monitor the NP when she was working at the facility. The DON further stated the Medical Director and the NP's supervising company had not agreed to allow another NP to see "their" residents, so the NP, for the time being, was continuing to provide services for the Medical Director's residents. The DON stated she was monitoring the NP's documentation and she would bring any concerns to the physician's attention. An interview on [DATE] at 3:46 PM with the DON revealed she was completing competency evaluations with return demonstrations for her weekend staff nurses, LVN B and LVN F along with a competency written test. An observation on [DATE] at 4:00 PM revealed the DON observed LVN B administer [MEDICATION NAME] IV (antibiotic) using aseptic technique with no contamination. On [DATE] at 5:00 PM, the DON and Assistant Administrator were informed the IJ remained. A Plan of Removal was requested at that time. An interview with the Administrator, on [DATE] at 9:30 AM regarding how the facility would address the concerns regarding NP I, revealed the facility made the decision to remove NP I from the facility. The Administrator stated Physician H would be taking all calls directly, so NP I was not involved with the residents. She stated the medical group, who employed NP I, would audit the charts of the residents seen by NP I. When asked how she thought the IJ came about, the Administrator stated she believed it arose due to a disagreement between LVN A and NP I. She stated they "played" this out in Resident #23's chart. The Administrator stated NP I and LVN A put the facility in the IJ situation. She stated NP I did not pick up on Resident #23's lab results because LVN A was fighting with her. The Administrator stated the facility got caught in the mix of problems. At 10:45 AM on [DATE], the Administrator stated NP I's privileges were revoked, and she would no longer be seeing residents in the facility. The facilility's new Plan of Removal revised [DATE] at 9:30 AM reflected, "Nurse Practitioner's privileges were suspended and revoked from practice in this facility effective [DATE] and this Nurse Practitioner will not return to practice in the facility. (Physician H) was notified of the suspension on [DATE]. Facility nurses instructed to call (Physician H) for any resident issues directly on his cell phone. (Physician H) is responsible for supervising his Nurse Practitioner and being available to supervise other physicians and their Nurse Practitioner's (sic) if issues arise under his role as Medical Director. See F501. Any Nurse Practitioner assigned to this facility will be monitored by the supervising physician and/or Medical Director. Nurse Practitioners providing services in the facility will work under the guidance of the attending physician as follows: 1) Practice within their scope of practice per Advanced Nurse Practice Act and level of education. 2) Be monitored by their attending physician as follows: 10% of charts will be monitored per month, discuss weekly and as needed any difficult residents or questions concerning residents; be available for backup call for issues that arise 24hrs, 7 days per week. 3) The results of the 10% chart audits will be presented to the Facility Quality Assurance purposes to be reviewed as part of the Performance Improvement process and will be addressed at the time of discovery. 4) Physician will follow Federal/State Regulations re: visit frequency. 5) Physician will address with Nurse Practitioner during chart audits any identified areas of deficient practice for immediate correction and report to the facility as part of the Performance Improvement process. (Physician H) currently has 51 residents. Out of the 51 resident charts, (Physician H) has stated that he has already completed 12 of the audits needed. He will completed 15% of the remaining 39 charts to review the lab results to ensure abnormal labs were addressed, which will be 6 charts to be completed by [DATE]. The remaining 33 charts will be audited by physicians or (medical group) made up of other physicians to ensure abnormal lab results were addressed by the Nurse Practitioner. Physician will provide a written report of all audits to DADS per request...." An interview with the MD on [DATE] at 1:00 PM revealed he had audited 12 residents' clinical records of NP I since [DATE]. He provided a list of 12 residents whom he had audited the care provided by NP I and reviewed the lab reports. The MD stated all of the records he reviewed were in order and the care had been provided by NP I according to the protocol. He further stated he was in the facility that day to complete 15% (6 records) of the clinical records for the three long term care units. The MD revealed he would audit two records on each unit that day. The MD also stated new labs were ordered, and once the labs were completed, he would review each lab himself to ensure the appropriate action if needed was taken for each resident. The IJ was removed on [DATE]. The Administrator, Assistant Administrator, the DON, and the Clinical Services Representative were notified on [DATE] at 2:00 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. On [DATE], the DON provided the survey team with a list of all of the residents as of [DATE], who were receiving IV therapy, and she identified a total of ten residents. Of the ten residents identified, nine had PICC lines and one had a central line.

Based on interview and record review, it was determined the facility failed to ensure two licensed nursing professionals (NP I and LVN F) provided services that met professional standards of quality for one (Resident #23) of five residents reviewed for IV therapy. 1. NP I failed to administer normal saline to Resident #23 via the resident's PICC line appropriately, when the resident was experiencing low blood pressure. NP I "stabbed" the side of the normal saline IV bag and withdrew the fluid and forcefully pushed the fluid through Resident #23's PICC line six times. Resident #23 turned "dusky" and began shaking all over, after the administration of the fluid by NP I. 2. NP I failed to notify Resident #23's physician she ordered Cathflo [MEDICATION NAME] on [DATE], which was not appropriate for the resident's clinical situation. 3. LVN F failed to provide services to Resident #23 limited to his scope of practice. LVN F, who did not have evidence of documented IV training, administered the Cathflo [MEDICATION NAME] to Resident #23 on [DATE]. Resident #23 expired at the facility on [DATE]. An Immediate and Serious Threat was identified on [DATE]. While the Immediate and Serious Threat was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 10 residents with PICC and central lines, residing on the [MEDICAL CONDITION] Suites Unit, by placing them at risk for a rupture of the catheter or the expulsion of a blood clot into the circulation causing a stroke or [MEDICAL CONDITION], infection, bleeding, and/or death. Findings included: After Administrative Review, it was determined the Immediate and Serious Threat remained until NP I's status at the facility was ascertained. The Texas Administrative Code Title 22 Examining Boards, Part 11 Texas Board of Nursing, Chapter 217 Licensure, Peer Assistance and Practice, Rule 217.11 Standards of Nursing Practice reflected: "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.... (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: .....(iv) implementing appropriate aspects of care within the LVN's scope of practice...." The Texas Board of Nurse Examiner's Position Statement 15.3 LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines last reviewed on [DATE] by the Board reflected: "The basic educational curriculum for Licensed Vocational Nurses (LVNs) does not mandate teaching of principles and techniques of insertion for peripheral intravenous catheters, or the administration of fluids and medications via the intravenous route. Knowledge and skills relating to maintaining patency and performing dressing changes of central line intravenous catheters is also not mandated as part of basic LVN education. As such, basic competency in management of intravenous lines/intravenous therapy is not a given for any specific LVN licensee. Applicable Nursing Standards LVN practice is guided by the Nursing Practice Act (NPA) and Board Rules. Rule 217.11, Standards of Nursing Practice, is the rule most often applied to nursing practice issues. Two standards applicable in all practice scenarios include: 217.11(1)(B) implement measures to promote a safe environment for clients and others, and 217.11(1)(T) accept only those assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability. Additional standards in Rule 217.11 that may be applicable when a LVN chooses to engage in an IV therapy-related task include (but are not limited to): (1)(C) Know the rationale for and effects of medications and treatments and shall correctly administer the same, (1)(D)Accurately and completely report and document: (i) ..client status....(ii) nursing care rendered...(iii) physician, dentist or podiatrist orders...(iv) administration of medications and treatments....(v) client response(s)..., (1)(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices, (1)(H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations, (1)(R) Be responsible for one's own continuing competence in nursing practice and individual professional growth, (2)(A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care ...((i)-(v)), and (2)(C) ...perform other acts that require education and training as prescribed by board rules and policies, commensurate with the LVN's experience, continuing education, and demonstrated LVN competencies." The Texas Board of Nurse Examiners' Position Statement 15.27 last reviewed [DATE] by the Board reflected: "The Licensed Vocational Nurse Scope of Practice provides additional clarification of the Standards Rule as it applies to LVN Scope of Practice. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow a LVN to expand his/her scope of practice to include intravenous therapy. It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an "IV Validation Course" or for "LVN IV certification." The LVN who chooses to engage in intravenous therapy must first have been instructed in the principles of intravenous therapy congruent with prevailing nursing practice standards.... Administration of IV Fluids and Medications The ability of a LVN to administer specific IV fluids or drugs, to prepare and/or administer IV "piggy-back" or IV "push" medications, or to monitor and titrate "IV drip" medications of any kind is up to facility policy. The LVN's practice relative to IV therapy must also comply with any other regulations that may exist under the jurisdiction of other regulatory agencies or entities. The LVN who accepts an assignment to engage in any aspect of intravenous therapy is responsible for adhering to the NPA and the Board rules, particularly 217.11 Standards of Nursing Practice, including excerpted standards listed above and any other standards or rules applicable to the individual LVN's practice. All nursing actions related to peripheral and/or central intravenous lines, as well as IV administration of medications, must be completed in accordance with the orders of the prescribing practitioner, as well as written policies, procedures and job descriptions approved by the health care employer." The Texas Board of Nursing Administrative Code for Advanced Practice Nurses (title 22, Part 11, Chapter 221 Rule 221.13 effective [DATE], 26 Tx-Reg 1509) Core Standards Advanced Practice reflected; " ... (1) Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commence her with his Ward/her education and experience. The degree of detail within protocols/policies/practice guidelines/clinical practice privileges may vary in relation to the complexity of the situations covered by such protocols, the advanced specialty area of practice, the advanced educational preparation of the individual, and the experience level of the individual practice nurse. (2) Protocols or other written authorization: (A) Should be jointly developed by the advanced practice nurse and the appropriate physicians, ... ... (D) Shall be maintained in the practice setting of the advanced practice nurse, and (E) Shall be made available as necessary to verify authority to provide medical aspects of care. ..." (http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=3&ti=22&pt=11, last accessed [DATE].) The Texas Board of Nursing recognizes that individual scopes of practice will vary and that what is within the individual scope of practice for one advanced practice nurse may not be within the individual scope of practice for another advanced practice nurse authorized to practice in the same role and specialty. However, it is important to keep in mind that the Board holds each advanced practice nurse accountable for knowing and [MEDICATION NAME] within his/her professional and individual scope of practice. (Adopted by the Texas Board of Nursing, [DATE]) The Standards of Nursing Practice in Rule 217.11 require nurses to accept only those assignments that take into consideration patient safety and that are commensurate with their own educational preparation, experience, knowledge, and physical and emotional ability ((1)(T). Resident #23's Record of admitted d [DATE] reflected she was a [AGE] year-old female, who was admitted to the facility's [MEDICAL CONDITION] Unit from the hospital on [DATE]. Resident #23's physician's orders [REDACTED]. Resident #23's History and Physical, dated [DATE] by Physician H (the resident's physician), reflected she had the following Diagnoses: [REDACTED]. The History and Physical reflected: "...CHRONIC SBO; NEED TO BE CORRECTED BY SURGERY. DEFERRED DUE TO SVC THROMBUS AND SUBSEQUENT ANTI-COAGULATION; WILL NEED TO F/U WITH SURGERY IN 1 MONTH." In addition, Physician H's History and Physical for Resident #23 reflected: "SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS." Resident #23's Physician's Progress Note, dated [DATE], reflected Physician H added the following Diagnoses: [REDACTED]...4. [MEDICAL CONDITION]: PLT COUNT WNL AT THE HOSPITAL; SEEMS TO BE TRENDING NOW; POSSIBLY ,[DATE] [MEDICATION NAME]; CONTINUE TO MONITOR AT THIS TIME AND SHE PROBABLY NEEDS TO BE SWITCHED TO [MEDICATION NAME] IF PLT CONTINUES TO GO DOWN....SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS BUT GIVEN #4 ([MEDICAL CONDITION]), WILL NEED TO CONTINUE MONITORING HER CBC Q 3 DAYS AT THIS TIME; [MEDICATION NAME] WAS NOT STARTED AT THE HOSPITAL GIVEN THAT IT MIGHT INTERACT WITH HER MEDICATIONS; WILL FOLLOW." Resident #23's chest x-ray report dated [DATE] reflected: "Impression: CHEST FOR PICC LINE PLACEMENT: LEFT PICC LINE IN POSITION. MILD CARDIOMEGALY AND SLIGHT CONGESTIVE FAILURE. Comment: CHEST FOR PICC LINE PLACEMENT: EXAMINATION REVEALS A PICC LINE IN POSITION EXTENDING FROM THE LEFT AXILLARY REGION INTO THE LEFT [MEDICATION NAME]. THE TIP IS APPROXIMATELY IN THE SUPERIOR VENA CAVA. THE HEART IS MILDLY ENLARGED. THE AORTA AND OTHER MEDIASTINAL STRUCTURES ARE IN THE MIDLINE. THE [MEDICAL CONDITION] VASCULATURE IS SLIGHTLY PROMINENT PROXIMALLY WITH PERIHILAR CONGESTION PERIPHERALLY." This report was initialed by NP I with a date of [DATE]. Resident #23's Nurse's Notes documented by LVN A on [DATE] reflected: 6:15 AM - "Initial A.M. assessment, finds this patient A & O, and in moderate distress. She is immediately given pain med, with (symbol used) the gt being clamped off. BSG WNL, no coverage. (L) upper (symbol used) PICC intact with (symbol used) TPN infusion in progress @ 75 cc/hr via pump, Liter bag N/S also infusing, via gravity @ 70 cc/hr. No (symbol used) Temp. this A.M. - patient drinking copious amts. of cold H2O. Nurse assisted patient OOB to the BSC, she voided QS with (symbol used) moderate loose stool noted. During the assessment, I observed skin wounds to her sacral upper (symbol used) buttock area, x2 areas. Will notify our facility tx. nurse." 7:00 AM - "G/T unclamped now. Patient is resting, & requested to have another hr. or so of sleep." 9:00 AM - "(L) PICC flushed prior to starting the [MEDICATION NAME] IV per piggyback. Her BBS are coarse with (symbol used) some crackles to the lower (symbol used) lobes, O2 SAT 93% - RT (RT G) asked to assess her resp. status @ this time - will monitor." 10:00 AM - "Patient awake & feeling better, wants to catch up on her therapy today." 10:15 AM - "PT in to work with (symbol used) her inside her room, as I instructed the therapist she would be tired & slow secondary to (symbol used) her being in bed for the past 2 days. PT fully understood, and took it easy. OT (name) to F/U PT to assist this patient with (symbol used) her shower. Patient became dizzy, clammy, & pale - B/P was ,[DATE] A/P 57 - OT/nurse safely assisted her to bed. Feet placed on pillow, patient reassured, her skin was dry now. B/P taken again was ,[DATE] A/P @ 59, patient responds to verbal & tactile stim." 11:30 AM - "Nurse Practioner (sic) (NP I) orders an IV be inserted to her rt. arm, I was unable to palpate a vein, nurse (RN C) attempted IV insertion x2, nurse (LVN D) attempted x2, & got an IV in, and the line infiltrated immediately. (NP I) has this nurse squeeze the N/S bag to speed up to N/S infusion rate, also she turns off the TPN infusion." On [DATE] at 12:45 PM, RN C, a charge nurse on the 6:00 AM-2:00 PM shift, was interviewed about her involvement with Resident #23 on [DATE]. RN C stated LVN A asked her to assist with inserting a peripheral line for Resident #23. She stated she heard the resident was experiencing low blood pressure, and they were trying to give the resident an IV [MEDICATION NAME]. RN C stated when she entered the room the IV lines were all tangled, and NP I told her she wanted to IV [MEDICATION NAME] the resident. RN C stated Resident #23's PICC line was patent, but it would not run really fast. She stated NP I was initially helping to trouble-shoot the issue with the PICC line. She stated LVN A flushed the line repeatedly with a 10 ml syringe. RN C stated she attempted to insert a peripheral IV line without success, but LVN D was able to start the line. RN C stated NP I wanted to get a manual blood pressure for Resident #23 so RN C proceeded to check her blood pressure using the resident's foot. Her systolic blood pressure was ,[DATE]. She stated she did not know if the [MEDICATION NAME] had been given yet when she checked the resident's blood pressure. During this time, NP I went to the nurses' station to review Resident #23's clinical record. RN C stated when she saw Resident #23 that day the resident was flushed, and she had her eyes closed. Her breathing was normal, but she was cold and shivering. On [DATE] at 12:45 PM, LVN D was interviewed about her involvement with Resident #23 on [DATE]. She stated LVN A, who was Resident #23's nurse, came to get her to put in a peripheral IV. LVN D stated she assisted with inserting the peripheral line, then she left the room. She stated when she left the room Resident #23 was relaxed after the peripheral line was inserted. LVN D stated, the next time she went into Resident #23's room was when NP I was yelling down the hall, "Does anyone know how to work a pump?" When she entered the resident's room, she observed the floor around Resident #23's IV pump to be wet, and she described the room as being chaotic. LVN D stated she observed Resident #23 covered up in bed, and her whole body was "violently" shaking. Resident #23's continued Nurse's Notes completed by LVN A on [DATE] reflected the following: 12:15 PM- "(NP I), then manually [MEDICATION NAME] 35 cc N/S after (symbol used) withdrawing the IV solution directly from the side of the IV solution (bag) rather than the rubber [MEDICATION NAME]. She used an 18 gauge needle to puncture & withdraw the solution. She then with max force injected the lower (symbol used) lumen on the PICC line, she did this x6...." 1:00 PM - "Patient started with hard chills, and verbalized pain, and was in acute distress. (NP I) told me to get the patient a [MEDICATION NAME] (an anti-anxiety medication)." 1:15 PM - "I raised the foot of her bed, and monitored this patient for s/s of shock, her B/P was ,[DATE], color pale, and some confusion noted with (symbol used) acute anxiety. The patient's (family member) was @ (Resident #23's) bedside during the manual [MEDICATION NAME] injections, and was trying to assist (Resident #23)." 1:45 PM - "During report to ,[DATE] (2:00 PM to 10:00 PM shift) nurse, I did inform him of the 'hypotensive', episode, and to monitor the patient with (symbol used) diligence secondary to (symbol used) the past 2 hrs. Reported this episode to my ADON, (ADON K)." An interview with LVN A on [DATE] at 8:48 AM, regarding her Nurse's Notes from [DATE], revealed Resident #23 had been sick up until [DATE] when she was able to work with PT. She stated after finishing PT, Resident #23 was able to work with the OT in her room. While working with the OT, NP I came onto the [MEDICAL CONDITION] Suites Unit. LVN A stated she gave report to NP I, and she shared her concern that Resident #23 was getting too much fluid. LVN A stated she and NP I then proceeded to Resident #23's room, and upon entering the room they discovered the resident was weak, dizzy, and was having a hypotensive episode. The resident was in the chair, at that time, and LVN A assisted her to the bed. LVN A stated NP I took over at that time, and she asked what the resident's rate of infusion was for the PICC line. LVN A stated the resident's PICC line ran slow. NP I then proceeded to unclamp Resident #23's [DEVICE], and she informed LVN A they needed to start a peripheral IV line. NP I next instructed LVN A to take the resident's pedal pulse, and it was 90 at that time (Normal resting pulse in adults is between 60 and 100 beats per minute). LVN A then explained NP I told her to squeeze the resident's Normal Saline IV bag which was not on the pump at that time. Next, NP I held an IV bag containing Normal Saline, and she "stabbed" the bag with an 18 gauge needle and a 30 ml syringe to draw up the Normal Saline instead of using the port to extract the Normal Saline. The Normal Saline squirted out of the bag, but she was able to fill the syringe. LVN A stated she gave NP I an alcohol prep pad to clean the port, and NP I proceeded to put the syringe directly on the lumen port of the PICC line. NP I pushed 30 cc of Normal Saline directly into the PICC line with maximum force. LVN A stated NP I pushed with the weight of her body, while injecting the Normal Saline, to push it in faster. LVN A stated NP I did this procedure six times and injected 210 ml of the solution into the port of the PICC line. After NP I completed the procedure, LVN A stated the resident went into shock. LVN A stated the resident appeared dusky and began shaking. NP I stated she "saved her life." LVN A stated NP I asked Resident #23's family member, who was present during the procedure, it this was how Resident #23 acted when she was having an anxiety attack. NP I told LVN A to give the resident a [MEDICATION NAME] for anxiety. LVN A stated she administered the [MEDICATION NAME] to Resident #23. After the occurrence, LVN A stated she informed ADON K about the incident. The next day, [DATE], LVN A learned the 2:00 PM to 10:00 PM charge nurse, LVN F, administered Cathflo [MEDICATION NAME] via Resident #23's PICC line per NP I's orders, and the resident died later that day after the medication was administered. Review of NP I's Progress Note, dated [DATE] for Resident #23, revealed there was no documented evidence the patency of the PICC line had been assessed prior to the administration of the Cathflo [MEDICATION NAME]. The Progress Note reflected NP I manually administered 210 ml of Normal Saline through Resident #23's PICC line to treat low blood pressure. In the same Progress Note, NP I documented: "While assessing pt sitting @ BS awaiting a shower she c/o dizziness, she was pale. BP ,[DATE] P 51, profoundly weak assisted to bed. BP ,[DATE] P 59 attempted to run in fluid wide open thru PICC but to no avail BP less dizzy but now "sleepy" requiring stimulation to stay awake BP ,[DATE] (P) 51." NP I further documented in the Progress Note that she manually [MEDICATION NAME] 0.9 Sodium Chloride via the resident's PICC line and infused 210 cc. In addition, NP I's Progress Note also reflected the following lab values for Resident #23: White Blood Cells increased from 5.1 to 17.4 Platelet Count decreased from 113 to 79 H & H decreased from 10XXX,[DATE].3 to 9XXX,[DATE].0 Note: Platelets are blood cells needed in the body to promote blood clotting. A platelet count below 100 indicates someone has a higher risk for bleeding due to low platelet count. Also, a white blood cell count above 10 indicates a person has an infection On [DATE] at 10:15 AM, NP I was interviewed about her involvement with Resident #23 on [DATE]. NP I revealed, when she entered the room on [DATE], Resident #23 was sitting up in a chair. The resident was pale and sweating, and she complained of dizziness. When the nurse put her back to bed, her blood pressure was ,[DATE] with a heart rate of 59. NP I stated Resident #23 was volume depleted, and she needed to be [MEDICATION NAME] with IV fluids. She stated there was a good blood return on the catheter. She added the PICC line was a small caliber, and it was sluggish. NP I stated, "I ordered the Cathflo. I don't know who gave it." When queried as to whom was to give the Cathflo [MEDICATION NAME], NP I stated the protocol was the company, who handled the PICC lines, was responsible for coming to the facility and administering it. She further revealed, "I don't know anything about Cathflo, and I wouldn't give it myself." Resident #23's NP I's Order, dated [DATE], reflected: "Cathflo 2 mg as needed for PICC x 2 lumens per protocol." The manufacturer's website (<http://www.cathflo.com>, last accessed on [DATE]) for Cathflo [MEDICATION NAME] reflected: "INDICATIONS AND USAGE Cathflo [MEDICATION NAME] (Atleplase) is indicated for the restoration of function to central venous devices as assessed by the ability to withdraw blood. PRECAUTIONS General Catheter dysfuction may be caused by a variety of conditions rather than thrombus formation, such as catheter malposition, mechanical failure, [MEDICATION NAME] by a suture, and lipid deposits or drug precipitates within the catheter lumen. These types of conditions should be considered before treatment with Cathflo [MEDICATION NAME] Bleeding ...In addition, caution should be exercised with patients who have [MEDICAL CONDITION], other [MEDICATION NAME] defects (including those secondary to severe hepatic or [MEDICAL CONDITION]), or any condition for which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location, or who are at high risk for embolic complications (e.g., venous [MEDICAL CONDITION] in the region of the catheter). Death and permanent disability have been reported in patients who have experienced stroke or other serious bleeding episodes when receiving pharmacologic doses of a [MEDICAL CONDITION] Infections Cathflo [MEDICATION NAME] should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo [MEDICATION NAME] in patients with infected catheters may release a localized infection into the systemic circulation (see ADVERSE REACTIONS). As with all catheterization procedures, care should be used to maintain aseptic technique... Geriatric Use ...In general, caution should be used in geriatric patients with conditions known to increase the risk of bleeding (see PRECAUTIONS, Bleeding)." An interview with LVN E, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:45 PM revealed he ordered the Cathflo [MEDICATION NAME] from the pharmacy, and LVN F administered it to Resident #23. Resident #23's [DATE] MAR indicated [REDACTED]. An interview with LVN F, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:30 PM revealed he administered Cathflo [MEDICATION NAME] to Resident #23 via her PICC line on [DATE] at 3:45 PM. LVN F provided a Witness Statement on [DATE], which reflected: "Reviewed order for Cathflo on (Resident #23). Got med out of refrigerator mixed according to mfg. Standards. Went to Pt room with (symbol used) her primary nurse, (LVN E), ID'd patient. Donned gloves, cleaned white hub with (symbol used) ETOH, injected 2 ml of med into PICC line. This was @ 1545 (3:45 PM). Returned to Pt room @ 1700 (5:00 PM). Cleaned white hub with (symbol used) ETOH. And with (symbol used) a new 10 ml syringe drew back 10 ml of blood. Then flushed with (symbol used) 10 ml NS. Cleaned clear hub with (symbol used) ETOH. With (symbol used) new 10 ml syringe, attempted to draw blood but was unsuccessful. Only got back the 2 ml of Cathflow. Primary nurse notified of outcome. This all occurred on [DATE]. Before admin of Cathflo assessed each hub by attempting to flush with (symbol used) 10 ml of ns & to draw blood from PICC. White hub flushed, but no blood return. Clear hub didn't flush or give blood return." LVN F's personnel file did not reflect a skills check-off list from the DON for IV competency. Resident #23's Nurse's Notes dated [DATE] reflected Resident #23 was found unresponsive and without a pulse at 5:45 PM. The Notes reflected LVN E called 911, and the paramedics came to the facility. The paramedics tried at length but were unsuccessful in resuscitating Resident #23. The Notes reflected the resident was pronounced dead at the facility by the DON at 8:00 PM. An interview with the MD, who was also Resident #23's attending physician (Physician H), on [DATE] at 9:20 AM revealed when asked about Resident #23's PICC line, he replied there was a [MEDICATION NAME] thrombus (blood clot) in the area of the PICC line. The MD was asked if the facility had notified him Resident #23's PICC line was occluded or sluggish, and he answered he was not notified. The MD stated he saw Resident #23 on [DATE] and [DATE]. The MD was asked about the facility's IV therapy program, and he responded it was his understanding all of the nurses were IV certified. When the MD was asked about an LVN administering Cathflo [MEDICATION NAME], he replied he thought an RN should administer the Cathflo [MEDICATION NAME]. He further stated if a LVN said he/she had experience administering the medication, without proof of training, that would not be acceptable. When he was asked if he was aware NP I ordered Cathflo [MEDICATION NAME] on [DATE], the MD replied no. When asked what his expectation would be regarding documentation if Cathflo [MEDICATION NAME] was used, the MD responded, "The circumstances should be documented for giving the medication." He was then asked if he had standing orders for Cathflo [MEDICATION NAME], and he replied, "No." The MD was asked about NP I forcing fluids through Resident #23's PICC line and stabbing the side of the IV bag repeatedly to fill syringes. The MD replied, "Not really. In this setting, I would have run the fluid on its own to see if it would help rather than forcing fluids through the PICC." The MD was provided with Resident #23's clinical record, and he examined the resident's lab reports. The MD revealed he was not aware Resident #23's platelet count was 40. The MD stated he would not have used Cathflo [MEDICATION NAME] for this situation. Resident #23's preliminary lab report for a Blood Culture drawn on [DATE] reflected Gram Negative Rods were present, which indicated an infection. This Blood Culture report was initialed and dated by NP I on [DATE]. Resident #23's CBC results drawn on [DATE] at 4:51 AM reflected her HGB, HCT (H & H), and platelets had declined since her admission to the facility. The results reflected the following: [DATE] - HGB 11.5 g/dL reference range 12.0 -15.6 g/dL; HCT 34.5% reference range 35.0 - 46.0%; and PLT 160 reference range 130 - 400 K/mm3 [DATE] - HGB 10.7 g/dL; HCT 31.7%; and PLT 113 [DATE] - HGB 8.3 g/dL; HCT 25.0%; and PLT 40 Note: HCT is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. The decline of HGB and HCT could be a sign of bleeding. NP I initialed and dated this laboratory result on [DATE]. An Immediate and Serious Threat was identified on [DATE]. The Administrator, DON, and Assistant Administrator were notified of the Immediate and Serious Threat on [DATE] at 12:07 PM. A Plan of Removal was requested at that time. An interview with the DON on [DATE] at 3:45 PM revealed when asked how the facility determined a LVN was IV certified, she replied, "The nurses on the unit (Pulmonary Suites Unit) are kept IV certified." She explained the facility had a vendor who conducted annual competency reviews for skills for all the licensed nurses. The DON provided the Pharmacy Services Routine Manual for Long-Term Care Facilities dated 2012. The pharmacy manual reflected step-by-step procedures for administering different medications. The manual gave procedures for inserting a PICC line over a guide wire and many advanced procedures for specialty advanced practice nurses. During the interview on [DATE] at 3:45 PM, the DON was asked to provide the licensed nurse skills checklist, the facility's IV policy, and the facility's protocol for the use of Cathflo [MEDICATION NAME]. The DON stated the vendor pharmacy protocol, and the chapter regarding IV therapy in the Perry and Potter nursing textbook were the policies the facility used. The DON provided a copy of Perry and Potter nursing textbook, and she stated it was the facility's policy. The DON was then asked specifically about LVN F's training and certification regarding IV therapy. The DON stated LVN F had training at a local hospital. When asked if she had LVN F's IV training certificate of completion and a skills check-off to verify his competency and training, the DON replied, "No." The facility's policy and procedures for IV therapy reflected the facility had no IV therapy policies or procedure of their own. In addition, the facility did not have policies reflecting the scope of practice of IV therapy at the facility. The facility's nursing policy and procedure manual dated [DATE] for IV therapy referred to the Perry and Potter nursing textbook. The facility policy for PICC line insertion reflected, "Refer to pharmacy infusion therapy manual." Review of the facility's vendor pharmacy infusion therapy manual dated 2012 revealed skills checklists and procedures for IV push administration of medications, midline catheter insertion, midline catheter insertion using a guide

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #23) of five residents reviewed for IV therapy. 1. NP I failed to administer normal saline to Resident #23 via the resident's PICC line appropriately, when the resident was experiencing low blood pressure. NP I "stabbed" the side of the normal saline IV bag and withdrew the fluid and forcefully pushed the fluid through Resident #23's PICC line six times. Resident #23 turned "dusky" and began shaking all over, after the administration of the fluid by NP I. 2. NP I failed to inform Resident #23's physician she ordered Cathflo [MEDICATION NAME] on [DATE], which was not appropriate for the resident's clinical situation. 3. LVN F failed to provide medications and services, which were in his scope of practice, to Resident #23. LVN F, who did not have evidence of documented IV training, administered the Cathflo [MEDICATION NAME] to Resident #23 on [DATE]. Resident #23 expired at the facility on [DATE]. An Immediate and Serious Threat was identified on [DATE]. While the Immediate and Serious Threat was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 10 residents with PICC and central lines, residing on the [MEDICAL CONDITION] Suites Unit, by placing them at risk for a rupture of the catheter or the expulsion of a blood clot into the circulation causing a stroke or [MEDICAL CONDITION], bleeding, and/or death. Findings included: After Administrative Review, it was determined the Immediate and Serious Threat remained until NP I's status at the facility was ascertained. Resident #23's Record of admitted d [DATE] reflected she was a [AGE] year-old female, who was admitted to the facility's [MEDICAL CONDITION] Unit from the hospital on [DATE]. Resident #23's physician's orders [REDACTED]. Resident #23's History and Physical, dated [DATE] by Physician H (the resident's physician), reflected she had the following Diagnoses: [REDACTED]. The History and Physical reflected: "...CHRONIC SBO; NEED TO BE CORRECTED BY SURGERY. DEFERRED DUE TO SVC THROMBUS AND SUBSEQUENT ANTI-COAGULATION; WILL NEED TO F/U WITH SURGERY IN 1 MONTH." In addition, Physician H's History and Physical for Resident #23 reflected: "SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS." Resident #23's Physician's Progress Note, dated [DATE], reflected Physician H added the following Diagnoses: [REDACTED]...4. [MEDICAL CONDITION]: PLT COUNT WNL AT THE HOSPITAL; SEEMS TO BE TRENDING NOW; POSSIBLY ,[DATE] [MEDICATION NAME]; CONTINUE TO MONITOR AT THIS TIME AND SHE PROBABLY NEEDS TO BE SWITCHED TO [MEDICATION NAME] IF PLT CONTINUES TO GO DOWN....SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS BUT GIVEN #4 ([MEDICAL CONDITION]), WILL NEED TO CONTINUE MONITORING HER CBC Q 3 DAYS AT THIS TIME; [MEDICATION NAME] WAS NOT STARTED AT THE HOSPITAL GIVEN THAT IT MIGHT INTERACT WITH HER MEDICATIONS; WILL FOLLOW." Resident #23's chest x-ray report dated [DATE] reflected: "Impression: CHEST FOR PICC LINE PLACEMENT: LEFT PICC LINE IN POSITION. MILD CARDIOMEGALY AND SLIGHT CONGESTIVE FAILURE. Comment: CHEST FOR PICC LINE PLACEMENT: EXAMINATION REVEALS A PICC LINE IN POSITION EXTENDING FROM THE LEFT AXILLARY REGION INTO THE LEFT [MEDICATION NAME]. THE TIP IS APPROXIMATELY IN THE SUPERIOR VENA CAVA. THE HEART IS MILDLY ENLARGED. THE AORTA AND OTHER MEDIASTINAL STRUCTURES ARE IN THE MIDLINE. THE [MEDICAL CONDITION] VASCULATURE IS SLIGHTLY PROMINENT PROXIMALLY WITH PERIHILAR CONGESTION PERIPHERALLY." This report was initialed by NP I with a date of [DATE]. Resident #23's Nurse's Notes documented by LVN A on [DATE] reflected: 6:15 AM - "Initial A.M. assessment, finds this patient A & O, and in moderate distress. She is immediately given pain med, with (symbol used) the gt being clamped off. BSG WNL, no coverage. (L) upper (symbol used) PICC intact with (symbol used) TPN infusion in progress @ 75 cc/hr via pump, Liter bag N/S also infusing, via gravity @ 70 cc/hr. No (symbol used) Temp. this A.M. - patient drinking copious amts. of cold H2O. Nurse assisted patient OOB to the BSC, she voided QS with (symbol used) moderate loose stool noted. During the assessment, I observed skin wounds to her sacral upper (symbol used) buttock area, x2 areas. Will notify our facility tx. nurse." 7:00 AM - "G/T unclamped now. Patient is resting, & requested to have another hr. or so of sleep." 9:00 AM - "(L) PICC flushed prior to starting the [MEDICATION NAME] IV per piggyback. Her BBS are coarse with (symbol used) some crackles to the lower (symbol used) lobes, O2 SAT 93% - RT (RT G) asked to assess her resp. status @ this time - will monitor." 10:00 AM - "Patient awake & feeling better, wants to catch up on her therapy today." 10:15 AM - "PT in to work with (symbol used) her inside her room, as I instructed the therapist she would be tired & slow secondary to (symbol used) her being in bed for the past 2 days. PT fully understood, and took it easy. OT (name) to F/U PT to assist this patient with (symbol used) her shower. Patient became dizzy, clammy, & pale - B/P was ,[DATE] A/P 57 - OT/nurse safely assisted her to bed. Feet placed on pillow, patient reassured, her skin was dry now. B/P taken again was ,[DATE] A/P @ 59, patient responds to verbal & tactile stim." 11:30 AM - "Nurse Practioner (sic) (NP I) orders an IV be inserted to her rt. arm, I was unable to palpate a vein, nurse (RN C) attempted IV insertion x2, nurse (LVN D) attempted x2, & got an IV in, and the line infiltrated immediately. (NP I) has this nurse squeeze the N/S bag to speed up to N/S infusion rate, also she turns off the TPN infusion." On [DATE] at 12:45 PM, RN C, a charge nurse on the 6:00 AM-2:00 PM shift, was interviewed about her involvement with Resident #23 on [DATE]. RN C stated LVN A asked her to assist with inserting a peripheral line for Resident #23. She stated she heard the resident was experiencing low blood pressure, and they were trying to give the resident an IV [MEDICATION NAME]. RN C stated when she entered the room the IV lines were all tangled, and NP I told her she wanted to IV [MEDICATION NAME] the resident. RN C stated Resident #23's PICC line was patent, but it would not run really fast. She stated NP I was initially helping to trouble-shoot the issue with the PICC line. She stated LVN A flushed the line repeatedly with a 10 ml syringe. RN C stated she attempted to insert a peripheral IV line without success, but LVN D was able to start the line. RN C stated NP I wanted to get a manual blood pressure for Resident #23 so RN C proceeded to check her blood pressure using the resident's foot. Her systolic blood pressure was ,[DATE]. She stated she did not know if the [MEDICATION NAME] had been given yet when she checked the resident's blood pressure. During this time, NP I went to the nurses' station to review Resident #23's clinical record. RN C stated when she saw Resident #23 that day the resident was flushed, and she had her eyes closed. Her breathing was normal, but she was cold and shivering. On [DATE] at 12:45 PM, LVN D was interviewed about her involvement with Resident #23 on [DATE]. She stated LVN A, who was Resident #23's nurse, came to get her to put in a peripheral IV. LVN D stated she assisted with inserting the peripheral line, then she left the room. She stated when she left the room Resident #23 was relaxed after the peripheral line was inserted. LVN D stated, the next time she went into Resident #23's room was when NP I was yelling down the hall, "Does anyone know how to work a pump?" When she entered the resident's room, she observed the floor around Resident #23's IV pump to be wet, and she described the room as being chaotic. LVN D stated she observed Resident #23 covered up in bed, and her whole body was "violently" shaking. Resident #23's continued Nurse's Notes completed by LVN A on [DATE] reflected the following: 12:15 PM- "(NP I), then manually [MEDICATION NAME] 35 cc N/S after (symbol used) withdrawing the IV solution directly from the side of the IV solution (bag) rather than the rubber [MEDICATION NAME]. She used an 18 gauge needle to puncture & withdraw the solution. She then with max force injected the lower (symbol used) lumen on the PICC line, she did this x6...." 1:00 PM - "Patient started with hard chills, and verbalized pain, and was in acute distress. (NP I) told me to get the patient a [MEDICATION NAME] (an anti-anxiety medication)." 1:15 PM - "I raised the foot of her bed, and monitored this patient for s/s of shock, her B/P was ,[DATE], color pale, and some confusion noted with (symbol used) acute anxiety. The patient's (family member) was @ (Resident #23's) bedside during the manual [MEDICATION NAME] injections, and was trying to assist (Resident #23)." 1:45 PM - "During report to ,[DATE] (2:00 PM to 10:00 PM shift) nurse, I did inform him of the 'hypotensive', episode, and to monitor the patient with (symbol used) diligence secondary to (symbol used) the past 2 hrs. Reported this episode to my ADON, (ADON K)." An interview with LVN A on [DATE] at 8:48 AM, regarding her Nurse's Notes from [DATE], revealed Resident #23 had been sick up until [DATE] when she was able to work with PT. She stated after finishing PT, Resident #23 was able to work with the OT in her room. While working with the OT, NP I came onto the [MEDICAL CONDITION] Suites Unit. LVN A stated she gave report to NP I, and she shared her concern that Resident #23 was getting too much fluid. LVN A stated she and NP I then proceeded to Resident #23's room, and upon entering the room they discovered the resident was weak, dizzy, and was having a hypotensive episode. The resident was in the chair, at that time, and LVN A assisted her to the bed. LVN A stated NP I took over at that time, and she asked what the resident's rate of infusion was for the PICC line. LVN A stated the resident's PICC line ran slow. NP I then proceeded to unclamp Resident #23's [DEVICE], and she informed LVN A they needed to start a peripheral IV line. NP I next instructed LVN A to take the resident's pedal pulse, and it was 90 at that time (Normal resting pulse in adults is between 60 and 100 beats per minute). LVN A then explained NP I told her to squeeze the resident's Normal Saline IV bag which was not on the pump at that time. Next, NP I held an IV bag containing Normal Saline, and she "stabbed" the bag with an 18 gauge needle and a 30 ml syringe to draw up the Normal Saline instead of using the port to extract the Normal Saline. The Normal Saline squirted out of the bag, but she was able to fill the syringe. LVN A stated she gave NP I an alcohol prep pad to clean the port, and NP I proceeded to put the syringe directly on the lumen port of the PICC line. NP I pushed 30 cc of Normal Saline directly into the PICC line with maximum force. LVN A stated NP I pushed with the weight of her body, while injecting the Normal Saline, to push it in faster. LVN A stated NP I did this procedure six times and injected 210 ml of the solution into the port of the PICC line. After NP I completed the procedure, LVN A stated the resident went into shock. LVN A stated the resident appeared dusky and began shaking. NP I stated she "saved her life." LVN A stated NP I asked Resident #23's family member, who was present during the procedure, it this was how Resident #23 acted when she was having an anxiety attack. NP I told LVN A to give the resident a [MEDICATION NAME] for anxiety. LVN A stated she administered the [MEDICATION NAME] to Resident #23. After the occurrence, LVN A stated she informed ADON K about the incident. The next day, [DATE], LVN A learned the 2:00 PM to 10:00 PM charge nurse, LVN F, administered Cathflo [MEDICATION NAME] via Resident #23's PICC line per NP I's orders, and the resident died later that day after the medication was administered. Review of NP I's Progress Note, dated [DATE] for Resident #23, revealed there was no documented evidence the patency of the PICC line had been assessed prior to the administration of the Cathflo [MEDICATION NAME]. The Progress Note reflected NP I manually administered 210 ml of Normal Saline through Resident #23's PICC line to treat low blood pressure. In the same Progress Note, NP I documented: "While assessing pt sitting @ BS awaiting a shower she c/o dizziness, she was pale. BP ,[DATE] P 51, profoundly weak assisted to bed. BP ,[DATE] P 59 attempted to run in fluid wide open thru PICC but to no avail BP less dizzy but now "sleepy" requiring stimulation to stay awake BP ,[DATE] (P) 51." NP I further documented in the Progress Note that she manually [MEDICATION NAME] 0.9 Sodium Chloride via the resident's PICC line and infused 210 cc. In addition, NP I's Progress Note also reflected the following lab values for Resident #23: White Blood Cells increased from 5.1 to 17.4 Platelet Count decreased from 113 to 79 H & H decreased from 10XXX,[DATE].3 to 9XXX,[DATE].0 Note: Platelets are blood cells needed in the body to promote blood clotting. A platelet count below 100 indicates someone has a higher risk for bleeding due to low platelet count. Also, a white blood cell count above 10 indicates a person has an infection On [DATE] at 10:15 AM, NP I was interviewed about her involvement with Resident #23 on [DATE]. NP I revealed, when she entered the room on [DATE], Resident #23 was sitting up in a chair. The resident was pale and sweating, and she complained of dizziness. When the nurse put her back to bed, her blood pressure was ,[DATE] with a heart rate of 59. NP I stated Resident #23 was volume depleted, and she needed to be [MEDICATION NAME] with IV fluids. She stated there was a good blood return on the catheter. She added the PICC line was a small caliber, and it was sluggish. NP I stated, "I ordered the Cathflo. I don't know who gave it." When queried as to whom was to give the Cathflo [MEDICATION NAME], NP I stated the protocol was the company, who handled the PICC lines, was responsible for coming to the facility and administering it. She further revealed, "I don't know anything about Cathflo, and I wouldn't give it myself." Resident #23's NP I's Order, dated [DATE], reflected: "Cathflo 2 mg as needed for PICC x 2 lumens per protocol." The manufacturer's website (<http://www.cathflo.com>, last accessed on [DATE]) for Cathflo [MEDICATION NAME] reflected: "INDICATIONS AND USAGE Cathflo [MEDICATION NAME] (Atleplase) is indicated for the restoration of function to central venous devices as assessed by the ability to withdraw blood. PRECAUTIONS General Catheter dysfuction may be caused by a variety of conditions rather than thrombus formation, such as catheter malposition, mechanical failure, [MEDICATION NAME] by a suture, and lipid deposits or drug precipitates within the catheter lumen. These types of conditions should be considered before treatment with Cathflo [MEDICATION NAME] Bleeding ...In addition, caution should be exercised with patients who have [MEDICAL CONDITION], other [MEDICATION NAME] defects (including those secondary to severe hepatic or [MEDICAL CONDITION]), or any condition for which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location, or who are at high risk for embolic complications (e.g., venous [MEDICAL CONDITION] in the region of the catheter). Death and permanent disability have been reported in patients who have experienced stroke or other serious bleeding episodes when receiving pharmacologic doses of a [MEDICAL CONDITION] Infections Cathflo [MEDICATION NAME] should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo [MEDICATION NAME] in patients with infected catheters may release a localized infection into the systemic circulation (see ADVERSE REACTIONS). As with all catheterization procedures, care should be used to maintain aseptic technique... Geriatric Use ...In general, caution should be used in geriatric patients with conditions known to increase the risk of bleeding (see PRECAUTIONS, Bleeding)." An interview with LVN E, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:45 PM revealed he ordered the Cathflo [MEDICATION NAME] from the pharmacy, and LVN F administered it to Resident #23. Resident #23's [DATE] MAR indicated [REDACTED]. An interview with LVN F, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:30 PM revealed he administered Cathflo [MEDICATION NAME] to Resident #23 via her PICC line on [DATE] at 3:45 PM. LVN F provided a Witness Statement on [DATE], which reflected: "Reviewed order for Cathflo on (Resident #23). Got med out of refrigerator mixed according to mfg. Standards. Went to Pt room with (symbol used) her primary nurse, (LVN E), ID'd patient. Donned gloves, cleaned white hub with (symbol used) ETOH, injected 2 ml of med into PICC line. This was @ 1545 (3:45 PM). Returned to Pt room @ 1700 (5:00 PM). Cleaned white hub with (symbol used) ETOH. And with (symbol used) a new 10 ml syringe drew back 10 ml of blood. Then flushed with (symbol used) 10 ml NS. Cleaned clear hub with (symbol used) ETOH. With (symbol used) new 10 ml syringe, attempted to draw blood but was unsuccessful. Only got back the 2 ml of Cathflow. Primary nurse notified of outcome. This all occurred on [DATE]. Before admin of Cathflo assessed each hub by attempting to flush with (symbol used) 10 ml of ns & to draw blood from PICC. White hub flushed, but no blood return. Clear hub didn't flush or give blood return." LVN F's personnel file did not reflect a skills check-off list from the DON for IV competency. Resident #23's Nurse's Notes dated [DATE] reflected Resident #23 was found unresponsive and without a pulse at 5:45 PM. The Notes reflected LVN E called 911, and the paramedics came to the facility. The paramedics tried at length but were unsuccessful in resuscitating Resident #23. The Notes reflected the resident was pronounced dead at the facility by the DON at 8:00 PM. An interview with the MD, who was also Resident #23's attending physician (Physician H), on [DATE] at 9:20 AM revealed when asked about Resident #23's PICC line, he replied there was a [MEDICATION NAME] thrombus (blood clot) in the area of the PICC line. The MD was asked if the facility had notified him Resident #23's PICC line was occluded or sluggish, and he answered he was not notified. The MD stated he saw Resident #23 on [DATE] and [DATE]. The MD was asked about the facility's IV therapy program, and he responded it was his understanding all of the nurses were IV certified. When the MD was asked about an LVN administering Cathflo [MEDICATION NAME], he replied he thought an RN should administer the Cathflo [MEDICATION NAME]. He further stated if a LVN said he/she had experience administering the medication, without proof of training, that would not be acceptable. When he was asked if he was aware NP I ordered Cathflo [MEDICATION NAME] on [DATE], the MD replied no. When asked what his expectation would be regarding documentation if Cathflo [MEDICATION NAME] was used, the MD responded, "The circumstances should be documented for giving the medication." He was then asked if he had standing orders for Cathflo [MEDICATION NAME], and he replied, "No." The MD was asked about NP I forcing fluids through Resident #23's PICC line and stabbing the side of the IV bag repeatedly to fill syringes. The MD replied, "Not really. In this setting, I would have run the fluid on its own to see if it would help rather than forcing fluids through the PICC." The MD was provided with Resident #23's clinical record, and he examined the resident's lab reports. The MD revealed he was not aware Resident #23's platelet count was 40. The MD stated he would not have used Cathflo [MEDICATION NAME] for this situation. Resident #23's preliminary lab report for a Blood Culture drawn on [DATE] reflected Gram Negative Rods were present, which indicated an infection. This Blood Culture report was initialed and dated by NP I on [DATE]. Resident #23's CBC results drawn on [DATE] at 4:51 AM reflected her HGB, HCT (H & H), and platelets had declined since her admission to the facility. The results reflected the following: [DATE] - HGB 11.5 g/dL reference range 12.0 -15.6 g/dL; HCT 34.5% reference range 35.0 - 46.0%; and PLT 160 reference range 130 - 400 K/mm3 [DATE] - HGB 10.7 g/dL; HCT 31.7%; and PLT 113 [DATE] - HGB 8.3 g/dL; HCT 25.0%; and PLT 40 Note: HCT is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. The decline of HGB and HCT could be a sign of bleeding. NP I initialed and dated this laboratory result on [DATE]. An Immediate and Serious Threat was identified on [DATE]. The Administrator, DON, and Assistant Administrator were notified of the Immediate and Serious Threat on [DATE] at 12:07 PM. A Plan of Removal was requested at that time. An interview with the DON on [DATE] at 3:45 PM revealed when asked how the facility determined a LVN was IV certified, she replied, "The nurses on the unit (Pulmonary Suites Unit) are kept IV certified." She explained the facility had a vendor who conducted annual competency reviews for skills for all the licensed nurses. The DON provided the Pharmacy Services Routine Manual for Long-Term Care Facilities dated 2012. The pharmacy manual reflected step-by-step procedures for administering different medications. The manual gave procedures for inserting a PICC line over a guide wire and many advanced procedures for specialty advanced practice nurses. During the interview on [DATE] at 3:45 PM, the DON was asked to provide the licensed nurse skills checklist, the facility's IV policy, and the facility's protocol for the use of Cathflo [MEDICATION NAME]. The DON stated the vendor pharmacy protocol, and the chapter regarding IV therapy in the Perry and Potter nursing textbook were the policies the facility used. The DON provided a copy of Perry and Potter nursing textbook, and she stated it was the facility's policy. The DON was then asked specifically about LVN F's training and certification regarding IV therapy. The DON stated LVN F had training at a local hospital. When asked if she had LVN F's IV training certificate of completion and a skills check-off to verify his competency and training, the DON replied, "No." The facility's policy and procedures for IV therapy reflected the facility had no IV therapy policies or procedure of their own. In addition, the facility did not have policies reflecting the scope of practice of IV therapy at the facility. The facility's nursing policy and procedure manual dated [DATE] for IV therapy referred to the Perry and Potter nursing textbook. The facility policy for PICC line insertion reflected, "Refer to pharmacy infusion therapy manual." Review of the facility's vendor pharmacy infusion therapy manual dated 2012 revealed skills checklists and procedures for IV push administration of medications, midline catheter insertion, midline catheter insertion using a guide wire, dressing changes of central lines, removal of central and PICC lines, insertion of peripheral IV lines, PICC catheter insertion, blood withdrawal from the central line for lab sampling, hypodermoclysis (administering IV fluids subcutaneously), accessing implanted ports, infusing spinal medications, clearing [MEDICAL CONDITION] occlusions with the [MEDICAL CONDITION], repair of the central line, and culturing drainage from the central venous catheter site. The facility policy procedure manual did not specify which of the tasks outlined in the pharmacy infusion therapy manual could be performed in the facility by facility staff, particularly LVNs. During the interview on [DATE] at 3:45 PM, the DON was asked what type of procedures there were to make sure the nursing needs of the residents were being met. The DON stated the facility followed physician orders [REDACTED]. The DON was asked how she monitored staff to ensure the systems they monitored were being done sufficiently. She stated she and the ADONs conducted rounds, and they observed medication passes and incontinent care. She also said they did follow-ups with nursing concerns brought to their attention in daily meetings and followed the standards of care. She said the ADONs would also review residents' clinical records to ensure proper care was being provided. The DON was asked how she thought the Immediate and Serious Threat came about, and she stated the facility had not done anything wrong. The facility's Plan of Removal was accepted on [DATE] and reflected: 1. Accessing an implanted port will be delegated to IV competent RNs only, and IV push medications requiring special monitoring will not be administered. 2. Administrator and DON will review resident referrals prior to admission to determine appropriate placement within the facility. "Any Residents requiring Intravenous therapy (IV) will be admitted on ly on the [MEDICAL CONDITION] Unit or the The Suites under the supervision of IV certified nurses until all facility nurses attend and receive IV certification." 3. All the nurses would be re-educated on Infusion Therapy to include insertion of peripheral intravenous sites and care and maintenance of PICC lines, central lines and peripheral lines via IV education by the facility's contracted pharmacy. 4. All IV certified nurses would have competency evaluations completed. All LVNs and RNs would have a competency evaluation satisfactorily completed prior to being allowed to administer IV medications. The DON and ADON will perform the competency evaluations of Administrative nurses, then Administrative will perform competency evaluations of the floor nurses. 5. Newly hired nurses would be required to provide documentation of IV certification. If unable to provide proof, the nurse would be prohibited from administering IV medication until IV certification class was completed and competency was established within the first 30 days of working. 6. Administrative nurses would observe residents receiving IV medications at least once a week for four weeks and then randomly. Identified deficient practices would be corrected immediately and reported to the Administrator as part of the Performance Improvement Process. On [DATE] at 10:56 AM, a telephone interview was conducted with the DON regarding how the facility addressed the role of the NP in the Immediate and Serious Threat. The DON stated the Administrator and she met with the Medical Director and the NP on the morning just prior to the survey team talking to them ([DATE]). They discussed the concerns, which were identified by the survey team. The Medical Director stated he would bring their concerns to his supervisor at the company, which employed him and the NP. The Medical Director told them (the Administrator and the DON) it would be up to the company to handle corrective actions regarding the NP. The DON further stated they had a Physician Dinner on [DATE], and they (the Administrator and the DON) again discussed their concerns regarding the NP. The DON then explained the facility planned to hire an NP on a full-time basis 8:00 AM - 5:00 PM Monday through Friday. The DON stated they had already met with a potential candidate on [DATE]. The DON stated the facility and staff were taking the situation seriously and would continue to monitor the NP when she was working at the facility. The DON further stated the Medical Director and the NP's supervising company had not agreed to allow another NP to see "their" residents, so the NP, for the time being, was continuing to provide services for the Medical Director's residents. The DON stated she was monitoring the NP's documentation and she would bring any concerns to the physician's attention. An interview on [DATE] at 3:46 PM with the DON revealed she was completing competency evaluations with return demonstrations for her weekend staff nurses, LVN B and LVN F along with a competency written test. An observation on [DATE] at 4:00 PM revealed the DON observed LVN B administer [MEDICATION NAME] IV (antibiotic) using aseptic technique with no contamination. On [DATE] at 5:00 PM, the DON and Assistant Administrator were informed the Immediate and Serious Threat remained. A Plan of Removal was requested at that time. An interview with the Administrator, on [DATE] at 9:30 AM regarding how the facility would address the concerns regarding NP I, revealed the facility made the decision to remove NP I from the facility. The Administrator stated Physician H would be taking all calls directly, so NP I was not involved with the residents. She stated the medical group, who employed NP I, would audit the charts of the residents seen by NP I. When asked how she thought the Immediate and Serious Threat came about, the Administrator stated she believed it arose due to a disagreement between LVN A and NP I. She stated they "played" this out in Resident #23's chart. The Administrator stated NP I and LVN A put the facility in the Immediate and Serious Threat situation. She stated NP I did not pick up on Resident #23's lab results because LVN A was fighting with her. The Administrator stated the facility got caught in the mix of problems. At 10:45 AM on [DATE], the Administrator stated NP I's privileges were revoked, and she would no longer be seeing residents in the facility. The fallibility's new Plan of Removal revised [DATE] at 9:30 AM reflected, "Nurse Practitioner's privileges were suspended and revoked from practice in this facility effective [DATE] and this Nurse Practitioner will not return to practice in the facility. (Physician H) was notified of the suspension on [DATE]. Facility nurses instructed to call (Physician H) for any resident issues directly on his cell phone. (Physician H) is responsible for supervising his Nurse Practitioner and being available to supervise other physicians and their Nurse Practitioner's (sic) if issues arise under his role as Medical Director. See F501. Any Nurse Practitioner assigned to this facility will be monitored by the supervising physician and/or Medical Director. Nurse Practitioners providing services in the facility will work under the guidance of the attending physician as follows: 1) Practice within their scope of practice per Advanced Nurse Practice Act and level of education. 2) Be monitored by their attending physician as follows: 10% of charts will be monitored per month, discuss weekly and as needed any difficult residents or questions concerning residents; be available for backup call for issues that arise 24hrs, 7 days per week. 3) The results of the 10% chart audits will be presented to the Facility Quality Assurance purposes to be reviewed as part of the Performance Improvement process and will be addressed at the time of discovery. 4) Physician will follow Federal/State Regulations re: visit frequency. 5) Physician will address with Nurse Practitioner during chart audits any identified areas of deficient practice for immediate correction and report to the facility as part of the Performance Improvement process. (Physician H) currently has 51 residents. Out of the 51 resident charts, (Physician H) has stated that he has already completed 12 of the audits needed. He will completed 15% of the remaining 39 charts to review the lab results to ensure abnormal labs were addressed, which will be 6 charts to be completed by [DATE]. The remaining 33 charts will be audited by physicians or (medical group) made up of other physicians to ensure abnormal lab results were addressed by the Nurse Practitioner. Physician will provide a written report of all audits to DADS per request...." An interview with the MD on [DATE] at 1:00 PM revealed he had audited 12 residents' clinical records of NP I since [DATE]. He p

Based on interview and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #23) of five residents reviewed for IV therapy. 1. The Administrator failed to have the Medical Director, Physician H, actively participate in the development and implementation of resident care policies and procedures as well as providing supervision to the other attending physicians and Nurse Practitioners who provided services in the facility. When Resident #23 experienced a low blood pressure, NP I "stabbed" the side of the normal saline IV bag and withdrew the fluid and forcefully pushed the fluid through Resident #23's PICC line six times. Resident #23 turned "dusky" and began shaking all over, after the administration. NP I failed to inform Resident #23's physician, Physician H, she ordered Cathflo [MEDICATION NAME] on [DATE], which was not appropriate for the resident's clinical situation. 2. The Administrator failed to supervise the DON to ensure nursing services were provided in a manner to promote the overall well-being of residents who received IV therapy services. 3. The DON failed to have IV therapy services provided by qualified LVNs and to have facility specific policies and procedures regarding IV therapy services. LVN F, who did not have evidence of documented IV training, administered the Cathflo [MEDICATION NAME] to Resident #23 on [DATE]. Resident #23 expired at the facility on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 10 residents, receiving IV therapy services, by placing them at risk for a rupture of the catheter or the expulsion of a blood clot into the circulation causing a stroke or [MEDICAL CONDITION], infection, bleeding, and/or death. Findings included: After Administrative Review, it was determined the IJ remained until NP I's status at the facility was ascertained. Resident #23's Record of admitted d [DATE] reflected she was a [AGE] year-old female, who was admitted to the facility's [MEDICAL CONDITION] Unit from the hospital on [DATE]. Resident #23's physician's orders [REDACTED]. Resident #23's History and Physical, dated [DATE] by Physician H (the resident's physician), reflected she had the following Diagnoses: [REDACTED]. The History and Physical reflected: "...CHRONIC SBO; NEED TO BE CORRECTED BY SURGERY. DEFERRED DUE TO SVC THROMBUS AND SUBSEQUENT ANTI-COAGULATION; WILL NEED TO F/U WITH SURGERY IN 1 MONTH." In addition, Physician H's History and Physical for Resident #23 reflected: "SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] (an anti-coagulant) FOR 3 MONTHS." Resident #23's Physician's Progress Note, dated [DATE], reflected Physician H added the following Diagnoses: [REDACTED]...4. [MEDICAL CONDITION]: PLT COUNT WNL AT THE HOSPITAL; SEEMS TO BE TRENDING NOW; POSSIBLY ,[DATE] [MEDICATION NAME]; CONTINUE TO MONITOR AT THIS TIME AND SHE PROBABLY NEEDS TO BE SWITCHED TO [MEDICATION NAME] IF PLT CONTINUES TO GO DOWN....SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS BUT GIVEN #4 ([MEDICAL CONDITION]), WILL NEED TO CONTINUE MONITORING HER CBC Q 3 DAYS AT THIS TIME; [MEDICATION NAME] WAS NOT STARTED AT THE HOSPITAL GIVEN THAT IT MIGHT INTERACT WITH HER MEDICATIONS; WILL FOLLOW." On [DATE] at 12:45 PM, RN C, a charge nurse on the 6:00 AM-2:00 PM shift, was interviewed about her involvement with Resident #23 on [DATE]. RN C stated LVN A asked her to assist with inserting a peripheral line for Resident #23. She stated she heard the resident was experiencing low blood pressure, and they were trying to give the resident an IV [MEDICATION NAME]. RN C stated when she entered the room the IV lines were all tangled, and NP I told her she wanted to IV [MEDICATION NAME] the resident. RN C stated Resident #23's PICC line was patent, but it would not run really fast. She stated NP I was initially helping to trouble-shoot the issue with the PICC line. She stated LVN A flushed the line repeatedly with a 10 ml syringe. RN C stated she attempted to insert a peripheral IV line without success, but LVN D was able to start the line. RN C stated when she saw Resident #23 that day the resident was flushed, and she had her eyes closed. Her breathing was normal, but she was cold and shivering. On [DATE] at 12:45 PM, LVN D was interviewed about her involvement with Resident #23 on [DATE]. She stated LVN A, who was Resident #23's nurse, came to get her to put in a peripheral IV. LVN D stated she assisted with inserting the peripheral line, then she left the room. She stated when she left the room Resident #23 was relaxed after the peripheral line was inserted. LVN D stated, the next time she went into Resident #23's room was when NP I was yelling down the hall, "Does anyone know how to work a pump?" When she entered the resident's room, she observed the floor around Resident #23's IV pump to be wet, and she described the room as being chaotic. LVN D stated she observed Resident #23 covered up in bed, and her whole body was "violently" shaking. An interview with LVN A on [DATE] at 8:48 AM, revealed Resident #23 had been sick up until [DATE] when she was able to work with PT. She stated after finishing PT, Resident #23 was able to work with the OT in her room. While working with the OT, NP I came onto the [MEDICAL CONDITION] Suites Unit. LVN A stated she gave report to NP I, and she shared her concern that Resident #23 was getting too much fluid. LVN A stated she and NP I then proceeded to Resident #23's room, and upon entering the room they discovered the resident was weak, dizzy, and was having a hypotensive episode. The resident was in the chair, at that time, and LVN A assisted her to the bed. LVN A stated NP I took over at that time, and she asked what the resident's rate of infusion was for the PICC line. LVN A stated the resident's PICC line ran slow. NP I then proceeded to unclamp Resident #23's [DEVICE], and she informed LVN A they needed to start a peripheral IV line. NP I next instructed LVN A to take the resident's pedal pulse, and it was 90 at that time (Normal resting pulse in adults is between 60 and 100 beats per minute). LVN A then explained NP I told her to squeeze the resident's Normal Saline IV bag which was not on the pump at that time. Next, NP I held an IV bag containing Normal Saline, and she "stabbed" the bag with an 18 gauge needle and a 30 ml syringe to draw up the Normal Saline instead of using the port to extract the Normal Saline. The Normal Saline squirted out of the bag, but she was able to fill the syringe. LVN A stated she gave NP I an alcohol prep pad to clean the port, and NP I proceeded to put the syringe directly on the lumen port of the PICC line. NP I pushed 30 cc of Normal Saline directly into the PICC line with maximum force. LVN A stated NP I pushed with the weight of her body, while injecting the Normal Saline, to push it in faster. LVN A stated NP I did this procedure six times and injected 210 ml of the solution into the port of the PICC line. After NP I completed the procedure, LVN A stated the resident went into shock. LVN A stated the resident appeared dusky and began shaking. NP I stated she "saved her life." LVN A stated NP I asked Resident #23's family member, who was present during the procedure, it this was how Resident #23 acted when she was having an anxiety attack. NP I told LVN A to give the resident a [MEDICATION NAME] for anxiety. LVN A stated she administered the [MEDICATION NAME] to Resident #23. After the occurrence, LVN A stated she informed ADON K about the incident. The next day, [DATE], LVN A learned the 2:00 PM to 10:00 PM charge nurse, LVN F, administered Cathflo [MEDICATION NAME] via Resident #23's PICC line per NP I's orders, and the resident died later that day after the medication was administered. On [DATE] at 10:15 AM, NP I was interviewed about her involvement with Resident #23 on [DATE]. NP I revealed, when she entered the room on [DATE], Resident #23 was sitting up in a chair. The resident was pale and sweating, and she complained of dizziness. When the nurse put her back to bed, her blood pressure was ,[DATE] with a heart rate of 59. NP I stated Resident #23 was volume depleted, and she needed to be [MEDICATION NAME] with IV fluids. She stated there was a good blood return on the catheter. She added the PICC line was a small caliber, and it was sluggish. An interview with the MD, who was also Resident #23's attending physician (Physician H), on [DATE] at 9:20 AM revealed when asked about NP I forcing fluids through Resident #23's PICC line and stabbing the side of the IV bag repeatedly to fill syringes, he replied, "Not really. In this setting, I would have run the fluid on its own to see if it would help rather than forcing fluids through the PICC." Continued interview with NP I on [DATE] at 10:15 AM revealed, "I ordered the Cathflo. I don't know who gave it." When queried as to whom was to give the Cathflo [MEDICATION NAME], NP I stated the protocol was the company, who handled the PICC lines, was responsible for coming to the facility and administering it. She further revealed, "I don't know anything about Cathflo, and I wouldn't give it myself." Resident #23's NP I's Order, dated [DATE], reflected: "Cathflo 2 mg as needed for PICC x 2 lumens per protocol." Continued interview with the MD on [DATE] at 9:20 AM revealed when asked about Resident #23's PICC line, he replied there was a [MEDICATION NAME] thrombus (blood clot) in the area of the PICC line. The MD was asked if the facility had notified him Resident #23's PICC line was occluded or sluggish, and he answered he had not been notified. The MD stated he saw the resident on [DATE] and [DATE]. When asked if he was aware NP I ordered Cathflo [MEDICATION NAME] on [DATE], the MD replied no. He was then asked if he had standing orders for Cathflo [MEDICATION NAME], and he replied, "No." The MD was provided with Resident #23's clinical record, and he examined the resident's lab reports. The MD revealed he was not aware Resident #23's platelet count was 40. The MD stated he would not have used Cathflo [MEDICATION NAME] for this situation. When asked if any nurses had discussed Resident #23's condition with him, the MD stated the only call he received was from his NP, who called him at 4:00 AM on [DATE] regarding blood work from that day, and that she started [MEDICATION NAME] (an antibiotic). The manufacturer's website (<http://www.cathflo.com>, last accessed on [DATE]) for Cathflo [MEDICATION NAME] reflected: "INDICATIONS AND USAGE Cathflo [MEDICATION NAME] (Atleplase) is indicated for the restoration of function to central venous devices as assessed by the ability to withdraw blood. PRECAUTIONS General Catheter dysfunction may be caused by a variety of conditions rather than thrombus formation, such as catheter malposition, mechanical failure, [MEDICATION NAME] by a suture, and lipid deposits or drug precipitates within the catheter lumen. These types of conditions should be considered before treatment with Cathflo [MEDICATION NAME] Bleeding ...In addition, caution should be exercised with patients who have [MEDICAL CONDITION], other [MEDICATION NAME] defects (including those secondary to severe hepatic or [MEDICAL CONDITION]), or any condition for which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location, or who are at high risk for embolic complications (e.g., venous [MEDICAL CONDITION] in the region of the catheter). Death and permanent disability have been reported in patients who have experienced stroke or other serious bleeding episodes when receiving pharmacologic doses of a [MEDICAL CONDITION] Infections Cathflo [MEDICATION NAME] should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo [MEDICATION NAME] in patients with infected catheters may release a localized infection into the systemic circulation (see ADVERSE REACTIONS). As with all catheterization procedures, care should be used to maintain aseptic technique... Geriatric Use ...In general, caution should be used in geriatric patients with conditions known to increase the risk of bleeding (see PRECAUTIONS, Bleeding)." Resident #23's [DATE] MAR indicated [REDACTED]. An interview with LVN F, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:30 PM revealed he administered Cathflo [MEDICATION NAME] to Resident #23 via her PICC line on [DATE] at 3:45 PM. LVN F provided a Witness Statement on [DATE], which reflected: "Reviewed order for Cathflo on (Resident #23). Got med out of refrigerator mixed according to mfg. Standards. Went to Pt room with (symbol used) her primary nurse, (LVN E), ID'd patient. Donned gloves, cleaned white hub with (symbol used) ETOH, injected 2 ml of med into PICC line. This was @ 1545 (3:45 PM). Returned to Pt room @ 1700 (5:00 PM). Cleaned white hub with (symbol used) ETOH. And with (symbol used) a new 10 ml syringe drew back 10 ml of blood. Then flushed with (symbol used) 10 ml NS. Cleaned clear hub with (symbol used) ETOH. With (symbol used) new 10 ml syringe, attempted to draw blood but was unsuccessful. Only got back the 2 ml of Cathflow. Primary nurse notified of outcome. This all occurred on [DATE]. Before admin of Cathflo assessed each hub by attempting to flush with (symbol used) 10 ml of ns & to draw blood from PICC. White hub flushed, but no blood return. Clear hub didn't flush or give blood return." LVN F's personnel file did not reflect a skills check-off list from the DON for IV competency. Continued interview with the MD on [DATE] at 9:20 AM revealed when asked about the facility's IV therapy program, he responded it was his understanding all of the nurses were IV certified. When the MD was asked about an LVN administering Cathflo [MEDICATION NAME], he replied he thought an RN should administer the Cathflo [MEDICATION NAME]. He further stated if a LVN said he/she had experience administering the medication, without proof of training, that would not be acceptable. When asked what his expectation would be regarding documentation if Cathflo [MEDICATION NAME] was used, the MD responded, "The circumstances should be documented for giving the medication." Resident #23's Nurse's Notes dated [DATE] reflected Resident #23 was found unresponsive and without a pulse at 5:45 PM. The Notes reflected LVN E called 911, and the paramedics came to the facility. The paramedics tried at length but were unsuccessful in resuscitating Resident #23. The Notes reflected the resident was pronounced dead at the facility by the DON at 8:00 PM. Resident #23's Nurse's Notes dated [DATE] reflected Resident #23 was found unresponsive and without a pulse at 5:45 PM. The Notes reflected LVN E called 911, and the paramedics came to the facility. The paramedics tried at length but were unsuccessful in resuscitating Resident #23. The Notes reflected the resident was pronounced dead at the facility by the DON at 8:00 PM. An IJ was identified on [DATE]. The Administrator, DON, and Assistant Administrator were notified of the IJ on [DATE] at 12:07 PM. A Plan of Removal was requested at that time. An interview with the DON on [DATE] at 3:45 PM revealed when asked how the facility determined a LVN was IV certified, she replied, "The nurses on the unit (Pulmonary Suites Unit) are kept IV certified." She explained the facility had a vendor who conducted annual competency reviews for skills for all the licensed nurses. The DON provided the Pharmacy Services Routine Manual for Long-Term Care Facilities dated 2012. The pharmacy manual reflected step-by-step procedures for administering different medications. The manual gave procedures for inserting a PICC line over a guide wire and many advanced procedures for specialty advanced practice nurses. During the interview on [DATE] at 3:45 PM, the DON was asked to provide the licensed nurse skills checklist, the facility's IV policy, and the facility's protocol for the use of Cathflo [MEDICATION NAME]. The DON stated the vendor pharmacy protocol, and the chapter regarding IV therapy in the Perry and Potter nursing textbook were the policies the facility used. The DON provided a copy of Perry and Potter nursing textbook, and she stated it was the facility's policy. The DON was then asked specifically about LVN F's training and certification regarding IV therapy. The DON stated LVN F had training at a local hospital. When asked if she had LVN F's IV training certificate of completion and a skills check-off to verify his competency and training, the DON replied, "No." The facility's policy and procedures for IV therapy reflected the facility had no IV therapy policies or procedure of their own. In addition, the facility did not have policies reflecting the scope of practice of IV therapy at the facility. The facility's nursing policy and procedure manual dated [DATE] for IV therapy referred to the Perry and Potter nursing textbook. The facility policy for PICC line insertion reflected, "Refer to pharmacy infusion therapy manual." Review of the facility's vendor pharmacy infusion therapy manual dated 2012 revealed skills checklists and procedures for IV push administration of medications, midline catheter insertion, midline catheter insertion using a guide wire, dressing changes of central lines, removal of central and PICC lines, insertion of peripheral IV lines, PICC catheter insertion, blood withdrawal from the central line for lab sampling, hypodermoclysis (administering IV fluids subcutaneously), accessing implanted ports, infusing spinal medications, clearing [MEDICAL CONDITION] occlusions with the [MEDICAL CONDITION], repair of the central line, and culturing drainage from the central venous catheter site. The facility policy procedure manual did not specify which of the tasks outlined in the pharmacy infusion therapy manual could be performed in the facility by facility staff, particularly LVNs. During the interview on [DATE] at 3:45 PM, the DON was asked what type of procedures there were to make sure the nursing needs of the residents were being met. The DON stated the facility followed physician orders [REDACTED]. The DON was asked how she monitored staff to ensure the systems they monitored were being done sufficiently. She stated she and the ADONs conducted rounds, and they observed medication passes and incontinent care. She also said they did follow-ups with nursing concerns brought to their attention in daily meetings and followed the standards of care. She said the ADONs would also review residents' clinical records to ensure proper care was being provided. The DON was asked how she thought the IJ came about, and she stated the facility had not done anything wrong. The facility's Plan of Removal was accepted on [DATE] and reflected: 1. Accessing an implanted port will be delegated to IV competent RNs only, and IV push medications requiring special monitoring will not be administered. 2. Administrator and DON will review resident referrals prior to admission to determine appropriate placement within the facility. "Any Residents requiring Intravenous therapy (IV) will be admitted on ly on the [MEDICAL CONDITION] Unit or the The Suites under the supervision of IV certified nurses until all facility nurses attend and receive IV certification." 3. All the nurses would be re-educated on Infusion Therapy to include insertion of peripheral intravenous sites and care and maintenance of PICC lines, central lines and peripheral lines via IV education by the faciilty's contracted pharmacy. 4. All IV certified nurses would have compentency evaluations completed. All LVNs and RNs would have a competency evaluation satisfactorily completed prior to being allowed to administer IV medications. The DON and ADON will perform the competency evaluations of Administrative nurses, then Administrative will perform competency evaluations of the floor nurses. 5. Newly hired nurses would be required to provide documentation of IV certification. If unable to provide proof, the nurse would be prohibited from administering IV medication until IV certification class was completed and competency was established within the first 30 days of working. 6. Administrative nurses would observe residents receiving IV medications at least once a week for four weeks and then randomly. Identified deficient practices would be corrected immediately and reported to the Administrator as part of the Performance Improvement Process. On [DATE] at 10:56 AM, a telephone interview was conducted with the DON regarding how the facility addressed the role of the NP in the IJ. The DON stated the Administrator and she met with the Medical Director and the NP on the morning just prior to the survey team talking to them ([DATE]). They discussed the concerns, which were identified by the survey team. The Medical Director stated he would bring their concerns to his supervisor at the company, which employed him and the NP. The Medical Director told them (the Administrator and the DON) it would be up to the company to handle corrective actions regarding the NP. The DON further stated they had a Physician Dinner on [DATE], and they (the Administrator and the DON) again discussed their concerns regarding the NP. The DON then explained the facility planned to hire an NP on a full-time basis 8:00 AM - 5:00 PM Monday through Friday. The DON stated they had already met with a potential candidate on [DATE]. The DON stated the facility and staff were taking the situation seriously and would continue to monitor the NP when she was working at the facility. The DON further stated the Medical Director and the NP's supervising company had not agreed to allow another NP to see "their" residents, so the NP, for the time being, was continuing to provide services for the Medical Director's residents. The DON stated she was monitoring the NP's documentation and she would bring any concerns to the physician's attention. An interview on [DATE] at 3:46 PM with the DON revealed she was completing competency evaluations with return demonstrations for her weekend staff nurses, LVN B and LVN F along with a competency written test. An observation on [DATE] at 4:00 PM revealed the DON observed LVN B administer [MEDICATION NAME] IV (antibiotic) using aseptic technique with no contamination. On [DATE] at 5:00 PM, the DON and Assistant Administrator were informed the IJ remained. A Plan of Removal was requested at that time. Another interview with the DON, on [DATE] at 5:00 PM, revealed she thought the disagreement between LVN A and NP I caused the facility to have the IJ. The DON was also asked how she monitored staff, primarily NP I, to ensure the systems they monitored were being done sufficiently. She stated the facility did not monitor the NP because she was not attached to the facility. The DON explained NP I worked for Physician H. She stated they both worked for a medical group, and NP I was an employee of the medical group and not the facility. The DON was then asked about the IV training for the LVNs in the facility who provided IV therapy services to residents. She stated the nurses were currently in the process of having skills check-offs. She stated LVN F was on the list of nurses to go through the IV therapy class. She stated he had a certificate of completion for an IV therapy class, but it was in off-site storage. She stated it would take two weeks for it to be sent to the facility. An interview with the Administrator on [DATE] at 9:30 AM regarding NP I, revealed the facility made the decision to remove NP I from the facility. The Administrator stated Physician H would be taking all calls directly, so NP I was not involved with the residents. She stated the medical group who employed NP I would audit the charts of the residents seen by NP I. The Administrator was asked what type of procedure was in place to ensure the nursing needs of residents were being met. She stated the facility had daily stand-up meetings, and they discussed residents experiencing changes of condition, new orders, falls, etc. The Administrator revealed there were weekly Quality of Care Meetings and monthly Performance Improvement Meetings which included the DON, Nurse Managers and other department heads. In addition, she stated they had the Guardian Angels Program, which she described as a program in which department heads visited with assigned residents twice a week. During the interview on [DATE] at 9:30 AM, when the Administrator was asked how she monitored the DON, she replied through daily meetings. When asked how she thought the IJ occurred, the Administrator stated she believed it arose due to a disagreement between LVN A and NP I. She stated they "played" this out in Resident #23's clinical record. The Administrator stated NP I and LVN A put the facility in the IJ situation. She stated NP I did not pick up on Resident #23's lab results because LVN A was fighting with her. The Administrator stated the facility got caught in the mix of problems. When asked about NP I and her relationship with the facility, the Administrator explained NP I was hired by the medical group. She stated the physicians and NPs were hired by the medical group which assigned them to the facility. At 10:45 AM on [DATE], the Administrator stated NP I's privileges were revoked, and she would no longer be seeing residents in the facility. Further interview with the MD, on [DATE] at 12:09 PM via telephone, revealed when asked what his expectations were regarding practitioners in the facility, he replied his expectations were nurse practitioners would see residents, anticipate problems, contact the physician, and inform the physician of any unusual findings. When asked what his role was in supervising NPs, physician's assistants, and other physicians in the facility as the MD, he responded, "I have not had any problem with other nurse practitioners. I try to help other staff physicians if they asked me. As director, if I find that a physician or nurse practitioner is not managing patient according to standard of care, I'll address it with them." The MD was asked if he had a job description for NPs in the facility, and he replied, "I do have the protocols for nurse practitioners for group." The MD was asked if he would be able to audit the residents' clinical records, whom NP I provided care to, for completeness and standards of care. He replied, "I do try to keep up with the visits. I see each patient every two weeks and the nurse practitioner sees them in between. I try to examine her charts at that time." An interview with the Regional Director, with the responsibility for post-acute providers from the medical group who employed NP I, on [DATE] at 11:45 AM, revealed when asked about policies and procedures, which govern what NPs could do in a facility, the Director responded NPs work under specific protocols. The Director stated each practice had protocols, which were between the NP and the physician. The Regional Director also revealed each physician managed the protocols with the NPs. When asked who was responsible for supervising the NP's work, the Regional Director replied, "The direct supervising physician is responsible for the nurse practitioner." Further interview with the MD on [DATE] at 12:09 PM revealed he had protocols for NPs for the group practice, but when the surveyor requested a copy, he stated he did not have them with him. He stated he would have to get the protocols from the group practice manager. An interview on [DATE] at 1:15 PM with the Director of Credentialing for the physician's group revealed when asked about the scope of practice for NPs in the medical group, she replied her department only checked the NP's license status and completed background checks of the NPs. Further interview with the Administrator on [DATE] at 9:45 AM revealed NP I was hired through the medical group and was not an employee of the facility. The Administrator stated they did not have any copies of NP I's protocol for practice and were unaware of what her protocols were. The facilility's new Plan of Removal revised [DATE] at 9:30 AM reflected, "Nurse Practitioner's privileges were suspended and revoked from practice in this facility effective [DATE] and this Nurse Practitioner will not return to practice in the facility. (Physician H) was notified of the suspension on [DATE]. Facility nurses instructed to call (Physician H) for any resident issues directly on his cell phone. (Physician H) is responsible for supervising his Nurse Practitioner and being available to supervise other physicians and their Nurse Practitioner's (sic) if issues arise under his role as Medical Director. See F501. Any Nurse Practitioner assigned to this facility will be monitored by the supervising physician and/or Medical Director. Nurse Practitioners providing services in the facility will work under the guidance of the attending physician as follows: 1) Practice within their scope of practice per Advanced Nurse Practice Act and level of education. 2) Be monitored by their attending physician as follows: 10% of charts will be monitored per month, discuss weekly and as needed any difficult residents or questions concerning residents; be available for backup call for issues that arise 24hrs, 7 days per week. 3) The results of the 10% chart audits will be presented to the Facility Quality Assurance purposes to be reviewed as part of the Performance Improvement process and will be addressed at the time of discovery. 4) Physician will follow Federal/State Regulations re: visit frequency. 5) Physician will address with Nurse Practitioner during chart audits any identified areas of deficient practice for immediate correction and report to the facility as part of the Performance Improvement process. (Physician H) currently has 51 residents. Out of the 51 resident charts, (Physician H) has stated that he has already completed 12 of the audits needed. He will completed 15% of the remaining 39 charts to review the lab results to ensure abnormal labs were addressed, which will be 6 charts to be completed by [DATE]. The remaining 33 charts will be audited by physicians or (medical group) made up of other physicians to ensure abnormal lab results were addressed by the Nurse Practitioner. Physician will provide a written report of all audits to DADS per request...." Further interview with the MD on [DATE] at 1:00 PM revealed he had audited 12 residents' clinical records of NP I since [DATE]. He provided a list of 12 residents whom he had audited the care provided by NP I and reviewed the lab reports. The MD stated all of the records he reviewed were in order and the care had been provided by NP I according to the protocol. He further stated he was in the facility that day to complete 15% (6 records) of the clinical records for the three long term care units. The MD revealed he would audit two records on each unit that day. The MD also stated new labs were ordered, and once the labs were completed, he would review each lab himself to ensure the appropriate action if needed was taken for each resident. The NP's protocols were not provided prior to exit. The IJ was removed on [DATE]. The Administrator, Assistant Administrator, the DON, and the Clinical Services Representative were notified on [DATE] at 2:00 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm, that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. On [DATE], the DON provided the survey team wit

Hearn, Lynda L. Based on interview and record review, it was determined the MD failed to implement resident care policies and to coordinate medical care in the facility for one (Resident #23) of 10 residents receiving IV therapy. 1. The MD failed to identify and address/resolve medical and clinical concerns and issues that were related to the provision of services by other licensed health care practitioners. The MD failed supervise NP I and the facility and the MD were unaware of the NP's scope of practice. NP I failed to notify Resident #23's physician she ordered Cathflo [MEDICATION NAME] on [DATE], which was not appropriate for the resident's clinical situation. When Resident #23 experienced a low blood pressure, NP I "stabbed" the side of the normal saline IV bag and withdrew the fluid and forcefully pushed the fluid through Resident #23's PICC line six times. Resident #23 turned "dusky" and began shaking all over, after the administration of the fluid by NP I. 2. The MD failed to collaborate with the facility leadership, staff, and other practitioners and consultants to develop policies and procedures to address IV therapy services. The facility did not have any policies and procedures addressing IV therapy services. LVN F failed to provide services to Resident #23 limited to his scope of practice. LVN F, who did not have evidence of documented IV training, administered the Cathflo [MEDICATION NAME] to Resident #23 on [DATE]. Resident #23 expired at the facility on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures contributed to Resident #23 expiring on [DATE] and could affect the 10 residents, who were receiving IV therapy via PICC lines and central lines, by placing them at risk for infection, a rupture of the catheter or the expulsion of a blood clot into the circulation causing a stroke or [MEDICAL CONDITION], infection, bleeding, and/or death. Findings included: After Administrative Review, it was determined the IJ remained until NP I's status at the facility was ascertained. Resident #23's Record of admitted d [DATE] reflected she was a [AGE] year-old female, who was admitted to the facility's [MEDICAL CONDITION] Unit from the hospital on [DATE]. Resident #23's physician's orders [REDACTED]. Resident #23's History and Physical, dated [DATE] by Physician H (the resident's physician), reflected she had the following Diagnoses: [REDACTED]. The History and Physical reflected: "...CHRONIC SBO; NEED TO BE CORRECTED BY SURGERY. DEFERRED DUE TO SVC THROMBUS AND SUBSEQUENT ANTI-COAGULATION; WILL NEED TO F/U WITH SURGERY IN 1 MONTH." In addition, Physician H's History and Physical for Resident #23 reflected: "SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS." Resident #23's Physician's Progress Note, dated [DATE], reflected Physician H added the following Diagnoses: [REDACTED]...4. [MEDICAL CONDITION]: PLT COUNT WNL AT THE HOSPITAL; SEEMS TO BE TRENDING NOW; POSSIBLY ,[DATE] [MEDICATION NAME]; CONTINUE TO MONITOR AT THIS TIME AND SHE PROBABLY NEEDS TO BE SWITCHED TO [MEDICATION NAME] IF PLT CONTINUES TO GO DOWN....SVC thrombus: WILL NEED TO BE ON FULL DOSE OF [MEDICATION NAME] FOR 3 MONTHS BUT GIVEN #4 ([MEDICAL CONDITION]), WILL NEED TO CONTINUE MONITORING HER CBC Q 3 DAYS AT THIS TIME; [MEDICATION NAME] WAS NOT STARTED AT THE HOSPITAL GIVEN THAT IT MIGHT INTERACT WITH HER MEDICATIONS; WILL FOLLOW." Resident #23's chest x-ray report dated [DATE] reflected: "Impression: CHEST FOR PICC LINE PLACEMENT: LEFT PICC LINE IN POSITION. MILD CARDIOMEGALY AND SLIGHT CONGESTIVE FAILURE. Comment: CHEST FOR PICC LINE PLACEMENT: EXAMINATION REVEALS A PICC LINE IN POSITION EXTENDING FROM THE LEFT AXILLARY REGION INTO THE LEFT [MEDICATION NAME]. THE TIP IS APPROXIMATELY IN THE SUPERIOR VENA CAVA. THE HEART IS MILDLY ENLARGED. THE AORTA AND OTHER MEDIASTINAL STRUCTURES ARE IN THE MIDLINE. THE [MEDICAL CONDITION] VASCULATURE IS SLIGHTLY PROMINENT PROXIMALLY WITH PERIHILAR CONGESTION PERIPHERALLY." This report was initialed by NP I with a date of [DATE]. Resident #23's Nurse's Notes documented by LVN A on [DATE] reflected: 6:15 AM - "Initial A.M. assessment, finds this patient A & O, and in moderate distress. She is immediately given pain med, with (symbol used) the gt being clamped off. BSG WNL, no coverage. (L) upper (symbol used) PICC intact with (symbol used) TPN infusion in progress @ 75 cc/hr via pump, Liter bag N/S also infusing, via gravity @ 70 cc/hr. No (symbol used) Temp. this A.M. - patient drinking copious amts. of cold H2O. Nurse assisted patient OOB to the BSC, she voided QS with (symbol used) moderate loose stool noted. During the assessment, I observed skin wounds to her sacral upper (symbol used) buttock area, x2 areas. Will notify our facility tx. nurse." 7:00 AM - "G/T unclamped now. Patient is resting, & requested to have another hr. or so of sleep." 9:00 AM - "(L) PICC flushed prior to starting the [MEDICATION NAME] IV per piggyback. Her BBS are coarse with (symbol used) some crackles to the lower (symbol used) lobes, O2 SAT 93% - RT (RT G) asked to assess her resp. status @ this time - will monitor." 10:00 AM - "Patient awake & feeling better, wants to catch up on her therapy today." 10:15 AM - "PT in to work with (symbol used) her inside her room, as I instructed the therapist she would be tired & slow secondary to (symbol used) her being in bed for the past 2 days. PT fully understood, and took it easy. OT (name) F/U PT to assist this patient with (symbol used) her shower. Patient became dizzy, clammy, & pale - B/P was ,[DATE] A/P 57 - OT/nurse safely assisted her to bed. Feet placed on pillow, patient reassured, her skin was dry now. B/P taken again was ,[DATE] A/P @ 59, patient responds to verbal & tactile stim." 11:30 AM - "Nurse Practioner (sic) (NP I) orders an IV be inserted to her rt. arm, I was unable to palpate a vein, nurse (RN C) attempted IV insertion x2, nurse (LVN D) attempted x2, & got an IV in, and the line infiltrated immediately. (NP I) has this nurse squeeze the N/S bag to speed up to N/S infusion rate, also she turns off the TPN infusion." On [DATE] at 12:45 PM, RN C, a charge nurse on the 6:00 AM-2:00 PM shift, was interviewed about her involvement with Resident #23 on [DATE]. RN C stated LVN A asked her to assist with inserting a peripheral line for Resident #23. She stated she heard the resident was experiencing low blood pressure, and they were trying to give the resident an IV [MEDICATION NAME]. RN C stated when she entered the room the IV lines were all tangled, and NP I told her she wanted to IV [MEDICATION NAME] the resident. RN C stated Resident #23's PICC line was patent, but it would not run really fast. She stated NP I was initially helping to trouble-shoot the issue with the PICC line. She stated LVN A flushed the line repeatedly with a 10 ml syringe. RN C stated she attempted to insert a peripheral IV line without success, but LVN D was able to start the line. RN C stated NP I wanted to get a manual blood pressure for Resident #23 so RN C proceeded to check her blood pressure using the resident's foot. Her systolic blood pressure was ,[DATE]. She stated she did not know if the [MEDICATION NAME] had been given yet when she checked the resident's blood pressure. During this time, NP I went to the nurses' station to review Resident #23's clinical record. RN C stated when she saw Resident #23 that day the resident was flushed, and she had her eyes closed. Her breathing was normal, but she was cold and shivering. On [DATE] at 12:45 PM, LVN D was interviewed about her involvement with Resident #23 on [DATE]. She stated LVN A, who was Resident #23's nurse, came to get her to put in a peripheral IV. LVN D stated she assisted with inserting the peripheral line, then she left the room. She stated when she left the room Resident #23 was relaxed after the peripheral line was inserted. LVN D stated, the next time she went into Resident #23's room was when NP I was yelling down the hall, "Does anyone know how to work a pump?" When she entered the resident's room, she observed the floor around Resident #23's IV pump to be wet, and she described the room as being chaotic. LVN D stated she observed Resident #23 covered up in bed, and her whole body was "violently" shaking. Resident #23's continued Nurse's Notes completed by LVN A on [DATE] reflected the following: 12:15 PM- "(NP I), then manually [MEDICATION NAME] 35 cc N/S after (symbol used) withdrawing the IV solution directly from the side of the IV solution (bag) rather than the rubber [MEDICATION NAME]. She used an 18 gauge needle to puncture & withdraw the solution. She then with max force injected the lower (symbol used) lumen on the PICC line, she did this x6...." 1:00 PM - "Patient started with hard chills, and verbalized pain, and was in acute distress. (NP I) told me to get the patient a [MEDICATION NAME] (an anti-anxiety medication)." 1:15 PM - "I raised the foot of her bed, and monitored this patient for s/s of shock, her B/P was ,[DATE], color pale, and some confusion noted with (symbol used) acute anxiety. The patient's (family member) was @ (Resident #23's) bedside during the manual [MEDICATION NAME] injections, and was trying to assist (Resident #23)." 1:45 PM - "During report to ,[DATE] (2:00 PM to 10:00 PM shift) nurse, I did inform him {oncoming nurse} of the 'hypotensive', episode, and to monitor the patient with (symbol used) diligence secondary to (symbol used) the past 2 hrs. Reported this episode to my ADON, (ADON K)." An interview with LVN A on [DATE] at 8:48 AM, regarding her Nurse's Notes from [DATE], revealed Resident #23 had been sick up until [DATE] when she was able to work with PT. She stated after finishing PT, Resident #23 was able to work with the OT in her room. While working with the OT, NP I came onto the [MEDICAL CONDITION] Suites Unit. LVN A stated she gave report to NP I, and she shared her with NP1 concern that Resident #23 was getting too much fluid. LVN A stated she and NP I then proceeded to Resident #23's room, and upon entering the room they discovered the resident was weak, dizzy, and was having a hypotensive episode. The resident was in the chair, at that time, and LVN A assisted her to the bed. LVN A stated NP I took over at that time, and she asked what the resident's rate of infusion was for the PICC line. LVN A stated the resident's PICC line ran slow. NP I then proceeded to unclamp Resident #23's [DEVICE], and she informed LVN A they needed to start a peripheral IV line. NP I next instructed LVN A to take the resident's pedal pulse, and it was 90 at that time (Normal resting pulse in adults is between 60 and 100 beats per minute). LVN A then explained NP I told her to squeeze the resident's Normal Saline IV bag which was not on the pump at that time. Next, NP I held an IV bag containing Normal Saline, and she "stabbed" the bag with an 18 gauge needle and a 30 ml syringe to draw up the Normal Saline instead of using the port to extract the Normal Saline. The Normal Saline squirted out of the bag, but she was able to fill the syringe. LVN A stated she gave NP I an alcohol prep pad to clean the port, and NP I proceeded to put the syringe directly on the lumen port of the PICC line. NP I pushed 30 cc of Normal Saline directly into the PICC line with maximum force. LVN A stated NP I pushed with the weight of her body, while injecting the Normal Saline, to push it in faster. LVN A stated NP I did this procedure six times and injected 210 ml of the solution into the port of the PICC line. After NP I completed the procedure, LVN A stated the resident went into shock. LVN A stated the resident appeared dusky and began shaking. NP I stated she "saved her life." LVN A stated NP I asked Resident #23's family member, who was present during the procedure, it this was how Resident #23 acted when she was having an anxiety attack. NP I told LVN A to give the resident a [MEDICATION NAME] for anxiety. LVN A stated she administered the [MEDICATION NAME] to Resident #23. After the occurrence, LVN A stated she informed ADON K about the incident. The next day, [DATE], LVN A learned the 2:00 PM to 10:00 PM charge nurse, LVN F, administered Cathflo [MEDICATION NAME] via Resident #23's PICC line per NP I's orders, and the resident died later that day after the medication was administered. Review of NP I's Progress Note, dated [DATE] for Resident #23, revealed there was no documented evidence the patency of the PICC line had been assessed prior to the administration of the Cathflo [MEDICATION NAME]. The Progress Note reflected NP I manually administered 210 ml of Normal Saline through Resident #23's PICC line to treat low blood pressure. In the same Progress Note, NP I documented: "While assessing pt sitting @ BS awaiting a shower she c/o dizziness, she was pale. BP ,[DATE] P 51, profoundly weak assisted to bed. BP ,[DATE] P 59 attempted to run in fluid wide open thru PICC but to no avail BP less dizzy but now "sleepy" requiring stimulation to stay awake BP ,[DATE] (P) 51." NP I further documented in the Progress Note that she manually [MEDICATION NAME] 0.9 Sodium Chloride via the resident's PICC line and infused 210 cc. In addition, NP I's Progress Note also reflected the following lab values for Resident #23: White Blood Cells increased from 5.1 to 17.4 Platelet Count decreased from 113 to 79 H & H decreased from 10XXX,[DATE].3 to 9XXX,[DATE].0 Note: Platelets are blood cells needed in the body to promote blood clotting. A platelet count below 100 indicates someone has a higher risk for bleeding due to low platelet count. Also, a white blood cell count above 10 indicates a person has an infection On [DATE] at 10:15 AM, NP I was interviewed about her involvement with Resident #23 on [DATE]. NP I revealed, when she entered the room on [DATE], Resident #23 was sitting up in a chair. The resident was pale and sweating, and she complained of dizziness. When the nurse put her back to bed, her blood pressure was ,[DATE] with a heart rate of 59. NP I stated Resident #23 was volume depleted, and she needed to be [MEDICATION NAME] with IV fluids. She stated there was a good blood return on the catheter. She added the PICC line was a small caliber, and it was sluggish. An interview with the MD, who was also Resident #23's attending physician (Physician H), on [DATE] at 9:20 AM revealed when asked about NP I forcing fluids through Resident #23's PICC line and stabbing the side of the IV bag repeatedly to fill syringes, he replied, "Not really. In this setting, I would have run the fluid on its own to see if it would help rather than forcing fluids through the PICC." Continued interview with NP I on [DATE] at 10:15 AM revealed, "I ordered the Cathflo. I don't know who gave it." When queried as to whom was to give the Cathflo [MEDICATION NAME], NP I stated the protocol was the company, who handled the PICC lines, was responsible for coming to the facility and administering it. She further revealed, "I don't know anything about Cathflo, and I wouldn't give it myself." Resident #23's NP I's Order, dated [DATE], reflected: "Cathflo 2 mg as needed for PICC x 2 lumens per protocol." Continued interview with the MD on [DATE] at 9:20 AM revealed when asked about Resident #23's PICC line, he replied there was a [MEDICATION NAME] thrombus (blood clot) in the area of the PICC line. The MD was asked if the facility had notified him Resident #23's PICC line was occluded or sluggish, and he answered he had not been notified. The MD stated he saw the resident on [DATE] and [DATE]. When asked if he was aware NP I ordered Cathflo [MEDICATION NAME] on [DATE], the MD replied no. He was then asked if he had standing orders for Cathflo [MEDICATION NAME], and he replied, "No." The MD was provided with Resident #23's clinical record, and he examined the resident's lab reports. The MD revealed he was not aware Resident #23's platelet count was 40. The MD stated he would not have used Cathflo [MEDICATION NAME] for this situation. When asked if any nurses had discussed Resident #23's condition with him, the MD stated the only call he received was from his NP, who called him at 4:00 AM on [DATE] regarding blood work from that day, and that she started [MEDICATION NAME] (an antibiotic). The manufacturer's website (<http://www.cathflo.com>, last accessed on [DATE]) for Cathflo [MEDICATION NAME] reflected: "INDICATIONS AND USAGE Cathflo [MEDICATION NAME] (Atleplase) is indicated for the restoration of function to central venous devices as assessed by the ability to withdraw blood. PRECAUTIONS General Catheter dysfunction may be caused by a variety of conditions rather than thrombus formation, such as catheter malposition, mechanical failure, [MEDICATION NAME] by a suture, and lipid deposits or drug precipitates within the catheter lumen. These types of conditions should be considered before treatment with Cathflo [MEDICATION NAME] Bleeding ...In addition, caution should be exercised with patients who have [MEDICAL CONDITION], other [MEDICATION NAME] defects (including those secondary to severe hepatic or [MEDICAL CONDITION]), or any condition for which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location, or who are at high risk for embolic complications (e.g., venous [MEDICAL CONDITION] in the region of the catheter). Death and permanent disability have been reported in patients who have experienced stroke or other serious bleeding episodes when receiving pharmacologic doses of a [MEDICAL CONDITION] Infections Cathflo [MEDICATION NAME] should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo [MEDICATION NAME] in patients with infected catheters may release a localized infection into the systemic circulation (see ADVERSE REACTIONS). As with all catheterization procedures, care should be used to maintain aseptic technique... Geriatric Use ...In general, caution should be used in geriatric patients with conditions known to increase the risk of bleeding (see PRECAUTIONS, Bleeding)." An interview with LVN E, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:45 PM revealed he ordered the Cathflo [MEDICATION NAME] from the pharmacy, and LVN F administered it to Resident #23. Resident #23's [DATE] MAR indicated [REDACTED]. An interview with LVN F, a 2:00 PM to 10:00 PM Charge Nurse, on [DATE] at 2:30 PM revealed he administered Cathflo [MEDICATION NAME] to Resident #23 via her PICC line on [DATE] at 3:45 PM. LVN F provided a Witness Statement on [DATE], which reflected: "Reviewed order for Cathflo on (Resident #23). Got med out of refrigerator mixed according to mfg. Standards. Went to Pt room with (symbol used) her primary nurse, (LVN E), ID'd patient. Donned gloves, cleaned white hub with (symbol used) ETOH, injected 2 ml of med into PICC line. This was @ 1545 (3:45 PM). Returned to Pt room @ 1700 (5:00 PM). Cleaned white hub with (symbol used) ETOH. And with (symbol used) a new 10 ml syringe drew back 10 ml of blood. Then flushed with (symbol used) 10 ml NS. Cleaned clear hub with (symbol used) ETOH. With (symbol used) new 10 ml syringe, attempted to draw blood but was unsuccessful. Only got back the 2 ml of Cathflow. Primary nurse notified of outcome. This all occurred on [DATE]. Before admin of Cathflo assessed each hub by attempting to flush with (symbol used) 10 ml of ns & to draw blood from PICC. White hub flushed, but no blood return. Clear hub didn't flush or give blood return." LVN F's personnel file did not reflect a skills check-off list from the DON for IV competency. Continued interview with the MD on [DATE] at 9:20 AM revealed when asked about the facility's IV therapy program, he responded it was his understanding all of the nurses were IV certified. When the MD was asked about an LVN administering Cathflo [MEDICATION NAME], he replied he thought an RN should administer the Cathflo [MEDICATION NAME]. He further stated if a LVN said he/she had experience administering the medication, without proof of training, that would not be acceptable. When asked what his expectation would be regarding documentation if Cathflo [MEDICATION NAME] was used, the MD responded, "The circumstances should be documented for giving the medication." Resident #23's Nurse's Notes dated [DATE] reflected Resident #23 was found unresponsive and without a pulse at 5:45 PM. The Notes reflected LVN E called 911, and the paramedics came to the facility. The paramedics tried at length but were unsuccessful in resuscitating Resident #23. The Notes reflected the resident was pronounced dead at the facility by the DON at 8:00 PM. Resident #23's preliminary lab report for a Blood Culture drawn on [DATE] reflected Gram Negative Rods were present, which indicated an infection. This Blood Culture report was initialed and dated by NP I on [DATE]. Resident #23's CBC results drawn on [DATE] at 4:51 AM reflected her HGB, HCT (H & H), and platelets had declined since her admission to the facility. The results reflected the following: [DATE] - HGB 11.5 g/dL reference range 12.0 -15.6 g/dL; HCT 34.5% reference range 35.0 - 46.0%; and PLT 160 reference range 130 - 400 K/mm3 [DATE] - HGB 10.7 g/dL; HCT 31.7%; and PLT 113 [DATE] - HGB 8.3 g/dL; HCT 25.0%; and PLT 40 Note: HCT is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. The decline of HGB and HCT could be a sign of bleeding. NP I initialed and dated this laboratory result on [DATE]. An IJ was identified on [DATE]. The Administrator, DON, and Assistant Administrator were notified of the IJ on [DATE] at 12:07 PM. A Plan of Removal was requested at that time. An interview with the DON on [DATE] at 3:45 PM revealed when asked how the facility determined a LVN was IV certified, she replied, "The nurses on the unit (Pulmonary Suites Unit) are kept IV certified." She explained the facility had a vendor who conducted annual competency reviews for skills for all the licensed nurses. The DON provided the Pharmacy Services Routine Manual for Long-Term Care Facilities dated 2012. The pharmacy manual reflected step-by-step procedures for administering different medications. The manual gave procedures for inserting a PICC line over a guide wire and many advanced procedures for specialty advanced practice nurses. During the interview on [DATE] at 3:45 PM, the DON was asked to provide the licensed nurse skills checklist, the facility's IV policy, and the facility's protocol for the use of Cathflo [MEDICATION NAME]. The DON stated the vendor pharmacy protocol, and the chapter regarding IV therapy in the Perry and Potter nursing textbook were the policies the facility used. The DON provided a copy of Perry and Potter nursing textbook, and she stated it was the facility's policy. The DON was then asked specifically about LVN F's training and certification regarding IV therapy. The DON stated LVN F had training at a local hospital. When asked if she had LVN F's IV training certificate of completion and a skills check-off to verify his competency and training, the DON replied, "No." The facility's policy and procedures for IV therapy reflected the facility had no IV therapy policies or procedure of their own. In addition, the facility did not have policies reflecting the scope of practice of IV therapy at the facility. The facility's nursing policy and procedure manual dated [DATE] for IV therapy referred to the Perry and Potter nursing textbook. The facility policy for PICC line insertion reflected, "Refer to pharmacy infusion therapy manual." Review of the facility's vendor pharmacy infusion therapy manual dated 2012 revealed skills checklists and procedures for IV push administration of medications, midline catheter insertion, midline catheter insertion using a guide wire, dressing changes of central lines, removal of central and PICC lines, insertion of peripheral IV lines, PICC catheter insertion, blood withdrawal from the central line for lab sampling, hypodermoclysis (administering IV fluids subcutaneously), accessing implanted ports, infusing spinal medications, clearing [MEDICAL CONDITION] occlusions with the [MEDICAL CONDITION], repair of the central line, and culturing drainage from the central venous catheter site. The facility policy procedure manual did not specify which of the tasks outlined in the pharmacy infusion therapy manual could be performed in the facility by facility staff, particularly LVNs. During the MD's interview on [DATE] at 9:20 AM, he described his role of Medical Director as assisting the facility to run efficiently, coordinating with third-party vendors, teaching nurses, chart reviews from time to time for documentation, talking with other physicians, coordinating the chain of command and communication regarding patient care, developing policies for resident care, and communication with staff regarding guidelines for infection control. The facility's Plan of Removal was accepted on [DATE] and reflected: 1. Accessing an implanted port will be delegated to IV competent RNs only, and IV push medications requiring special monitoring will not be administered. 2. All the nurses would be re-educated on Infusion Therapy to include insertion of peripheral intravenous sites and care and maintenance of PICC lines, central lines and peripheral lines via IV education. 3. All IV certified nurses would have compentency evaluations completed. All LVNs and RNs would have a competency evaluation satisfactorily completed prior to being allowed to administer IV medications. The DON and ADON will perform the competency evaluations of Administrative nurses, then Administrative will perform competency evaluations of the floor nurses. 4. Administrative nurses would observe residents receiving IV medications at least once a week for four weeks and then randomly. Identified deficient practices would be corrected immediately and reported to the Administrator as part of the Performance Improvement Process. On [DATE] at 10:56 AM, a telephone interview was conducted with the DON regarding how the facility addressed the role of the NP in the IJ. The DON stated the Administrator and she met with the Medical Director and the NP on the morning just prior to the survey team talking to them ([DATE]). They discussed the concerns, which were identified by the survey team. The Medical Director stated he would bring their concerns to his supervisor at the company, which employed him and the NP. The Medical Director told them (the Administrator and the DON) it would be up to the company to handle corrective actions regarding the NP. The DON further stated they had a Physician Dinner on [DATE], and they (the Administrator and the DON) again discussed their concerns regarding the NP. The DON then explained the facility planned to hire an NP on a full-time basis 8:00 AM - 5:00 PM Monday through Friday. The DON stated they had already met with a potential candidate on [DATE]. The DON stated the facility and staff were taking the situation seriously and would continue to monitor the NP when she was working at the facility. The DON further stated the Medical Director and the NP's supervising company had not agreed to allow another NP to see "their" residents, so the NP, for the time being, was continuing to provide services for the Medical Director's residents. The DON stated she was monitoring the NP's documentation and she would bring any concerns to the physician's attention. An interview on [DATE] at 3:46 PM with the DON revealed she was completing competency evaluations with return demonstrations for her weekend staff nurses, LVN B and LVN F along with a competency written test. An observation on [DATE] at 4:00 PM revealed the DON observed LVN B administer [MEDICATION NAME] IV (antibiotic) using aseptic technique with no contamination. On [DATE] at 5:00 PM, the DON and Assistant Administrator were informed the IJ remained. A Plan of Removal was requested at that time. An interview with the Administrator, on [DATE] at 9:30 AM regarding how the facility would address the concerns regarding NP I, revealed the facility made the decision to remove NP I from the facility. The Administrator stated Physician H would be taking all calls directly, so NP I was not involved with the residents. She stated the medical group, who employed NP I, would audit the charts of the residents seen by NP I. When asked how she thought the IJ came about, the Administrator stated she believed it arose due to a disagreement between LVN A and NP I. She stated they "played" this out in Resident #23's chart. The Administrator stated NP I and LVN A put the facility in the IJ situation. She stated NP I did not pick up on Resident #23's lab results because LVN A was fighting with her. The Administrator stated the facility got caught in the mix of problems. When asked about NP I and her relationship with the facility, the Administrator explained NP I was hired by the medical group. She stated the physicians and NPs were hired by the medical group which assigned them to the facility. At 10:45 AM on [DATE], the Administrator stated NP I's privileges were revoked, and she would no longer be seeing residents in the facility. Further interview with the MD, on [DATE] at 12:09 PM via telephone, revealed when asked what his expectations were regarding practitioners in the facility, he replied his expectations were nurse practitioners would see residents, anticipate problems, contact the physician, and inform the physician of any unusual findings. When asked what his role was in supervising NPs, physician's assistants, and other physicians in the facility as the MD, he responded, "I have not had any problem with other nurse practitioners. I try to help other staff physicians if they asked me. As director, if I find that a physician or nurse practitioner is not managing patient according to standard of care, I'll address it with them." The MD was asked if he had a job description for NPs in the facility, and he replied, "I do have the protocols for nurse practitioners for group." The MD was asked if he would be able to audit the residents' clinical records, whom NP I provided care to, for completeness and standards of care. He replied, "I do try to keep up with the visits. I see each patient every two weeks and the nurse practitioner sees them in between. I try to examine her charts at that time." An interview with the Regional Director, with the responsibility for post-acute providers from the medical group who employed NP I, on [DATE] at 11:45 AM, revealed when asked about policies and procedures, which govern what NPs could do in a facility, the Director responded NPs work under specific protocols. The Director stated each practice had protocols, which were between the NP and the physician. The Regional Director also revealed each physician managed the protocols with the NPs. When asked who was responsible for supervising the NP's work, the Regional Director replied, "The direct supervising physician is responsible for the nurse practitioner." Further interview with the MD on [DATE] at 12:09 PM revealed he had protocols for NPs for the group practice, but when the surveyor requested a copy, he stated he did not have them with him. He stated he would have to get the protocols from the group practice manager. An interview on [DATE] at 1:15 PM with the Director of Credentialing for the physician's group revealed when asked about the scope of practice for NPs in the medical group, she replied her department only checked the NP's license status and completed background checks of the NPs. Further interview with the Administrator on [DATE] at 9:45 AM revealed NP I was hired through the medical group and was not an employee of the facility. The Administrator stated they did not have any copies of NP I's protocol for practice and were unaware

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards as is possible by failing to identify, evaluate and analyze hazards and risks for one (Resident #1) of three residents reviewed for accidents. Resident #1 fell in her room and sustained a Left Humeral Fracture due to water on the floor from a roof leak. This failure placed all 25 residents who resided on Hall 200, including Resident #1 at risk for possible injuries. Findings Included: Resident #1 resided on the Secured Unit on the 200 Hall. The quarterly MDS assessment dated [DATE] reflected the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was severely impaired in cognitive skills for daily decision making, independent in ambulation, and independent in dressing. Observation on 04/04/12 at 9:48 a.m. revealed Resident #1 was lying in bed with a sling to her left arm and was asleep. A Patient/Resident Incident/Accident Investigation Worksheet dated 03/25/12 at 2:15 p.m. reflected the location of Resident #1's incident was the resident's closet in the room. The report reflected the incident was a witnessed fall, and she had a fracture. A Family Member reported when he/she was walking in the room, the resident opened the closet door and slipped down on the floor of the closet due to the floor being wet. Resident #1's x-ray report on 03/25/12 at 2:40 p.m. reflected a Fracture to the Left Humerus. The facility's Provider Investigation Report sent to the Department of Aging and Disability Services dated 03/26/12 reflected: "On 03/25/12 at 2:15 p.m.(Resident #1) and (family member) were in the resident's room. The resident went to her closet to retrieve a sweater and when she opened the closet door the resident slipped and fell from water on the floor sustaining a fracture of the left Humerus. The resident was transferred to the hospital and received treatment in the emergency room and returned to the facility with a splint in place. The facility began the investigation into the water on the floor and the cause. It was determined that the water was on the floor from a leak in the ceiling. The roof needed repair after damage from a severe storm that occurred on Monday March 26th. The ceiling was leaking water and staff notified maintenance about the issue and a bucket was placed under the leak to catch all the water until another roof repair could be done. The bucket did not catch all the water so some water had dripped on the floor in the closet. This is the area the resident slipped on. The resident received a head to toe assessment and was sent to the emergency room at (local hospital) hospital for evaluation. The x-rays done revealed a left humeral fracture. The resident received a splint and a sling for the fracture and returned to the facility. The facility provided the following corrective action. The ceiling in the resident's room was repaired and new ceiling tiles placed. The leak on the roof above this room was also repaired. The facility is also in the process of taking bids for a total facility wide roof repair and entire roof will be replaced. The assistant maintenance director was suspended pending the outcome of measures made by him towards the roof issue. The employee received corrective action... Clarification: There was one area in the investigation report which states storms occurred on 03/26/12 this date was mistakenly entered and the storms were 03/19/12." In an interview on 04/04/12 at 4:35 p.m. CNA A stated on 02/15/12 she reported it (roof) was leaking to maintenance and he put a bucket there. CNA A stated she would go and clean the water up every once in a while "when I noticed it was wet." During an interview on 04/04/12 at 4:15 p.m. LVN B stated she did not know there was a leak in Resident #1's closet. LVN B stated it did leak around the windows in the dining room on the 200 Hall Secured Unit. The staff would put towels down, a yellow slip (wet floor) sign, and watch the residents from going near the windows. During an interview on 04/04/12 at 2:45 p.m. the ADM stated the failure was the maintenance man did not report the problem to his supervisor and instead put a trash can there. The leak had been fixed but the ceiling tile and insulation was wet and needed to be pulled down and replaced. The water was dripping from that. The ADM stated she did "write him up" and gave him his last warning. Review of an invoice from the roof repair agency dated 12/02/11 revealed: "Service to repair roof leaks. Repaired roof leaks in rooms #499, #411, suite #21 and #24." An invoice from the roof repair agency dated 12/12/11 reflected: "Service to repair roof leaks. Repaired leaks in rooms #128, and front overhang at entry areas." An invoice from the roof repair agency dated 01/05/12 reflected: "Service to repair roof leaks. Repaired roof leak in middle of room #416. Repaired both leaks in hallway of 400 wing." An invoice from the roof repair agency dated 03/08/12 reflected: "Service to repair roof leaks. Repaired leaks at Rooms #416, #419, #423, #216, #219, #200 terrace area, and office by #216." An invoice from the roof repair agency dated 03/15/12 reflected: "Service to repair roof leak at front administration office, and suite #51. Repaired roof leaks as instructed." An invoice from the roof repair agency dated 03/28/12 reflected: "Service to inspect and repair roof as follows: Inspected and repaired cuts in the roof caused by flying debris in high winds. Found cuts allowed water to flow into building in the 400 hall section corridor. Repaired roof leak and raised roof area at former chapel area space." In an interview on 04/04/12 at 9:05 a.m. the Maintenance Director stated there had been several patches on the roof. A new roof for the entire facility had been approved and they were getting bids. Life Safety had told him until the roof got fixed that he needed to go up there and sweep the roof every time it rained. He said he already swept it, as it rained yesterday. A roofing bid from a roofing contractor dated 03/31/12 reflected: "Remove all fasteners, Remove and replace wall coping, Install 1 (inch) ISO board with correct tapers, Install Mule-Hide 45 mil TPO system, and Seal all penetrations. Total Materials and Labor $345,000.00." A letter from another roofing contractor dated 04/04/12 reflected: "...We are preparing a bid to replace the entire roof at your facility. We have taken the measurements. We will have the bid to replace your entire roof to you by this Friday (04/06/12)." Review of the undated Room Roster provided by the DON on 04/04/12 revealed there were 25 residents on the 200 Hall.