**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility neglected to provide sufficient numbers of nursing staff to meet the physical and psychosocial needs of residents in the facility. The facility failed to ensure facility residents were free of neglect resulting in the actual or potential physical and/or psychosocial harm to 18 of 18 residents in a sample of 23. This failure resulted in physical harm to R1 who was observed to have two re-opened, previously healed pressure ulcers and scratch marks on her skin from skin irritation, psychosocial harm to R1 after not receiving showering assistance from staff which caused her to become more depressed, physical harm to R16 after R16's previously healed pressure injury reopened, physical harm to R4 after development of a new pressure injury, as well as psychosocial harm to R3 and R10, as well as putting R2, R5-R9, R11, R12, R14, R15, R17, R19 and R20 at serious risk of physical/psychosocial harm. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy began on 2/1/23 when a severe lack of facility staff caused the neglect of facility residents requiring assistance from facility staff. V1 (Administrator) was notified of the Immediate Jeopardy on 2/7/23 at 1:49 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 2/9/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the staffing interventions. The findings include: On 2/1/23 at 12:45 PM, V6 (C.N.A.-Certified Nursing Assistant) stated the third floor AM shift usually has only two CNAs scheduled on the floor for the 54 total residents. V6 stated each CNA was responsible for 27 residents on 2/1/23. V6 stated six of her residents require two staff to assist with mechanical lifts for transfers and four of her residents require two staff because of behaviors during care. At 12:55 PM, V6 stated when the CNAs have time, they toilet residents before and after breakfast and again before lunch. V6 stated when there are only two CNAs working on the third floor, they are unable to toilet residents after breakfast or before lunch because they need to get residents out of bed that remain in bed for breakfast. V6 stated she had five residents that remained in bed during breakfast. V6 stated the CNAs are unable to give residents showers/bed baths when only two CNAs are scheduled on the third floor. V6 stated they document in the computer when they perform resident showers. V6 stated if there are three CNAs on the floor and a Resident Assistant (RA), the RA helps transport residents and they are sometimes able to give showers. On 2/1/23 at 12:48 PM, V5 (CNA) stated he was caring for 24 residents - six of which required two staff for mechanical lift transfers. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated there were only 2 CNAs working for a total of 62 residents residing on the second floor. Resident Council Minutes, dated 12/26/232, show, Staffing issues are still working progress and is getting better Resident Council minutes, dated 11/21/22, show, .CNA staffing is still being worked on On 2/1/23 at 1:43 PM with V16 (RN), V12 (CNA/Scheduler) stated the facility census had remained fairly stable for the last couple months and any census changes that did occur did not change staffing needs on the facility floors. V12 stated if she had sufficient staff, she would schedule 5 CNAs on the 2nd floor and 5 CNAs on the 3rd floor during both the AM and PM shifts. V12 stated those 5 CNAs scheduled would be in addition to any restorative staff working in the facility. V12 stated restorative staff only get pulled to help on the second or third floor if only 1 CNA shows up for a shift on a floor. V12 stated she was currently working as one of the two CNAs on the second floor and she alone was caring for 31 residents. V12 stated V10 (CNA) was the only other CNA working on the second floor during the AM shift on 2/1/23 and V12 alone was caring for 32 residents. V12 stated the second-floor census is higher than usual and is almost at capacity as they have 63/68 beds filled. V12 stated there were 24 residents requiring mechanical lifts for transfers in addition to several other residents requiring two staff's assistance for ADLs. V12 stated 2 CNAs on the floor of approximately 63 residents had been typical at the facility for a long time. V12 stated she is only allowed to call staff employed by the facility. V12 stated, We just do not have the staff to call. V12 stated she has been requesting for the use of agency staff to help fill in the schedule for some time. Facility Roster, dated 2/1/23, shows the facility census was 160 residents. The roster shows there were 43 residents residing on the first floor, 63 residents residing on the second floor, and 54 residents residing on the third floor. Review of schedules, dated 1/30/23 to 2/6/23, show on the AM or PM shifts on either the second or third floors of the facility: 1. 13/36 shifts had only 2 CNAs working on the entire floor. 2. 4/36 shifts had three CNAs but one CNA only worked part of the shift 3. 17/36 shifts had only three CNAs working on the entire floor Review of Facility Nurses and CNAs list, provided 2/8/23, shows the facility only employed 15 full time CNAs, 4 part time CNAs, and 7 casual CNAs. Facility Assessment, reviewed 11/22/22, shows the facility average census was 153 residents. The assessment shows the total number of CNA full time equivalents required at the facility were 34-37. The assessment shows, .Facility budgets are established to act as a general guideline for facilities to follow when determining staffing levels needed to provide care to residents being serviced. These budgets are established based on the average resident census along with their projected needs for care and support. Facility budgets are maintained by the Administrator and are flexible based on the actual acuity and unique individual care needs of the residents. To promote continuity of care, and consistent practices, we avoid the use of contract staff and agency staff for direct care positions Individual staffing assignments are determined at the facility level and take into consideration the current support/care needs of the residents that include, but are not limited to medical/physical conditions, acuity, physician orders, therapeutic needs, infection prevention and control needs, behavioral support as well as any other special care needs as identified, Consultation with [NAME] Management Services in customizing and revising individual staffing assignment is obtained, if necessary. On 2/1/23 at 3:03 PM, V1 (Administrator) stated she was aware of the schedule being short staffed and stated the facility was offering financial incentives for staff to work longer or extra shifts. V1 stated the facility was only able to rely on the staff on the facility payroll and the facility recently lost two CNAs to another facility. V1 stated she was not given permission to utilize agency nursing staff by her corporate supervisors. 1. Face sheet, printed 2/1/23, shows R1's diagnoses included multiple sclerosis, quadriplegia, spinal stenosis, overactive bladder, anxiety, and depression. MDS (Minimum Data Set), dated 1/30/23, shows R1 was cognitively intact, was totally dependent on staff for transfers, personal hygiene, eating and dressing, and required extensive assistance from two staff for bed mobility, R1 was always incontinent of bowel and bladder, and R1 had an indwelling urinary catheter. Braden scale, dated 1/28/23, shows R1 was at moderate risk for development of a pressure ulcer and R1 was not able to make even slight changes in body or extremity position without staff assistance. ADL Care Plan, initiated 8/7/22, shows R1 required a mechanical lift for transfers and requires staff assistance for bathing, toileting, and personal hygiene. Interventions include R1 refuses to take showers on non-scheduled dates. Skin integrity care plan, revised on 2/17/22, shows R1 had a history of skin injuries to her sacrum, had a reopened injury to sacrum and impaired mobility. Interventions include inspect skin with showers and as needed and turn and reposition every two hours and as needed. Depression care plan, revised 1/29/23, shows R1 had a diagnosis of depression and was observed of feeling down and tearful. Incontinence care plan, dated 10/18/21, shows R1 was incontinent of bowel related to multiple sclerosis and quadriplegia and interventions included offering toileting opportunities based on R1's pattern of elimination. Bed mobility care plan, revised 4/19/18, shows R1 was unable to turn and reposition herself in bed without assistance with staff. On 2/1/23 at 2:00 PM with V14 (Sister) on speaker phone, R1 stated the facility did not have enough staff to care for residents including providing showers, repositioning, and checking/changing incontinence briefs. R1 stated she had not received a shower for two weeks. R1 stated had not received her showers twice a week for a few months and that was when R1 began having skin irritation. R1 stated not having showers twice weekly caused her to itch and scratch her skin until she bled. R1 had visible, scabbed, scratch marks on her left upper thigh, right upper arm near her shoulder, and bright red scabs on her right breast. R1 stated, Once I start scratching, I can't stop! It started a couple months ago when it began to be one shower a week. I started itching more as it declined. R1 also stated, I feel terrible, wouldn't you!? Sometimes I can smell myself! V14 (Sister) stated, I have called her and she has been so depressed and feels so bad about herself. She has told me it is depressing. R1 also stated, They're not turning me. The other day I was not moved for 13 hours. R1 stated she had pressure ulcers and her repositioning schedule is never followed by staff. R1 stated, When I am left sitting in one position for so long my pressure ulcer starts burning and I call my sister and she calls and talks to nurses and gets them in here. R1 stated she has waited two hours for staff to answer her call light for ADL assistance. R1 had a repositioning schedule over her bed that showed R1 was to be turned every two hours on the even hours. On 2/6/23 at 3:35 PM, R1 was observed with V8 (Assistant Director of Nursing) and two open areas were noted during the observation - one area on the sacrum and one area on the left buttock. Per V8, these areas had been healed, were previously closed, and now were newly open. Facility's wound report, dated 2/2/23, shows R1's wounds were healed. On 2/7/23 V17 (Wound Physician) stated that he would expect that R1 be repositioned at least every two hours and that R1 has a history of skin breakdown. On 2/9/23 at 8:08 AM, V2 (Director of Nursing) stated R1 could not move her body and would not be able to scratch herself. At 9:20 AM, V2 stated she visited R1 and asked R1 to show her if she could reach the areas that were observed to have scratch marks on 2/1/23. V2 stated she bathed R1 on 2/3/23 and saw no scratch marks red marks, or skin irritation on R1. V2 stated the night nurse on 2/8/23-2/9/23 stated R1 was scratching all night and the nurse called the physician for cream the AM of 2/9/23. V2 stated she was unaware of any creams R1 was provided prior to 2/9/23 for her itching. At 10:09 AM, V2 stated R1 told V2 she could reach those areas R1 stated she had been scratching and had caused scratch marks. On 2/9/23 at 9:34 AM, V14 (Sister) stated she previously provided R1 with a back scratcher and creams because R1 became so itchy recently. V14 stated the staff previously gave her a tube of cream to put on her skin when she started itching. V14 stated I was just talking to her about the back scratcher. She just told me V2, and a nurse came in asking her about her scratch marks. You can't tell them anything because they deny it or downplay it. I told them not to do that to me. [R1] told them she could reach as far as the scratches are. Progress notes, dated 2/9/23, show, Prior to resident scratching no skin issues noted. Resident noted to scratch skin at times this shift with dry brownish scratch marks noted to both anterior thigh, right chest and pinkish discoloration noted to right arm, with complaint of itching and per resident she scratches her skin. Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R1 received only 5 showers from 1/1/23 to 1/31/23 (showered on 1/6/23, 1/10/23, 1/13/23, 1/16/23, 1/20/23). The shower sheet shows R1 refused showers on 1/4/23, 1/25/23, and 2/1/23 all of which were documented as late entries by V9 (Restorative Nurse) on 2/2/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report was not accurate and then provided hand-written shower sheets for R1 showing she provided R1 a shower on 1/16/23. V9 stated the hand-written shower sheets she provided were accurate documentation of showers she provided R1. V9 stated she filled out the shower sheet dated 1/20/23 for V12 (CNA/Scheduler) when V12 gave R1 a shower. V9 stated on 1/4/23 and 1/25/23 she offered R1 PM showers which she knew R1 did not prefer and R1 subsequently refused. V9 stated she only provided R1 one shower during January 2023 despite the documentation she recorded on 2/2/23 on the Bath/Shower Follow Up Question Report. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R1 only preferred her showers in the morning and all staff are aware of her preferences. V12 stated if you try to offer R1 showers in the afternoon/evening, she normally refuses. V12 stated the prior week was the second week in a row R1 had not received showers. V12 stated the last time she gave R1 a shower was on 1/20/23. V12 stated she was able to give R1 showers on 1/6/23, 1/10/23, 1/13/23, and 1/16/23 because they had more CNA staff. V12 stated the CNAs choose Not Applicable in the electronic record as a response when a resident's shower task appears during a day/shift that R1 was not scheduled for a shower. V12 stated residents are not offered showers when the response in the computer was marked Not Applicable. Second floor facility shower list, dated 11/22/22, shows all residents are scheduled to receive two showers each week. Third floor facility shower list, dated 6/20/19, show all residents are scheduled to receive two showers each week. On 2/1/23 at 2:14 PM, V2 (Director of Nursing) stated staff were expected to check resident's incontinence briefs in their rooms every two hours if the residents were incontinent. 2. On 2/6/23 at 10:18 AM on the third floor, there was a strong smell of concentrated urine throughout each of the two hallways. R16 was a [AGE] year-old resident with multiple diagnosis including: Diabetes, Heart Failure, Hypertension, Protein Calorie Malnutrition, Gout, Dysphagia, and Muscle Weakness. Per R16's MDS (Minimum Data Assessment) dated December 27, 2022, R16 was dependent on staff for personal hygiene, transfers, position change, and is always incontinent of bowel and bladder. R16's care plan dated January 11, 2023, shows R16 required a two-person mechanical lift to transfer and R16's interventions included turning and repositioning R16 every two hours and as needed. R16 was assessed as cognitively impaired per the MDS assessment. Facility wound list, dated 2/2/23, shows R16 as having a healed wound to the left buttock and open Stage III wound to right buttock. R16 also has a previous Stage III pressure injury to the right heel that was documented as closed on October 25, 2022. R16's wound to the left buttock was noted as healed on January 24, 2023. Braden Scale, dated 2/1/23, shows R16 was at mild risk for development of a pressure injury. On 2/6/23, V13 (CNA) stated between 7:30 AM and 8:30 AM on 2/6/23, there was only one CNA working on the floor providing direct care for all 54 residents. At 8:30, a second CNA began working on the floor. On 2/6/23, R16 was observed on the third floor in the dining room or directly outside the dining room near the nursing station from 9:10 AM until 1:40 PM. R16 was noted sitting directly on the sling for the mechanical lift in an adult reclining chair. During this time, R16 was not checked for incontinence nor was she repositioned. At 3:20 PM, R16's wounds were observed with V2 (Director of Nursing RN) and V8 (Assistant Director of Nursing RN) and the area on the left buttocks was noted to be open. Both V2 and V8 confirmed that this area was now reopened and V8 stated he would notify the wound doctor. V17 (Wound Physician) was notified about the re-opened wound, was interviewed on February 7, 2023, at 1:15 PM, and stated that R16 should be repositioned at least every two hours to remove pressure. V17 also stated that since he is not in the facility all of the time that he assumed the staff would change R16's position at least every two hours. V17 stated that not providing position changes leads to new skin issues. 3. Face sheet, printed 2/1/23, shows R3's diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure with hypoxia, morbid obesity, and depression. MDS, dated [DATE], shows R3 was cognitively intact, required total assistance from staff for transfers, required the extensive assistance from two staff for bed mobility, dressing, toilet use, bathing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/5/22, shows R3 was at mild risk for the development of a pressure ulcer. On 2/1/23 at 2:29 PM, R3 stated during the day shifts she usually waits approximately 45 minutes for staff to answer her call light. R3 stated staff fail to turn her every two hours and fail to provide R3 showers. R3 stated she had not had a shower for weeks. R3 stated, It makes me feel horrible. R3 stated front office staff had to help last time she was bathed because she needed so much cleaning. On 2/6/23 at 9:40 AM, V12 (CNA) stated in early December 2022, R3 was seen by her Nurse Practitioner who told the facility to give R3 a shower because R3 was unclean, had foul odor, and R3's hair was matted. V12 stated she showered R3 at that time and had not given her a shower since. On 2/6/23 at 11:48 AM, V20 (Nurse Practitioner) stated she did ask staff to give R3 a shower because R3's hair was not able to be combed out, R3 had an odor, and R3 had a denuded area under her breasts. Review of facility Bath/Shower Follow Up Question report, printed 2/6/23, shows R3 received only 3 showers between 1/1/23 and 1/31/23 (showered on 1/20/23, 1/27/23, and 1/31/23). The report shows the staff marked Not Applicable on 1/3/23, 1/10/23, 1/17/23 and 1/24/23 indicating no shower was offered. Hand-written shower sheets provided by V9 (Restorative Nurse), showed she provided R3 showers on 1/20/23, 1/27/23, and 1/31/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation she entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R3 was provided multiple showers by V9 (1/6/23, 1/13/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R3. The shower sheets showed V9 only provided R3 showers on 1/20/23, 1/27/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R3 did not receive showers on 1/6/23, 1/13/23, 1/17/23, 1/20/23 and 1/21/23. V12 stated the CNAs responded, Not Applicable in the computer when the task comes up in the computer and it is not the resident's shower/bath day. V12 stated no baths were provided to R3 on those days. ADL care plan, revised 2/6/23, shows R3 required two staff assistance with bed mobility, transfers, toileting, grooming and bathing. The revision shows, Often declines ADL cares - showers, repositioning then says she was not offered care. Intervention, revised 2/6/23, shows, Provide resident with a sponge bath when a full bath cannot be tolerated. If [R3] declines cares offer her a different time. Re-approach- re-attempt task. Alteration in skin integrity care plan, revised 1/6/22, shows R3 was at risk for an alteration in skin integrity and refuses to allow staff to provide incontinence care in a timely manner and to turn and reposition off a skin tear to thighs. Interventions include staff to provide toileting and incontinence care with care rounds and as needed as well as turn and reposition every two hours as needed. Transfer care plan, dated 12/13/22, shows R3 requires the use of a mechanical lift for transfers. On 2/8/23 at 2:43 PM, V12 stated the care plan for R3 was inaccurate that R3 declined ADL cares including repositioning, incontinence care and showers. V12 stated she had worked with R3 every day for a couple of years and R3 never refused her offers of showers, incontinence care, or turning/repositioning. On 2/8/23 at 12:24 PM, V1 (Administrator) stated V21 (Corporate Consultant) altered R3's care plan on 2/6/23. Attempts to reach V21 were unsuccessful. 4. Face sheet, printed 2/2/23, shows R10's diagnoses included pressure ulcer right heel, dementia, Alzheimer's disease, adult failure to thrive, restlessness and agitation, and legally blind. MDS, dated [DATE], shows R10 was severely cognitively impaired, was totally dependent on staff for bed mobility, transfers, dressing, toileting, required extensive assist from staff for bathing, eating, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/26/22, shows R10 was at only mild risk for the development of pressure ulcers. Impaired skin integrity care plan, revised on 2/21/22, shows R10 was admitted with an alteration in skin integrity / pressure injury and interventions included R10 was to receive incontinence care with care rounds and as needed. Transfer care plan, initiated 12/29/22, shows R10 required the use of a mechanical lift for transfers and interventions included providing two staff assistance for transferring. Incontinence care plan, revised 12/29/22, shows R10 was incontinent related to dementia and interventions included provide assistance for toileting. On 2/1/23 at 9:30 AM, R10 was sitting reclined in her reclining wheelchair just outside the third floor dining room doorway. R10 yelled, I have to pee! What am I gonna do!? V7 (RN-Registered Nurse) responded to R10 and stated, Go ahead and pee. They will change your brief in a little bit. R10 responded to V7 and stated, That's embarrassing! Oh Lord! V7 then looked away from R10 and stated, She's a [mechanical] lift. R10 continued to ask to go to the bathroom and V7 left R10's vicinity. At 9:33 AM, V7 stated R10 was very demented and incontinent. R10 was observed sitting in her wheelchair on 2/6/23 from 9:47 AM-1:30 PM without being repositioned or having her incontinence brief checked/changed. R10 was noted with large amounts of facial hair, uncombed and matted hair, and strong body odor. R10's clothing was soiled with food and debris along with her chair. 5. Care plan, initiated 9/27/22, shows R4's diagnoses included dementia, cerebral infarction without residual deficits, muscle weakness, chronic obstructive pulmonary disease, non-pressure chronic ulcer of skin, chronic kidney disease, and diabetes. The ADL care plan, revised 9/27/22, shows R4 required assistance with transfer, bed mobility, hygiene, toileting and bathing. The care plan interventions included assisting R4 with ADLs and utilizing a mechanical lift for transfers. Skin integrity care plan, revised 9/27/22, shows R4 was at risk for alterations in skin integrity related to poor skin turgor, dementia, poor hygiene, dermatitis to scalp and feet, incontinence of bowels and bladders, and noncompliant with ADL care including turning, positioning, and incontinence care. The care plan shows R4 had chronic on and off redness to buttock and scrotum and a non-pressure wound to the right great toe and left second toe. Interventions included incontinence care with care rounds and as needed and turn and reposition as per schedule and as needed. Transfer care plan shows R4 required the use of a mechanical lift and two staff assisting R4 for transfers. Incontinence care plan shows R4 experienced bowel/bladder incontinence due to prostate enlargement and an inability to delay voiding. Interventions included checking R4 for incontinence. Repositioning care plan, revised 9/27/22, shows R4 required assistance from staff for bed mobility and was unable to turn/reposition himself in bed without physical assistance. Interventions included providing R4 weight bearing assistance as needed while sitting up, laying down, or turning side to side in bed. MDS, dated [DATE], shows R4 was severely cognitively impaired, required total assistance from staff for bathing, transfers and toileting, required extensive assistance from two staff for bed mobility, dressing, and required the extensive assistance of one staff for personal hygiene. The MDS shows R4 was always incontinent of bowel and bladder. Braden scale, dated 12/13/22, shows R4 was at mild risk for pressure ulcer development On 2/1/23 at 9:19 AM, R4 was sitting in the third-floor dining room slightly reclined in his wheelchair and finishing breakfast. On 2/1/23 during continuous observation between 9:19 AM and 12:19 AM, R4 sat in the same reclined position with no staff repositioning R4 and no staff checking/changing R4's incontinence brief. At 12:19 PM, R4 was taken to his room to have his incontinence brief checked/changed. On 2/6/23 R4 was again observed in his wheelchair from 9:15 AM until 1:36 PM and R4was not repositioned or checked for incontinence. R4 was noted with long jagged fingernails with a brownish substance underneath. R4 had food crumbs and debris on his clothing and face. R4 had dirty greasy hair, long facial hair, and strong body odor. At 1:36 PM, V13 (CNA) proceeded to provide personal care to R4. R4 was noted with saturated brief and hard dried fecal matter. R4's right buttock area was noted to be red and inflamed. V13 needed numerous wipes to clean the dried fecal matter from R4's buttock and anal area since the stool was dried. V13 stated that R4 will scratch his buttock and that is why R4 has fecal matter under his nails. V13 stated that this was the first time he had to change R4 since they only had 2 nurse aides on the floor. R4's skin assessment sheet dated February 7, 2023, documents that R4 has a pressure injury on the left buttock measuring 5.5 by 0.5 by 0.1 centimeters and another injury on the sacrum measuring 5.0 by 0.5 by 0.1 centimeters. 6. Face sheet, printed 2/1/23, shows R2's diagnoses included incontinence without sensory awareness, dementia, depression, and cervicalgia. MDS, dated [DATE], shows R2 was cognitively intact, was totally dependent on staff for transfers, required the extensive assistance of two staff for bed mobility and toileting, required the extensive assistance of one staff for bathing, dressing and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 11/11/22, shows R2 was at mild risk for development of a pressure ulcer. On 2/1/23 at 2:39 PM, R2 stated there were often only two CNA staff for the whole second floor of residents. R2 stated she sometimes waited 12-15 hours for her soiled briefs to be changed. R2 stated her last bed bath was 1/20/23 and before that she had not had a shower in a long time because there were not enough staff at the facility. R2 stated at times there is only one CNA working the entire second floor on a AM or PM shift. R2 stated the staff only reposition her when they change her incontinence brief. R2 stated the staff typically change her incontinence brief approximately three times a day - usually at 4:00 AM during the PM shift, at 10:00 AM after breakfast, and then at approximately 9:30 PM before she goes to sleep. On 2/8/23 at 2:43 PM, V12 (CNA/Scheduler) stated R2 preferred her showers on the AM shift per her shower schedule which had been followed for years. Review of Bath/Shower Follow Up Question Report, printed 2/6/23, shows R2 received only 4 showers from 1/1/23 to 1/31/23 (showered on 1/17/23, 1/24/23, 1/27/23, 1/31/23). The report shows on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 the CNA responded, Not Applicable in the computer. Review of hand -written shower sheets, provided by V9 (Restorative Nurse), shows R2 received showers by V9 only on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. No hand-written shower sheets were provided for 1/3/23 and 1/10/23. On 2/6/34 at 3:50 PM, V9 (Restorative Nurse) stated the documentation entered on 2/2/23 on the Bath/Shower Follow Up Question report showing R2 was provided multiple showers by V9 (1/3/23, 1/10/23) was not accurate and provided hand-written shower sheets which accurately showed the showers she provided for R2. The shower sheets showed V9 provided R2 showers on 1/17/23, 1/24/23, 1/27/23, and 1/31/23. On 2/6/23 at 9:40 AM, V12 (Scheduler/CNA) stated R2 did not receive showers on 1/6/23, 1/13/23, 1/20/23 and 1/21/23 because the CNAs responded, Not Applicable in the computer. V12 stated facility CNAs mark Not Applicable on the bath/shower task when the task comes up in the computer and it is not the resident's shower/bath day. ADL Care Plan, revised 11/18/22, shows R2 required staff assistance with ADLs related to weakness and pain. Interventions included one staff assistance for bed baths, assist with ADLs as needed, check for skin changes during bathing, Intervention, revised 7/24/18, shows R2 prefers bathing after dinner between 8:00 PM and 9:00 PM. On 2/8/23 at 2:31 PM, V12 (Scheduler/CNA) stated R2 prefers showers in the AM which had been her shower schedule for years. 7. Care plan, revised 9/22/21, shows R7's diagnoses included dementia, bipolar disorder, psychotic disorder, depression, and anxiety. Care plan, revised 9/21/21, shows R7 had a potential for impaired skin integrity and interventions included turning and repositioning every two hours as needed. MDS, dated [DATE], shows R7 was severely cognitively impaired, required the extensive assistance of staff for bathing, bed mobility, transfers, dressing, toileting, and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 9/30/22, shows R7 was at mild risk for the development of pressure ulcers. On 2/1/23 at 9:19 AM, R7 was sitting in her wheelchair finishing her breakfast in the third-floor main dining room. On 2/1/23, during continuous observation between 9:10 AM and 12:05 PM, R7 sat in her wheelchair without staff repositioning R7 or checking/changing R7's incontinence brief. At 2:05 PM, R7 was toileted by V5 (CNA). V5 stated he got R7 up from bed at approximately 8:00 AM and checked/changed R7's incontinence brief at that time. R7's incontinence brief had a very strong smell of urine. 8. Face sheet, printed 2/1/23, shows R9's diagnoses included dementia, anxiety, and depressive disorder. MDS, dated [DATE], shows R9 was severely cognitively impaired, was totally dependent on staff for bathing, required the extensive assistance of two staff for bed mobility and transfers, required the extensive assistance of one staff for dressing, eating, toileting and personal hygiene, and was always incontinent of bowel and bladder. Braden scale, dated 12/2/22, shows R9 was at mild risk for development of a pressure ulcer. On 2/1/23 at 9:24 AM, R9 was laying in her bed in her room on her back sleeping with a thick blanket covering her body from her toes to her neck. The room temperature was very warm. During continuous observation, R9 was laying in the same position without incontinence check/change or repositioning from 9:24 AM to 12:29 PM. As R9 laid in bed, R9's cheeks became more red and at 12:08 PM R9 pulled the blanket down from her chin to her chest. On 2/1/23 at 12:16 PM, V18 (Assistant Administrator) stated R9

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident identified as a high risk for elopement was provided adequate supervision to prevent elopement from the facility. This failure resulted in R1 eloping from the facility without being witnessed on December 8, 2022. R1 was found across a six lane busy road at a gas station and required warming with blankets from emergency medical services. R1 was found at approximately 4:57 AM. At the time of R1's elopement, V9 (RN/Registered Nurse) and V10 (CNA/Certified Nursing Assistant) were the staff members working on the unit R1 resided. V9 and V10 were responsible for monitoring 44 residents, and of the 44 residents, 16 residents required every 30 minute observations. This failure resulted in Immediate Jeopardy. This applies to 5 of 5 residents (R1-R5) reviewed for safety and supervision from the total sample of 16. The Immediate Jeopardy began on December 8, 2022, when R1 eloped from the facility without being witnessed by facility staff. R1 was found at a gas station, across a six lane, busy road. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on December 12, 2022, at 11:47 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on December 9, 2022, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: On December 9, 2022, at 10:47 AM, the facility provided an undated list entitled At Risk of Elopement. The list identified R2-R16 as residents at risk of elopement who were residing on the first floor. On December 9, 2022, at 10:20 AM, V2 (DON) said staff are to perform every 30 minute observations on residents who's BIMS (Brief Interview for Mental Status) Score decreases and if the resident is not residing on the third floor of the facility. 1. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses including: chronic kidney disease, dementia, and atrial fibrillation. R1's MDS (Minimum Data Set) dated October 4, 2022, showed R1 was moderately cognitively impaired and required supervision of facility staff for locomotion on and off the unit. R1's elopement care plan revised on December 8, 2022, showed [R1] is noted to have short term memory deficits and having difficulty in recall. [R1] is sometimes/often exploring/elopement/exit seeking as evidenced by: can't find place he wants to go. Attempts to get on elevator. Attempts to use alarmed, fire exit doors. The care plan continued to show multiple interventions date February 17, 2022, including, Orient resident to surroundings and situation as needed. Facility documentation titled, Exit Seeking/Wandering/Elopement Risk Assessment, dated October 4, 2022, showed R1 was at risk for elopement. On December 9, 2022, at 10:20 AM, V2 said R1 eloped from the facility using a side exit door. V2 continued to say R1 said he left the facility to go buy a soda. On December 9, 2022, at 1:40 PM, V9 (RN) said she was working when R1 eloped. V9 said the last time she saw R1 was around 4:25 AM and R1 was sleeping in his bed. V9 continued to say around 4:55 AM, V9 was on the opposite side of the unit where R1 resided. V9 said she was returning to the nurse's station and heard the exit door alarm sounding. V9 continued to say she did not hear the alarm until she was closer to the nurse's station. V9 said she was unsure how long the alarm was sounding for. V9 said emergency services dispatch called the facility and told V9 that R1 was across the street at the gas station. On December 12, 2022, at 9:40 AM, V10 (CNA) said she was working when R1 eloped from the facility. V10 continued to say she was providing care to a resident on the opposite side of the unit from where R1 resided. V10 said she did not hear the door exit alarm when R1 eloped from the facility. V10 continued to say emergency services dispatch called the facility and asked if the facility had a resident named [R1]. V10 said her and another facility staff member went to the gas station where R1 had eloped to and when V10 arrived, R1 was receiving care by emergency services inside of an ambulance. On December 9, 2022, at 1:07 PM, V11 (Fireman) said he was working on December 8, 2022, and responded to the gas station where R1 was found. V11 continued to say eye witnesses at the gas station said R1 was at the gas station for about an hour. V11 said when emergency services arrived at the gas station it was cold outside and R1 was very cold, requiring blankets to help warm him. V11 continued to say the street R1 crossed is a busy street and R1 had to cross six lanes to get to the gas station. On December 9, 2022, at 12:32 PM, R1 was standing near the elevator on the third floor of the facility. R1 said Why would I leave the facility to get a soda when I can just go in the basement? On December 9, 2022 at 1:30 PM, V7 (CNA) was completing documentation in the facility's elopement risk binder. V7 said the monitoring is for fall risk residents. V7 continued to say he completes hourly observations for residents at risk for falls. On December 9, 2022, at 10:54 AM, exit door alarms were checked with V3 (Building Director). The alarm on the exit door stops alarming once the door is closed. V3 said the alarm on the exit door stops once the door is closed, but there is a separate alarm at the nurse's station that sounds. V3 continued to say that staff can reset the door exit alarm at the nurse's station. Facility documentation titled Post Occurrence Documentation dated December 9, 2022, at 11:30 PM, by V2 showed, Report was received from [local] police that resident was noted lying on the ground from a gasoline station . 2. The EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including: chronic kidney disease, malnutrition, and dementia. R2's MDS dated [DATE], showed R2 had moderate cognitive impairment and required supervision for locomotion off the unit. R2's elopement care plan dated September 6, 2022, showed, [R2] can be considered an elopement risk related to current cognitive status. The care plan continued to show multiple interventions dated September 7 2022, including Will be on 30 minute monitoring. On December 9, 2022, V2 (DON) said nurses and CNAs are to complete the 30 minute observation tool located in the Elopement Binder. V2 continued to say the purpose of the 30 minute observation is for residents at risk for elopement, and staff should be documenting the location of the resident every 30 minutes. On December 9, 2022, at 11:59 AM, V1 (Administrator) provided copies of the 30 minute observation tools from the elopement binder for the dates of December 8, 2022 and December 9, 2022. On December 9, 2022, at 12:30 PM, V2 provided the 30 minute observation tools from October 13, 2022 to December 6, 2022. The facility did not have documentation to show R2's 30 minute observations were completed on December 8, 2022, from 12:00 AM to 5:30 AM and from 3:30 PM to 10:30 PM. 3. The EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including: heart failure, pacemaker, and cerebrovascular disease. R3's MDS dated [DATE], showed R3 had moderate cognitive impairment and required supervision for locomotion on and off the unit. R3's elopement care plan revised on September 2, 2022, showed [R3] is noted to have short term memory deficits. Resident can be considered an elopement risk related to current cognitive status. The care plan continued to show multiple interventions including the following intervention dated September 7, 2022, Will be on 30 minute monitoring. The facility does not have documentation to show R3's 30 minute observations were completed on December 5, 2022, from 3:30 PM to 11:30 PM and December 6, 2022 from 3:30 PM to 10:30 PM. 4. The EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia. R4's MDS dated [DATE], showed R4 had severe cognitive impairment and required supervision from facility staff for locomotion on and off the unit. R4's elopement care plan dated September 6, 2022, [R4] can be considered an elopement risk related to current cognitive status. The care plan continued to show the following intervention dated December 7, 2022, Will be on 30 minute monitoring. On December 12, 2022, at 3:13 PM, R4 was standing in the hallway and said an old woman is walking around wanting to take his hair. R4 was able to ambulate independently into his room. The facility does not have documentation to show R4's 30 minute observations were completed on December 5, 2022, from 3:30 PM to 11:30 PM and December 6, 2022 from 3:30 PM to 10:30 PM. 5. The EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, alcohol dependence, and psychosis. R5's MDS dated [DATE], showed R5 had moderate cognitive impairment and required supervision from facility staff for locomotion on and off the unit. The MDS continued to show R5 was steady at all times when walking. R5's elopement care plan revised on December 12, 2022, showed, [R5] is at risk for impaired mobility with diagnosis of Parkinson's disease or other movement disorder. [R5] is at risk for elopement due to diagnosis of Parkinson's with impaired cognition. The care plan continued to show the following intervention dated, December 12, 2022, Complete 30 minute checks. On December 9, 2022, at 10:47 AM, the facility provided an undated list entitled At Risk of Elopement. R5 was included on the At Risk of Elopement list. On December 9, 2022, at 1:01 PM, V2 said staff are to complete the 30 minute observation tool for the residents on the At Risk of Elopement list. The facility does not have documentation to show R5 had 30 minute observations prior to December 9, 2022. The facility policy titled, EXIT SEEKING/ELOPEMENT VS. AN UNPLANNED DISCHARGE POLICY AND PROCEDURE, revised on 11/2017 showed, POLICY: Staff of [facility] will strive to respect the independence and dignity of all residents, as well as their right to self-determination by honoring all requests to be discharged , as most residents are voluntarily admitted to the facility. This will be done in a manner that also respects the facility's legal responsibility as well as the responsibility to maintain resident safety. An unplanned discharge incident is classified as a resident who is alert, oriented to at least three, is his/her own decision-maker, is not an immediate threat to him/herself or others and is making the decision to leave the facility. This includes not returning to the facility while out on pass and/or not returning from day program/community appointments without a proper discharge order. An exit seeking attempt/elopement incident is classified as a resident who is not alert, not oriented to at least thee, has a resident representative and/or is an immediate threat to him/herself or others and attempts/is successful in fleeing from the facility. PROCEDURE: . For an Elopement: Any resident who leaves under the following conditions will be considered to have eloped, and all elopement procedures will be followed: Resident is not considered to be alert and/or oriented times three. Resident has a legal/state guardian, Healthcare Surrogate, or active Power of Attorney and leaves without the permission of the responsible party. Resident is deemed to be an immediate risk to him/herself or others (e.g., suicidal, homicidal, etc.). Resident has been assessed at admission, quarterly, annually and episodically for elopement risk and is currently assessed as being 'At-Risk' for elopement . If a resident is evaluated at being 'At-Risk' for elopement, the following procedures will be implemented: 1. The resident's picture will be taken and provided to the nursing station of the unit the resident resides on and to the front office for monitoring of the front door to the facility. 2. Increased monitoring will be initiated if there is a change in condition for an elevated concern of elopement. 3. The resident will be re-assessed quarterly and/or as needed to continue monitoring the resident's behavior as it relates to elopement risk. The Immediate Jeopardy that began on December 8, 2022 was removed on December 9, 2022 when the facility took the following actions to remove the immediacy: Corrective Action Taken: Resident identified was placed on the third floor (locked unit) immediately on 12/08/2022 when the incident happened. Elopement risk assessment was performed on 12/08/22. Care plan was updated pertaining to elopement on 12/08/2022. Designated employee is assigned for door watch starting 12/09/22 every night, designated employee's job description is to watch the exit door for night shift. Emergency QA (Quality Assurance) meeting was held on 12/09/2022 with medical director pertaining to elopement and intervention in place. Identifying other residents having the potential to be affected by the same deficient practice: All resident's elopement risk were re-assessed on 12/08/22 and ongoing. All residents that are identified as at risk and high risk were care planned and pictures were placed in a binder on all floors on 12/08/2022 and ongoing. All residents with an active exit seeking behavior will be assigned on the third floor to keep resident away from the entrance door. Reassessments were performed on 12/08/2022. Exit doors were checked by building manager for patency of the alarms on 12/08/2022. Measures taken to ensure that the problem is corrected and will not recur: A review of Policy and procedure regarding elopement, in-service provided on 12/09/22 and ongoing. A designated employee started door watch on 12/09/2022. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur: A review of compliance using Quality Assurance Audit tool for elopement risk. A review of Quality improvement data collection pertaining to elopement risk. A review of compliance regarding patency of alarms on all exit doors using quality assurance audit tool. A review of quality improvement data collection pertaining to patency of exit doors. A review of results of audit regarding elopement and patency of exit doors with the facility's interdisciplinary team. Quality Assurance Plans to monitor facility performance: Audits on all residents requiring elopement risk and patency of exit doors will be reviewed to make sure that elopement risk was performed by the facility in a timely manner and identified residents were moved to designated floor either on second or third floor to keep residents away from the exit doors. Audits will be done weekly for four weeks, monthly times three months, and randomly by Administrator/designee. All audits will be reviewed by QA committee with evaluation of trends/patterns and corrective action implemented as indicated. Ongoing audit frequency will be based up goal attainment. Interdisciplinary team will review compliance weekly times four weeks, then monthly times three months, and randomly. Frequency will be based upon goal attainment. Compliance will be monitor using Quality Assurance tool for elopement risk by Administrator designee once a week for four weeks then monthly for three months and randomly, until concern with elopement is resolved. Administrator/designee will report the result of audits with the facility interdisciplinary team during the Quality Assurance and Performance improvement meeting.