**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R259s Face sheet documents an admission date of 07/30/24, with diagnoses of unspecified dementia severe with agitation, altered mental status, anxiety disorder, unspecified osteoarthritis, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, acute cystitis with hematuria and atherosclerotic heart disease of native coronary artery without angina pectoris. R259's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, which indicates severely impaired cognition. This MDS also documented R259 was dependent with eating, oral hygiene, toileting, and dependent with transfers. Under Fall History, R259's MDS documented on Admission/Entry or Reentry: R529 has had a fall within the last month. R259's Care plan, dated 07/31/24, documents a focus area of, '(R259) is at risk for falls related to: confusion, deconditioning, incontinence, psychotropic drug use, unaware of safety needs, dementia with agitation.' Interventions for this focus area include: 07/31/24 be sure call light is within reach and encourage to use it for assistance as needed. Needs prompt response to all requests for assistance, 07/31/24 ensure wearing appropriate footwear when transferring or mobilizing in w/c (wheelchair), 07/31/24 keep furniture in locked position, 07/31/24 keep needed items, water, etc, in reach, 07/31/24 maintain a clear pathway in room, free of obstacles, 07/31/24 monitor position in wheelchair to prevent sliding, 08/01/24 transfer require max assist of two. There were no further fall prevention interventions added after 08/01/24. R259's Fall Risk Evaluation, dated 08/11/24, documents a score of 15 which indicated R259 was at risk for falls. R259's untitled Fall report, dated 08/11/24 at 9:20AM, documented under incident Description: Nursing Description. Approached by (V37, Certified Nurse Assistant) who stated that resident fell from the bed. (V37) had gone into the room to help (R259) off the floor after seeing him crawl to the fall mat. (V37) stated that she got (R259) back in the bed facing toward the wall and stepped to the door to ask for assistance, when she did that, she said she looked back and (R259) threw his legs away from the wall and fell from the bed to his knees on the fall mat. (No injury) R259's untitled Fall report, dated 08/16/24 at 6:03PM, documented under Incident Description: Nursing Description. The nurse was called to the room by (R259's) roommate's family upon entering the room this writer observed (R259) lying in the floor on his left side. (No Injury) On 08/19/24 at 1:38PM, V38 (New MDS/Care Plan Nurse) stated she doesn't see any new fall prevention interventions put in place for R259 after his recent falls on 08/11/24 and 08/16/24. V38 said that has been one of the problems at the facility; lately there hasn't been new interventions put in place for anything. V38 said she was getting ready to take over the Minimum Data Set (MDS) position. V38 said no one at the facility gets trained correctly on their positions, and this is a problem because no one knows what they are supposed to be doing. On 08/19/24 at 2:05PM, V50 (MDS/Care Plan Nurse) stated there have been no new fall prevention interventions put in place for at least 2-3 weeks. V50 said they usually have a fall meeting to talk about causative factors and put new interventions in to place on all falls, but they have been busy with surveys and over half of the IDT (Interdisciplinary team) have been working on the floor or just not showing up to work. V50 said the floor nurses don't usually put any fall interventions in to place. V50 said she doesn't feel like they have enough staff right now to be able to care for the residents properly. V50 said that she was usually notified of any new falls, wounds, elopements, and any abuse. V50 said that since they have been short of staff that she thinks it has caused a negative impact on residents with them having increased behaviors. The Facility Policy titled Falls- Clinical Protocol, dated May 2024, documents in part under Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature of category of falling, until falling reduces or stops or until a reason is identified for its continuation. (for example, if the individual continues to try to get up and walk without waiting for assistance). 2. R85's face sheet documents an admission date of 10/23/23, with diagnoses including: hypoglycemia, cerebral palsy, other seizures, weakness, severe intellectual disabilities, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, and intermittent explosive disorder. R85's Minimum Data Sheet (MDS), dated [DATE], documents no brief interview of mental status (BIMS) should be conducted due to resident is rarely/never understood. Section GG - Functional abilities and goals documents: for roll left and right R85 needs substantial/maximal assistance. For the abilities of: sit to lying, lying to sitting on side of bed, sit to stand, and toilet transfer R85 is documented as: not applicable; not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. R85's care plan documents a focus area of: R85 is at risk for falls related to: confusion, deconditioning, gait/balance problems, psychoactive drug use, unaware of safety needs, and spasticity with an initiated date of 11/22/23. R85's interventions include: keep bed in lowest position at all times, second mattress placed beside bed and fall mat on other side of mattress with a initiated date of 10/26/23. On 08/13/24 at 2:11 PM, R85 was in bed, there was a fall mat by his bed. There was no mattress between his bed and the fall mat. On 08/14/24 at 2:01 PM, R85 was in bed, there was a fall mat by his bed. There was no mattress between his bed and the fall mat. On 08/15/24 at 1:42 PM, R85 was in his bed, there was a fall mat by his bed. There was no mattress between his bed and the fall mat. On 08/15/24 at 1:44 PM, V7 (Care Plan Coordinator) stated, she has only been at the facility for a couple of weeks. she stated R85 is supposed to have a mattress by his bed, then a fall mat by the mattress. V7 stated, he does not currently have the mattress by his bed, and he should since he is in bed. Deficiencies at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to ensure residents assessed as being at risk for elopement were supervised and interventions were implemented to prevent elopement for 2 of 3 (R96 and R162) residents reviewed for accidents and supervision in the sample of 51. This failure resulted in R96, who had a history of elopement, and was assessed as being at risk of elopement, exiting the facility when a visitor entered, without staff knowledge, walking half the length of the facility and re-entering through the kitchen door that is located at the end of the facility, and R162 exiting the facility through a window, crossing a busy highway, and walking approximately 1.3 miles without staff knowledge. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 8/3/24 when R96 exited the facility without staff knowledge. On 8/3/24 when a visitor entered the facility through the front door, R96 exited the facility without staff knowledge. R96 walked half the length of the facility and re-entered through the kitchen door. On 8/9/24, R162 left the facility through a window, without staff knowledge. The local police notified the facility R162 was at a local business located across a busy highway and approximately 1.3 miles from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 08/20/2024 at 1:18 PM. The surveyors confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 08/12/2024, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings Include: 1. R96's admission Record, with a print date of 8/16/24, documents R96 was admitted to the facility on [DATE], with diagnoses that include dementia, anxiety disorder, weakness, cognitive communication deficit, conduct disorder, delirium, major depressive disorder, and insomnia. R96's MDS (Minimum Data Set), dated 7/12/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. R96's current Care Plan documents a Focus area of, Is an elopement risk/wanderer related to: Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness. Date Initiated: 07/01/2024. This Focus area documents the following interventions: (electronic monitoring device) (wandering ) management system at all times. Date Initiated: 07/01/2024 .Resident to be seen by Geri-psych (geriatric psychiatry). Date Initiated: 07/31/2024. Psych NP (Psychiatric Nurse Practitioner) to do med review (medication review) and medication adjustment one on one care till (until) able to rest and sleep. Date Initiated: 07/15/2024.Initiate monitoring of change of behaviors after family visits. Date Initiated: 07/18/2024. Implement one to one observation anytime resident begins wandering hallways, displaying anxiety after family visits and attempts exit seeking. Date Initiated 07/16/24. Front door to remain locked, and sign posted for visitors to ring doorbell and visitors can now only enter with staff assistance. Date Initiated: 08/08/24. Sign to be posted at front and back entrance for all staff and visitors to look behind them before opening door and re-direct (R96) away from doorway before entering or exiting. Date Initiated: 08/08/2024.Check (electronic monitoring device) battery function weekly and PRN (as needed). Date Initiated: 07/01/2024.Check (electronic monitoring device) placement every shift and PRN (as needed). Date Initiated: 07/01/2024. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 07/01/2024.Monitor for fatigue and weight loss. Date Initiated: 07/01/2024.Offer a warmed blanket. Date Initiated: 07/01/2024.Offer reassurance appropriate to the concern. Dated Initiated: 07/01/2024. Offer to take to a scheduled or planned activity. Date Initiated: 07/01/2024.Offer to take to the toilet or assist with continence care. Date Initiated: 07/01/2024. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: 07/01/2024 .Redirect resident when wandering or exit seeking. Date Initiated: 07/01/2024. Resident is to be one on one anytime the resident starts to wander, and exit seek. Resident is to remain one on one until behavior resolves. One on One is to be implemented every time this behavior occurs. Date Initiated: 8/15/2024. Return to bed for additional rest or comfort. Date Initiated: 07/01/2024. Scan (electronic monitoring device) every shift for battery percentage, ensure placement and skin integrity. Location: LLE (left lower extremity). Date Initiated 08/05/2024. Use distraction to change thought pattern. Date Initiated: 07/01/2024. R96's Elopement Evaluation, dated 7/10/24, documents a score of 04, indicating R96 is at risk of elopement. R96's Elopement Evaluation, dated 8/6/24, documents a score of 08, which indicates R96 is at risk of elopement. R96's Elopement Evaluation, dated 8/14/24, documents a score of 09, which indicates R96 is at risk of elopement. R96's Progress Notes, dated 8/3/24, documents, (V21, LPN/Licensed Practical Nurse) advises resident had left the building and no alarm sounded. Found the (electronic monitoring device) was malfunctioning r/t (related to) placement and extra socks. Contacted ADON (Assistant Director of Nurses - V2 RN/Registered Nurse) and reported resident leaving the building. Awaiting further direction at this time. POA (Power of Attorney) aware. One on one direct supervision with resident directly after occurrence until confirmed wanderguard placement and activation. A Facility Incident Report regarding R96, dated 8/3/24, documents, IDT (Interdisciplinary Team) met and reviewed incident. Complete head count was conducted. NP (Nurse Practitioner) and POA (Power of Attorney) notified. Investigations immediately conducted. Staff, resident and visitor interviews conducted. (R96) was seen ambulating the long-term care hallways on video camera. Then (R96) was seen at (name) nursing station with (V32, CNA/Certified Nursing Assistant). At 3:15 pm a visitor was entering front entrance facility when (R96) exited the facility. Visitor told (R96) she is not supposed to be outside. (R96) told visitor 'well I am going outside'. Visitor proceeded down to his father's room and did not inform the facility staff that a resident had exited the facility. (R96) walked out the front entrance and immediately re-entered the facility through the dietary door. The dietary staff took the resident to the (name) nurse station and informed the nurse that (R96) came into the dietary exit door from outside the facility. When the staff started checking (R96) (electronic monitoring device) the visitor stated I forgot to tell you that she went outside when I was coming in. (R96) (electronic monitoring device) transmitter was checked, and the red light was blinking. Blinking light indicates transmitter is active. When the transmitter was checked with the transmitter tester it indicated the transmitter was active. All resident (electronic monitoring device) transmitters were checked for the red blinking light, checked with transmitter tester and at each exit door and all alarms sounded. All staff was in-serviced with elopement policy, checking transmitters for red blinking light and checking with transmitter tester. Visitors inserviced upon entering facility not to let residents out and to immediately notify staff if it occurs. Medication review was completed, NP (Nurse Practitioner) and POA (Power of Attorney) updated, Care Plan Updated. Front door was locked, and sign posted for visitors to ring doorbell and visitors can not only enter with staff assistance. 15 minute safety checks were initiated. NP and POA updated. Care Plan updated. On 8/14/24 at 10:01 AM, V21 (Licensed Practical Nurse/LPN) stated she didn't recall what happened on 8/3/24 when R96 left the facility without staff knowledge. R96's progress note, dated 8/3/24, was reviewed with V21 and she stated, No., when asked if she could recall the events. On 8/14/24 at 10:03 AM, V31 (CNA/Certified Nursing Assistant) stated she was in with another resident, and when she came out, a nurse (V21) was walking with R96, and stated the kitchen staff just let R96 in the back door. V31 stated she never heard the alarm sound. V31 stated they kept R96 with them after that, because they do 15-minute checks when R96 has elopement behaviors. V31 stated she was walking with a visitor to let them out the front door, when the visitor said R96 got out the door when they came in. V31 stated the visitor tried to stop R96, but she said she was going. V31 stated that is when they started locking the front door. When asked if the door alarm should sound even if it was opened by a visitor, V31 stated it should, and they had checked R96's (electronic monitoring device) and it was on, and the battery level was working. V31 stated she didn't know why the alarm didn't sound. V31 stated they have a little box they hold up to the bracelet, and it will say if it is on and check the battery level. V31 stated there is also a blinking light on the bracelet, and if it is blinking, it means the bracelet is working. When asked if there was a way to see if the alarm would sound, V31 stated they took R96 to the door to see if would sound. V31 stated she wasn't there when it was checked. V31 stated they check the bracelet daily, and have always checked placement, and if the light on the bracelet was blinking. V31 stated she had forgotten they could check the battery level with the box. V31 stated they were shown how to check it after R96 eloped on 8/3/24. V31 stated R96's wanderguard was working, and they have no idea what happened. On 08/14/24 at 12:28 PM, V33 (Dietary Aid/Cook) stated she was working on 8/3/24 between 3:00 and 3:30 PM, when R96 came into the kitchen. V33 stated they thought it was V30 (Dietary Manager) coming in the door, but when it opened it was R96. V33 stated the door she entered is down by the dumpsters, near the stop sign on the south side of the facility. V33 stated she took R96 to the unit, and she was unable to locate the nurse. V33 stated once she found V21 (LPN), she (V21) got an attitude and then came back into the kitchen and told them to mind their own business; she had gotten R96 another (electronic monitoring device). V33 stated she never heard an alarm sound. On 8/14/24 at 10:05 PM, V35 (Anonymous) stated she was down the hall doing treatments, when V21 stated to her the kitchen staff said R96 was outside, and knocked on the Dietary door. V35 stated V21 walked R96 up to the front door to see if the door would alarm, and it didn't. V35 stated R96 was then placed on one to one, and V21 left the floor. V35 stated she thought V21 was calling to report the elopement to management, but she didn't. V35 stated she called V2 (Assistant Director of Nursing/ADON) to report it. V35 stated she later found out, R96 pushed past a visitor that was entering the facility and was let outside. V35 stated R96 was placed on one to one after the incident. V35 stated she didn't go with V21 when she walked R96 to the front door to see if the alarm would sound. When asked why it wouldn't alarm, V35 stated it may be an equipment malfunction. V35 stated they had training after the incident on how to check the battery and how to check for placement. V35 stated they placed a new (electronic monitoring device) bracelet on R96 after the incident, and they verified everyone else's (electronic monitoring device)were working. V35 stated she knows now how to check the bracelets. V35 stated they have a device that checks the battery. V35 stated she didn't have any idea how to use it before the incident, but now she does. When asked if she was aware they could check the battery's prior to this incident, V35 stated, No, not a clue. V35 stated prior to this incident where they documented the checks, it said to check placement. V35 stated so they were checking placement, not to make sure it was working properly. On 8/14/24 at 1:56 PM, V34 (Plant Operations Manager) stated they check the (electronic monitoring device) weekly, and staff check each day. V34 stated maintenance checks all the door alarms, but doesn't check the individual bracelets. V34 stated the nurses check the individual bracelets. V34 stated the nurses have a tester on the med cart, and it reads the warranty date, serial number, and tells if the battery is good. V34 stated if the battery is not good, it says it is zero, and to replace it. V34 stated they should be tested daily. V34 stated he is sure it is a manufacturer recommendation. V34 stated they are getting ready to enhance the system they have. When asked why the alarm didn't sound, V34 stated they called him and he in-serviced everyone, but R96's alarm was functioning properly. V34 stated they figured out staff had put the code in for another resident, and there is a 30 second delay on the door alarm, and before that 30 seconds was up the visitor let R96 out. The (electronic monitoring device) manufacturer recommendations were provided by V34, and they document the following, Testing Tags Accutech Tags operate by internal battery. Over the course of normal operations, Tags (wanderguards) eventually lose battery power and the Tags will need to be replaced. The Tag battery is not replaceable. For maximum protection of residents or assets, Accutech recommends that tags be tested on a weekly basis. There are many ways that you can test Tags: Enter a monitored zone, With an S-TAD, the Keypad's Auxiliary LED (Yellow) will light when a Tag is detected (Optional: additional wire required). Check Visual Pulse LED if present. On 8/14/24 at 4:40 PM, V1 (Administrator) stated on 8/3/24, she got a call at home telling her R96 eloped, and they didn't know how she got out. V1 stated R96 left out the front door and came in the Dietary door. V1 stated she came to the facility and when she got there, they went through the entire building because the staff were all questioning the alarm system. V1 stated apparently a visitor came in, and R96 was trying to leave. V1 stated the visitor told R96 he didn't think she was supposed to leave, and she did anyway. V1 stated the visitor said he forgot to tell anyone she left, until he heard staff talking about it. V1 stated she checked the cameras, and R96 was seen wandering the hallway by the time clock around 3:00 PM. V1 stated R96 was with V32 (CNA) at the nurse's station and then the visitor was coming in around 3:15 PM. V1 stated based on when kitchen staff take their lunch breaks, R96 entered the kitchen right before 3:30 PM. V1 stated they took R96 to the nurse and she was assessed. V1 stated no one remembers hearing an alarm. V1 stated the facility staff checked R96's (electronic monitoring device) and told her it was working, and then took R96 to the door, and no alarm sounded. V1 stated they first checked the alarm by the blinking light that indicates it was working, then they checked it against the door once, and it didn't work and then again, and it did work. V1 stated they got a different (electronic monitoring device) bracelet for R96, and it alarmed as it should. V1 stated they checked every resident's bracelet against all three doors, and they all alarmed as they should. V1 stated she decided they needed to lock the doors because they can't have visitors letting people outside and staff not know they are gone. V1 stated it may have been a delay on the alarm after the code was put in for someone else, but they can't say for sure that is what happened. V1 stated before this incident, staff were checking placement and to ensure the red light was blinking on the bracelet. V1 stated after this incident, the staff were educated to use the tester to make sure the battery was full. V1 stated they didn't use the tester on R96's bracelet until she came into the facility, and when she checked it with the tester, it was working as it should. V1 stated she had R96 assessed by the psychiatric nurse, and they did medication adjustments. V1 stated she was diagnosed with a urinary tract infection, but it wasn't a bad one. V1 stated after the elopement on 8/3/24, R96 was placed on one to one. R96's Resident Safety Checks reviewed, and do not document safety checks were being done on 8/3/24. 2. R162's admission Record, with a print date of 8/16/24, documents R162 was admitted to the facility on [DATE], with diagnoses that include unspecified dementia, altered mental status, anxiety disorder, cognitive communication deficit, weakness, insomnia, and suicidal ideations. R162's MDS, dated [DATE], documents a BIMS score of 09, which indicates a moderate cognitive impairment. R162's Elopement Evaluation, dated 7/31/24, documents a risk for wandering/elopement was identified. R162's Elopement Evaluation, dated 8/9/24, documents a score of 07, which indicates R162 is at risk for elopement. R162's current Care Plan documents a Focus area of, Is an elopement risk/wanderer related to: Impaired safety awareness, dementia with mood disturbance. Date Initiated: 08/01/2024. The interventions documented for this Focus area are Check (electronic monitoring device) battery function weekly and PRN (as needed). Date Initiated: 08/01/2024. Check (electronic monitoring device) placement every shift and PRN. Date Initiated: 08/01/2024 .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers watching television and being able to go out to smoke every couple of hours. Date Initiated: 08/01/2024 .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicated the need for more exercise: Intervene as appropriate. (R162) wanders purposefully looking for her family and wandering (sic) why she is here. Date Initiated: 08/01/2024. Offer a warmed blanket. Date Initiated 08/01/2024. Offer food or snacks. Date Initiated: 08/01/2024. Offer to take to a scheduled or planned activity. Date Initiated: 08/01/2024. Redirect resident when wandering or exit seeking. Date Initiated: 08/01/2024. Resident is to be one on one due to elopement out of the window. Date Initiated: 08/16/2024. Resident to be one to one at all times due to exit seeking behaviors. Date Initiated 08/16/2024. Use distraction to change thought pattern. Date Initiated: 08/01/2024. (electronic monitoring device) to be applied at all times. Date Initiated: 08/01/2024. R162's Facility Incident Report Form, dated 8/9/24, documents, Investigation conducted. IDT met and reviewed incident. Resident and staff interviews conducted. A visitor came to visit (R162) when it was discovered that (R162) could not be located. A full facility head count was conducted and determined (R162) was not in the building. All other residents were accounted for. Facility and facility grounds searched with no findings of (R162). While search was in process a staff member was notified by phone from the (local) Police department that (R162) was at the (name of business) on (name of road). Staff members then got into vehicle and went to collect (R162). (R162) was found safe with no injuries or any signs of distress. MD (physician) and Family member notified of resident elopement and safe entry back into the facility. Nurse completed full body assessment and vital signs upon reentry to facility with no abnormal findings. Safety checks initiated and (R162) was placed 1:1 at this time. (R162) admitted to kicking out the window screen and jumping out the window during interview which resulted in the alarm not sounding. Staff then assisted to check windows or any other possible site of exit. It was found on a closed Memory unit that a window was open with screen bent and had been kicked out. Upon these findings immediate interventions placed with placing a sign on the closed memory unit and placing an alarm on the closed doors that will sound anytime the doors are opened. Upon further investigation and interview with (R162) it is noted that (R162) was complaining of bilateral knee pain. Call placed to NP (Nurse Practitioner) (V5) with new orders for bilateral knee X-ray and UA (urinalysis) with culture if indicated. All labs and Xray results with negative findings. Staff continues to monitor resident for any changes in mood, status, or behavior. No changes noted. MD and family member updated on findings of investigation. Care plan updated. On 8/15/24 at 1:00 PM, V10 (Certified Nursing Assistant/CNA) stated she was working when R162 eloped. V10 stated R162 had called the police earlier that day. V10 stated she was working in the dining room, and everyone had been fed. V10 stated R162's family member came into the facility around 12:45 or 1:00 PM looking for R162 and they couldn't find her. V10 stated they searched each room and down the unit R162 lived on. V10 stated she didn't see R162 had opened a window. V10 stated V38 (MDS Coordinator) said the local police had pinged R162's phone and got her location. V10 stated they went to get her, and she was inside a place of business drinking water. V10 stated R162 was disoriented and confused. V10 stated she offered R162 a cigarette and told her they would call her family. V10 stated prior to his incident, R162 had never succeeded in eloping. V10 stated the window R162 went out was on the closed memory unit, and all the staff but one person was in the dining room, and that one person was passing meal trays. On 8/15/24 at 2:32 PM, V36 (CNA) stated she noticed right after lunch R162 was gone. V36 stated they looked through the whole building and outside, and there was a window on the closed memory unit that was open, and the screen was bent. V36 stated they assumed R162 went out the window because she was wearing a (electronic monitoring device) and no alarm went off. V36 stated they looked for approximately 20 minutes and was not able to locate R162. V36 stated R162 had been calling 911 all day that day. V36 stated V38 (MDS Coordinator) told her and V10 that R162 was on a nearby road. V36 stated then they got a call R162 was at a local business. V36 stated once they got to R162, she told them she went out a window. V36 stated R162 was very emotional, not angry or combative, just really sad. V36 stated they did a skin check when they got back to the facility. V36 stated she wasn't aware of R162 exiting the facility prior to this incident. V36 stated R162 had a (electronic monitoring device) on, and the light was blinking indicating that it was working. On 8/15/24 at 2:56 PM, V21 (Licensed Practical Nurse/LPN) stated she was working on the day R162 eloped, but she had no information related to it. V21 stated she knows nothing. On 08/15/24 at 4:05 PM, V3 (Infection Preventionist/Licensed Practical Nurse/LPN) stated she was working in the conference room, and sometime around 2:00 PM, she heard a page overhead that they needed a facility head count. V3 stated unknown staff told her R162 was missing. V3 stated they completed the head count and did not locate R162. V3 stated they had people searching outside the building and down the road. V3 stated they found an open window on the closed memory unit, with the screen bent, where it had been kicked out. V3 stated she thought V38 got a phone call stating they had R162 at a local business. V3 stated staff offered to go pick R162 up and bring her back to the facility. V3 stated R162 is a newer admission, they did an elopement risk assessment on her, and she was assessed as being at risk for elopement. V3 stated she wasn't aware of that risk prior to admission she thought she just had behavior/psychiatric issues. V3 stated when R162 got back to the facility they did an assessment, checked her vital signs, and called their corporate team, who had them place her on one to one observation. V3 stated she took R162's statement, and she was confused and didn't remember leaving. V3 stated she spoke with her later on and she said her knee was hurting. V3 stated when she asked her what she did to her knee, R162 stated it was probably when she kicked that thing out so she could escape. V3 stated they also placed an alarm on the closed memory units door so they would know if anyone entered the unit. When asked if she knew how long R162 had been gone, V3 stated she had been seen 30 minutes prior to them realizing she was missing. On 08/15/24 at 4:41 PM, V37 (CNA) stated around 11:30 AM, right before lunch, R162 came out of the activity room and handed her phone to her. V37 stated it was the local police, and R162 had called them and asked for help. V37 stated she explained to the police R162 was a confused resident. V37 stated R162 was sitting in the activities room. V37 stated she left and went to the dining room. V37 stated about 20 or 30 minutes later, after lunch the announcement went out for a head count. V37 stated she went out the back door with another CNA to look for R162. V37 stated she was checking windows, but didn't think to look on the closed memory unit. V37 stated her boyfriend, who also works at the facility, came to pick her up, so it was probably closer to 2:00 PM when they were looking for R162. V37 s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to ensure a resident was free from neglect when they failed to accurately assess, treat, and prevent a significant decline in condition for 1 (R1) of 3 residents reviewed for neglect in the sample of 24. This failure resulted in R1, who has a history of confusion with infections, experiencing altered mental status and refusing overall care after being diagnosed with a urinary tract infection. R1's refusals of care additionally led to R1 developing a Stage 3 pressure ulcer, an unstageable pressure ulcer with sepsis secondary to skin and soft tissue infection, subsequently requiring an 11-day hospitalization for IV antibiotic therapy. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 6/19/2024 when R1 was readmitted to the facility from a hospitalization. R1 was on a physician ordered treatment for urinary tract infection, yet the facility failed to implement interventions to prevent worsening of infection. R1 endured confusion with delusions related to infection, which led to refusal of medications and refusal of care with activities of daily living. R1's refusal of care included care with incontinence and repositioning, which led to development of pressure ulcers. R1's facility acquired pressure ulcers were not treated, and led to hospitalization on 7/2/2024 for sepsis related to infection of skin and soft tissue in relation to the stage 3 pressure ulcer and unstageable pressure ulcer. V1 (Administrator) was notified of the Immediate Jeopardy on 7/11/2024 at 2:12 PM. The surveyors confirmed by observations, interview, and record review the Immediate Jeopardy was removed on 7/17/2024, but the noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R1's admission Record documents R1 was admitted to the facility on [DATE]. R1's POS (Physician order sheet), dated 7/2024, list diagnoses that include angina pectoris, heart failure, GERD (Gastroesophageal Reflux Disease), unspecified dementia, unspecified severity with other behavioral disturbances, atrial fibrillation, type 2 diabetes mellitus, paranoid schizophrenia, chronic kidney disease stage 4, hypothyroidism, chronic peripheral disease, gout, and COPD (Chronic Obstructive Pulmonary Disease). R1's MDS (Minimum Data Set), dated 4/10/2024, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. The same MDS section GG documents R1 requires substantial/maximal assistance with toileting/hygiene and with shower/bathing, and R1 requires assistance for sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfers. R1's care plan, dated 4/12/2024, documents R1 has risk for skin impairment and risk for pressure injury related to impaired mobility/use of assistive device, chronic kidney disease, and cardiac issues. Documented interventions include: minimize exposure to moistures and keep skin clean and dry especially fecal contaminant, assist with turning and positioning approximately every 2 hours and more often if needed or requested, and notify nurse immediately of any new areas of skin breakdown. R1's care plan also dated 4/12/2024 documents R1 is considered at risk for abuse/neglect (per assessment) due to depression, being dependent on others, Schizophrenia. Documented goals include R1 will be free from harm secondary to abuse/neglect through the review period with interventions including Report any suspected of abuse/neglect to Administrator immediately. R1's Progress Note, dated 6/19/2024 at 7:45 PM, documents, (R1) was returned to the facility via ambulance from local hospital with orders for Augmentin 875-125 mg (milligrams) twice daily for 10 days to treat urinary tract infection with ESBL (extended spectrum be-lactamase) in the urine. The same note documents R1 was alert and oriented to person, place, and time, refused a skin evaluation and was refusing to take medications as ordered. R1's Nursing Notes documents on 6/21/2024 at 5:11 PM, referral information faxed to a behavioral hospital for possible placement related to (R1's) delusions, refusal of care, and verbal behaviors. R1's Progress Note dated 6/21/2024 at 3:08 PM, documents, Resident refused to get up out of bed. He is mumbling to himself unable to understand what he is saying. He refused to take all meds. He would not allow writer to take his vitals. He did allow (blood glucose monitoring) to be done in thumb only but refused sliding scale coverage. He did eat about half of his breakfast and lunch. R1's Progress Note, dated 6/23/2024 at 5:27, PM documents, Resident has been in room talking to people that are not there all day he was heard telling people to get out of his room and mumbling under his breath. He refused to get up this shift has refused all meds. He did allow (blood glucose monitoring) but not insulin. R1's Progress Note, dated 6/24/2024 at 2:28 PM, documents, Res (resident) refusing to take meds and insulins. Refusing to get out of the bed as well as get dressed. Res educated on the importance of taking meds. Res became verbally aggressive and argumentative. Res non-compliant. (V26, Physician) notified. R1's Progress Note, dated 6/27/2024 at 4:13 AM, documents, refused meds and meals for past 1-2 weeks. R1's Progress Note, dated 6/28/2024 at 3:26 PM, documents, CNA (Certified Nursing Assistant) states that resident has been incontinent of stool and is lying in his bed with genitals exposed and refusing to be changed. V23 (Nurse Practitioner/NP) present for conversation and aware of continued behaviors. R1's Progress Notes, dated 6/28/2024 at 3:44 PM by V2, documents, this writer spoke with (V23), NP (Nurse Practitioner) regarding (R1's) continued behaviors, (V23) reports that she spoke with (V26, Physician) about (R1) and stated they both feel that IM (Intramuscular) medication is needed but they are fearful for the safety of staff if they were to attempt to administer an IM medication to resident and therefore feel that a placement in a behavioral health facility is the best option at this time. On 7/1/2024 an order was given by (V18, Psychiatric Nurse Practitioner) gave an order for Haldol solution three times a day with meals. R1's Progress Notes, dated 7/1/2024 at 2:55 AM, documents, All shift resident has refused to let staff change him. Resident's bed is saturated in urine and dripping into the floor. Resident has a puddle of urine under his bed and was trailing to the door. Resident let staff clean the urine from his bed to the door but refused to let staff change him or clean under the bed. When cleaning under the bed was mentioned, the resident started yelling 'no' at the staff. Resident has been pleasant since that interaction and calling for needs. R1's Progress Note, dated 7/2/2024, signed by V2 (DON/Director of Nursing) documents, spoke with (V23) about resident's altercation with (R9) and CNA. (V23) immediately called (V26) and reported to (V26) (R1's) aggressive behavior. (V26) and (V23) agree that (R1) must be sent to ER for evaluation. (V26) advises to send resident to ER and to call local police if needed to assist EMS (Emergency Medical Services) with the transfer. (V26) states At this point you have to get (R1) out of there. What he has done tonight is assault and it is not safe for (R1) or other residents for him to remain in the building. Floor nurse (V7 Licensed Practical Nurse) notified of order to send to ER and transfer process begun at this time. R1's Progress Notes, dated 7/2/2024 at 6:45 PM, documents, (R1) was transported out by way of local ambulance service to local hospital after an altercation with (R9). Noted local police contacted and sent an officer in case assistance was needed due to acts of violence. R1's Shower Sheets, dated June 2024, documents R1 refused showers on 6/24/24 and 6/25/2024. The last documented shower R1 received was on 6/11/2024. There were no other showers documented indicating R1 did not receive a shower for 22 days. R1's Medication Administration Record (MAR), dated June 2024, documents Augmentin 875-125 mg one tab every 12 hours for bacterial infection for 10 days, start date of 6/19/2024. This same MAR documents from the dates of 6/19/2024 through 6/29/2024, R1 refused Augmentin 875-125 mg, 16 out of 20 offered dosages. The same document contains a physician order for another antibiotic of Levaquin 500mg, give one tablet by mouth one time a day for urinary tract infection for 7 days with start date of 6/20/2024, the same MAR documents R1 refused Levaquin 500mg 5 out of 7 offered doses. R1's Treatment Administration Record (TAR), dated 6/1/2024-6/30/2024, documents a physician's order for skin checks scheduled every Monday and Thursday with a start date of 9/17/2020. The TAR documents R1 refused the skin checks on 6/20/2024, 6/24/2024, and 6/27/2024. The same TAR documents a physician order for antifungal powder under bilateral breast folds, bilateral abdominal folds and groin every bedtime, start date of 11/22/2023. The TAR documents R1 refused treatment from 6/19/2024 to 6/30/2024. R1's local hospital ER (Emergency Room) record, dated 7/2/2024, documents R1 reports he is here to have his wounds on his bottom addressed. This is the only area of pain that he has. No other complaints. Calm and cooperative at this time in ER. The ER's Impression and Disposition notes under clinical impression documents the following: 1. Sepsis due to unspecified organism, unspecified whether acute organ dysfunction present. 2. Altered mental status, unspecified altered mental status type. 3. Cystitis. Differential Diagnosis includes but not limited to, UTI (urinary tract infection), Electrolyte abnormality, medication induced psychiatric illness. Hospital Progress Notes on 7/3/2024 at 1:36 AM documents Sepsis secondary to skin and soft tissue infection. Hospital Wound Care Notes on 7/3/2024 at 10:00 AM documents, wound care consult completed at this time. Patient noted to have ITD (Intertriginous Dermatitis) to bilateral axilla's, bilateral chest folds, bilateral abdominal flanks, bilateral groin, and inner thighs and to scrotum and coccyx. Patient noted to have evolving DTPI (Deep Tissue Pressure Injury) to right buttocks and Stage 3 pressure injury to left buttocks. Left buttocks, stage 3 wound measuring 4 cm (centimeters) length, 2.5 cm width, 0.3 cm depth and wound surface area 10 cm. Right buttocks DTPI measuring 3 cm length, 2cm width, 0.3cm depth and 6 cm wound surface area. The hospital records from the ER on [DATE] at 1:36 AM, indicates R1 was given IV (Intravenous) antibiotics of Vancomycin 2 gm (grams) and Levofloxin 750 mg (milligrams) after blood cultures were obtained. On 7/10/2024 at 11:17 AM, V9 (Certified Nurse Assistant/CNA) stated she sometimes takes care of R1. V9 stated, I had noticed for the last 2 weeks or more (R1) had not been acting himself. He has been refusing care and having bad behaviors. (R1) did get sent to the hospital and he is still there. On 7/10/2024 at 11:25 AM, V6 (Licensed Practical Nurse/LPN) stated she had taken care of R1, as he is on her hall. V6 stated, I noticed a change with (R1) the last 2 weeks. (R1) had been more violent and was refusing care. (R1) was supposed to be taking antibiotics for a urinary tract infection, but he was refusing his medications. V6 stated the floor nurses do treatments on the residents except for Thursdays because that is the day that the wound doctor comes to the facility. V6 stated she was not aware of any wounds on R1, and he was not getting any treatments. V6 stated she heard of his behaviors when he tried to pull another resident out of the bed. On 7/10/2024 at 11:20 AM, V5 (CNA) stated she always works 6am to 2pm shift. V5 states she normally takes care of R1. V5 stated, (R1) was always fine until the last few weeks, and he started refusing care. V5 stated, I did not know of any wounds on (R1). We tried to provide care to him, but he would get upset. On 7/10/2024 at 12:00PM, V7 (Licensed Practical Nurse/LPN) stated she works all halls here, and she is familiar with R1, as she takes care of him when she works his hall. V7 stated the floor nurses do the treatments on the residents. V7 stated, I was here when (R1) tried to pull (R9) out of bed. (R1) had tried to go into (R9's) room several times on that day and we had to keep redirecting him. I moved my medication cart down the hall closer to (R9's) room so that I could keep an eye on the situation. (R1) went into (R9 's) room and started yelling that (R9) was causing electrical shock to his beard and something about black stuff, then (R1) grabbed (R9's) foot and tried to drag him out of bed. When the CNA tried to separate them, (R1) hit (V14, Certified Nurse Assistant) in the abdomen, and (R1) had earlier grabbed (R9's) over bed table and threw it. I witnessed (R1) trying to grab (R9) out of bed. V7 was asked if she felt this was considered abuse to R9, she replied, No because (R1) did not do that intentionally because he did not know what he was doing. V7 stated, Prior to 2 weeks or so ago, (R1) was so sweet and real easy going. I was unaware of any wounds on (R1) until right before I sent him out to the hospital the last time on 7/2/2024. (V12, CNA) was helping try to get (R1) ready to be transported to the hospital and she noted a large wound to (R1's) buttocks, (V12) reported it to me immediately, but when I went into the room to assess the wound (R1) refused, so I did not get to even look at it. V7 was asked how often they did skin checks on R1, and V7 stated weekly. V7 stated they document those on the (MAR) Medication Administration Record. On 7/10/2024 at 3:55 PM, V12, CNA, stated she works the hall where R1 resides. V12 stated, I had taken care of (R1) for a long while. (R1) was always nice up until the last month to month and a half. V12 stated, (R1) was refusing all care as of lately. One day we went in his room, and (R1) was drenched in urine, the floor had urine everywhere, and the mattress was leaking urine on the floor and under the bed. It was bad. (R1) allowed us to clean the urine off the floor, but would not let them clean under the bed, clean him up or change the mattress out. V12 stated, We offered care for days before (R1) went to the hospital, but he just refused. When V12 was asked about any skin issues with R1 she stated, I would apply powder to his groin area prior to his refusal of care because it was gaulded, but on the day we were getting ready to send him out to the hospital, I noticed a big circular area on (R1's) bottom and it was bleeding pretty good. I then went to (V7, LPN) and told her, but (R1) refused to let (V7) look at it and then the ambulance came. I was not aware the big area on (R1's) bottom was there until that day. V12 stated R1 is wheelchair bound, but R1 can walk a few steps. On 7/11/2024 at 2:59 PM, V18 (Psychiatric Nurse Practitioner) stated she started seeing R1 about 2 years ago. V18 stated R1 told her he first started having issues like delusions/hallucination when he got a UTI. V18 stated, I was asked to stop the Zyprexa a couple of years ago because he didn't have the proper diagnosis to support giving it. (R1) was a very pleasant and very knowledgeable man that was always alert and oriented x 4. V18 stated she was not aware of any psychiatric problems over the past 2 years until recently. V18 stated she had gotten a couple of calls from the facility about R1's behaviors lately and R1 refusing care. V18 stated she had talked with V23 (Nurse Practitioner/NP) and the staff about giving some medication IM (intramuscular) so they could get him better, and hopefully R1 would start taking his regular medications, antibiotics, and especially his insulin. V18 stated, The nurses would not give the medications IM due to it being unsafe for the nurses and I was told they could not hold him down to administer it. V18 stated she expressed concerns with him not getting his insulin, and she even offered to come to the facility and give the IM injections herself. V18 stated, The facility declined my offer because they stated he would refuse. V18 stated at this point, he was harmful to himself and others. V18 was asked if she felt the UTI could have caused the hallucinations/delusions, she replied, Due to the infection effects, it possibly started when (R1) refusing medications then refusing care and has had a definite effect on his well-being. V18 stated she feels R1 is misdiagnosed, and she feels he does not have Schizophrenia. V18 stated, First, Schizophrenia is a mental illness that is continuous, and he has been off medications for 2 years with no issues. V18 then stated she feels like he has bipolar, and that is why he can go for a while without medications before any issues come up. V18 stated, Sometimes any type of infection can cause confusion and that leads to other issues in people that are normally not confused. On 7/12/2024 at 8:01 AM, V27 (Healthcare Power of Attorney for R1) stated, I was not sure where (R1) was at this time. Before coming to the nursing home, (R1) was at another hospital because he wasn't taking his medications and got violent. This all started with a urinary tract infection. Once he got over the infection, he went back to his normal self and did good. (R1) has been a preacher for several years. (R1) never had his own church, but helped churches and filled in when a pastor was not available. I didn't know he was back in the hospital. V27 was asked if she was aware an Involuntary Discharge had been issued to the resident from the nursing home, and she stated, No, I didn't know. V28 (family member) was present on the phone call and stated, His behaviors are always triggered by infections. V27 was asked if she was aware of any skin issues like wounds and she stated, No, I didn't know anything about this either. On 7/12/2024 at 8:40 AM, R1 was visited at the local hospital. R1 was sitting up in bed watching television. R1 was alert and oriented x 4. R1 stated he is feeling much better. R1 stated his bottom is not hurting like it was so he thought his wounds were healing. R1 stated he got the wounds while at the facility. R1 stated, When I get any kind of infection it goes to my brain for some reason, and I am not right when I do get an infection. R1 stated he wants to go back to the facility. R1 was asked if he was aware of possibly not being able to return to the facility and he said, No, I don't know anything about that. R1 stated he is taking his medication and he is taking his insulin when he needs it. R1 stated he must take medications for his Neuropathy; he stated it is Gabapentin and it does help me. R1 also stated he has hypothyroidism, and he takes Levothyroxine for that as well. R1 stated he was tired and was going to take a nap at this time. R1 then stated, I miss my friends at the facility, and I teach Bible study classes there as well. On 7/12/2024 at 8:25AM, V29 (Case Manager at local hospital) stated (R1) is doing much better now that the infection is better. V29 stated, Facility said if he was seen by Psych (inpatient) that he could come back, but the behavioral hospital denied him after review of his hospital course, and said it was a medical issue. V29 stated R1 is taking his medications and his wounds are healing. V29 stated he is showing signs of sundown syndrome, as he tries to refuse medications at night, but is fine throughout the day. On 7/12/2024 at 11:07 AM, V3 (LPN/Licensed Practical Nurse/Infection Preventionist) was asked to describe R1 prior to 6/19/2024. V3 stated R1 was alert and oriented x4, he led Bible Study at the facility. V3 stated she noticed his behaviors when they moved a roommate in with R1. V3 stated, The resident we moved in was on Enhanced Barrier Precautions, and this set (R1) off. (R1) became withdrawn and was going to the dining room, but was observed talking back to himself, but it escalated. He was saying things about his family coming through the backdoor and threw stuff on him causing skin issues. This was definitely a change in condition. We know when (R1) starts acting off, he is afraid of an infection. I believe he was freaked out about the roommate that we had moved in, but we didn't leave that roommate in there very long at all. (R1) will come and ask us to do a urinalysis when he thinks he is getting a UTI because he is scared to get any kind of infection. We had received orders for urinalysis, but (R1) was refusing to give us a urinalysis for several days. He finally went to the ER because of his groin pain and cellulitis. V3 explained what happened once he returned from that hospitalization. V3 stated, Well, the hospital stated he was taking his medications, but we found out later that he did not take medications there either, and he had ripped out his IV's. V3 stated R1 returned 6/19/2024, with antibiotic orders for UTI. He was still having delusions and was refusing medications, and he was refusing care. When V3 was asked if the Healthcare Power of Attorney was called, she stated, I believe she was, but every time we talk to her, she is always saying (R1) wants attention, and he knows I am busy with my son who has cancer. V3 stated The hospital can do more than we can, he is a bigger guy. V3 was asked, since she was the Infection Control Preventionist Nurse, was she looking at R1 from an infection standpoint, V3 replied, I was focused on the behaviors more, but he wouldn't let me screen him about infections, and I believe half of his problems were stemming from infections. V3 was asked if she was aware of his wounds and she stated, No, I do not do skin checks or deal with wounds. V3 stated she was with V2 when they went to the hospital to give IVD (Involuntary Discharge) papers. V3 stated, (R1) was alert, but I questioned if he understood what all we were reading and telling him, about the appeal process. V3 was asked about the lack of care, especially from 6/19/2024 through 7/2/2024. She stated, We tried to do more for (R1), and we felt if we sent him to the hospital that they would just send him right back. When (R1) tried to pull another resident out of bed, this was an isolated incident besides hitting the CNA in the stomach. Again, we looked more at the psych and behaviors even though we knew he did this with infections. V3 stated, I am going to review the updates, but I did see the pictures of his wounds that were taken at the hospital, and they didn't look good, but I did not know he had those. On 7/12/2024 at 9:40 AM, V2 (Director of Nursing/DON) was asked to explain issues with R1, from the time of readmission from the hospital on 6/19/2024. V2 stated, (R1) had been having unusual behaviors like, refusing medications, he would say that he didn't need his medications, and he was refusing care up until he went back to the hospital on 7/2/2024. (R1) was sent out to the ER at his request on 6/16/2024 because he was having pain in his groin area. He was admitted for cellulitis of the groin area then noted to have a urinary tract infection (UTI). (R1) was being seen by the wound doctor for the yeast on his groin area, but had refused to allow the wound doctor to see him the last couple of times. (R1) came back on 6/19/2024, was refusing medications including antibiotics for UTI. We were trying to get him into a behavioral facility because of his Psych (psychiatric) issues. I was aware (R1) was refusing all care most of the time. V2 stated she received a call one night from the facility that (R1) had so much urine everywhere in his room, his mattress was saturated and leaking on the floor, the urine was even running out into the hallway. (R1) would only let the staff mop the hallway and barely in his room. V2 was asked if care was provided at that time to clean up R1 and change out the mattress, V2 stated, (R1) would not let the staff clean anything else. I was looking more at the Psych issues than I was the medical issues. During interview, V2 reviewed the shower sheet documentation for R1 from the time of readmission 6/19/2024 until R1 went back out to the hospital on 7/2/2024, and there were no showers given due to refusals. V2 stated, I was not aware of any wounds on (R1), and nobody reported wounds to me, and I do all the wounds in the facility and round with the wound doctor on Thursdays. V2 stated, We did call the EMS (Emergency Medical Services) on 6/10/2024 and for (R1) to go out to the ER, but EMS would not take him because he refused, and he was able to answer all their questions appropriately. V2 was asked how they got him to go to the hospital on 7/2/2024, she stated, He didn't have a choice; he tried to harm another resident. V2 was asked if she was aware there was documentation of talk between V23 (NP) and V26 (physician) about giving medications IM to help get R1 care, but there was concern with the safety for the staff. V2 replied, Yes, I made that entry, and I was worried that staff would get hurt because (R1) is a big strong guy, and I didn't want any staff to get harmed. When V2 was asked if R1 received care from 6/19/2024 through 7/2/2024, she stated, No, not really, he was refusing all care. We were documenting to try to get enough documentation to get him out to a behavioral facility to help with his Psych issues. On 7/12/2024 at 9:10 AM, V1 (Administrator) stated she was out of town the week of 7/2/2024, when she got the call from V2 (DON/Director of Nursing). V1 stated V2 had a report of abuse with R1 and another male resident. V1 stated V2 reported R1 was sent out to the hospital. V1 stated she received another call a little later from V2, who stated Corporate contacted her and said they had to give an Involuntary Discharge (IVD) to R1. V1 stated she told V2 that many others had to be contacted before an IVD could be given, including the Ombudsman, and it was too late in the night for all those calls. V1 stated someone called V2 and said R1 qualified for IVD because he was harmful to himself and others. V1 said on 7/3/2024, V2 and V3 (LPN/Licensed Practical Nurse/Infection Control Nurse) took IVD papers to R1 at the local hospital. V1 stated she was pretty sure V27 (Healthcare Power of Attorney for R1) was called about the IVD. V1 stated, I think it was an emergency discharge. We want (R1) back if he gets his infections taken care of because he goes over the deep end when he gets an infection. It's a cycle he has done before. (R1) is normally our best resident, he is [NAME] President of Resident Council, he teaches Bible Study classes, and he is our facility Santa Claus every year, and he does so well with the kids that the employees bring in to see him as Santa. When V1 was asked if she knew R1 had pressure ulcers that he acquired at the facility she stated, No, I did not know that. I get updates from the hospital, but I only look at Case Manager notes. V1 stated she hates that, but he was refusing all care for a while. V1 stated she was going to go see R1 at the hospital as she really wants to get him back to the facility. V1 stated, We all love (R1), and we want him here. On 7/12/2024 at 1:57 PM, V23 (Nurse Practitioner) stated, I have known and cared for (R1) for a long time. V23 stated normally R1 is a pleasant guy that is alert and oriented x4. V23 stated, I feel (R1) needs inpatient psych to get his meds regulated. V23 stated she had worked closely with V18 (Psych NP) regarding R1. V23 stated V18 ordered Haldol liquid and they tried giving it to R1 in a drink, and R1 wouldn't drink it. V23 stated, I was afraid someone would get hurt if they tried to give him an IM injection. V23 stated, That would only help for a little bit though. V23 stated, (R1) was urinating everywhere and was pouring urine all over himself, was laying in urine and feces, and refused care for long periods of time. V23 was asked if she was aware of the wounds on R1's buttocks and she stated, I didn't know anything about wounds, but have seen the pictures taken at the hospital. V23 stated, (R1) was always cautious about getting a UTI and (R1) would come and tell me that he needs a UA (urinalysis) because he may be getting a UTI. V23 stated, I ordered a UA when the staff told her that he was talking to himself, but (R1) refused it. V23 stated she would stop by and check on him and he would say, I am doing ok, then I would walk past the doorway and he would be talking to the television. V23 stated, I was there the night (R1) went out the last time and I had them to call the police to come because I was afraid R1 would hurt someone because he is a big strong guy. V23 was asked if she felt the infection caused the confusion and delusions and she stated, It is hard to say which came first the psych issues or the infection. V23 stated, I was aware (R1) was refusing care including personal care and refusing medications with most concerning medications of antibiotics. On 7/12/2024 at 12:50 PM, V26 (Physician/Medical Director) stated he was aware of R1's behaviors. V26 stated he was aware R1 tried to harm another resident and R1 went out to the hospital. V26 was asked if he was aware R1 was refusing all care from the staff, he stated, I was aware he was refusing medications, but was not aware of how long he was refusing. V26 was asked if he was aware R1 refused all care from 6/19/2024 through 7/2/2024 and he stated, (V18 Psych NP) has been dealing with him mostly, but I wasn't aware that he refused care for that many days. V26 was asked if he talked with V18 at one point about possibly giving medications IM so R1 would allow care or be sent to the ER, V26 stated, Yes, but I was told they were afraid someone would get hurt as he is a big guy, but I have been hit myself and I am sure you have too. V26 stated, My biggest concern was that (R1) was going to hurt himself or other residents. V26 stated, I am sure they tried to care for him, and I know (V18) was trying, sometimes it is just difficult. The tipping point is why they sent him out, when he tried to pull the other guy out of the bed. V26 was asked if he felt like R1 was harming himself by refusing care and medications, V26 replied, Of course he was. V26 stated, I know (V23) had gone to see him including the day they sent him out. V26 was asked if he knew about the wounds R1 had once he got to the ER, and he stated, No, nobody has told me about that. V26 was asked if he felt the infection could have caused the behaviors which led to the lack of care, which in turn caused the wounds and he stated, Well lack of care can cause wounds and infection of any kind can cause worsening of confusion. Infections are rough on some folks. V26 was asked if he felt R1 was causing harm to himself by refusing his medications including Insulin and antibiotics and refusal of care and he replied, Yes, he was not helping his situation. V26 stated R1 has been at the facility a long time and is usually very pleasant and active in different activities there. R1's Progress Note, dated 7/13/24 at 3:40 PM, documents R1 returned to the facility and is alert and oriented x 3, has no complaints, and is cooperative. The facility policy titled Pressure [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents assessed as being at risk for elopement were supervised, interventions to prevent elopement were implemented, and incidents of elopement were thoroughly investigated for 1 of 3 (R16) residents reviewed for accidents and supervision in the sample of 24. This failure resulted in R16, who had a history of elopement and was assessed as being at risk of elopement, exiting the facility and walking approximately two tenths of a mile down a busy road without staff supervision. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 6/13/24 when R16 was identified to be at risk for elopement and the facility did not implement interventions to prevent elopements. On 6/16/24, R16 attempted to exit the facility and while facility staff were looking for an elopement bracelet to put on R16, R16 left the facility and was located approximately 25 yards from the facility. R16 again exited the facility on 7/10/24. R16 walked approximately two tenths of a mile down the busy street before being joined by staff and approximately eight tenths of a mile down the same street before staff were able to convince R16 to return to the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 7/11/24 at 2:12 PM. The surveyors confirmed by observations, interview, and record review the Immediate Jeopardy was removed on 07/17/24, but the noncompliance remains at a Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R16's admission Record, with a print date of 7/15/24, documents R16 was admitted to the facility on [DATE], with diagnoses that include unspecified dementia, cognitive communication deficit, altered mental status, and delirium. R16's Minimum Data Set, dated [DATE], documents a Brief Interview for Mental Status score of 03, which indicates a severe cognitive deficit. R16's Elopement Evaluation, dated 6/13/24, documents a score of 01, which indicates R16 is at risk of elopement. This same assessment documents R16 has a history of attempted elopement and wandering aimlessly. They were no interventions addressed as part of this evaluation. R16's Progress Notes document the following: 6/13/24 Elopement Score 1.0, History of elopement while at home. Yes . 6/16/24 6:29 PM, Resident noted attempted exit through back staff entrance at 1720 (5:20 PM), also witnessed by (V13/CNA-Certified Nursing Assistant). Upon entry resident resistant to moving away from door and had to be corralled back towards unit. Once she was back on the unit this nurse (V21/RN-Registered Nurse) and (V30, CNA) went looking for a wanderguard transponder. We looked on (unit name) with no success. Then went down to (unit name). While in the med (medication) room looking, I texted (V2/Director of Nurses/DON) to ask if there was an extra in her office or another location and then heard the front door alarm go off. I immediately headed in that direction walking very briskly. As I came through the main dining room, CNA (V31) said that it was (R16). I ran towards the front door. At the door, (name of family member) was frantically trying to get into the door to alert us that she (R16) was out of the building. Once getting out of the door the resident was noted down the road about 25 yards north of the building. Upon reaching her she was verbally combative and physically evasive. CNA (V31 and V32) were able to calm resident and get her to agree to come back into the building. DON (Director of Nursing) immediately notified. DON in at 1740 (5:40 PM) to address .NP (Nurse Practitioner) notified at 1814 (6:14 PM). Attempt made to contact resident's husband .No answer. Message left for call back. The facility Abuse Investigation Summary, dated 6/16/24, documents under Initial Allegation, A visitor was entering the building when (R16) attempted to go out the open front door. As the visitor was telling (R16) that she needed to stay inside, (R16) became verbally aggressive and went out the door. Visitor immediately ran to get staff for help. Abuse coordinator notified. Wanderguard placed on resident. Facility head count conducted, and all residents accounted for. NP (Nurse Practitioner) and spouse notified. All exit doors wander guard alarms checked. Investigation begun Final Summary/conclusion: Investigation conducted. IDT (Interdisciplinary) met and reviewed incident. Resident and staff interviews conducted. A visitor was entering the building when (R16) attempted to go out the open front door. As the visitor was telling (R16) that she needed to say inside, (R16) became verbally aggressive and went out the door. Visitor immediately ran to get staff for help. Another resident with a wanderguard alarm in place was near the front door at time of elopement which set off the wanderguard alarm causing more staff to come to the front door to assist. Resident was assisted back inside the building by nurse and CNA's (certified nursing assistants). Resident continued to be physically evasive and stated, I've got to go get my husband. Please my house is just right down the road here and I have to go get my husband! Abuse coordinator and DON notified. Wanderguard placed on resident. Facility head count conducted, and all residents accounted for. NP and spouse notified. All exit doors wander guard alarms checked. Staff continues to monitor resident for changes in mood, status, or behavior. No changes noted. MD (physician) and POA (power of attorney) updated on findings of investigation. Care plan updated. R16's Elopement Evaluation, dated 6/21/24, documents a score of 03, which indicates R16 is at risk of elopement. This assessment documents R16 has a history of or attempted leaving the facility without informing staff, verbally expressed desire to go home, packed belongings, and/or stayed near an exit door, wanders, wandering behavior likely to affect the safety or well-being of self/others, and is a recent admission. R16's Progress Notes, dated 6/26/24 at 11:00 PM, document, Employee entrance door alarming at 1940 (7:40 PM), (V22, Licensed Practical Nurse/LPN), went to check door and check outside for residents. Resident was urinating behind employee entrance. Resident was redirected and assisted back inside. Resident reports she was looking for husband and trying to go home. Resident was brought back inside, toileted and pajamas placed on. Resident then was assisted to bed. Said nurse (V22) administered HS (hour of sleep) medications, medications taken whole without difficulty. (V2/DON) notified .husband notified, and on-call MD (physician) notified. Resident diagnosed with unspecified dementia with agitation, altered mental status, cognitive communication deficit. (R16) is ambulatory and wanders throughout facility, staff redirects resident and brings her back to assigned hall. Resident agitated with staff at present time redirection attempt. The facility Abuse Investigation Summary, dated 6/26/24, documents under Initial allegation: Wander-guard alarm system alerted staff to the back door. Staff immediately responded and discovered (R16) right outside the doorway and escorted her back inside . Final summary/conclusion: Wander guard alarm system alerted staff to the back door. Staff immediately responded and discovered (R16) right outside the employee entrance door at the back of the building. When found resident was directly behind the employee door urinating. Staff escorted her back inside and to her unit. Head to toe assessment preformed with no abnormalities noted. IDT met and reviewed incident. Resident and staff interviews conducted. Abuse coordinator and DON notified. Wander guard in place and functioning properly. Facility head count conducted, and all residents accounted for. NP and spouse notified. All exit doors wander guard alarms checked. (V18/Psychiatric NP) contacted to complete a med (medication) review. Staff continues to monitor resident for changes in mood, status, or behavior. No changes noted. MD and POA updated on findings of investigation. Care plan updated. R16's Order Summary Report active orders as of 7/15/24 includes the following physician orders; Monitor Wander Guard each shift for placement, start date 6/28/24. R16's current Care Plan documents the Focus area dated 7/1/24 of Is an elopement risk/wanderer related to: Disoriented to place, History of attempts to leave facility unattended, Impaired safety . This same Focus area documents the following interventions all initiated on 7/1/24, Check wanderguard battery function weekly and PRN (as needed) .Check wanderguard placement every shift and PRN Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Monitor for fatigue and weight loss .Offer a warmed blanket Offer food or snacks .Offer reassurance appropriate to the concern .Offer to take to a scheduled or planned activity . Offer to take Thereto the toilet or assist with incontinence care .Provide structured activities: toileting, walking inside and outside, reorientation strategies including sings, pictures, and memory boxes .Redirect resident when wandering or exit seeking .Return to bed for additional rest or comfort .Use distraction to change thought pattern .Wanderguard applied at all times On 7/10/24 at 2:55 PM, R16 was sitting in the common area just outside the dining room. R16 appeared clean and well-groomed. R16 was alert, confused, but pleasant. R16 was saying she wanted to go home. R16 stated it is like being in jail because they won't let her leave. R16's Progress Note, dated 7/10/24 at 1650 (4:50 PM), documents, .This writer (V1/Adminstrator) heard wander guard alarm sound around 4:50 PM at front door. This writer watched (V17/RN) respond to alarm. At 1452 (V19/Corporate Chef) came into office and stated 'I think one of your residents went out the front door.' This writer out (sic) front door and witnessed (R16) walking across front parking lot and (V17) and the IDPH (Illinois Department of Public Health) surveyor (name of surveyor) walking behind her attempting to re-direct her. She became agitated with their attempts to re-direct and started running. She ran out into the road and started running north down the roadway. The IDPH surveyor (name of surveyor) and (V17) could not catch up to (R16) and she kept telling them to get away from them that she was going home. This writer ran past (V17) and (name of surveyor) and was able to catch up to (R16) and began walking side by side with (R16). This writer attempted to re-direct her back to facility and she said no I am going home. I just live down the road here. I have to get back to my kids. (R16) continued to walk with this writer approximately 5 blocks down the road. This writer told (V17/RN) to call 911 and family during the unsuccessful attempts to re-direct (R16) back to facility. (V17) did go back to facility to get vehicle in the event (R16) would be able to be re-directed back to facility. This writer and V17 stayed with (R16) until (name of local police) and family responded. The (name of local police) were unsuccessful in their attempts to re-direct (R16) back to facility also. The son (V20) was able to get (R16) into his vehicle and bring her back to facility. (R16) was taken back to room to have assessment and vital taken. This writer also notified (V18/Psychiatric Nurse Practitioner) for a medication review. (V18) reviewed medication list. New orders were reported to nurse and orders processed. The IDPH surveyor (as described above) reported to this surveyor on 7/10/2024 at 4:52PM the following occurred: The IDPH surveyor walked out the front door of the facility. When the IDPH surveyor approached the front door there was an elderly couple coming through the second set of double doors. The lady was in front and using a walker, the IDPH surveyor approached to help her with the door. As the lady was coming through the door, suddenly another female resident (R16) went through the lady in front of the gentleman that was coming in the door. The other female resident (R16) exited the facility and went through the second set of doors. The door alarm sounded. The IDPH surveyor went out the doors to the front parking lot of the facility and approached R16 and attempted to get her to go back into the facility. The IDPH surveyor was aware R16 was not supposed to be out of the facility since she had observed R16 being redirected earlier in the day. R16 stated, No I am going home. V19 (Regional Chef) pulled up close to the facility and stated he had come back to the facility to return a charger he took. The IDPH surveyor explained to V19 she had tried to get R16 back into the facility and she wouldn't go back in with her. V19 asked the resident to go in with him and she wouldn't go. When asked if he had her V19 replied, I will go in and get the administrator. R16 then started walking to the north end of the parking lot. The IDPH surveyor stayed with R16 attempting to redirect her back to the facility. R16 told the IDPH surveyor she was pregnant and needed to go home then went onto the main road heading north. The IDPH surveyor stayed with the resident, and she began running down the side of the road. V17 (RN) came and then stated she couldn't run. Then V1 came running up the road yelling at R16 to stop running but R16 kept running. Once V1 caught up to the resident the IDPH surveyor returned to the facility. The IDPH surveyor (as described above) reported to this surveyor on 7/10/24 at 5:27 PM R16, V20 (Family Member), and V1 (Administrator) came back into the facility. At that time, V1 stated they had to call the local police and V20 to get R16 to come back to the facility. V1 stated R16 got all the way to the end of the road. R16's hair was wet with sweat and V20 stated, I have to take her to the nurse and get her vital signs, she is hot. On 7/11/24 at 11:10 AM, V13 (CNA) stated R16 tried to get out of the facility a lot, about ten times a day. V13 stated R16 is always going to the back door and knows to hold the door for 15 seconds to get it to stop alarming because she used to work at the facility. V13 stated R16 left not more than a week ago but stopped herself. V13 stated there was four staff with her and they followed R16. When asked what interventions were in place to prevent R16 from eloping, V13 stated R16 didn't reside on the hall she typically worked on, but when R16 was with her, she would have her help fold laundry. V13 stated R16 will sit and talk to residents and likes to read magazines to them. V13 stated they just keep R16 busy. On 7/11/24 at 11:31 AM, V11 (CNA) stated R16 was fairly new to the facility. V11 stated she had met her and R16 was a busy body. V11 stated R16 didn't reside on the hall she typically worked on. V11 stated she wasn't familiar with R16's interventions, but today she combed R16's hair, took her out on the enclosed patio, and sometimes R16 goes into laundry and folds towels. V11 stated it is hard to keep R16 busy. When asked if she had any concerns with residents who wander, V11 stated she didn't think there was enough entertainment for them. V11 stated there is not enough staff to keep the residents who wander busy. On 7/12/2024 at 12:33 PM, V17 (RN) stated she responded to the door alarm on 7/10/24 and saw a female resident and her husband standing at the front window. V17 stated there was a male resident (R4) standing close to the doors, and he wears an elopement alert bracelet. V17 stated she thought R4's elopement alert bracelet set off the alarm due to him standing close to the doors. V17 stated R4 tends to go out the door, so she was trying to get him away from the door and she turned the alarm off. V17 stated, I suspected he (R4) was the one that set off the alarm. V17 stated she didn't go outside to see if another resident had exited. V17 stated, (V19/Corporate Chef) came in and told us that (R16) was outside, so I responded by going outside to get her. V17 stated when she looked out the window, she saw the state surveyor and R16 at the end of the parking lot and by the time she got there R16 was down the road. V17 stated she caught up with them and told the state surveyor she couldn't run, then V1 caught up with them. V17 stated, I was concerned because people fly down that road, I know because I live down that road and there are no sidewalks on either side of that road. V17 stated that once the Administrator was with the resident, she went back to get her car so she could turn on the flashers to slow down the cars so they wouldn't hit R16. V17 stated she also called the police and V20 (Family Member) to help get R16 safe and back to the facility. On 7/15/24 at 12:14 PM, V34 (Receptionist/Medical Records) stated R16 had been attempting to elope all day on 7/10/24. V34 stated when R16 would see someone come up to the door she would run up to it. V34 stated she was watching R16 and would keep her from going out. V34 stated she wasn't aware of R16 getting out of the facility prior to 7/10/24. V34 stated she didn't know what interventions were in place to keep R16 from eloping. On 7/15/24 at 3:37 PM, V2 (DON) stated she wasn't at the facility on 7/10/24 when R16 eloped. This surveyor reviewed with V2 the incident and V17's interview that she didn't go outside when she heard the alarm. V2 stated she believed it was the policy of the facility to look outside and call a full facility head count. On 7/16/24 at 8:28 AM, V21 (RN/Registered Nurse) stated R16 was not his resident, but he was called to her unit because she was attempting to exit the facility through the activity room door on 6/16/24. V21 stated her attempt to leave prompted him to look for an elopement alert bracelet. V21 stated while he was looking for the bracelet, he heard the alarm going off and went to the front door. V21 stated a family member was between the two sets of doors and said she had tried to stop her. V21 stated R16 was approximately 25 yards down the street when he got outside. V21 stated R16 was very resistant to coming back to the facility and became verbally combative. V21 stated they did eventually get R16 back to the building. V21 stated as far as he knew, it was the first time R16 had attempted to and/or eloped. V21 stated when he left R16 to look for the elopement alert bracelet, there were several staff members with R16, and he wasn't sure where R16 was while he was looking and/or how she got out of the facility without staff being aware. When asked if he could remember interventions that were in place to prevent elopement prior to 6/16/24, V21 stated there was no elopement alert bracelet in place, and he couldn't remember any specific interventions. When asked what current interventions were in place to prevent elopement, V21 stated he wasn't sure if they were care planned, but R16 liked to fold clothes and clean up after meals. V21 stated the facility setting makes R16 feel like she is working. V21 stated evening is worse, but R16 always wanders and is exit seeking. V21 stated they are short staffed, and he didn't feel like they had enough staff to meet the needs of the residents. V21 stated he felt like R16 needed to be 1:1. V21 stated 2 nurses and 2-3 CNA's are not enough eyes to keep an eye on her. V21 stated they don't have enough staff to implement person centered interventions to prevent behaviors. On 7/17/24 at 8:37 AM, V1 (Administrator) stated they did not have an elopement alert bracelet on R16 after she was assessed on 6/13/24 as being an elopement risk. V1 stated she talked with staff to determine who monitored R16 on 6/16/24 after she was exit seeking and before she eloped, and she was not able to find anyone who was responsible for ensuring R16 didn't elope while they were looking for the bracelet. V1 stated R1's Care Plan for elopement was not implemented until 7/1/24. According to this interview, there were no specific person-centered interventions implemented to prevent R16 from eloping from 6/13/24 when she was assessed as being at risk for elopement until 7/1/24 and there are no person-centered interventions currently in place. On 7/17/24 at 11:25 AM, V33 (LPN/Licensed Practical Nurse) stated she was working on 6/16/24. V33 stated R16 was attempting to leave, and she and V21 went to look for an elopement alert bracelet. V33 stated a staff member (unknown) stated R16 was on the parking lot by the front door. When asked if anything was put in place to keep R16 from eloping while they looked for the elopement alert bracelet, V33 stated, Not that I am aware of. On 7/17/24 at 2:35 PM, V30 (CNA) stated R16 does exit seek and she has exited the facility. V30 stated it gets worse in the evening, and she has learned that if she keeps R16 busy it is better. V30 stated she will find things for her to do such as talk to other residents, or help her with a task by walking with her when she is getting something. V30 stated she also calls R16's son to talk with her and that helps as well. On 7/18/24 at 12:54 PM, V32 (CNA) stated R16 has gotten out of the facility a couple of times. V32 stated there was one incident (6/16/24) when R16 got out and was walking down the road. V32 stated she, V31, and V21 were chasing R16, and they were able to redirect her back into the facility. R32 stated R16 didn't have an elopement alert bracelet on, and she believed the facility staff were looking for one to place when R16 exited the facility. When asked what happened between R16's attempt on 6/16/24 and R16 exiting the facility, V32 stated it was dinner time, they have family members come in through that time frame, and they told them R16 was outside. V32 stated she was not aware R16 was exit seeking before 6/16/24. V32 stated on some days they have enough staff and other days they don't. When asked if they had enough staff to monitor and implement interventions for residents who have exit seeking behaviors, V32 stated, No, I wouldn't say that. On 7/20/24 at 10:52 PM, V31 (CNA) stated she was working when R16 exited the facility on 6/16/24. V31 stated she is usually the one who responds to the door alarms when they go off. V31 stated R16 likes to slip through the doors when visitors come in. V31 stated R16 knows how to work the system and is very charming. V31 stated on 6/16/24 she responded to the front door alarm and V21 was right behind her. V31 stated the intervention in place on 6/16/24 was to respond to the door alarm and try to get her back in as quickly as possible. V31 stated they did not have interventions in place then like they do now. V31 stated she was not aware R16 was an elopement risk prior to her elopement on 6/16/24. On 7/22/24 at 1:18 PM, V22 (LPN) stated she was working on 6/26/24 when R16 exited the facility. V22 stated she heard the alarm and immediately went to check on it and she thought she saw R16 dart out the employee entrance door. V22 stated she followed her out and R16 was just outside the door, but not outside the building. V22 stated R16 had her pants down and was urinating. V22 stated she redirected R16 back into the facility. The facility Missing Resident and Elopement Policy and Procedure, dated 8/10/23, documents, It is the policy of this facility to provide a safe environment for all residents. We will properly assess residents and plan the care to prevent accidents related to wandering behavior or elopement. Procedure Assessment and Identification of Wandering Residents 1. History of behaviors, including wandering, will be obtained prior to admission. 2. A resident with Alzheimer's/Dementia that is ambulatory will be considered at risk for elopement and an appropriate care plan will be put in place Residents identified at risk of elopement: Residents whose assessment identified wandering behavior shall also be considered at risk for elopement. If a resident is identified at risk for elopement, the following steps will be taken.: 1. If clinically indicated, an alarm bracelet will be placed on the resident to audibly alert staff of attempts by the resident to exit, in facilities with this capability. 2. The residents care plan shall address behavior using resident specific goals and/or approaches as assessed by the interdisciplinary team .4. Facility staff will ensure that all exit alarms will be responded to immediately When a door alarm sounds: When any door alarm sounds, staff shall: 1. Check the alarm panel to determine which door has been opened. Do Not Assume someone else has already done this. 2. Check the exit door for any exiting resident by means of a visual check. Also perform search of building parameter (sic) for exited resident. 3. If a resident is discovered outside the facility inappropriately, staff will assist him/her back into the facility. Follow the confirmed elopement procedure. 4. Reset the door alarm after it is determined by visual check that no resident has exited the facility inappropriately or is returned to the facility. The Immediate Jeopardy that began on 6/13/24 was removed on 07/17/24 when the facility took the following actions to remove the immediacy: *R16 was safely brought back into building on 7/10/24, elopement evaluation completed on 7/10/24, medication review completed on 7/10/24, medications adjusted on 7/10/24. Initiated monitoring of change of behaviors after family visits on 7/11/24, on 7/15/24 monitored behavior after family visits and identified increased exit seeking behavior, care planned for increased safety checks during the evening hours after family visits until behavior resolves on 7/16/24. Also discussed with family potential activities for re-direction during increased anxiety periods on 7/17/24. *Residents who are wander risks are at potential risk to be affected by the same alleged deficit. An audit was completed by the administrator (V1) and (V36) MDS coordinator on 7/17/24 of all wandering residents and no issues were identified *The Administrator (V1) and Maintenance Director (V35) in-serviced staff on 7/16/24 and 7/17/24 on the facility Elopement and Search (Code Amber) policy. Inservice included the topics elopement assessment, placing wander guard alarm band immediately when identified at risk, physician orders and where to locate the wander guard bands. Inservice included location of wander guard exit doors, wander guard alarm panels. Inservice included topics who responds to alarms, search indoors and outdoor perimeter, announcing alarm and calling all clear when resident is returned safely to building. Inservice includes remaining with resident and completing safety checks until exit seeking behavior resolves. *All staff have been in serviced on the Elopement and search code amber policy and will be in serviced prior to their next scheduled shift. *In-services were initiated on 7/16/24 and 7/17/24 and will continue to be given by Administrator designee prior to the staff next scheduled shift until completed. *The administrator has ensured all residents who are at risk for elopement have been assessed and appropriate interventions have been implemented. *The Administrator (V1) has reviewed the policy and procedure Elopement and Search Code [NAME] Policy and no updates at this time. *Administrator (V1) and/or designee will complete one Elopement drill rotating shifts daily for 2 weeks. Any areas for improvement will be immediately addressed. *Director of Nursing/DON (V2) and or designee will audit all new admissions/re-admission 5 days a week for 4 weeks for Elopement evaluation, wander guard placement if applicable and interventions initiated, interventions on care plan. Any issues will be addressed immediately. *Administrator (V1) or designee will audit incidents of elopement 5 days a week for 4 weeks to ensure they were thoroughly investigated. *Results of all audits will be discussed at QAPI in meetings and any further recommendations of interdisciplinary team will be immediately implemented and audit until 100 percent compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents right to be free from neglect by failing to accurately assess, treat, document, and report a decline in condition to the physician and seek timely medical treatment for 1 of 5 residents reviewed for neglect in the sample of 25. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 12/26/22, when the facility failed to monitor R2's vital signs and report a decline in condition to R2's physician and/or seek timely medical treatment. These failures resulted in R2 becoming unresponsive on 12/28/22, and being admitted to the local hospital for end-of-life care, and R2's subsequent death from septic shock due to Covid-19, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, and severe protein calorie malnutrition. V1, Administrator, was notified of the Immediate Jeopardy on 1/09/23 at 1:55 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/10/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. R2's facility admission Record, with a print date of 1/3/23, documents R2 was admitted to the facility on [DATE] with diagnoses that include fracture of right femur, diabetes, anxiety disorder, depression, heart failure, atrial fibrillation, chronic obstructive pulmonary edema, history of pulmonary embolism, and cognitive communication deficit. R2's MDS (Minimum Data Set), dated 10/27/22, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive impairment. This same MDS documents R2 requires assistance of one staff for bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. R2's local emergency services transport record, dated 12/28/22, documents, Upon arrival at scene EMS (Emergency Medical Services) met staff nurse who was unable to give much history of patient (R2). Nurse reported that (R2's) skin was cold, mottling at feet. Nurse reports (R2's) oxygen saturation was in mid-80's. (R2) was currently on oxygen at 4L (liters) nasal cannula .At patient (R2) contact (R2) found unresponsive in bed breathing independently. Other nurse present states that (R2) is normally vocal when being touched, crying out in pain. This writer attempted to wake (R2) but no response from (R2). Sternal rub performed without any response from (R2). Minimal pupil response when pupils were assessed . R2's local hospital record, dated 12/28/22, documents under Emergency Department Provider Notes, C/O: (complaints of) unresponsive. DNR (Do Not Resuscitate). Onset: unk (unknown). EMS (Emergency Medical Services) reports NH (nursing home) RN (registered nurse) was unfamiliar w/ pt (with patient/R2) and called family reporting (R2) was unresponsive. Family wanted (R2) sent in Family notified us (R2) was dx (diagnosed) w/ Covid on Thursday last week. Family did not know (R2) signed DNR (Do Not Resuscitate) form and stated she never discussed it w/them. They note (R2) had been slowly declining and not eating well. V26 (Physician) examined (R2) and d/w (discussed with) the family the prognosis. Family was given some time to think about it. Ultimately, we agreed to .provide comfort measures only Under History Provided by: EMS personnel documents, .(R2) to ED (Emergency Department) via EMS (Emergency Medical Services) from (name of facility). EMS states that patient has been increasingly less conscious the past couple of days . R2's local hospital records, dated 12/28/22, documents under Physical Exam, .Pt (patient/R2) was unresponsive to painful stimuli .no gag reflex .pupil is not reactive .diaper was dry .skin is mottled (at distal extremities) .She did start to make sounds and have small movements after approximately 500 ml (milliliters) of IVF (intravenous fluid) . R2's local hospital records documents under End of Life Care that R2's diagnoses include Covid positive, acute hypoxemic respiratory failure, anion gap metabolic acidosis, acute on chronic renal failure, severe protein calorie malnutrition, and elevated troponin. R2's local hospital record, dated 12/28/22, documents a chest x-ray with findings documenting, .No acute cardiopulmonary process. R2's local Hospital Discharge summary, dated [DATE], documents, .Primary Discharge Diagnosis Covid positive, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, anion gap metabolic acidosis, severe protein calorie malnutrition, and elevated troponin . R2's local hospital record, dated 12/28/22 to 12/30/22, documents under Hospital Course,(R2) presented to (name of local hospital) ER (emergency room) from her nursing facility after becoming unresponsive Family was present throughout most of her time and she was kept comfortable before she passed away peacefully at 8:02 AM on 12/30/2022. R2's Certificate of Death Worksheet documents R2's date of death as 12/30/2022, with cause of death documented as septic shock due to novel corona Covid-19 virus infection, acute hypoxemic respiratory failure, and acute on chronic renal failure. This same form documents significant conditions contributing to death as severe hyperkalemia and severe protein calorie malnutrition. R2's facility Progress Notes document the following: 12/22/22 10:50 AM, Family notified of resident (R2) being placed on isolation r/t (related to) (+) (positive) Covid test. Family thankful for the call. 12/22/22 3:40 AM, New orders per V27 (Nurse Practitioner) Vit C (Vitamin C) 500 mg (milligrams) PO (by mouth) BID (twice daily), Zinc 50 mg daily r/t Covid. 12/24/22 4:57 AM, res (R2) non-compliant with care, refuses to stay in contact isolation. No s/o (signs of) discomfort. Cont. (continue) to receive routine pain meds (medications) as ordered. Congested non prod (productive cough). Cont on abt (antibiotic) therapy as ordered. Hollering freq (frequently) throughout shift. R2's facility Nursing Progress Notes do not document a nursing assessment or update related to R2's physical status until 12/28/22, when R2's progress notes document the following: 12/28/22 2:09 PM, .Resident listless/nonresponsive .Gray color, mouth dry with tip of tongue black in coloration. Blue color noted to all extremities, cold to touch, v/s (vital signs) 96.4 (temperature), 90/50 (blood pressure), 24 (unknown), 26 (unknown), 88 (oxygen saturation) with O2 (oxygen) .Notifications made: (V27, Nurse Practitioner) and POA (power of attorney). 3:52 PM Hospital called report resident is admitted for end of life. Covid positive, hypoxia, family at side. R2's POC (Point of Care) Response, History Nutritional task, with a print date of 1/4/23, documents the following food intakes for R2, 12/25/22 8:46 AM 0-25%, 12:45 PM 26-50% and 12/26/22 12:00 PM 26-50, 12:29 PM 0-25%. There is no documentation of food intake for R2 on 12/27/22. R2's POC Response History, Fluid Intake with meals and outside of meals task, with a print date of 1/4/23, documents R2 had the following fluid intakes, 12/24/22- 1020 cc's (cubic centimeters), 12/25/22- 1000 cc's, 12/26/22- 965 cc's, and 12/27/22- 250 cc's. R2's POC Response History, documents under safety checks tasks, with a print date of 1/4/23, R2 was checked 16 times on 12/24/22, 8 times on 12/25/22, 14 times on 12/26/22, and 12 times on 12/27/22, with the last check documented at 11:40 PM on 12/27/22. R2's Facility Care Plan, last review date of 12/01/22, documents under the Fall focus area an intervention that R2 is to be checked every hour. R2's Order Summary Report, with an order date range of 12/01/22 to 12/31/22, documents the following orders, 12/22/22- 10-day Covid-19 Quarantine Contact and Droplet Precautions, Covid-19 Positive/symptomatic monitoring Q 4 (every 4 hours) .for Covid-19 daily monitoring for 10 days, and maintain droplet isolation precautions at all times r/t Covid + (positive). R2's TAR (Treatment Administration Record), dated 12/1/22 -12/31/22, documents the following physician order, with a start date of 12/22/22 6:00 AM, Covid-19 Positive/symptomatic monitoring Q4 (every four hours): Fever (T>99.9F/temperature greater than 99.9 Fahrenheit), Temp (temperature), P (pulse), RR (respiratory rate), O2 Sat (oxygen saturation) & (and) symptoms (Fever, SOB (shortness of breath), Cough, Sore Throat). R2's TAR documents R2 was monitored every four hours as ordered from 12/22/22 2:00 PM until 12/26/22 2:00 PM. There is no assessment and no vital signs documented on this form, from 12/26/22 2:00 PM until R2 was transferred to the local hospital on [DATE]. The vital signs documented for 12/25/22 at 10:00 AM, 2:00 PM, and 6:00 PM are all as follows, B/P (blood pressure) 130/66, P (pulse) 72, RR (respiratory rate) 18, T (temperature) 98.5, and O2 sat (oxygen saturation) 92%. R2's MAR (Medication Administration Record), dated 12/01/22 to 12/31/22, documents an order to monitor R2's vital signs every shift, with a start date of 10/20/22. R2's vitals are documented and within normal limits each shift on 12/24/22 and 12/25/22. There are no vital signs documented on 12/26/22. The following vital signs are documented on 12/27/22 6 am-6pm shift, B/P 102/58, P 70, R 16, T 97.1, and O2 sat of 93%. There are no vital signs documented on 12/27/22 6 pm - 6 am shift. This indicates R2's vital signs were to be monitored every four hours and the same vital signs were documented multiple times on 12/25/22, no vital signs were documented after 2:00 PM on 12/26/22, and vital signs were documented once on 12/27/22 6am-6pm shift with none documented on the 6pm-6am shift. On 1/4/23 at 3:21 PM, V31 (Registered Nurse (RN)/Agency Nurse) stated she worked on 12/28/22 beginning at 6:00 AM. V31 stated during the morning medication pass (approximately 8:00 AM), unknown Certified Nursing Assistants told her she needed to assess R2. V31 stated R2 appeared listless, her tongue was black, her legs were mottling, her fingertips were blue, her vital signs were not within normal range, but R2 was comfortable. V31 stated she notified the physician and the family, and the family wanted R2 evaluated at the local emergency room. V31 stated she does not remember being told anything in report on the morning of 12/28/22 regarding R2's condition. On 1/5/23 at 10:45 AM, V15 (Licensed Practical Nurse/LPN) stated she worked on 12/24 and 12/25/22, and R2 was her normal self. When asked why R2's vital signs are all the same readings at each time on 12/25/22, V15 stated the Certified Nursing Assistant's (CNA's) get the vital signs, and V15 was just using the last recorded in R2's electronic health record. When asked about the oxygen saturation of 92%, V15 stated R2 would take her oxygen off. When asked if R2's oxygen saturation was rechecked to determine if they improved after reapplying her oxygen, V15 stated it was continually being rechecked. (There is no documentation in R2's medical record of oxygen saturation rechecks). On 1/5/23 at 10:10 AM, V13 (Certified Nursing Assistant/CNA) stated she provided care to R2 on 12/25, 12/26, and 12/28/22. V13 stated she attempted to feed R2, but R2 wasn't eating. V13 stated R2 was taking fluids. When asked if she checked R2's vital signs, V13 stated she was still in orientation and couldn't do vital signs yet. When asked how R2 appeared on those days, V13 stated R2 appeared, Sick, really sick. V13 stated it was either 12/25 or 12/26/22 when she noticed R2 did not appear well. V13 stated R2 kept telling V13 she was dying. V13 stated she reported R2's appearance and condition to V15 (LPN/Licensed Practical Nurse). On 1/5/23 at 10:24 AM, V14 (Certified Nursing Assistant/CNA) stated she worked on 12/26-12/28/22. V14 stated she provided care to R2 and worked with V13 (CNA). V14 stated on 12/27/22, R2's tongue was going black, and R2's extremities were mottling. V14 stated R2 wouldn't eat anything, and R2 kept taking her oxygen off. V14 stated she made sure R2 stayed clean, dry, and comfortable throughout her shift. V14 stated R2 wouldn't swallow when she attempted to give her a drink, so the liquids would just run out of R2's mouth. V14 stated R2's oxygen saturation wasn't reading when R2 would take her oxygen off, but would go up to 92% when she had the oxygen on. V14 stated she didn't remember what nurse was working on 12/27/22, but she did report R2's condition to the nurse. V14 stated she checked R2's vital signs and kept her comfortable and in bed since she was so sick. When reviewed with V14, there were no vital signs documented, V14 stated when the vital signs are abnormal, she gives them to the nurse to review and document. V14 stated she didn't even think she could put abnormal results in the electronic record. V14 stated R2's blood pressure was low at one point and then high at another. On 1/5/23 at 11:43 AM, V17 (RN/Registered Nurse) stated she was an agency nurse and worked at the facility and provided care to R2 on 12/27/22. V17 stated she held R2's blood pressure medication on 12/27/22 because R2's blood pressure was soft. V17 stated V27 (Nurse Practitioner/NP) was at the facility, and she let her know R2's blood pressure was low and that she held the medication. There is no documentation in R2's medical record of V27 being notified. When asked if there was any follow up vital signs obtained after she held R2's blood pressure medication, V17 stated she was only able to get R2's vital signs one time during her 6 am-6 pm shift. V17 stated she had another resident who was critical that was being sent to the emergency room and four admissions that day. When asked if she notified administration that she couldn't provide the needed care, V17 stated, They are well aware of staffing issues. I don't think I could notify them every day. V17 stated the CNAs did not report a decline in R2's condition to her, and did not get any vital signs on 12/27/22. V17 stated she gave report to V18 (Licensed Practical Nurse/LPN) who worked the shift after her (6 PM-6 AM), and told him to watch R2 since her blood pressure was soft. R2's Facility Progress notes documents on 12/27/22, the following medications were Held r/t (related to) hypotension 8:39 AM-furosemide 40 mg (milligrams), 3:40 PM metoprolol tartrate 50 mg, lisinopril 5 mg, 3:41 PM- spironolactone 25 mg, and 5:33 PM- metoprolol tartrate 50 mg. On 1/6/23 at 1:29 PM, V11 (LPN) stated she worked on 12/27/22, but only saw R2 when she passed medications at 9:00 PM. V11 stated R2's lights were down, and she was going to bed. V11 stated she didn't get report of a decline in R2's condition. On 1/5/23 at 1:01 PM, V18 (Licensed Practical Nurse/LPN) stated worked from 12:00 AM to 6:00 AM on 12/28/22. V18 stated R2 was her normal self, and he had to reapply her oxygen when he would go into her room. V18 stated he administered medications to R2 at 5:00 AM on 12/28/22,, and she took them with no issues. V18 stated he forgot to chart R2's vital signs that were obtained during his shift. V18 stated he remembered R2's blood pressure was high, and R2's oxygen saturation was in the low 90's. V18 stated R2's respirations were in the 20's, not labored, but R2 had heavy breathing. V18 stated no one had reported to him R2's blood pressure was low or that she had a decline in her condition. On 1/5/23 at 2:31 PM, V28 (CNA) stated she took care of R2 beginning on the night of 12/27/22 until early morning on 12/28/22. V28 stated R2 was her normal self. V28 stated she did not check R2's vital signs because she did not have dedicated isolation vital sign equipment available. V28 stated she checked R2 every two hours. When asked if R2 ate or drank anything on her shift V28 stated, I think I gave her some water. On 1/6/23, this surveyor reviewed R2's medical record with V2 (Director of Nurses/DON). V2 confirmed R2 did not have Covid monitoring documented, including assessment and/or vital signs on 12/26/22 at 6:00 PM and 10:00 PM, and no monitoring was documented on 12/27/22. V2 confirmed R2's hourly checks were not completed hourly, and the last hourly check documented was at 11:40 PM on 12/27/22. V2 stated there was one set of vital signs documented on 12/27/22, and R2's blood pressure was 102/58, and her oxygen saturation was 93%. V2 stated there was no documentation in R2's facility progress notes of nursing assessments or physician notification of R2's condition from 12/25/22 until 12/28/22. V2 stated she would expect the nursing staff to notify the physician if a resident has a decline in condition including not eating/drinking, and abnormal vital signs. V2 stated she would expect vital signs to be monitored per current standards or practice, physician orders, and policy and procedure. V2 stated if the nursing staff had notified her of R2's decline she would have called the physician and gotten orders for labs and IV fluids. On 1/5/23 at 1:55 PM, V27 (NP/Nurse Practitioner) stated she believed she saw R2 on the afternoon of 12/27/22 and assessed her. V27 stated R2 was pretty much sleeping, very weak, ill appearing. V27 stated R2 was oxygen dependent, and she was able to get R2 to wake up and answer a couple of question. V27 stated she did not prescribe any new orders for R2. This surveyor reviewed with V27, R2's oxygen saturation of 92%-93% on 12/25 and 12/27/22, vital signs not being monitored, fluid and food intake, and that V17 had held R2's blood pressure medication on 12/27/22. V27 stated she was not aware of that information, and if she had been she would have ordered labs, a chest x-ray, and possibly intravenous fluids. V27 stated if a resident's oxygen is trending low, she typically sends them to the emergency room for evaluation. V27 stated she did a head-to-toe physical assessment of R2 and did not see any mottling. R2's Physician Progress note, dated 12/27/22 (not timed), documents, (R2) is seen today for Covid. She (R2) is resting in bed during exam. Confused per baseline and unable to aid in assessment. Oxygen intact via NC (nasal cannula). No distress noted. She is weak and ill appearing. No concerns reported by nursing. Under Objective the physician progress note, documents, Recent Vitals: Reviewed, Date/Time Vitals taken: today, Reviewed at the nursing home with staff. Physical Exam: Constitutional: General: She is not in acute distress. Appearance: She is well-developed. She is ill-appearing. She is not diaphoretic . Skin: General: Skin is warm and dry .Psychiatric: Speech: Speech normal. Behavior: Behavior is cooperative. Cognition and Memory: Cognition is impaired. Memory is impaired. Judgement: Judgement is inappropriate. There is nothing documented under Assessment/Plan. Under Diagnosis and all orders for this visit the physician progress note documents, Covid. This physician progress note, documents under Plan: Covid: Acute. Covid precautions/isolation per facility protocol: vitamin regimen, .if not already taking or other anticoag. Nursing staff will monitor temp and O2 sat each shift and prn (as needed). Supportive therapy. Will monitor for worsening systemic infections. Orders reviewed/signed. Pt (R2) instructed in importance of adequate fluid to stay hydrated. Pt (R2) instructed to inform nursing staff of questions, concerns, changes or concerns. On 1/10/23 at 1:54 PM, after reviewing V27 (NP) interview on 1/5/23 at 1:55 PM with V27 and V39 (Physician), V27 stated she couldn't say the outcome would have been different for R2 if she had known, R2's vitals were not being monitored as ordered, R2's oxygen saturation was trending down, R2 had a decline in food/fluid intake, R2's blood pressure was low, R2's medication had been held, and R2's extremities were reported as mottling, and been able to order labs, intravenous fluids, and chest x-ray. V39 stated, I don't think it would have, having read (R2's) record from the hospital, it may not have made a difference. On 1/5/23 at 8:50 AM, V25 (emergency room Physician) stated R2 was near dead when she was arrived at the emergency room on [DATE]. V25 stated R2's family was not aware R2 had signed a Do Not Resuscitate form, so V25 discussed with R2's family the potential outcomes, and they decided to admit her with comfort care measures only. V25 stated R2 appeared like someone who had been pretty sick for a few days. V25 stated if R2 had been assessed at the emergency room a few days before, it would have presumably been a better outcome. V25 stated R2 was mottling and the length of time for that depends on the disease process. V25 stated in his experience, it is a multi-day process. V25 stated fluid intake is incredibly important for someone who is acutely ill. V25 stated R2 was in multiorgan failure and hypoxic when she arrived at the emergency room. V25 stated in the 24 hours prior to her coming to the emergency department, someone should have noticed a decline in R2's condition. V25 stated the odds are good R2 would have made it through the hospitalization if she had been treated earlier. V25 stated at the very least, R2's primary physician should have been notified so they could have ordered labs, fluids, and/or determine if R2 needed evaluated at the emergency room. R2's Facility Care Plan, last review date of 12/01/22, documents a Focus area of (R2) is a risk for s/sx (signs/symptoms) of Covid-19. 12/22/2022 Covid + (positive). Interventions are documented as 10/21/22- Educate Staff, Resident, family and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screening/precautions, observe for s/sx of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues, provide alternative methods of communications with family/visitors. 12/22/22- Maintain droplet isolation, maintain droplet precautions. And 12/27/22 - Administer medication as ordered. The facility Abuse Prevention Training Program, dated 11/22/2017, documents, The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention .Federal and state laws and regulations mandate that a nursing home resident has the right to be free from verbal, sexual, physical, and mental abuse, exploitation, corporal punishment, and involuntary seclusion. The following definitions for these actions are based on federal and state laws, regulations, and interpretive guidelines: . Neglect is a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident (201 ILCS 45/1-117). Neglect is also the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress (42 C.F.R. § 483.5). The surveyor confirmed through interview, observation, and record review that the Immediate Jeopardy that began on 12/26/22 was removed on 1/10/2,3 when the facility took the following actions to remove the immediacy: *On 1/9/23, V1 (Administrator), V3 (Infection Control Preventionist), and V18 (Wound Certified Nurse Manager) assessed all residents that are COVID 19 positive or at risk for a decline in condition charts to ensure orders for vital signs and monitoring are in place per MD order. *Paper vital sign sheets were implemented with electronic charting for all residents that are COVID 19 positive or at risk for a decline in condition to ensure accuracy and compliance of all vital signs on 1/9/23. *All staff have been in-serviced by V1, V3, V18 on 1/9/23 regarding assessment, monitoring, acute change in condition, documentation, and implementation of orders timely. *All staff have been in-serviced by V1, V3, V18 on 1/10/23 regarding neglect policy and procedure *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding assessment and monitoring of residents that are positive for COVID 19. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding notifying MD of acute change in condition and implementation of orders timely. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding documentation. *In-servicing was completed by V1, V3, V18 on 1/10/23 on neglect policy and procedure. *All employees that were not on duty were contacted by phone on 1/9/23 and 1/10/23 by V1, V3, V18 for verbal compliance of all in-services. *Policy review was completed regarding neglect, change in condition, physician notification, and documentation on 1/10/23. *The Administrator or designee will monitor the following 5 days a week for 6 weeks: The Quality Assurance Committee will monitor the facility's performance by monitoring all audits weekly to ensure the corrections are achieved. The first Quality Assurance Committee meeting will be held on Thursday January 12, 2023. All COVID 19 residents' vital signs are completed per MD orders. All COVID 19 residents' rounds for monitoring acute change in condition, notification to MD with any changes, and implementation of timely orders is being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care was provided per current standards of practice when they failed to accurately assess, treat, document, and report a decline in condition to the physician and seek timely medical treatment for 3 of 5 residents (R2, R3, and R5) residents reviewed for quality of care in the sample of 25. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 12/26/22, when the facility failed to monitor R2's vital signs, report a decline in condition to R2's physician, and/or seek timely medical treatment. These failures resulted in R2 becoming unresponsive on 12/28/22, being admitted to the local hospital for end-of-life care, and R2's subsequent death from septic shock due to Covid-19, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, and severe protein calorie malnutrition. V1, Administrator, was notified of the Immediate Jeopardy on 1/09/23 at 1:55 PM. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 1/10/23, but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: The facility undated Covid-19 Line List documents R2 tested positive for Covid-19 on 12/22/22, R3 tested positive for Covid-19 on 12/19/22, and R5 tested positive for Covid-19 on 12/29/22. 1. R2's facility admission Record, with a print date of 1/3/23, documents R2 was admitted to the facility on [DATE], with diagnoses that include fracture of right femur, diabetes, anxiety disorder, depression, heart failure, atrial fibrillation, chronic obstructive pulmonary edema, history of pulmonary embolism, and cognitive communication deficit. R2's MDS (Minimum Data Set), dated 10/27/22, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive impairment. This same MDS documents R2 requires assistance of one staff for bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. R2's local emergency services transport record, dated 12/28/22, documents, Upon arrival at scene EMS (Emergency Medical Services) met staff nurse who was unable to give much history of patient (R2). Nurse reported that (R2's) skin was cold, mottling at feet. Nurse reports (R2's) oxygen saturation was in mid-80's. (R2) was currently on oxygen at 4L (liters) nasal cannula .At patient (R2) contact (R2) found unresponsive in bed breathing independently. Other nurse present states that (R2) is normally vocal when being touched, crying out in pain. This writer attempted to wake (R2) but no response from (R2). Sternal rub performed without any response from (R2). Minimal pupil response when pupils were assessed . R2's local hospital record, dated 12/28/22, documents under Emergency Department Provider Notes, C/O: (complaints of) unresponsive. DNR (Do Not Resuscitate). Onset: unk (unknown). EMS (Emergency Medical Services) reports NH (nursing home) RN (registered nurse) was unfamiliar w/ pt (with patient/R2) and called family reporting (R2) was unresponsive. Family wanted (R2) sent in Family notified us (R2) was dx (diagnosed) w/ Covid on Thursday last week. Family did not know (R2) signed DNR (Do Not Resuscitate) form and stated she never discussed it w/them. They note (R2) had been slowly declining and not eating well. V26 (Physician) examined (R2) and d/w (discussed with) the family the prognosis. Family was given some time to think about it. Ultimately, we agreed to .provide comfort measures only Under History Provided by: EMS personnel documents, .(R2) to ED (Emergency Department) via EMS (Emergency Medical Services) from (name of facility). EMS states that patient has been increasingly less conscious the past couple of days . R2's local hospital records, dated 12/28/22, documents under Physical Exam, .Pt (patient/R2) was unresponsive to painful stimuli .no gag reflex .pupil is not reactive .diaper was dry .skin is mottled (at distal extremities) .She did start to make sounds and have small movements after approximately 500 ml (milliliters) of IVF (intravenous fluid) . R2's local hospital records documents under End of Life Care that R2's diagnoses include Covid positive, acute hypoxemic respiratory failure, anion gap metabolic acidosis, acute on chronic renal failure, severe protein calorie malnutrition, and elevated troponin. R2's local hospital record, dated 12/28/22, documents a chest x-ray with findings documenting, .No acute cardiopulmonary process. R2's local Hospital Discharge summary, dated [DATE], documents, .Primary Discharge Diagnosis Covid positive, acute hypoxemic respiratory failure, acute on chronic renal failure, severe hyperkalemia, anion gap metabolic acidosis, severe protein calorie malnutrition, and elevated troponin . R2's local hospital record, dated 12/28/22 to 12/30/22, documents under Hospital Course,(R2) presented to (name of local hospital) ER (emergency room) from her nursing facility after becoming unresponsive Family was present throughout most of her time and she was kept comfortable before she passed away peacefully at 8:02 AM on 12/30/2022. R2's Certificate of Death Worksheet documents R2's date of death as 12/30/2022, with cause of death documented as septic shock due to novel corona Covid-19 virus infection, acute hypoxemic respiratory failure, and acute on chronic renal failure. This same form documents significant conditions contributing to death as severe hyperkalemia and severe protein calorie malnutrition. R2's facility Progress Notes document the following.: 12/22/22 10:50 AM, Family notified of resident (R2) being placed on isolation r/t (related to) (+) (positive) Covid test. Family thankful for the call. 12/22/22 3:40 AM New orders per V27 (Nurse Practitioner) Vit C (Vitamin C) 500 mg (milligrams) PO (by mouth) BID (twice daily), Zinc 50 mg daily r/t Covid. 12/24/22 4:57 AM, res (R2) non-compliant with care, refuses to stay in contact isolation. No s/o (signs of) discomfort. Cont. (continue) to receive routine pain meds (medications) as ordered. Congested non prod (productive cough). Cont on abt (antibiotic) therapy as ordered. Hollering freq (frequently) throughout shift. R2's facility Nursing Progress Notes do not document a nursing assessment or update related to R2's physical status until 12/28/22 when R2's progress notes document the following; 12/28/22 2:09 PM, .Resident listless/nonresponsive .Gray color, mouth dry with tip of tongue black in coloration. Blue color noted to all extremities, cold to touch, v/s (vital signs) 96.4 (temperature), 90/50 (blood pressure), 24 (unknown), 26 (unknown), 88 (oxygen saturation) with O2 (oxygen) .Notifications made: V27 (Nurse Practitioner) and POA (power of attorney). 3:52 PM Hospital called report resident is admitted for end of life. Covid positive, hypoxia, family at side. R2's POC (Point of Care) Response History Nutritional task, with a print date of 1/4/23, documents the following food intakes for R2: 12/25/22 8:46 AM 0-25%, 12:45 PM 26-50% and 12/26/22 12:00 PM 26-50%, 12:29 PM 0-25%. There is no documentation of food intake for R2 on 12/27/22. R2's POC Response History Fluid, Intake with meals and outside of meals task, with a print date of 1/4/23, documents R2 had the following fluid intakes: 12/24/22- 1020 cc's (cubic centimeters), 12/25/22- 1000 cc's, 12/26/22- 965 cc's, and 12/27/22- 250 cc's. R2's POC Response History documents under safety checks tasks, with a print date of 1/4/23, R2 was checked 16 times on 12/24/22, 8 times on 12/25/22, 14 times on 12/26/22, and 12 times on 12/27/22 with the last check documented at 11:40 PM on 12/27/22. R2's Facility Care Plan, last review date of 12/01/22, documents under the Fall focus area an intervention that R2 is to be checked every hour. R2's Order Summary Report, with an order date range of 12/01/22 to 12/31/22, documents the following orders: 12/22/22- 10-day Covid-19 Quarantine Contact and Droplet Precautions, Covid-19 Positive/symptomatic monitoring Q 4 (every 4 hours) .for Covid-19 daily monitoring for 10 days and maintain droplet isolation precautions at all times r/t Covid + (positive). R2's TAR (Treatment Administration Record), dated 12/1/22 -12/31/22, documents the following physician order, with a start date of 12/22/22 6:00 AM, Covid-19 Positive/symptomatic monitoring Q4 (every four hours): Fever (T>99.9F/temperature greater than 99.9 Fahrenheit), Temp (temperature), P (pulse), RR (respiratory rate), O2 Sat (oxygen saturation) & (and) symptoms (Fever, SOB (shortness of breath), Cough, Sore Throat). R2's TAR documents R2 was monitored every four hours as ordered from 12/22/22 2:00 PM until 12/26/22 2:00 PM. There is no assessment and no vital signs documented on this form, from 12/26/22 2:00 PM until R2 was transferred to the local hospital on [DATE]. The vital signs documented for 12/25/22 at 10:00 AM, 2:00 PM, and 6:00 PM are all as follows, B/P (blood pressure) 130/66, P (pulse) 72, RR (respiratory rate) 18, T (temperature) 98.5, and O2 sat (oxygen saturation) 92%. R2's MAR (Medication Administration Record), dated 12/01/22 to 12/31/22, documents an order to monitor R2's vital signs every shift, with a start date of 10/20/22. R2's vitals are documented and within normal limits each shift on 12/24/22 and 12/25/22. There are no vital signs documented on 12/26/22. The following vital signs are documented on 12/27/22 6 am-6pm shift, B/P 102/58, P 70, R 16, T 97.1, and O2 sat of 93%. There are no vital signs documented on 12/27/22 6 pm - 6 am shift. This indicates R2's vital signs were to be monitored every four hours and the same vital signs were documented multiple times on 12/25/22, no vital signs were documented after 2:00 PM on 12/26/22, and vital signs were documented once on 12/27/22 6am-6pm shift with no vital signs documented on the 6pm-6am shift. On 1/4/23 at 3:21 PM, V31 (Registered Nurse (RN)/Agency Nurse) stated she worked on 12/28/22, beginning at 6:00 AM. V31 stated during the morning medication pass (approximately 8:00 AM), unknown Certified Nursing Assistants told her she needed to assess R2. V31 stated R2 appeared listless, her tongue was black, her legs were mottling, her fingertips were blue, her vital signs were not within normal range, but R2 was comfortable. V31 stated she notified the physician and the family, and the family wanted R2 evaluated at the local emergency room. V31 stated she does not remember being told anything in report on the morning of 12/28/22 regarding R2's condition. On 1/5/23 at 10:45 AM, V15 (Licensed Practical Nurse/LPN) stated she worked on 12/24/22 and 12/25/22, and R2 was her normal self. When asked why R2's vital signs are all the same readings at each time on 12/25/22, V15 stated the Certified Nursing Assistant's (CNA's) get the vital signs, and V15 was just using the last recorded in R2's electronic health record. When asked about the oxygen saturation of 92%, V15 stated R2 would take her oxygen off. When asked if R2's oxygen saturation was rechecked to determine if they improved after reapplying her oxygen, V15 stated it was continually being rechecked. (There is no documentation in R2's medical record of oxygen saturation rechecks). On 1/5/23 at 10:10 AM, V13 (Certified Nursing Assistant/CNA) stated she provided care to R2 on 12/25, 12/26, and 12/28/22. V13 stated she attempted to feed R2, but R2 wasn't eating. V13 stated R2 was taking fluids. When asked if she checked R2's vital signs, V13 stated she was still in orientation and couldn't do vital signs yet. When asked how R2 appeared on those days, V13 stated R2 appeared, Sick, really sick. V13 stated it was either 12/25 or 12/26/22 when she noticed R2 did not appear well. V13 stated R2 kept telling V13 she was dying. V13 stated she reported R2's appearance and condition to V15 (LPN/Licensed Practical Nurse). On 1/5/23 at 10:24 AM, V14 (CNA) stated she worked on 12/26-12/28/22. V14 stated she provided care to R2 and worked with V13 (CNA). V14 stated on 12/27/22, R2's tongue was going black, and R2's extremities were mottling. V14 stated R2 wouldn't eat anything, and R2 kept taking her oxygen off. V14 stated she made sure R2 stayed clean, dry, and comfortable throughout her shift. V14 stated R2 wouldn't swallow when she attempted to give her a drink, so the liquids would just run out of R2's mouth. V14 stated R2's oxygen saturation wasn't reading when R2 would take her oxygen off, but would go up to 92% when she had the oxygen on. V14 stated she didn't remember what nurse was working on 12/27/22 day, but she did report R2's condition to the nurse. V14 stated she checked R2's vital signs and kept her comfortable and in bed since she was so sick. When reviewed with V14, there were no vital signs documented, V14 stated when the vital signs are abnormal, she gives them to the nurse to review and document. V14 stated she didn't even think she could put abnormal results in the electronic record. V14 stated R2's blood pressure was low at one point, and then high at another. On 1/5/23 at 11:43 AM, V17 (RN/Registered Nurse) stated she was an agency nurse and worked at the facility and provided care to R2 on 12/27/22. V17 stated she held R2's blood pressure medication on 12/27/22 because R2's blood pressure was soft. V17 stated V27 (Nurse Practitioner/NP) was at the facility, and she let her know R2's blood pressure was low, and that she held the medication. There is no documentation in R2's medical record of V27 being notified. When asked if there was any follow up vital signs obtained after she held R2's blood pressure medication V17 stated she was only able to get R2's vital signs one time during her 6 am-6 pm shift. V17 stated she had another resident who was critical that was being sent to the emergency room and four admissions that day. When asked if she notified administration that she couldn't provide the needed care, V17 stated, They are well aware of staffing issues. I don't think I could notify them every day. V17 stated the CNAs did not report a decline in R2's condition to her, and did not get any vital signs on 12/27/22. V17 stated she gave report to V18 (Licensed Practical Nurse/LPN) who worked the shift after her (6 PM-6 AM) and told him to watch R2 since her blood pressure was soft. R2's Facility Progress notes documents on 12/27/22 the following medications were Held r/t (related to) hypotension: 8:39 AM-furosemide 40 mg (milligrams), 3:40 PM metoprolol tartrate 50 mg, lisinopril 5 mg, 3:41 PM- spironolactone 25 mg, and 5:33 PM- metoprolol tartrate 50 mg. On 1/6/23 at 1:29 PM, V11 (LPN) stated she worked on 12/27/22, but only saw R2 when she passed medications at 9:00 PM. V11 stated R2's lights were down, and she was going to bed. V11 stated she didn't get report of a decline in R2's condition. On 1/5/23 at 1:01 PM, V18 (Licensed Practical Nurse/LPN) stated he worked from 12:00 AM to 6:00 AM on 12/28/22. V18 stated R2 was her normal self, and he had to reapply her oxygen when he would go into her room. V18 stated he administered medications to R2 at 5:00 AM on 12/28/22, and she took them with no issues. V18 stated he forgot to chart R2's vital signs that were obtained during his shift. V18 stated he remembered R2's blood pressure was high, and R2's oxygen saturation was in the low 90's. V18 stated R2's respirations were in the 20's, not labored, but R2 had heavy breathing. V18 stated no one had reported to him R2's blood pressure was low or that she had a decline in her condition. On 1/5/23 at 2:31 PM, V28 (CNA) stated she took care of R2 beginning on the night of 12/27/22 until early morning on 12/28/22. V28 stated R2 was her normal self. V28 stated she did not check R2's vital signs because she did not have dedicated isolation vital sign equipment available. V28 stated she checked R2 every two hours. When asked if R2 ate or drank anything on her shift V28 stated, I think I gave her some water. On 1/6/23, this surveyor reviewed R2's medical record with V2 (Director of Nurses/DON). V2 confirmed R2 did not have Covid monitoring documented, including assessment and/or vital signs on 12/26/22 at 6:00 PM and 10:00 PM, and no monitoring was documented on 12/27/22. V2 confirmed R2's hourly checks were not completed hourly, and the last hourly check documented was at 11:40 PM on 12/27/22. V2 stated there was one set of vital signs documented on 12/27/22, and R2's blood pressure was 102/58 and her oxygen saturation was 93%. V2 stated there was no documentation in R2's facility progress notes of nursing assessments or physician notification of R2's condition from 12/25/22 until 12/28/22. V2 stated she would expect the nursing staff to notify the physician if a resident has a decline in condition including not eating/drinking, and abnormal vital signs. V2 stated she would expect vital signs to be monitored per current standards or practice, physician orders, and policy and procedure. V2 stated if the nursing staff had notified her of R2's decline, she would have called the physician and gotten orders for labs and IV fluids. On 1/5/23 at 1:55 PM, V27 (NP) stated she believed she saw R2 on the afternoon of 12/27/22 and assessed her. V27 stated R2 was pretty much sleeping, very weak, ill appearing. V27 stated R2 was oxygen dependent, and she was able to get R2 to wake up and answer a couple of question. V27 stated she did not prescribe any new orders for R2. This surveyor reviewed with V27, R2's oxygen saturation of 92% and 93% on 12/25 and 12/27/22, vital signs not being monitored, fluid and food intake, and that V17 had held R2's blood pressure medication on 12/27/22. V27 stated she was not aware of that information, and if she had been she would have ordered labs, a chest x-ray, and possibly intravenous fluids. V27 stated if a resident's oxygen is trending low, she typically sends them to the emergency room for evaluation. V27 stated she did a head-to-toe physical assessment of R2, and did not see any mottling. R2's Physician Progress note, dated 12/27/22 (not timed), documents, (R2) is seen today for Covid. She (R2) is resting in bed during exam. Confused per baseline and unable to aid in assessment. Oxygen intact via NC (nasal cannula). No distress noted. She is weak and ill appearing. No concerns reported by nursing. Under Objective the physician progress notes documents, Recent Vitals: Reviewed, Date/Time Vitals taken: today, Reviewed at the nursing home with staff. Physical Exam: Constitutional: General: She is not in acute distress. Appearance: She is well-developed. She is ill-appearing. She is not diaphoretic . Skin: General: Skin is warm and dry .Psychiatric: Speech: Speech normal. Behavior: Behavior is cooperative. Cognition and Memory: Cognition is impaired. Memory is impaired. Judgement: Judgement is inappropriate. There is nothing documented under Assessment/Plan. Under Diagnosis and all orders for this visit the physician progress note documents, Covid. This physician progress note documents under Plan: Covid: Acute. Covid precautions/isolation per facility protocol: vitamin regimen, . if not already taking anticoag (anticoagulant). Nursing staff will monitor temp and O2 sat each shift and prn (as needed). Supportive therapy. Will monitor for worsening systemic infections. Orders reviewed/signed. Pt (R2) instructed in importance of adequate fluid to stay hydrated. Pt (R2) instructed to inform nursing staff of questions, concerns, changes or concerns. On 1/10/23 at 1:54 PM, after reviewing V27 (NP) interview on 1/5/23 at 1:55 PM with V27 and V39 (Physician), V27 stated she couldn't say the outcome would have been different for R2 if she had known R2's vitals were not being monitored as ordered, R2's oxygen saturation was trending down, R2 had a decline in food/fluid intake, R2's blood pressure was low, R2's medication had been held, and R2's extremities were reported as mottling, and she (V27) had been able to order labs, intravenous fluids, and a chest x-ray. V39 (Physician) stated, I don't think it would have, having read (R2's) record from the hospital, it may not have made a difference. On 1/5/23 at 8:50 AM, V25 (emergency room Physician) stated R2 was near dead when she was arrived at the emergency room on [DATE]. V25 stated R2's family was not aware R2 had signed a Do Not Resuscitate form, so V25 discussed with R2's family the potential outcomes, and they decided to admit her with comfort care measures only. V25 stated R2 appeared like someone who had been pretty sick for a few days. V25 stated if R2 had been assessed at the emergency room a few days before, it would have presumably been a better outcome. V25 stated R2 was mottling and the length of time for that depends on the disease process. V25 stated in his experience, it is a multi-day process. V25 stated fluid intake is incredibly important for someone who is acutely ill. V25 stated R2 was in multiorgan failure and hypoxic when she arrived at the emergency room. V25 stated in the 24 hours prior to her coming to the emergency department, someone should have noticed a decline in R2's condition. V25 stated the odds are good R2 would have made it through the hospitalization if she had been treated earlier. V25 stated at the very least, R2's primary physician should have been notified so they could have ordered labs, fluids and/or determine if R2 needed evaluated at the emergency room. R2's Facility Care Plan, last review date of 12/01/22, documents a Focus area of, (R2) is a risk for s/sx (signs/symptoms) of Covid-19. 12/22/2022 Covid + (positive). Interventions are documented as 10/21/22- Educate Staff, Resident, family and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screening/precautions, observe for s/sx of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues, provide alternative methods of communications with family/visitors. 12/22/22- Maintain droplet isolation, maintain droplet precautions. And 12/27/22 - Administer medication as ordered. 2. R3's facility admission Record, with a print date of 1/11/23, documents R3 was admitted to the facility on [DATE], with diagnoses that include fracture, pleural effusion, heart failure, anemia, chronic kidney disease. R3's MDS, dated [DATE], documents a BIMS score of 10, which indicates R3 has a moderate cognitive impairment. R3's Care Plan, dated 12/28/22, documents a Focus Area of Covid + (positive) on 12/19/22 Resolved. This same care plan documents the following interventions 12/12/22- Educate staff, resident, family, and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screening/precautions. Observe for s/sx (signs/symptoms) of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues. Provide alternative methods of communications with family/visitors. 12/20/22- Maintain droplet isolation as ordered. R3's Order Summary Report, dated 1/11/23, documents the following physician orders, Covid-19 Positive/Symptomatic monitoring Q4; Fever (T>99.9F) Temp, P, RR, B/P, O2 Sat & Symptoms (Fever, SOB, Cough, Sore Throat) ., Maintain Droplet Isolation precaution at all times r/t Covid +. R3's TAR (Treatment Administration Record), dated 12/1/22 to 12/31/22, documents a physician order to monitor for Covid-19 symptoms and monitor vital signs every four hours, with a start date of 12/22/22. R3's same MAR does not document Covid monitoring and/or vital signs were done on 12/26/22 at 10:00 PM, 12/27/22 at 2:00 PM, 6:00 PM, and 10:00 PM, and 12/28/22 at 6:00 PM. 3. R5's facility admission Record, with a print date of 1/10/23, documents R5 was admitted to the facility on [DATE]. R5's MDS, dated [DATE],2 documents a BIMS score of 06, which indicates R5 has a severe cognitive impairment. R5's Care Plan, with a review date of 12/19/22, documents a Focus Area of, (R5) is at risk for s/sx of Covid-19, Covid + 12/29/22. This same care plan documents the following interventions. 12/05/2022- Educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions. Follow facility protocol for Covid-19 screenings/precautions. Observe for s/sx of Covid-19-document and promptly report s/sx: coughing, sneezing, sore throat, respiratory issues. Provide alternative methods of communication with family/visitors. 1/03/23-maintain droplet precautions. R5's Care Profile, with a print date of 1/12/23, documents a physician order, dated 12/31/22, for, Covid-19 positive/symptomatic monitoring Q4: Fever (T>99.9 F), Temp, P, RR, B/P, O2 Sat & symptoms (Fever, SOB, Cough, Sore Throat) . R5's TAR, dated 12/1/22 to 12/31/22, documents an order to monitor vital signs and for Covid-19 symptoms every four hours for eight days, with a start date of 12/31/22 at 2:00 PM. The same TAR does not document vital signs and/or Covid monitoring was done at 10:00 PM at 12/31/22. R5's TAR, dated 1/1/23 to 1/31/23, documents an order to monitor vital signs and for Covid-19 symptoms every four hours for eight days, with a start date of 12/31/22 at 2:00 PM. The same TAR does not document vital signs and/or Covid monitoring were done as ordered on the following dates/times; 1/1/23 8:00 AM, 1/2/23 2:00 AM and 6:00 PM, 1/4/23 6:00 AM, and from 1/5/23 6:00 AM through 1/8/23. On 1/6/23 at 8:52 AM, V2 (DON) stated she would have expected vital signs/assessments to have been done as ordered and per current standards of practice. The facility undated Notification of Resident Change in Condition Policy documents, .It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physician of changes in the resident's health condition Standards: 1. A licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify the resident's legal representative or an interested member of: .b. A significant change in the resident's physical, mental, or psychosocial status, i.e., deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications 2. The licensed nurse is to use professional judgment in determining changes in condition based on assessment and findings or signs and symptoms of change which could lead to deterioration if not treated. 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issues such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 4. Following the assessment, observing signs and symptoms, and obtaining vital signs, the attending physician, family/guardian will be promptly notified of significant findings 7. Changes in the resident's condition will be communicated to the direct care staff by verbal shift-to-shift report, revision in resident assignments and by use of the 24-hour written shift report .11. The licensed nurse will document in the nurse's notes all assessment findings and all attempts to notify physician(s). The facility Guidelines for Notifying Physicians of Clinical Problems, dated 4/2007, documents, Overview: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely , efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record .The Charge Nurse or supervisor should contact the Attending Physician at any time if they fell a clinical situation requires immediate discussion and management . The facility Policy and Procedure for SARS-CoV-2 (Covid-19), dated 3/22/22, documents under Residents with Confirmed Covid-19 .Monitor the resident every four hours for clinical worsening. Include an assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam to identify and to quickly manage serious infections. The surveyor confirmed through interview, observation, and record review that the Immediate Jeopardy that began on 12/26/22 was removed on 1/10/23 when the facility took the following actions to remove the immediacy: *On 1/9/23, the V1(Administrator), V3 (Infection Control Preventionist), and V18 (Wound Certified Nurse Manager) assessed all residents that are COVID 19 positive or at risk for a decline in condition charts, to ensure orders for vital signs and monitoring are in place per MD order. *Paper vital sign sheets were implemented with electronic charting for all residents that are COVID 19 positive or at risk for a decline in condition to ensure accuracy and compliance of all vital signs on 1/9/23. *All staff have been in-serviced by V1, V3, V18 on 1/9/23 regarding assessment, monitoring, acute change in condition, documentation, and implementation of orders timely. *In-servicing was completed by V1, V3, V18, on 1/9/23 regarding assessment and monitoring of residents that are positive for COVID 19. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding notifying MD of acute change in condition and implementation of orders timely. *In-servicing was completed by V1, V3, V18 on 1/9/23 regarding documentation. *All employees that were not on duty were contacted by phone on 1/9/23 and 1/10/23 by V1, V3, V18 for verbal compliance of all in-services. *Policy review was completed regarding neglect, change in condition, physician notification, and documentation on 1/10/23. *V1 or designee will monitor the following 5 days a week for 6 weeks: The Quality Assurance Committee will monitor the facility's performance by monitoring all audits weekly to ensure the corrections are achieved. The first Quality Assurance Committee meeting will be held on Thursday January 12, 2023. All COVID 19 residents' vital signs are completed per MD orders. All COVID 19 residents' rounds for monitoring acute change in condition, notification to MD with any changes, and implementation of timely orders is being completed .