**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that their residents were free from abuse and neglect. This was evident for 2 (#112 and #107) out of 26 residents reviewed for abuse and neglect. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On [DATE] at 5:45 PM, a review of the facility's investigation file for a facility reported incident #MD00181072 was completed which stated that the facility had received an allegation of neglect for Resident #112. The former Director of Nursing Staff #47 conducted an investigation and failed to recognize that staff failed to promptly assess, identify, and notify the attending physician of acute changes in the resident's condition. Furthermore, she failed to note whether she had substantiated the neglect or not. A statement in the facility's investigation report read that measures were taken to prevent further incidents of similar nature, however, she failed to indicate what these measures were, and the investigation file had no evidence of these measures. Subsequently, on [DATE] at 9:00 AM 2 allegations of neglect of Resident #112 were reviewed: #MD00180651 and #MD00182736. MD00182736 alleged that the neglect of Resident #112 led to an unexpected death of the resident. The investigation findings were as follows. On 4/22, according to the attending physician's History and Physical (H&P) note, Resident #112 was admitted to the facility for rehabilitation and continued treatment of cellulitis following a hospitalization for sepsis, cellulitis, and wound care. The resident had a foley catheter for urinary retention. Further review of the medical record revealed that the resident had the capacity to make his/her own medical decisions. Furthermore, review of the admission Minimum Data Set, with the assessment reference date of [DATE], revealed in section C that the resident had no cognitive impairment. A review of the wound Nurse Practitioner (NP) Staff #67's visit note, dated [DATE], indicated the resident had a Stage 4 pressure ulcer on his/her left heel. A Stage IV pressure ulcer means that there had been skin and tissue loss deep enough to expose the muscle and bone. The resident had a second wound on his/her left posterior (back) thigh that was classified as a Stage 3 wound. A Stage 3 wound means there was skin loss, and the layer of fat has been exposed. A review of the resident lab reports revealed that Resident #112 was diagnosed with C-Diff (Clostridioides difficile - a bacteria that causes diarrhea and inflammation of the colon. Cdc.gov) on [DATE]. A review of the physician's order summary revealed the resident was treated with Vancomycin until [DATE]. This illness was known to cause a decrease in appetite, vomiting, and diarrhea, placing the resident at risk for malnutrition. According to the National Institute of Health (https://pubmed.ncbi.nlm.nih.gov) optimal wound healing requires adequate nutrition. Poor nutrition slows down or stops the wound from progressing through the stages of wound healing and malnutrition can increase the risk of infection. A review of the Dietitian's note dated [DATE], revealed Resident #112's weight was 218 lbs. which represented a 19 lbs. (8% body weight) loss in 30 days. However, she stated the weight loss was expected due to a gastrointestinal illness.Review of the resident's physicians order summary for [DATE], revealed the resident had an order in place for a protein supplement daily to aid in wound healing and a protein shake daily for unspecified protein calorie malnutrition. The Wound NP Staff #76 wrote in her progress notes on the following dates that the resident had complained of abdominal pain and/or discomfort: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Staff #76 failed to document that the attending physician had been made aware of any of these complaints. Registered Nurse (RN) #16, the facility's wound nurse, was present at these visits and wrote a progress note of her own and failed to mention the resident's complaints of abdominal pain, as well as reporting it to the attending physician. A review of the progress note written by Licensed Practical Nurse (LPN) #76 on [DATE], revealed the resident's attending Physician #61 had seen the resident for complaints of abdominal pain. The note stated that he ordered the following medications: Mirlax and Colace for stool softener and Bentyl (a medication used to treat irritable bowel syndrome) for abdominal pain. However, further review revealed no physician's progress note. Furthermore,when questioned, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. A review of the attending Physician #61's progress note, dated [DATE], revealed that he failed to document the plan of treatment for the abdominal pain and mention the medications he had ordered. Under the section plan, he wrote the resident was medically stable, continuing with present medications and care. On [DATE], LPN Staff #75 documented that the resident complained of side pain and was administered acetaminophen (Tylenol) and then had a small emesis. An hour later when Staff #75 followed up on the effectiveness of the acetaminophen, she administered the Bentyl that had been ordered on [DATE] as-needed for abdominal pain. According to the MAR this had been effective. LPN Staff #20 wrote on [DATE] that the resident was eating poorly, refused his/her bowel medications, and had a complaint of stomach gasses and bloating. Staff #20 then wrote that the resident had recently spoken to his/her doctor and Colace (stool softener) and MiraLAX (stool softener) had been ordered. The physician visit had been [DATE], 5 days prior to this note, and there was no evidence that the nurse conducted an assessment of this medical concern and or notified the attending physician. On [DATE], the Dietitian noted in the progress notes that the Resident's weight continued to drop. The admission weight was 262 lbs. At the time of the note, the resident weighed 190 lbs. The resident informed the Dietitian that s/he had not eaten because it made his/her stomach swell up. However, there was no documentation that the physician had been notified. On [DATE], the Dietitian sent the surveyor email correspondence,dated [DATE], that she sent to LPN #68, who was the unit manager at the time, which made the unit manager aware of the weight loss. There was no mention of abdominal distress. Furthermore, there was no evidence in the medical record that attending Physician #61 was made aware of the weight loss or the abdominal distress. That same day, on [DATE], LPN Staff #20 told the Dietitian the resident had not been taking her supplements, was eating poorly, and complaining of nausea when out of bed. However, LPN #20 failed to notify the attending physician. Review of attending Physician #61's progress note, dated [DATE], revealed that s/he documented the resident had no concerns, with no mention of the resident's complaints of abdominal pain and emesis. Again, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. On [DATE], LPN #20 wrote a note that the resident continued to report the medications made him/her feel ill and reported that his/her stomach was upset. The nurse failed to further assess the stomach concern and there was no documentation that the attending physician was made aware that, 3 weeks after the visit on [DATE], the resident was not feeling better and the treatment he prescribed was not effective. On [DATE], a late note for [DATE], was entered by LPN Staff #76, who wrote that Resident #112 complained of pain in the right lower quadrant. Staff #76 failed to document an assessment of the abdomen and gave Tylenol despite having a PRN (as needed) order for Bentyl for abdominal pain. When LPN #76 contacted the on-call Nurse Practitioner (NP) #79, for a new area on the resident's head, she failed to report the abdominal distress. A review of the Resident's vital sign report revealed that on [DATE] at 1:28 AM, the resident's blood pressure (B/P) was 87/56. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm. On [DATE] at 9:00 AM, a review of the facility's standards of professional practice revealed that hypotension (low blood pressure) is present when the systolic (top number) of the blood pressure falls to 90 mm Hg or below. Furthermore, it stated that while some adults have low b/p normally, for most people a low b/p is an abnormal finding associated with illness. ([NAME] and [NAME], 9th Version, 2017). However, further review of the medical record revealed the nurse failed to notify the attending physician of this change in condition. An interview with LPN Unit Manager Staff #8 on [DATE] at 11:33 AM revealed that she would call the doctor when a systolic (top number) was less than 110 mm HG (millimeters of mercury). She stated that nurses learn that information when they are in nursing school. A review of the Resident's vital signs revealed that, on [DATE] at 9:48 PM, the resident's vital signs were as follows: B/P 83/57, temperature (T) 97.7 F, pulse (P) 115, respirations (R) 16, and oxygen saturation (SP02) 99%. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm and there was no evidence in the medical record that LPN Staff #78 reported this change to the attending physician. Review of the nurse's skin assessment sheet on [DATE] revealed the resident had been pale, which was a change from the previous skin checks. However, there was no evidence that the physician had been made aware of this change. The Dietitian entered a note on [DATE], that read, nutrition note for supplement review with nursing; ensure, prostat, and B complex with C discontinued. There was no indication that this was discussed with the physician or that he had been aware of the change. A review of the attending Physician #61's progress note dated [DATE],with a note added under HPI section, that the resident reported continued weakness. There was no indication in this note that attending Physician #61 had been aware of the resident's continued weight loss of 31 % of his/her body weight, the continued abdominal pain, the decrease in blood pressure and increased pulse. Furthermore, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. A review of the Medication Administration Record (MAR) revealed the resident's urinary output for 24 hours on [DATE] was 300 milliliters (mL). (Urine output in 24 hours less than 400 mL can be one of the first signs of kidney failure) The resident had a urinary catheter due to urinary retention and nursing staff failed to recognize that this change was significant enough to contact the attending physician. A review of the MAR revealed on [DATE] at 12:20 AM that the resident complained of shortness of breath and was given an albuterol as-needed dose. According to the record, this was a new symptom. In addition, a review of the Resident's vital signs revealed that, on [DATE] at 12:31 AM, the resident's vital signs were as follows: B/P 71/51, T 97.97 F, P 95, R 18, and SP02 96%. This was a decrease in the blood pressure from the resident's norm and from the previous readings on [DATE] at 9:48 PM. LPN #75 failed to recognize that the shortness of breath was new and the decrease in blood pressure may indicate a significant change in the resident ' s medical condition and failed to report the changes to the attending physician. A review of the MAR for [DATE] revealed that the LPN #20 documented at 9:05 AM she attempted to administer Cardizem ER 24 hr. 180 mg, but the resident refused it and stated it upset their stomach. Lasix 20 mg was given. (Lasix is a medication that helps the body get rid of excess water and salt. In the process of doing this Lasix may lower the blood pressure and is at times given to lower blood pressure) This was prior to obtaining a set of vital signs at 9:57 AM, so the last set of VS indicated a B/P of 71/51. Further review revealed the resident's urinary output for the last 24 hours was again very low at 375 cc and staff failed to inform the physician. On [DATE], LPN Staff #77 wrote that the resident had complaints of generalized pain, however she failed to conduct an assessment of the pain. The resident continued to have weight loss as the recorded weight for [DATE] was 179.4 lbs. However, the staff failed to notify the physician. The Dietitian failed to assess the resident who, despite her attempts, had continued to lose weight and she failed to discuss this with the attending physician. A review of the MAR for [DATE] revealed that RN #70 attempted at 9:05 AM to administer the resident's blood pressure medication, but the resident refused. Lasix 20 mg was administered. A review of the resident's vital signs taken on [DATE] at 9:41 AM revealed a B/P of 93/53, T 98 F, P 109, R 16, and SP02 of 94%. The RN failed to recognize the resident's continued decrease in blood pressure and increase in pulse rate were indications of a change in his/her medical status and failed to notify the physician. On [DATE], Registered Nurse (RN) #70 wrote a note that the resident continued to complain of abdominal pain and that the resident's doctor was aware because it was not a new symptom. There was no evidence that RN #70 assessed the pain or evaluated the plan of care. RN #70 failed to notify the physician of the continued abdominal pain and that the resident continued to refuse medications. A review of the resident's vital signs taken on [DATE] at 9:41 AM revealed a B/P of 93/53, T 98 F, P 109, R 16, and SP02 of 94%. RN Staff #70 failed to reassess the blood pressure and notify the physician. A progress note written by the RN Staff #70 on [DATE] at 5:17 PM read, Resident did state that he/she felt his/her Symbicort inhaler wasn't working today. Educated the resident that he/she needed to take a deep breath in at the same time she pushes down on the inhaler. Otherwise she is not getting the full dose of her medication. Offered her the Albuterol inhaler and he/she used it. It seemed to help her symptoms. SpO2 this AM was 94%. SpO2 this PM was 93%. Assessed her lungs and they were clear but diminished. Resident diminished sounds are not uncommon due to her history. She has a history of SOB, Anxiety, Moderate persistent Asthma and environmental Allergic Rhinitis. VSS. Will continue to monitor. A review of the medical record failed to reveal that the resident had diminished lungs sounds previously, nor was there frequent use of the as-needed inhaler until [DATE] and [DATE], indicating there was a change. RN Staff #70 failed to recognize these signs that the resident's health condition had changed and notify the physician. A review of the MAR revealed that on [DATE] the resident's total urinary output was 350 cc and the nursing staff failed to recognize that this decrease in urinary output had continued for 2 days and nursing staff failed to notify the physician. A review of the MAR for [DATE] revealed that RN #70 wrote a note at 8:03 AM that she attempted 2 times to give the resident his/her blood pressure medication, but the resident had refused that and his/her Lasix. RN Staff #70 had knowledge of the resident's low blood pressure the day before and failed to obtain a blood pressure prior to offering the resident their blood pressure medication. When the nurse obtained the vital signs at 10:20 AM that day, they were as follows: B/P 91/55, T 98 F, P 106, R 16, and SP02 of 93%. However, she failed to notify the physician at this time. In a progress note on [DATE] at 11:52 AM, RN Staff #70 wrote, Encouragement given all shift to the resident to drink more water. Her urine is a dark amber color. NO symptoms of a UTI. Denies any pain in the lower abdominal region where the bladder lies. Went into the resident's room several hours later and he/she still had not drank any fluids. Resident has been non-compliant with any suggestions to help himself/herself feel better or the functionality of his/her body. RN Staff #70 failed to recognize that the resident's urinary output of less than 400 mL for the last 3 days, coupled with the assessment of dark amber urine, the low blood pressure readings, and increased pulse rate were all significant signs that the resident's health condition was declining and failed to call the physician at this time. On [DATE] at 5:55 PM, RN #70 wrote, Resident's family into visit resident at this time resident is not talking to them and will not answer them when they talk to her. O2 [oxygen] sat [saturation] 88 % on room air, O2 put on resident, at 3 liters. O2 sat came up to 90% had to turn O2 up 5 liters to get it to come up to 92%. Resident Lung sounds assessed by this writer. He/she has congestion in the right upper lung field. Resident has a dry congested cough. Resident is unresponsive; he/she will open his/her eyes but will not speak to us. Temp. 98.1 pulse 40 Resp 18 B/P 69/42. Certified Registered Nurse Practitioner (CRNP) Staff #79 notified N/O to send resident To ER [Emergency Room] for evaluation 911 called. However, due to subsequent notes written by RN #70 on [DATE] it was unclear if 911 had been called at this time. In addition, the Situation, Background, Assessment, and Recommendation (SBAR) tool that was completed by RN #70 failed to document all the symptoms the resident had been having and it was unclear if the on call CRNP #80 had been made aware the resident's full decline in condition. On [DATE] at 6:24 PM Social Service Staff #80 wrote, [Resident #112] being sent to [hospital] at the family's request as [his/her] HCA [Health Care Agent] is argumentative and adamant that there is something medically wrong with [resident]. [Resident's] vital signs are stable and no vital alerts at this time contrary to family's adamancy. [Resident's] symptoms of concern for the family are variable to the attention it receives and is observed by various staff and witnesses . On [DATE] at 6:59 PM, RN Staff #70 wrote a note that the resident had voiced s/he did not want to live any longer. The resident complained of an upset stomach and was given Bentyl which had been effective. The resident had refused all routine medications that day and napped off and on. The nurse failed to recognize these symptoms of the resident's decline in condition and notify the physician earlier that day. On [DATE] at 7:26 PM, RN Staff #70 wrote a note that she informed CRNP #80 of the situation with Resident #112 and it was approved to send the resident to the emergency room per the family request. She wrote she called the hospital and gave a report. It was unclear when the resident left the facility to go to the hospital. A review of the hospital records on [DATE] at 8:30 AM revealed the resident was admitted with septic shock, pneumonia [infection in the lungs] and a urinary tract infection. At times a person with an infection may develop a condition called sepsis. Sepsis is defined as the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis occurs when a person has an infection and it triggers a chain reaction throughout the body. Most cases of sepsis start before a patient goes to the hospital. Infections that lead to sepsis most often start in the lung, urinary tract, skin, and gastrointestinal tract. Sepsis presents with low blood pressure, high pulse rate, and trouble breathing. Sepsis-induced hypotension (low blood pressure) is defined as the top number of the blood pressure is less than 65 mmHg. Septic Shock is a life threatening condition characterized by sepsis-induced hypotension that does not respond to treatment. Without timely treatment, sepsis/septic shock can rapidly lead to tissue damage, organ failure, and death. (www.cdc.gov) Furthermore, the hospital records showed the resident was treated with intravenous fluids (fluids administered into the veins) with vasopressin (medications to increase the blood pressure) added. Subsequently, the resident expired on [DATE] at 11:27 AM. An interview with Geriatric Nursing Assistant (GNA) Staff #81 on [DATE] at 9:24 AM revealed that she had been unaware that she was assigned Resident #112 on [DATE]. A subsequent review of the GNA documentation on [DATE] at 9:45 AM revealed that Resident #112 had not been provided care by a GNA that day. During an interview with LPN Staff #46 on [DATE] at 12:02 PM, he reported that he was working on [DATE] and went to Resident #112 ' s room to get a set of vital signs for RN Staff #70. He reported that the resident was only responding to a sternal rub (a painful technique of rubbing a person's sternum with the knuckles of the hand to check if they respond to the pain.) He stated he took the resident's vital signs and then stayed with the resident until emergency services arrived. He was unable to recall the time. He was unable to recall the vital sign readings that day, but he stated he would call the doctor for a systolic (top number) b/p below 100 mm Hg or a diastolic (bottom number) below 60. An interview with RN #70 on [DATE] at 2:50 PM, revealed that if a resident was on a blood pressure medication with no parameters, if she observed a large drop in the blood pressure or if the systolic (top number) was below 100, she would hold a blood pressure medication and call the doctor. However, the documentation in Resident #112's medical record showed RN #70 failed to notify the physician on multiple occasions. When asked about monitoring a resident's urinary output, she reported she would notify the doctor if the resident's urinary output was less than 400 mL for the day. Furthermore, she stated she would check to see if the urine was amber, a decrease in appetite, their fluid intake, and behavior changes. However, documentation in Resident #112 medical record showed RN #70 failed to report these changes to the doctor. RN #70 reported that she had been assigned to Resident #112 for 16 hours on Saturday [DATE] and Sunday [DATE]. She reported on Saturday ([DATE]) there was not too much going on with the resident, no complaints. It was Sunday ([DATE]) morning that the resident was upset and stated s/he did not want to be here anymore. The resident stated s/he did not want me to call his/her family because they may interrogate him/her. RN #70 stated she remembered the resident talking back and forth with his/her roommate. She stated that closer to lunch time, she was checking the resident every 30 to 45 minutes due to the concern with him/her feeling sad. RN #70 reported that she tried to conduct a physical assessment, but the resident would not turn for her. She reported she obtained a full set of vital signs and had no concerns with the readings, but more concerned about the resident's psychological state. She reported that she remembered the family coming and they were concerned because the resident would open his/her eyes but not talk to them. She stated she thought it was the family dynamics. When the family wanted the resident to be sent out, she called the on-call and explained to her that I thought it was behavioral and she said we could send her out per family request. Then RN #70 went down and took the vital signs and the SPO2 was 88% and that was when the resident went downhill fast. Reviewed with RN #70 the times the resident had a low blood pressure, high pulse, and a decreased urinary output. She reported that if the blood pressure had been that low, she would have retaken it but may not have documented it in the record. She offered no explanation for the failure to notify the physician earlier. An interview with the Director of Nursing on [DATE] at 3:55 PM revealed that if a resident has a normal blood pressure and then drops, she expects staff to report that to the physician. If a resident has a catheter and the urinary output drops, then she expected staff to check the catheter for kinks/blockages and notify the physician if there were no issues and urinary output was low. Surveyor reviewed the concerns and she stated she had no rationale for why the nurses would not have reported changes to the physician. When asked if a resident had a history of sepsis, still had wounds, and a urinary catheter what changes would she monitor, she stated the low blood pressure, high pulse rate, and decreased urinary output. An interview with LPN #20 on [DATE] at 11:51 AM revealed she remembered reporting Resident #112's stomach concerns to attending Physician #61. When asked where she had documented these interactions, she stated that at least once it was a verbal interaction and then another time, she wrote it on a list of concerns that was given to him when he came to the unit. She stated she should have written a progress note, but at that time they were using agency staff and she was busy helping them take care of their residents. As result of these findings an Immediate Jeopardy (IJ) was called on [DATE] at 3:00 PM. The facility provided a plan of correction to lift the immediacy and it was accepted by the State Agency on [DATE] at 6:34 PM. The plan of correction was as follows: Resident #112 no longer resides in the facility. Completed on [DATE]. Residents who reside in the facility with a Change of Condition have the potential to be affected by this alleged deficient practice. Completed on [DATE]. The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction. This will be completed by [DATE]. An alternate physician has been assigned to residents and will be acting as Medical Director. Completed on [DATE]. Licensed nurses to be re-educated by Director of Nursing and Assistant Director of Nursing on the following: Identifying, assessing and reporting acute change in condition, including abnormal vital signs and notifying physician for further direction; Abuse, Neglect and Misappropriation of Funds. Director of Nursing/ Assistant Director of Nursing will educate the Dietitian on the importance of identifying changes of condition/weight changes and notifying the DON immediately. This reeducation will be completed by [DATE]. Any licensed nurse not receiving this training by this date for exceptions such as LOA will receive it prior to the next scheduled shift. Vital alerts were added to the Matrix system ensuring abnormal vital signs are alerted. Completed on [DATE]. The Medical Director was notified on [DATE] of Immediate Jeopardy. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting will be held on [DATE] to discuss the contents of this plan. Ongoing QAPI monitoring will include: Director of Nursing/Assistant Director of Nursing will review the Vitals out of Range report daily Monday through Friday in a clinical morning meeting. The Weekend Supervisor will review on the weekend. The Director of Nursing or Designee will review the Facility Activity report and 24-hour report to identify any documentation regarding a change of condition and validate that the resident has been assessed appropriately and physician notified. This will be completed Monday through Friday in the Clinical Morning meeting and by the weekend supervisor on the weekends. Results of the monitoring will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendation for 3 months. Any concern identified will be addressed at time of discovery. Final date of Compliance will be [DATE]. The facility's plan of correction to lift the immediacy was accepted on [DATE] at 6:34 PM. The immediate jeopardy was cleared through record review and interview on [DATE] at 12:30 PM. Cross Reference: F607, F692, and F711. 2) Review of facility report MD00177205 revealed that on [DATE], the facility received an allegation of abuse of Resident #107 by Geriatric Nursing Assistant (GNA - Staff #56). Review of Resident #107's medical record, on [DATE], revealed the resident was his/her own responsible party, and was certified as able to make his/her own decisions. The resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15/15. The resident was discharged from the facility in [DATE] and was not available to be interviewed during the survey. On [DATE] review of a Complaint/Grievance Report, completed by then Director of Social Services (Staff #87), revealed Resident #107 made the initial report of abuse to Staff #87 on [DATE]. On [DATE], the statement of an interview with Resident #107 was reviewed. This statement was signed by then Director of Nursing (Staff #62) and Assistant Director of Nursing (Staff #47) on [DATE]. This statement included the following: Resident stated that [name of GNA #56] aggressively turned [him/her] via pushing and pulling [him/her]. Resident stated this caused pain to [his/her] shoulder. Resident then stated [name of GNA #56] made some African American racial comments. I asked the resident twice what these comments were and both times [s/he] stated [s/he] rather not say. Resident also states [GNA] told [him/her], I don't have to do shit for you, I just have to make it look good. Resident was tearful and stated [s/he] had fear of repercussion if [name of GNA] knew [s/he] told. On [DATE], the statement of an interview with GNA #42 was reviewed. This statement was signed by then Director of Nursing (Staff #62) and Assistant Director of Nursing (Staff #47) on [DATE]. This statement included the following: I asked [GNA #42] to please explain to me in detail what occurred in [room #] with [Resident #107]. She then told me [GNA #56] was already in the room when she came in and [GNA #56] did aggressively attempt to roll the resident by pushing and pulling. The resident asked [GNA #56] to stop. [GNA #56] then stated I don't have to do shit for you, I just have to make it look good for everyone else. Further review of the investigation documentation revealed that additional residents were interviewed and and three of them reported concerns regarding GNA #56. Review of the statement signed by Staff #62 and #47 on [DATE] regarding these interviews revealed the following statements: When my shoulder was broken she jerked my arm and made it hurt bad. Her care is rough sometimes. She yells at me sometimes and refuses to answer my call light and says it's because I make her mad. She is always cussing at me and telling me she doesn't like me. Review of GNA #56's employee file, on [DATE], revealed that, on [DATE], a grievance was filed about the GNA and a Performance Feedback form was completed and signed by then Director of Nursing (Staff #62) and Assistant Director of Nursing (Staff #47). There is a notation that Employee acknowledged incident and future process but in the area for Employee Comments: Refused to sign was documented and the area for employee to sign was noted to be blank. Further review of the employee file revealed that, on [DATE], a Corrective Action Form was completed and signed by Staff #62 and #47. There is a notation that the employee Refused to sign. Reason for Action: [GNA #56] has multiple performance feedbacks and corrective actions in the last 12 months. [GNA #56] has several reports re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that residents received optimal quality of care that aligned with standards of professional practice. This was evident for 4 (Residents #112, #107, #118, and #86) of 84 residents reviewed during the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On [DATE] at 5:45 PM, a review of the facility's investigation file for a facility reported incident #MD00181072 was completed which stated that the facility had received an allegation of neglect for Resident #112. The former Director of Nursing Staff #47 conducted an investigation and failed to recognize that staff failed to promptly assess, identify, and notify the attending physician of acute changes in the resident's condition. Furthermore, she failed to note whether she had substantiated the neglect or not. A statement in the facility's investigation report read that measures were taken to prevent further incidents of similar nature, however, she failed to indicate what those measures were, and the investigation file had no evidence of these measures. Subsequently, on [DATE] at 9:00 AM, two allegations of neglect of Resident #112 were reviewed: #MD00180651 and #MD00182736. MD00182736 alleged that the neglect of Resident #112 led to an unexpected death of the resident. The investigation findings were as follows. On 4/22, according to the attending physician's History and Physical (H&P) note, Resident #112 was admitted to the facility for rehabilitation and continued treatment of cellulitis following a hospitalization for sepsis, cellulitis, and wound care. The resident's other diagnoses were asthma, morbid obesity, hypothyroidism, and high blood pressure. The resident had a foley catheter for urinary retention. This review of the medical record revealed that the resident had the capacity to make his/her own medical decisions. The admission Minimum Data Set, with the assessment reference date of [DATE], revealed in section C that the resident had no cognitive impairment. Further review of the medical record revealed the wound Nurse Practitioner (NP) Staff #67's visit note, dated [DATE], the resident had a Stage 4 pressure ulcer on his/her left heel. A Stage IV pressure ulcer means that there had been skin and tissue loss deep enough to expose the muscle and bone. The resident had a second wound on his/her left posterior (back) thigh that was a Stage 3. A Stage 3 wound means there was skin loss, and the layer of fat has been exposed. According to the resident's lab reports, s/he was diagnosed with C-Diff (Clostridioides difficile - a bacteria that causes diarrhea and inflammation of the colon. Cdc.gov) on [DATE]. Further review of the progress notes revealed on [DATE], it was noted that the C-diff was resolved. This illness was known to cause a decrease in appetite, vomiting, and diarrhea, placing the resident at risk for malnutrition. According to the National Institute of Health https://pubmed.ncbi.nlm.nih.gov) optimal wound healing requires adequate nutrition. Poor nutrition slows down or stops the wound from progressing through the stages of wound healing and malnutrition can increase the risk of infection. A review of the Dietitian's note, dated [DATE], revealed that Resident #112's weight was 218 lbs. which represented a 19 lbs. (8% body weight) loss in 30 days. However, she stated the weight loss was expected due to a gastrointestinal illness (referring to C-diff). The resident's physician's order summary for [DATE], revealed that the resident had a protein supplement daily to aid in wound healing and a protein shake daily for unspecified protein calorie malnutrition. The Wound NP Staff #67 wrote in her progress notes on the following dates that the resident had complained of abdominal pain and/or discomfort: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Staff #67 failed to document that the attending physician had been made aware of any of these complaints. According to the progress notes, Registered Nurse (RN) #16, the facility's wound nurse, was present at these visits and wrote a progress note of her own but failed to mention the resident's complaints of abdominal pain, as well as reporting it to the attending physician. Licensed Practical Nurse (LPN) #76 wrote a progress note on [DATE], that documented the attending Physician #61 had seen the resident for complaints of abdominal pain. Furthermore, the note stated that he ordered the following medications: Mirlax and Colace for stool softener and Bentyl (a medication used to treat irritable bowel syndrome) for abdominal pain. Upon review of the physician's progress note uploaded in the electronic record, it was revealed that there was no progress note uploaded for this date. However, on [DATE] when the surveyor requested the physician progress notes for the resident's entire stay, facility staff provided a physician's progress note, dated [DATE]. In addition, according to the electronic medical record time stamp, attending Physician #61 had not signed the note until [DATE]. A review of the progress note dated [DATE], revealed that attending Physician #61 failed to document the plan of treatment for the abdominal pain and mention the medications he had ordered. Under the section plan, he wrote the resident was medically stable, continuing with present medications and care. A progress note written on [DATE] by LPN Staff #75 documented that the resident complained of side pain and was administered acetaminophen (Tylenol) and then had a small emesis. An hour later when Staff #75 followed up on the effectiveness of the acetaminophen, it had not been effective so she administered the Bentyl which had been ordered on [DATE] as-needed for abdominal pain. According to the medication administration record (MAR) this had been effective. LPN Staff #20 wrote in a progress note on [DATE] that the resident was eating poorly, refused his/her bowel medications, and had a complaint of stomach gasses and bloating. Furthermore, she documented the resident had recently spoken to his/her doctor and Colace (stool softener) and MiraLAX (stool softener) had been ordered. The physician visit had been [DATE], 5 days prior to this note, and there was no evidence that the nurse conducted an assessment of this medical concern and/or notified the attending physician. The Dietitian noted in a progress note on [DATE], that the Resident's weight continued to drop. The admission weight was 262 lbs. At the time of the note, the resident weighed 190 lbs. The resident informed the Dietitian that s/he had not eaten because it made his/her stomach swell up. However, there was no documentation that the physician had been notified. On [DATE], the Dietitian forwarded the surveyor email correspondence, dated [DATE], that she sent to LPN #68, who was the unit manager at the time. The email read that the resident had weight loss, however, there was no mention of abdominal distress. Furthermore, there was no evidence in the medical record that attending Physician #61 was made aware of the weight loss or the abdominal distress. According to a progress note written by LPN Staff #20 on [DATE], she told the Dietitian the resident had not been taking his/her supplements, was eating poorly, and complaining of nausea when out of bed. However, there was no evidence in the medical record that LPN #20 or the Dietitian notified the attending physician. Review of attending Physician #61's progress note, dated [DATE], revealed documentation that the resident had no concerns, with no mention of the resident's complaints of abdominal pain and emesis. Again, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. On [DATE], LPN #20 wrote a note that the resident continued to report the medications made him/her feel ill and reported that his/her stomach was upset. There was no evidence that the nurse further assessed the stomach concern and there was no documentation that the attending physician was made aware that, 3 weeks after the visit on [DATE], the resident was not feeling better and the treatment he prescribed was not effective. On [DATE], a late note for [DATE], was entered by LPN Staff #76. Review of the note revealed that Resident #112 complained of pain in the right lower quadrant. Staff #76 failed to document an assessment of the abdomen and gave Tylenol despite having a PRN (as needed) order for Bentyl for abdominal pain. Further review revealed that LPN #76 contacted the on-call Nurse Practitioner (NP) #79 to report a new area on the resident's head, but failed to report the resident's complaint of abdominal distress. A review of the Resident's vital sign report revealed that, on [DATE] at 1:28 AM, the resident's blood pressure (B/P) was 87/56. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm. On [DATE] at 9:00 AM, a review of the facility's standards of professional practice revealed that hypotension (low blood pressure) is present when the systolic (top number) of the blood pressure falls to 90 mm Hg or below. Furthermore, it stated that while some adults have low b/p normally, for most people a low b/p is an abnormal finding associated with illness. ([NAME] and [NAME], 9th Version, 2017). However, further review of the medical record revealed that the nurse failed to notify the attending physician of this change in condition. On [DATE] at 11:33 AM, an interview with LPN Unit Manager Staff #8 revealed that she would call the doctor when a systolic (top number) was less than 110 mm HG (millimeters of mercury). When asked why she used this as a standard, she stated that nurses learn that information when they are in nursing school. On [DATE] at 9:48 PM, the resident's recorded vital signs were as follows: B/P 83/57, temperature (T) 97.7 F, pulse (P) 115, respirations (R) 16, and oxygen saturation (SP02) 99%. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm and there was no evidence in the medical record that LPN Staff #78 reported this change to the attending physician. A weekly skin assessment conducted on [DATE] revealed the resident had been pale which was a change from the previous skin checks. However, there was no evidence that the nursing staff notified the physician of this change. The Dietitian entered a note on [DATE], that read, nutrition note for supplement review with nursing; ensure, prostat, and B complex with C discontinued. There was no indication that this was discussed with the physician or that he had been aware of the change. A review of the attending Physician #61's progress note, dated [DATE],with a note added under HPI section, that the resident reported continued weakness. There was no indication in this note that attending Physician #61 had been aware of the resident's continued weight loss of 31 % of his/her body weight, the continued abdominal pain, the decrease in blood pressure and increased pulse. Furthermore, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record, and was not signed until [DATE]. A review of the Medication Administration Record (MAR) revealed the resident's urinary output for 24 hours on [DATE] was 300 milliliters (mL). (Urine output in 24 hours less than 400 mL can be one of the first signs of kidney failure) The resident had a urinary catheter due to urinary retention and nursing staff failed to recognize this change significant enough to contact the attending physician. A review of the MAR revealed on [DATE] at 12:20 AM that the resident complained of shortness of breath and was given an Albuterol as-needed dose. According to the record, this was a new symptom. In addition, a review of the Resident's vital signs revealed that, on [DATE] at 12:31 AM, the resident's recorded vital signs were as follows: B/P 71/51, T 97.97 F, P 95, R 18, and SP02 96%. This was a decrease in the blood pressure from the resident's norm and from the previous readings on [DATE] at 9:48 PM. LPN #75 failed to recognize that the shortness of breath was new and the decrease in blood pressure may indicate a significant change in the resident's medical condition and failed to report the changes to the attending physician. A review of the MAR for [DATE] revealed that the LPN #20 documented at 9:05 AM that she attempted to administer Cardizem ER 24 hr. 180 mg, but the resident refused it and stated it upset their stomach. Lasix 20 mg was given. (Lasix is a medication that helps the body get rid of excess water and salt. In the process of doing this Lasix may lower the blood pressure and is at times given to lower blood pressure) This was prior to obtaining a set of vital signs at 9:57 AM, so the last set of VS indicated a B/P of 71/51. Further review revealed the resident's urinary output for the last 24 hours was again very low at 375 cc and staff failed to inform the physician. On [DATE], LPN Staff #77 wrote that the resident had complaints of generalized pain, however she failed to conduct an assessment of the pain. The resident continued to have weight loss as the recorded weight for [DATE] was 179.4 lbs. However, the staff failed to notify the physician. The Dietitian failed to assess the resident who, despite her attempts, had continued to lose weight and she failed to discuss this with the attending physician. A review of the MAR for [DATE] revealed that RN #70 attempted at 9:05 AM to administer the resident ' s blood pressure medication but the resident refused. Lasix 20 mg was administered. A review of the resident's vital signs taken on [DATE] at 9:41 AM revealed a B/P of 93/53, T 98 F, P 109, R 16, and SP02 of 94%. The RN failed to recognize the resident's continued decrease in blood pressure and increase in pulse rate were indications of a change in his/her medical status and failed to notify the physician. RN Staff #70 failed to reassess the blood pressure and notify the physician. On [DATE], Registered Nurse (RN) #70 wrote a note that the resident continued to complain of abdominal pain and that the resident's doctor was aware because it was not a new symptom. There was no evidence that RN #70 assessed the pain or evaluated the plan of care. RN #70 failed to notify the physician of the continued abdominal pain and that the resident continued to refuse medications. A progress note written by the RN Staff #70 on [DATE] at 5:17 PM read, Resident did state that he/she felt his/her Symbicort inhaler wasn't working today. Educated the resident that he/she needed to take a deep breath in at the same time she pushes down on the inhaler. Otherwise she is not getting the full dose of her medication. Offered him/her the Albuterol inhaler and he/she used it. It seemed to help his/her symptoms. SpO2 this AM was 94%. SpO2 this PM was 93%. Assessed his/her lungs and they were clear but diminished. Resident diminished sounds are not uncommon due to her history. She/he has a history of SOB, Anxiety, Moderate persistent Asthma and environmental Allergic Rhinitis. VSS. Will continue to monitor. A review of the medical record failed to reveal that the resident had diminished lungs sounds previously, nor was there frequent use of the as-needed inhaler until [DATE] and [DATE], indicating there was a change. RN Staff #70 failed to recognize these signs that the resident's health condition had changed and notify the physician. A review of the MAR revealed that, on [DATE], the resident's total urinary output was 350 cc and the nursing staff failed to recognize that this decrease in urinary output had continued for 2 days and nursing staff failed to notify the physician. A review of the MAR for [DATE] revealed that RN #70 wrote a note at 8:03 AM that she attempted 2 times to give the resident his/her blood pressure medication, but the resident had refused that and his/her Lasix. RN Staff #70 had knowledge of the resident's low blood pressure the day before and failed to obtain a blood pressure prior to offering the resident their blood pressure medication. When the nurse obtained the vital signs at 10:20 AM that day, they were as follows: B/P 91/55, T 98 F, P 106, R 16, and SP02 of 93%. However, she failed to notify the physician at this time. In a progress note on [DATE] at 11:52 AM, RN Staff #70 wrote, Encouragement given all shift to the resident to drink more water. Her urine is a dark amber color. NO symptoms of a UTI. Denies any pain in the lower abdominal region where the bladder lies. Went into the resident's room several hours later and he/she still had not drank any fluids. Resident has been non-compliant with any suggestions to help himself/herself feel better or the functionality of his/her body. RN Staff #70 failed to recognize that the resident's urinary output of less than 400 mL for the last 3 days, coupled with the assessment of dark amber urine, the low blood pressure readings, and increased pulse rate were all significant signs that the resident's health condition was declining and failed to call the physician at this time. On [DATE] at 5:55 PM RN #70 wrote, Resident's family into visit resident at this time resident is not talking to them and will not answer them when they talk to her. O2 [oxygen] sat [saturation] 88 % on room air, O2 put on resident, at 3 liters. O2 sat came up to 90% had to turn O2 up 5 liters to get it to come up to 92%. Resident Lung sounds assessed by this writer. He/she has congestion in the right upper lung field. Resident has a dry congested cough. Resident is unresponsive; he/she will open his/her eyes but will not speak to us. Temp. 98.1 pulse 40 Resp 18 B/P 69/42. Certified Registered Nurse Practitioner (CRNP) Staff #79 notified N/O to send resident To ER [Emergency Room] for evaluation 911 called. However, due to subsequent notes written by RN #70 on [DATE], it was unclear if 911 had been called at this time. In addition, the Situation, Background, Assessment, and Recommendation (SBAR) tool that was completed by RN #70 failed to document all the symptoms the resident had been having and it was unclear if the on call CRNP #80 had been made aware the resident's full decline in condition. On [DATE] at 6:24 PM, Social Service Staff #80 wrote, [Resident #112] being sent to [hospital] at the family's request as [his/her] HCA [Health Care Agent] is argumentative and adamant that there is something medically wrong with [resident]. [Resident's] vital signs are stable and no vital alerts at this time contrary to family's adamancy. [Resident's] symptoms of concern for the family are variable to the attention it receives and is observed by various staff and witnesses . On [DATE] at 6:59 PM, RN Staff #70 wrote a note that the resident had voiced s/he did not want to live any longer. The resident complained of an upset stomach and was given Bentyl which had been effective. The resident had refused all routine medications that day and napped off and on. The nurse failed to recognize these symptoms of the resident's decline in condition and notify the physician earlier that day. On [DATE] at 7:26 PM, RN Staff #70 wrote a note that she informed CRNP #80 of the situation with Resident #112 and it was approved to send the resident to the emergency room per the family request. She wrote she called the hospital and gave a report. It was unclear when the resident left the facility to go to the hospital. A review of the hospital records on [DATE] at 8:30 AM revealed the resident was admitted with septic shock, pneumonia [infection in the lungs] and a urinary tract infection. At times a person with an infection may develop a condition called sepsis. Sepsis is defined as the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis occurs when a person has an infection and it triggers a chain reaction throughout the body. Most cases of sepsis start before a patient goes to the hospital. Infections that lead to sepsis most often start in the lung, urinary tract, skin, and gastrointestinal tract. Sepsis presents with low blood pressure, high pulse rate, and trouble breathing. Sepsis-induced hypotension (low blood pressure) is defined as the top number of the blood pressure is less than 65 mmHg. Septic Shock is a life threatening condition characterized by sepsis-induced hypotension that does not respond to treatment. Without timely treatment, sepsis/septic shock can rapidly lead to tissue damage, organ failure, and death. (www.cdc.gov) Furthermore, the hospital records showed the resident was treated with intravenous fluids (fluids administered into the veins) with vasopressin (medications to increase the blood pressure) added. Subsequently, the resident expired on [DATE] at 11:27 AM. An interview with Geriatric Nursing Assistant (GNA) Staff #81 on [DATE] at 9:24 AM revealed that she had been unaware that she was assigned Resident #112 on [DATE]. A subsequent review of the GNA documentation on [DATE] at 9:45 AM revealed that Resident #112 had not been provided care by a GNA that day. During an interview with LPN Staff #46 on [DATE] at 12:02 PM, he reported that he was working on [DATE] and went to Resident #112's room to get a set of vital signs for RN Staff #70. He reported that the resident was only responding to a sternal rub (a painful technique of rubbing a person's sternum with the knuckles of the hand to check if they respond to the pain.). He stated he took the resident's vital signs and then stayed with the resident until emergency services arrived. He was unable to recall the time. He was unable to recall the vital sign readings that day, but he stated he would call the doctor for a systolic (top number) b/p below 100 mm Hg or a diastolic (bottom number) below 60. An interview with RN #70 on [DATE] at 2:50 PM, revealed that, if a resident was on a blood pressure medication with no parameters, and if she observed a large drop in the blood pressure or if the systolic (top number) was below 100, she would hold a blood pressure medication and call the doctor. However, the documentation in Resident #112's medical record showed RN #70 failed to notify the physician on multiple occasions. When asked about monitoring a resident's urinary output, she reported she would notify the doctor if the resident's urinary output was less than 400 mL for the day. Furthermore, she stated she would check to see if the urine was amber, a decrease in appetite, their fluid intake, and behavior changes. However, documentation in Resident #112 medical record showed RN #70 failed to report these changes to the doctor. RN #70 reported that she had been assigned to Resident #112 for 16 hours on Saturday [DATE] and Sunday [DATE]. She reported on Saturday ([DATE]) there was not too much going on with the resident, no complaints. It was Sunday ([DATE]) morning that the resident was upset and stated s/he did not want to be here anymore. The resident stated s/he did not want me to call his/her family because they may interrogate him/her. RN #70 stated she remembered the resident talking back and forth with his/her roommate. She stated that closer to lunch time, she was checking the resident every 30 to 45 minutes due to the concern with him/her feeling sad. RN #70 reported that she tried to conduct a physical assessment, but the resident would not turn for her. She reported she obtained a full set of vital signs and had no concerns with the readings, but more concerned about the resident's psychological state. She reported she remembered the family coming and they were concerned because the resident would open his/her eyes but not talk to them. She stated she thought it was the family dynamics. When the family wanted the resident to be sent out, she called the on-call and explained to her that I thought it was behavioral and she said we could send her out per family request. Then RN #70 went down and took the vital signs and the SPO2 was 88% and that was when the resident went downhill fast. During a review of the times the resident had a low blood pressure, high pulse, and a decreased urinary output, RN #70 reported that if the blood pressure had been that low, she would have retaken it but may not have documented it in the record. She offered no explanation for the failure to notify the physician earlier. An interview with the Director of Nursing on [DATE] at 3:55 PM revealed that if a resident has a normal blood pressure and then drops, she expects staff to report that to the physician. If a resident has a catheter and the urinary output drops, then she expects staff to check the catheter for kinks/blockages and notify the physician if there were no issues and urinary output was low. Surveyor reviewed the concerns and she stated she had no rationale for why the nurses would not have reported changes to the physician. When asked if a resident had a history of sepsis, still had wounds, and a urinary catheter what changes would she monitor, she stated the low blood pressure, high pulse rate, and decreased urinary output. An interview with LPN #20 on [DATE] at 11:51 AM revealed she remembered reporting Resident #112's stomach concerns to attending Physician #61. When asked where she had documented these interactions, she stated that at least once it was a verbal interaction and then another time, she wrote it on a list of concerns that was given to him when he came to the unit. She stated she should have written a progress note, but at that time they were using agency staff and she was busy helping them take care of their residents. As result of these findings an Immediate Jeopardy (IJ) was called on [DATE] at 3:00 PM. The facility provided a plan of correction to lift the immediacy and it was accepted by the State Agency on [DATE] at 6:34 PM. The plan of correction was as follows: Resident #112 no longer resides in the facility. Completed on [DATE]. Residents who reside in the facility with a Change of Condition have the potential to be affected by this alleged deficient practice. Completed on [DATE]. The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction. This will be completed by [DATE]. An alternate physician has been assigned to residents and will be acting as Medical Director. Completed on [DATE]. Licensed nurses to be re-educated by Director of Nursing and Assistant Director of Nursing on the following: Identifying, assessing and reporting acute change in condition, including abnormal vital signs and notifying physician for further direction Abuse, Neglect and Misappropriation of Funds. Director of Nursing/ Assistant Director of Nursing will educate the Dietitian on the importance of identifying changes of condition/weight changes and notifying the DON immediately. This reeducation will be completed by [DATE]. Any licensed nurse not receiving this training by this date for exceptions such as LOA will receive it prior to the next scheduled shift. Vital alerts were added to the Matrix system ensuring abnormal vital signs are alerted. Completed on [DATE]. The Medical Director was notified on [DATE] of Immediate Jeopardy. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting will be held on [DATE] to discuss the contents of this plan. Ongoing QAPI monitoring will include: Director of Nursing/Assistant Director of Nursing will review the Vitals out of Range report daily Monday through Friday in a clinical morning meeting. The Weekend Supervisor will review on the weekend. The Director of Nursing or Designee will review the Facility Activity report and 24-hour report to identify any documentation regarding a change of condition and validate that the resident has been assessed appropriately and physician notified. This will be completed Monday through Friday in the Clinical Morning meeting and by the weekend supervisor on the weekends. Results of the monitoring will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendation for 3 months. Any concern identified will be addressed at time of discovery. Final date of Compliance will be [DATE]. The facility's plan of correction to lift the immediacy was accepted on [DATE] at 6:34 PM. The immediate jeopardy was cleared through record review and interview on [DATE] at 12:30 PM. 2) On [DATE], review of Resident #107's medical record revealed the resident was admitted to the facility in [DATE] with diagnoses that included, but were not limited to, diabetes, high blood pressure and obesity (overweight). Further review of the medical record revealed a physician order for monthly weights, in effect from [DATE] until the resident's discharge in [DATE]. Review of the vital signs section of the medical record revealed the resident's weight on [DATE] was 228.4 lbs and on [DATE] was 227.9 lbs. No weight was found for the month of October. During an interview with the unit nurse manager (Staff #8) on [DATE] at 9:35 AM revealed that, if a resident refused a weight, she would go and talk to the resident and that the expectation is that the nurses would document the refusal in the medical record and that staff would attempt to obtain the weight the next day or later. Further review of the medical record failed to reveal documentation to indicate the resident refused to be weighed during his/her admission. Surveyor reviewed the concern with the Clinical Service Director (Staff #41) on [DATE] at 9:33 AM regarding the failure to obtain the monthly weight as per the physician order. As of time of exit on [DATE], no documentation was provided to indicate a weight was obtained or attempted for [DATE]. Further review of the medical record revealed a weight of 200.8 lbs was obtained on [DATE]. This 27.1 lbs weight loss represents a loss of more than 10% in two months. A weight loss is considered to be severe if it is greater than 7.5% in 3 months, or greater than 10% in 6 months. Further review of the medical record failed to reveal documentation to indicate the primary care provider was made aware of this significant weight loss. The resident was seen by the primary care provider nurse practitioner (NP Staff #59) on [DATE]. Review of this note failed to reveal documentation acknowledging the recently identified weight loss and included the following notation: .no sig[TRUNCATED]

Based on medical record review and staff interview, it was determined that the facility 1) failed to prevent a cognitively impaired resident from exiting the facility, unsupervised, for an unknown amount of time. This was found to be evident for 1 (#84) of 16 residents reviewed for accidents. The findings include: 1) Elopement occurs when residents who are incapable of protecting themselves from harm are able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm's way. On 7/19/23 at 10:45 AM, a review of Resident #84 ' s medical record was conducted. In a History and Physical note, the physician documented that Resident #84 was admitted from home with progressive dementia, and stated the resident was alert to self only and could only communicate basic needs. A review of a Physician Certification Related to Medical Condition, Substitute Decision Making and Treatment Limitations form, which was signed by two physicians on 8/10/22, Resident #84 was deemed incapable due to dementia. On 8/10/22 at 1:00 PM, in a psychotherapy progress note, the psychiatrist documented that Resident #84 could not understand his/her medical conditions and diagnoses and lacked the ability to make informed medical decisions. Review of Resident #84's quarterly assessment with a reference date of 2/11/23 documented the resident's BIMS (brief interview for mental status) score was 5, indicating Resident #84 had severe cognitive impairment. Review of the resident's progress notes revealed on 2/23/23 at 8:15 AM, the SSA (social services assistant) documented that Resident #84 was observed getting on the elevator independently, and once downstairs, the resident went outside with a staff member. The SSA indicated that once outside, Resident #84 would not come back inside the facility, that several staff attempts were made to get him/her to come inside, the police were called, and after a while, Resident #84 agreed to go back in the building and returned to his/her unit. Following the incident on 2/23/23, staff initiated the following a care plan, [Resident #84] is at risk for elopement related to impaired cognitive function - Dementia evidenced by going outside of the building (staff aware and were with him) and refusing to come back in . The care plan goal was for the resident not to have any unplanned/unsupervised outings during the review period and the interventions listed were to have Activities staff check on the resident periodically to ensure that s/he had activities to do, encourage participation in activities programs of h/her choosing and socialization with his/her peers, and plan supervised outings to places he/she may wish to visit, encourage family support and to monitor the residents whereabouts and redirect when s/he is standing or hovering near the elevators, and to have the family take the resident ' s hat, coat and gloves home. During an interview on 7/20/23 at 1:00 PM, Staff #20, LPN (Licensed Practical Nurse), indicated that in the days following the incident with Resident #84 on 2/23/23, when he/she was assigned to care for the resident, the nurse was not aware that Resident #84 had attempted to elope and h/she was not conducting frequent checks on the resident. Staff #20 reported that Resident #84 did not consider him/herself a resident in the facility and that he/she was staying at the facility until he/she could get another place to live. Staff #20 stated Resident #84 would seek out new staff and visitors to get them to let him/her on the elevator. Also, Staff #20 reported Resident #84 had been overheard telling other residents that knew the elevator code that s/he was able to go down the elevator to the snack machine with them. Staff #20 stated Resident #84 would hang out at the elevator at the change of shift (between 2:30 PM - 3:00 PM) because it is chaotic at that time, and the resident could slip out. A review of the progress notes dated 2/24/23 - 7/9/23 revealed Staff #20 had failed to document the resident's exit seeking behaviors and the fact that the resident thought that they were not a resident in the facility. Further review of the progress notes revealed that, on 2/27/23 at 2:48 PM, the Social Services Director wrote that Resident #84 was witnessed attempting to enter the elevator and when they intervened, Resident #84 became upset for preventing the resident from getting on the elevator. Resident #84's medical record review revealed Elopement Risk Assessments (used to identify a resident's risk for elopement and implement interventions to prevent a resident from leaving the facility unsupervised) which documented responses to observation detail questions, the decision to proceed or not proceed based on the assessment, and interventions to prevent elopement. On 3/27/23, the assessment documented that Resident #84 had a diagnosis of unspecified dementia, the resident was confused, he/she was able to walk or self-propel in a wheelchair, had a history of wandering, expressed a desire to leave the health care center and had a diagnosis that required supervision. Further review revealed Resident #84's elopement risk assessment was inaccurate and incomplete: On 3/27/23 at 12:07 PM, in a quarterly Elopement Risk Assessment, the question has the resident attempted to leave the health care center? was coded no, which was inaccurate. On 2/23/23 at 8:15 AM, in a progress note, the SSA documented Resident #84 was observed accessing the elevator independently, and once outside with a staff member, the resident would not come back in. Following the incident, on 2/23/23, a care plan, [Resident #84] is at risk for elopement ., was implemented. Also, on 2/27/23 at 2:48 PM, in a progress note, the SSA documented Resident #84 was witnessed attempting to enter the elevator and the resident became upset when prevented from getting on the elevator. In addition, the decision to proceed or not proceed was unanswered, with no interventions documented.A review of an initial self-reported incident #MD00192154 revealed a facility self-report form dated 5/6/23 at 6:10 pm, that documented Resident #84 was missing from the facility. It was unclear how long the resident had been missing, however, the Director of Nurses (DON), the writer of the self-report form, was notified at 5:34 PM. The facility reported the resident was not located in the building and did not sign him/herself out for leave of absence, the resident's representative was contacted and had not heard from the resident and 911 was called. The facility's final self-report, dated 5/8/23 at 1:25 PM, documented Resident #84 was located by local law enforcement at 8:11 PM at a Rescue Mission and returned to the facility around 9:30 PM on 5/6/23 with no injuries noted. The self-report documented that following the resident's elopement, an intervention to place a wanderguard on Resident #84 was attempted, but the resident refused, and the facility conducted 15-minute checks on the resident. In a progress note written on 5/6/23 at 11:41 PM, Staff # 31, LPN wrote that when the nurse went to get the Resident #84's blood pressure, the nurse was unable to find the resident. The nurse checked the bathroom and dining room and was unable to locate the resident. The nurse made the supervisor aware, and a code yellow was announced. Staff came to the 3rd floor and helped search for the resident. The DON and NHA (Nursing Home Administrator) were notified, came to the facility and the police were called. While the police were in the facility, a call was received from Resident 84's family, reporting Resident #84 was seen in town around 1:30 pm. The police located Resident #84 at 8:30 PM and returned them to the facility around 9:35 PM. The resident refused a head-to-toe assessment and refused a wanderguard. The nurse indicated that a new order for 15 min checks was obtained, and the resident was in bed resting. Following Resident #84's elopement on 5/6/23, the resident ' s Risk for Elopement care plan was updated with the interventions, elevator access code changed, 15 minute checks in place for this resident for safety, and apply wanderguard to resident for safety one he/she will allow staff to place it. On 5/7/23 at 12:32 PM, in a progress note Staff #20, LPN indicated Resident #84 would not allow the staff to apply a wanderguard. On 5/7/23 at 2:20 PM, Staff #47, RN (registered nurse) documented that the resident continued to refuse a wanderguard, and on 5/7/23 at 2:40 PM, in a progress note, Staff #20, LPN, wrote that Resident #84 continued to refuse the wanderguard. No other documentation was found in the medical record to indicate that further attempts were made to apply a wanderguard to Resident #84. On 6/21/23 at 3:33 PM, in a social service note, the Social Services Assistant (SSA) Staff #14 wrote that the resident displayed exit seeking behavior, blocking the elevator with staff on it. Staff de-escalated the situation and redirected the resident. Further review of Resident #84's Elopement Risk Assessments revealed that, on 6/21/23, the assessment documented that Resident #84 had a diagnosis of unspecified dementia, the resident was confused, he/she was able to walk or self-propel in a wheelchair, had a history of wandering, expressed a desire to leave the health care center and had a diagnosis that required supervision. Further review revealed Resident #84 ' s elopement risk assessments inaccurate and incomplete. On 6/21/23 at 1:54 PM, in an Elopement Risk Assessment, the question has the resident attempted to leave the health care center? was coded no, which was inaccurate as the Resident #84 attempted to elope on 2/23/23 and eloped from the facility on 5/6/23. Also, on 6/21/23 at 3:33 PM, in a progress note, the nurse documented Resident #84 displayed exit seeking behavior, blocked the elevator with staff on it and was redirected by staff. The question, Decision, was unanswered, and no interventions were documented. On 7/25/23 at 12:56 PM, Unit Manager Staff #33, LPN revealed that they were responsible for completing the elopement assessments and had not been aware that Resident #84 had attempted an elope on 2/23/23 or 5/6/23. An interview on 7/26/23 at 9:25 AM with Staff #21, GNA revealed that the last time s/he saw Resident #84 on 5/6/23 was at 2:30 PM when the resident was standing at the elevators, which was at the time the dayshift GNAs left for the day. Furthermore, Resident #84 had frequently been observed hanging at the elevators. Staff #21 reported that the resident's appearance could be mistaken for a visitor. An interview with Staff #32, GNA on 7/26/23 at 9:35 AM revealed they had cared for Resident #84 on the day the resident eloped. Staff #32 reported s/he had been aware the resident attempted to elope in February 2023 and was supposed to check on the resident more frequently. However, when Resident #84 was out of his/her room during last rounds the GNA was unable to keep an eye on the resident. Staff #32 reported Resident #84 continued to hang around the elevators. When asked what Staff #32 does when they see this behavior, Staff #32 stated he/she would watch the resident or alert someone else. Staff #32 stated it was concerning because the resident could slip on the elevator at any time the elevator opened if no one was watching him/her. Also, Staff #32 could understand how someone could mistake Resident #84 for a visitor due to the resident's appearance. A subsequent interview with LPN #20 on 7/26/23 at 10:33 PM revealed that Resident #84 continued to have exit seeking behaviors. Staff #20 stated that the resident had told him/her that they will get on a bus and will not get caught the next time, however, there was no documentation in the medical record to reflect this information. Based on the investigation, Resident #84's whereabouts were unknown for 5 ½ hours. The resident was located by local law enforcement officers hours later at a Rescue Mission, which was located 1.3 miles away from the facility. The place where the resident was found required the resident to cross multiple high-trafficked city streets and one busy snow emergency route. This placed the resident at risk for serious injury or death. In addition, in the facility, there were two elevators that are accessible from the nursing units. Although a code is required to access them, once the doors open, there is up to 15 seconds during which the doors remain open. This delay allows time for a resident to go into the elevator and once in the elevator, they can go to the lobby and exit the facility because the front doors are accessible and unlocked during the day. Resident #84 attempted to leave the facility on 2/23/23, by accessing the elevators independently. On 5/6/23, Resident #84 left the facility unsupervised for 5 ½ hours. Resident #84 refused to wear a wanderguard which would activate an alarm at the front door. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 7/26/23 at 4:34 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 7/26/23 at 7:02 PM and it was not accepted. The facility submitted a second draft at 7:44 PM, and it was not accepted. The third draft was submitted on 7/26/23 at 8:04 PM and the facility's written plan to remove the immediacy was accepted on 7/26/23 at 8:28 PM with and alleged date of compliance of 7/27/23. The provisions of the plan to remove the immediacy included the following: 1) Resident #84 currently in the facility. Elopement risk assessment and risk alert added to plan of care. 2) Licensed nursing staff will be educated on appropriate documentation pertaining to elopement, behaviors, wandering behaviors and verbal expressions of wanting to leave the facility. 3) Elevator code changed on 7/26/23. Education to facility staff completed by Administrator that new elevator code is not shared to residents and during the time doors remain open that no resident has unintentionally entered the elevator. 4) Front door access changed on 7/26/23. Education to facility staff completed by the Administrator that employee-fob access will be required to exit the building. 5) Licensed nurses were re-educated by the Director of Nursing/designee on the following: · Documentation exit seeking behavior · Elopement Policy and Procedure · The elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This included intervening if the resident verbalizes the desire to leave the facility, or threatens to leave the facility, or refuses to wear a wanderguard. · Education to be completed by the Assistant Director of Nursing or Director of Nursing by 7/27/23. 6) Facility staff will be educated on documentation of elopement and exit seeking behaviors and identifying exit seeking behaviors. DON and ADON will educate by 7/27/23. 7) The Director of Nursing and Assistant Director of Nursing will randomly interview a minimum of 2 staff weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with documentation for residents exhibiting exit seeking behaviors. 8) The facility activity report will be reviewed for documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. 9) Any concerns will be addressed at time of discovery 10) The medical director was notified on 7/26/23 of the Immediate Jeopardy 11) Ad Hoc Quality Assurance Performance Improvement Meeting will be held on 7/27/23 to discuss the contents of this plan. 12) Administrator will oversee compliance of this plan for three months. 13) Alleged date of compliance: 7/27/23 An observation conducted on 7/28/23 at 8:00 AM found the facility's plan, Employee fob access will be required to exit the building to remove the immediacy of the immediate jeopardy had not been implemented as evidenced by the facility's unlocked front entrance doors, allowing a person to leave the building without an employee fob access. On 7/28/23 at 8:06 AM, the surveyor exited the facility through the front doors, which were unlocked and unattended. On 7/28/23 at 8:10 AM, another surveyor walked into the facility's unlocked front doors. At that time, Staff #38, Admissions Director, asked if the surveyor had a fob. The surveyor replied that they did not have a fob and asked if the doors were not staying locked. Staff #38 indicated that, every once in a while, the doors would not stay locked, and they were trying to figure it out. The front doors continued to be unlocked when the surveyor walked out of the building on 7/28/23 at 8:40 AM. During an observation on 7/28/23 at 8:42 AM, the receptionist was observed in the lobby, sitting outside of the enclosed receptionist area. The receptionist was turned to face the enclosed area, with their back towards the front entrance doors, which did not allow a view of the unlocked front door thus potentially allowing unauthorized persons to leave the facility unattended. On 7/28/23 at 9:00 AM, the NHA, DON, ADON and Staff #41, Clinical Service Director were made informed the immediate jeopardy was not cleared, as their plan to remove the immediacy, Employee- fob access will be required to exit the building had not been implemented, that the front doors were found unlocked, and unattended, allowing a person to leave the facility without employee fob access. In response, the NHA stated that they were unable to get the doors to lock and indicated they were working with an outside company to get the doors to lock. At that time, the NHA was made aware that if the facility could not lock the doors, then a plan/provision needed to be in place until they could implement their plan. On 7/28/23 at 10:40 AM, the NHA stated that the front door was now locked and presented an updated Plan of Removal, to remove the immediacy, which was not accepted. The facility submitted an updated written plan to remove the immediacy which was accepted on 7/28/55 at 12:55 PM with an alleged date of compliance of 7/28/23. The updated written plan to remove the immediacy included the following changes: 1) Vendor door company technician validated on 7/28/23 that the facility door was now locked and only able to be accessed by a key fob. The front door was to be accessed with a key fob. The front door entrance and exit to the facility would be monitored by a facility staff member 24 hours a day through Monday 7/31/23 at 7 PM. Documentation of front door monitoring would be completed in 15-minute increments. NHA attached a schedule of designated door monitors through 7/31/23 at 7 PM. 2) Education was provided to the staff who were assigned to monitor the front door on 7/28/23 by the Administrator. Education included: · Required 15-minute documentation. · Door monitoring is the staff's only assigned duty · If break is required, the door monitor must secure someone else to cover prior to taking break · If the door is able to be opened without a key fob, NHA must be notified immediately. 3) Licensed nurses were re-educated by the Director of Nursing/designee on the following: · Documentation exit seeking behavior · Elopement Policy and Procedure · The elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This included intervening if the resident verbalized the desire to leave the facility, or threatened to leave the facility, or refused to wear a wander guard. · Education to be completed by the Assistant Director of Nursing or Director of Nursing by 7/27/23. 4) Targeted audience not receiving the above education would receive it prior to their next scheduled shift. 5) The Medical Director was notified of changes on 7/28/23. 6) Changes were discussed in the Ad Hoc Quality Assurance Performance Improvement Meeting on 7/28/23. On 8/2/23 at 8:00 AM, an onsite visit was conducted. After validation of the implementation of the facility's plan of removal, which included staff interviews, record reviews and direct observation, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 7/28/23 at 12:55 PM