**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation, medical record review, and interview, the facility failed to prevent nonconsensual sexual contact between Resident #200 and 3 residents (Resident #8, #112, and #126). On 8/16/2023, Certified Nursing Assistant (CNA) #12 observed Resident #200 standing over Resident #126 pulling down his brief and Resident #126 was resisting the actions. CNA #12 left Resident #200 and Resident #126 alone in the room to get assistance in removing Resident #200 from the room. CNA #12 failed to protect Resident #126 from further potential nonconsensual sexual contact with Resident #200. Nursing staff failed to provide interventions and within 4 hours, Resident #200 was observed touching Resident #112's genital area while sitting in the 2 East common area. Nursing staff failed again to intervene appropriately and within 2 hours, Resident #200 had nonconsensual sexual contact with Resident #8 when she grabbed him and gave him an open mouth kiss then began licking his face. The facility's failure to prevent Resident #200's continued aggressive sexual behavior placed Resident #8, #112, and #126 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility also failed to ensure 2 (Resident #52, and #62) of 3 sampled residents reviewed were free from verbal abuse which did not rise to the level of IJ. The Administrator was notified of the Immediate Jeopardy on 9/20/2023 at 7:20 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-600 with a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy was effective from 8/16/2023 to 9/27/2023. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was verified onsite by the survey team on 9/27/2023. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Abuse Prevention/Reporting Policy and Procedure, revealed, .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents .The facility has developed and instituted policies and procedures for screening and training employees in regard to the protection of residents and for the prevention, identification, investigation, and reporting of abuse .Sexual Abuse: Touching the resident in an intimate or suggestive manner .Facility management is required to accept all allegations of abuse and conduct a complete and thorough investigation .Facility staff/supervisors will immediately intervene, identify and correct reported or identified situations in which abuse .is a risk for occurring . facility will protect residents from harm during the investigation .1:1 observation of resident (alleged perpetrator) .Resident's family and the attending physician should be notified of the situation after the call to administration .The Administrator and the DON [Director of Nursing] will conduct a comprehensive investigation of any and ALL allegations .The investigating team will interview all parties concerned .and obtain signed statements .The investigation will proceed and conclude by fact-finding, root cause analysis and comparison of information . Review of the undated facility's policy titled, Abuse Prevention Program, revealed, Our residents have the right to be free from abuse .This includes but is not limed to freedom from .verbal .sexual .abuse .As part of the resident abuse prevention, the administration will .Protect our residents from abuse by anyone including .facility staff .other residents . Review of the undated facility policy titled, Sexual Expression of Residents, revealed, .policy of this facility to respect the right of residents to express themselves sexually, as long as it does not violate the rights of other residents .policy applies to individuals who exhibit intact cognitive decision-making capacity staff will document observation of residents engaging in intimacy and/or sexual activity and notify social services and the Director of Nursing .social services staff will notify the interdisciplinary team .physician will be notified regarding all residents participating in sex for a clinical and cognitive evaluation to determine .capacity to give consent .Care plan meetings with the Interdisciplinary team shall be scheduled as soon as possible .Outcomes of the interdisciplinary team review will be shared with the residents involved and documented in the plan of care .facility shall provide initial staff orientation and ongoing staff training regarding abuse .awareness about residents' sexual rights .staff documenting and reporting .staff should immediately report suspected sexual abuse to immediate supervisor Review of the facility's policy titled, [Facility #1] Associate Code of Conduct, dated 2/25/2023, revealed, .Treat all residents .with respect and courtesy. Be professional, prompt and caring to everyone .Refrain from use of profane or potentially offensive language or jokes .Never verbally .abuse .any customer .Abuse is defined as intentionally causing distress to a person through harsh words or tone of voice .or causing any form of mental trickery known or likely to cause mental anguish or distress . 2. Review of the medical record revealed Resident #200 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Dementia, unspecified severity, and Hallucinations, unspecified. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Review of the Medicare Skilled Daily Notes for Resident #200 revealed, .8/16/2023 .6:13 PM .responds appropriately .Verbal behavioral symptoms .Other behavioral symptoms .displaying sexually inappropriate behaviors .treated for UTI [Urinary Tract Infection], due to increased confusion and abnormal behaviors .continual inappropriate behaviors are mostly to the male residents .rubbing Resident A [Resident #112] on his crouch [crotch] .inserted her tongue in resident B's mouth [Resident #8] .sat on his lap and danced inappropriately .into Resident C's [Resident #126] room, laid in bed next to him, rubbing his head and hands .Resident has been reminded severally that her behaviors were unacceptable, inappropriate, and also reminded to maintain boundaries, unable to redirect .EDON [Executive Director of Nursing]/DON/NP [Nurse Practitioner]/Unit mgr [manager] all notified of residents continual advances and behavior .several times this shift . During a telephone interview on 8/23/2023 at 3:58 PM, Family Member #3 stated he received a call from the EDON on 8/23/2023. Family Member #3 stated, .[EDON] told me [Resident #200] approached a man and grabbed his crotch .[Resident #200] was found in the bed with another man trying to take his underwear off .[Resident #200] had grabbed a man and gave him an open mouth kiss .to expect a call from state .I told her the nurse told me she was being sent out because she had symptoms of a bad UTI .never mentioned the sexual behaviors . During an interview on 8/30/2023 at 11:02 AM, Registered Nurse (RN) #6 stated, .I came in on 8/16/2023 .[CNA #12] came to me and said [Resident #200] was in the bed with [Resident #126] stroking his hands and face [Resident #200] was in the chair beside the bed rubbing [Resident #126]'s face and hands [Resident #200] refused to get up at first because she said [Resident #126] was her husband .around 10:00 AM [CNA #13] reported [Resident #200] was at the table with [Resident #112] rubbing on his crotch and down his leg [CNA #13] redirected [Resident #200] and assisted her to another table called [Unit Manager #2] to ask for assistance and she was busy .texted the DON and was told he was in a meeting, to contact [Unit Manager #1] for assistance .[Activity Assistant #3] reported [Resident #200] went over to [Resident #8], grabbed him and gave him an open mouth kiss .[Activity Assistant #3] redirected her again and I called the NP and texted the DON .[DON] brought [EDON] upstairs and they talked to the NP .[EDON] told me to make sure I documented everything very well . During an interview on 8/30/2023 at 11:24 AM, CNA #13 stated on 8/16/2023 before lunch she observed (Resident #200) sitting at the table with (Resident #112) rubbing his leg and groping his crotch. CNA #13 stated she asked (Resident #200) to stop touching (Resident #112) and (Resident #200) stated, Its okay, this is my husband. CNA #13 stated she assisted (Resident #200) to another table and notified RN #6. During an interview on 8/30/2023 at 12:04 PM, Activity Assistant #3 stated, during the afternoon on 8/16/2023 (Resident #8) was sitting in 2 East common area and (Resident #200) walked up, grabbed him, gave him an open mouth kiss, and then started licking his face. Activity Assistant #3 stated she immediately separated the residents, notified RN #6, and monitored (Resident #200) while she (Activity Assistant #3) was on the unit. During an interview on 8/30/2023 at 12:09 PM, the NP stated RN #6 notified him on 8/16/2023 at 1:53 PM about Resident #200's inappropriate behaviors. The NP stated he went to 2 East and met with RN #6, the EDON, and the DON to discuss sending Resident #200 to the emergency room for further evaluation. During a telephone interview on 9/12/2023 at 1:40 PM, the Social Services Director (SSD) stated she had not been asked to evaluate Residents #8, #112, #126, and Resident #200 for capacity to consent to sexual activity. The SSD stated Residents #8, #112, and #126 had cognitive impairments that would prevent them from being able to consent to sexual contact. During a telephone interview on 9/14/2023 at 11:58 AM, CNA #12 stated, .I went to [Resident #126]'s room .When I entered the room, [Resident #200] was standing over [Resident #126] pulling his disposable brief down. [Resident #126] looked confused and kept pulling his brief up I told [Resident #200], stop, you can't be doing that to him [Resident #200] turned and walked into the bathroom I told [Resident #200] to go to her room . [Resident #200] kind of lunged forward at me . I stepped out into the hallway and yelled for help .[Human Resource-HR] asked me for a statement on August 22 or 23 [8/22/2023, 8/23/2023] .I took a picture of my statement and texted it to [HR] that same day Review of the written and signed statement provided by CNA #12 revealed she documented that she found (Resident #200) attempting to pull down (Resident #126)'s brief, and was not in bed with (Resident #126.) HR provided a copy of the statement to surveyor. During an interview on 9/14/2023 at 2:01 PM, CNA #14 stated, .8/16/2023 [CNA #12] came hurriedly up the hall yelling that she needed help with [Resident #200], because she was in the room with [Resident #126] .[Resident #200] was sitting in a chair beside the bed . CNA #14 pointed to the area where she first saw CNA #12 standing and asking for help. The area was approximately 8 feet from Resident #126's door. During an interview on 9/20/2023 at 6:05 PM, RN #6 reviewed the statement written by CNA #12 and stated, .I wasn't aware that [CNA#12] found [Resident #200] standing by the bed pulling down [Resident #126]'s brief .[CNA #12] came down the hall .she did leave [Resident #200] in the room alone with [Resident #126] for a moment . During a telephone interview on 9/25/2023 at 4:19 PM, the EDON stated CNA #12 should not have left Resident #200 and #126 alone in the room to get assistance and nursing should have taken appropriate actions to prevent Resident #200 from continued sexually aggressive behaviors. The EDON stated staff failed to protect Residents #8, #112, and #126 from abuse. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Dementia with Lewy Bodies, Vascular Dementia, mild, with anxiety, and Depression. Review of the Significant Change in Status MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 4, which indicated severe cognitive impairment. During an interview on 9/12/2023 at 10:02 AM, Family Member #9 stated she received notification related to Resident #8 being involved in nonconsensual sexual contact with Resident #200 on 8/23/2023. Family Member #9 stated, .[Resident #8] was a germ-a-phobe [overly afraid of germs] and would have had panic attacks over her [Resident #200] kissing and licking on his face .if he was in his right mind, he would have been humiliated cognitively impaired, there isn't any way he could or would consent to sexual contact 4. Review of the medical record revealed Resident #112 was admitted to the facility on [DATE] with diagnoses which included Essential Hypertension, Dementia in other diseases classified elsewhere, mild, with agitation. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #112 had a BIMS score of 0, which indicated the resident was unable to complete the interview. During a telephone interview on 9/12/2023 at 10:10 AM, Family member #8 stated she did not receive a notification related to the nonconsensual sexual contact between Resident #200 and Resident #112 until 8/23/2023. Family Member #8 stated, .[Resident #112] would have been very humiliated before his decline .so impaired he cannot consent to sexual contact or relationship . 5. Review of the medical record revealed Resident #126 was admitted to the facility on [DATE] with diagnoses which included Acute Pulmonary Edema, Dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance, and Vascular Dementia, unspecified severity, with other behavioral disturbance. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #126 had a BIMS score of 2, which indicated severe cognitive impairment. During a telephone interview on 9/12/2023 at 10:21 AM, Family Member #10 stated he had not been informed of the nonconsensual sexual contact between Resident #126 and Resident #200. Family Member #10 stated, .[Resident #126] could not consent to sexual contact with anyone .very understanding .would have been embarrassed . 6. The surveyors verified an acceptable Immediate Action Removal Plan on 9/27/2023 by: A. On 8/22/2023, the Administrator and Executive Director of Nursing conducted 1:1 training with RN#6 regarding abuse prevention and reporting. RN#6 completed a posttest regarding abuse policy/procedure, prevention and reporting with 100% competency. B. The Unit Managers, wound nurse and charge nurses conducted skin assessments on all residents. An abuse observation review (attached) was conducted on all residents with a BIMS less than 8 with no indicators of possible abuse noted. Reviews include all current residents to date with a BIMS less than 8. C. On 8/23/2023, the Administrator conducted an adHoc QAPI committee meeting regarding the events on 8/16/2023 and subsequent reportable. The committee includes, but is not limited to: the Administrator, DON, Business Office Manager, Activities Director, Unit Managers, MDS nurses, Social Service Director, Medical Records, Dietician, Maintenance Director, Housekeeping Supervisor, education nurse, and the Medical Director. D. The adHoc QAPI committee will meet weekly to review results of interviews, audits, reportables, outcomes of using new tools and status of education. E. New abuse training began by the education nurse, Director of Clinical Operations and Nursing Supervisors: Resident abuse Prevention and Reporting- Protecting a Vulnerable Population for all staff and new hires along with a competency posttest (attached). Staff will not work until they have this education and testing. Any wrong answers will be reviewed 1:1 with the staff member by the Admin, DON and/or education nurse. The education includes: aa. Resident Rights-Abuse bb. Who are the abusers? cc. Definitions of the types of abuse F. Understanding Abuse dd. Examples of abuse (includes sexual) ee. Actual situations resulting in citations ff. Signs of abuse gg. Resident to resident abuse G. Regulations on Reporting Abuse hh. Reporting Requirements ii. Elder Justice Act H. Facility Specific Policy/Procedures jj. Protect and Comply I. Abuse Prevention kk. Vulnerable Populations ll. Communication Strategies mm. Understanding Behaviors nn. Brainstorming oo. Responding to abuse J. Agency staff will receive abuse training/posttest as part of their orientation before they work as well. The Daily assignment sheets are reviewed daily by Admin and/or education nurse to ensure all staff working have received education. Any found to have not received education will immediately be removed from the patient care area and education will be completed. K. On-going competency monitoring- 1:1 and huddle quizzes have been conducted 3 times per week by the DCO (Director of Clinical Operations), DON, Education nurse and nursing supervisors to ensure staff can properly discuss abuse and verbalize topics such as: who the abuse coordinator is and how to protect residents. L. The facility Abuse Policy dated 2018 was reviewed and compared to F600 to F610 by the Administrator, VP (Vice President) of Operations and Director of Clinical Operations. The policy has been revised to be clearer and more concise and places Protection as #1 in the protocol of what to do in the event of an allegation of abuse. M. By 9/21/2023, The Administrator and Director of Clinical Operations developed a new Abuse Investigation Checklist (attached) that will aid the Administrator and team in conducting a thorough investigation. This checklist will remain with the investigation file in the Administrators office. Copies of the checklist will be placed in the Staff tools/education binders at each station for use as well. In addition, 2 new investigation tools have been initiated: Abuse- Complainant Statement and Abuse- Investigation Statement (attached). This will guide the Administrator in obtaining more thorough attestations in an abuse investigation. N. On 9/21/2023, the Administrator, a Licensed Administrator from a sister facility and the RN [NAME] President began conducting abuse interviews with all residents with a BIMS of 8 and greater. The questionnaire (attached) covers all types of abuse, including sexual. There were no allegations of abuse reported. The Administrative team will continue conducting 20 interviews per week for a minimum of 8 weeks. All residents with a BIMS of 8 and greater will have a minimum total of 3 interviews. The facility Administration will follow the abuse policy/procedures for any allegations of any type of abuse noted in the interviews. O. On 9/21/2023, the Director of Clinical Operations and MDS nurses began conducting staff interviews regarding all types of abuse (attached). Interviews will continue until all staff have been interviewed. The facility Administration will follow the abuse policy/procedures for any allegations of any type of abuse noted in the interviews. P. The Director of Clinical Operations completed education with the Administrator, DON and Deputy Administrator regarding the Abuse policy and procedure, Investigating abuse, F600, F607, F609, F610 and Tennessee specific reporting training. An abuse prevention and reporting posttest was completed with a 100% pass rate. Any new hires in these positions will receive immediately upon hire. Q. Resident Counsel met on 9/21/2023- they reviewed residents rights, the Care line phone number and the abuse policy/procedure. Each member will receive a copy of the 2023 Abuse, Neglect, Misappropriation, Exploitation Policy delivered to their room. Others who are their own RP (Responsible Party) will also receive a hand delivered copy. All others will receive a copy in the mail. R. The VP of Operations, RN VP, Corporate Nurse Specialist and/or the Director of Clinical Operations will have weekly oversight of Administration to ensure plan/processes are compliant. 7. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Personal history of Urinary (tract) Infections, Personal history of Pulmonary Embolism, Personal history of other Venous thrombosis and emboli, Anemia, Scoliosis, and Osteoarthritis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #52 revealed a BIMS score of twelve (12), which indicated moderate cognitively impairment. During an interview in Resident #52's room on 8/28/2023 at 1:35 PM, Resident #52 was asked about care on Saturday 8/19/2023. Resident #52 stated I had a run in with her about breakfast. Resident #52 was asked who did you had a run in with about breakfast. Resident #52 stated I asked [Named CNA #28] to bring me some coffee .[CNA #28] is always hyper and in a hurry. She [CNA #28] is not polite. She [CNA #28] came in and set my food down and wasn't in my room more than 15 seconds before I realized there was no coffee on my tray. I had to ring the call light. She [CNA #28] came back into my room and said, 'What do you need now?' I said I need some coffee. She [CNA #28] said 'Don't get smart with me.' We had words. We don't like each other she [CNA #28] is not polite .She told me in a mean voice not to get smart. 8. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Acute Respiratory Failure with Hypoxia, Heart Failure, Anxiety disorder, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction without residual deficit, Type 1 Diabetes Mellitus with Diabetic Neuropathy, Morbid Obesity, and Chronic Obstructive Pulmonary Disease (COPD). Review of admission MDS assessment dated [DATE] for Resident #62 revealed a BIMS score of thirteen (13) which indicated resident was cognitively intact. During an interview in Resident #62's room on 8/28/2023 at 6:00 PM, Resident #62 was asked about her care on Saturday 8/19/2023. Resident #62 stated, I turned on my call light to get my ostomy emptied. [CNA #28] answered my call light and I told her I needed my bag emptied. [CNA #28] responded 'Can't you do that yourself?' in a mean tone of voice. Resident #62 stated CNA #28 returned with CNA #21 to assist with care. Resident #62 stated [CNA #28] repeated 'Can't you take care of it yourself' and the two CNA's had private side bar conversations making me feel very self-conscious. Resident #62 stated CNA #28 starting spraying air freshener in the air. Resident #62 stated You can't spray air freshener in the air I can't breathe it's landing on my legs. Resident #62 stated CNA #28 was very rude and disrespectful. During an interview on 8/30/2023 at 11:15 AM, Resident #62 was asked if she feels safe. Resident #62 stated, I am not afraid. I wouldn't want them [CNA #28 and CNA #21] back in my room. I felt intimidated, angry, and they were being jerks. They [CNA #28 and CNA #21] were verbally inappropriate and rude. Review of the facility's investigation dated 8/21/2023 at 3:42 PM, revealed, .Allegation Type .Abuse .Verbal .Alleged Victim(s) .[Resident #52] .Alleged Perpetrator(s) .[CNA #28] .Who made the allegation .[CNA #22] .What was reported and to whom .Reported to .Executive Director of Nursing .Date and time when the alleged incident occurred .8/19/2023 3:00 PM .Where the alleged incident occurred .In Resident's room .Resident #52] does not want that CNA [CNA #28] to return to his room .Conclusion .Verified .the allegation was verified by evidence collected during the investigation .[named CNA #28] was suspended during the investigation and was terminated on 8/24/2023 . Review of the facility's investigation email dated 8/21/2023 at 7:28 PM, from CNA #22 to the Executive Director of Nursing (EDON) revealed, .This message is in regards to the CNA [CNA #28] that worked 2 north Saturday [8/19/2023] I seen and heard multiple things she .shouldn't have done .that morning she [CNA #28] delivered the breakfast tray to [Resident #52's Room number] .and walked back out before he [Resident #52] could say anything .He [Resident #52] rang .to ask for coffee .As soon as she [CNA #28] walked in, she [CNA #28] said what do you need now? He [Resident #52] told her [CNA #28] that he needed coffee .didn't get any on his tray .she [CNA #28] said, why didn't you tell me when I came in here .he [Resident #52] said he didn't have time to .she [CNA #28] proceeded to tell him [Resident #52] .he was getting on her nerves and she [CNA #28] wasn't dealing with that today' .Then the resident [Resident #62] .at approximately three o'clock she [Resident #62] rang .to be changed .When [CNA #28] .walked in the room she [CNA #28] said what do you need? The resident [Resident #62] replied that she needed her brief changed and her bag emptied .she [Resident #62] has an ostomy bag. [CNA #28] responded .don't you empty your own bag? The resident said no .[CNA #28] said she didn't believe that . Review of the personnel record document titled Separation Notice, dated 8/24/2023, revealed, .[Named CNA #28] .Last Employed: From: 2/25/2022 to 8/24/2023 .Reason for Separation .Discharge .explain the circumstances of this separation .Lack of Code of Conduct - Care of Residents . During an interview on 8/28/2023 at 2:50 PM, CNA #22 confirmed the statements made in an email dated 8/21/2023 at 6:54 PM that she [CNA #22] sent to the EDON. CNA #22 stated .CNA #28 was arguing with residents on 8/19/2023 and being very disrespectful to the residents . During an interview on 8/28/2023 at 4:17 PM, CNA #21 stated she worked on Saturday 8/19/2023 with CNA #28. CNA #21 stated [CNA #28] asked me to help with [Resident #62] . CNA #21 stated Resident #62 has a colostomy and while emptying it the bag broke and CNA #21 asked for air freshener due to the odor. CNA #21 stated [CNA #28] got the air freshener and started spraying it on [Resident #62]'s feet and I told her to spray it behind me. [CNA #28] stopped me and stated 'I am spraying' in a loud voice. Further interview revealed that CNA #21 stated CNA #28 was loud and disrespectful asking Resident #62 Can you empty your own bag? CNA #21 stated when the nurse asked CNA #28 to take a resident to the bathroom CNA #21 heard CNA #28, say I just got him up and I'm not taking him to the bathroom, in a very disrespectful tone. During an interview on 8/28/2023 at 6:10 PM, the EDON stated, I investigated the incident that happened on Saturday August 19th with the Administrator. [CNA #28] was phoned for an interview and denied the allegations. [CNA #21] was interviewed and stated that [CNA #28] was aggressive, boisterous in tone stating, 'Can't you do this' to [Resident #62] .The result of the investigation was the CNA [CNA #28] concerns were substantiated and [CNA #28] was terminated for actions not appropriate toward residents and resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, website www.localconditions.com review, medical record review, facility document review, observation, and interview, the facility failed to provide adequate supervision to prevent an avoidable accident for 2 (Residents #200, and #201) of 22 residents reviewed. Resident #200 and #201 moved from a safe environment to an unsafe environment when Resident #201 exited the building unsupervised, on 8/12/2023, and Resident #200 exited the building unsupervised, on 8/13/2023. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility also failed to accurately assess 22 (Resident #11, #22, #29, #31, #45, #53, #72, #73, #74, #76, #90, #91, #110, #112, #114, #118, #135, #140, #144, #200, #201, and #250) sampled residents reviewed for wandering/elopement risk. The Administrator was notified of the Immediate Jeopardy on 8/30/2023 at 4:09 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-689 with a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy was effective from 8/12/2023 to 9/26/2023. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was verified onsite by the survey team on 9/26/2023. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopements, revised 12/2007, revealed, .Staff shall investigate and report all cases of missing residents .Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director Of Nursing . Review of the facility policy titled, Wandering Residents, implemented in 2023 (No specific date) revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .facility is equipped with door locks/alarms to help avoid elopements .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk . Review of the facility's policy titled, admission Criteria, revised 12/2016 revealed, .The objectives of our admission criteria policy are to .assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission .The Administrator, through the Admissions Department, shall assure that the resident and the facility follow applicable admission policies . Review of the website www.localconditions.com revealed on 8/12/2023 at 3:30 PM (time of day Resident #201 was found outside) the temperature was 80.6 degrees Fahrenheit (F). On 8/13/2023 at 9:30 AM (time of day Resident #200 was brought back inside the facility) the temperature was 84.2 degrees F. 1. Review of (Hospital #2) Hospitalist (Doctor who provides care for patients at the hospital) Progress Notes for Resident #201 revealed, .6/28/2023 .HPI [History of Physical Illness] . doing well until this past weekend .develops a mental status change .has a history of some Alzheimer's Dementia .patient was quite confused . Review of the medical record revealed Resident #201 was admitted to the facility on [DATE] with diagnoses which included Dementia, Alzheimer's Disease, Pathological Fracture, Right Femur, and Repeated Falls. Review of the Elopement Risk Tool dated 7/11/2023 for Resident #201 revealed, .cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? Yes .diagnoses that may increase the risk of elopement? Depression .Has family communicated that the resident has eloped or attempted to elope from home .may have wandering/elopement tendencies? No .Resident has not been found to be at risk for elopement at this time . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #201 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Review of Certified Nursing Assistant (CNA) #4's written statement (found in unrelated investigation) dated 8/8/2023 revealed, .[Resident #201] is a patient who continually tries to get out of bed during his waking hours. Most of the time he says he has to go to work or he has to go see about something across the room that's not there . Review of the progress notes for Resident #201 revealed, .8/12/2023 .Resident was up in w/c [wheelchair] rolling around hallway in unit CNT [Certified Nursing Tech] assisting other resident .noticed this [Resident #201] was not in hallway .residents w/c at back door [Resident #201] not in w/c Door is suppose to alarm when opened and it did not alarm observed [Resident #201] sitting on crub [curb] 3 feet away from door . Review of the facility investigation dated 8/12/2023 revealed (Resident #201), .CNA #5 reported .around 3:20 PM-3:30 PM .she went into room [ROOM NUMBER] and [Resident #201] was not in his room. She began looking for the resident and saw that his wheel chair was at the end of the hallway. She looked out of the window and saw [Resident #201] sitting on the curb outside .The alarm to the exit door was in the off position which allowed him to open the door without our knowledge . Review of the facility document Vital Signs Grid for Resident #201, revealed there was no documented assessment of vital signs on 8/12/2023 at 3:30 PM. Resident #201 returned to the facility on 8/12/2023 at 3:30 PM, after being outside an undetermined amount of time, in temperature approximately 80.6 F. Symptoms of heat illness in older adults include high body temperature and strong, rapid pulse. The facility was able to provide video footage of the main entrance which includes the road that runs parallel to the curb. The staff reported Resident #201 was found 8/12/2023 sitting on curb that runs parallel to the road. Review of the video footage of the main entrance on 8/12/2023 from 2:30 PM-3:55 PM revealed 35 cars that passed on the road that runs parallel to the curb where Resident #201 was found sitting. At 3:36 PM a fire truck arrived, 3:37 PM an ambulance arrived and then 3:44 PM fire truck left and ambulance left the facility at 3:54 PM. During an interview on 8/22/2023 at 9:15 AM, the Facility Maintenance Director stated, The key alarms on the door were put on years ago. The alarm to the exit door can be turned off if someone has a key. We found out the nurses had keys to these alarms on the door so we pulled all the keys from the nurses to prevent someone turning off the alarm. I would think you would put the Dementia patients on the secured unit or the 2nd floor because the North hall has access to the main entrance door that you can walk out of at any time. The main entrance door has a button to push to be able to get in but you can walk right out of the automatic door when you step in front of it. The Facility Maintenance Director stated, We put all these break away alarms on all the doors that a resident could walk out of from the 1 North hall so we would be alerted that the door opened but as soon as the door closes the alarm will silent. During an interview on 8/22/2023 at 9:30 AM, the Clinical Director stated, .We had an agency nurse call the maintenance man on 8/12/2023 due to the exit door on 1 North was not alarming when [Resident #201] was found outside sitting on the curb. When Maintenance arrived he found the alarm box was not on at all and we have no idea when the alarm was turned off. The Maintenance man reset the alarm and made sure it was working. The Executive Director of Nursing (EDON) came in on Saturday 8/13/2023 to start the investigation on [Resident #201] leaving the building. We had a discussion and found the nurses had keys to the alarm box on the door so it was possible the nurse took the key and turned the alarm off on the door. The EDON removed all keys to the exit door from the nurses keys. Around 12:00 AM, [Resident #200] sets off the alarm on the same exit door on 1 North and the alarm will not quit, and continued to sound. The Maintenance man comes back over and the alarm will not reset so ultimately the alarm is off. Maintenance #3 says he will report the issue with the oncoming Maintenance staff. The nursing staff watched (Resident #200) the rest of the night Observation of 1 North Hall nurse station on 8/22/2023 at 10:00 AM, revealed Registered Nurse (RN) #5 and the EDON were unable to locate the Elopement book. Observation and interview on 8/23/2023 at 10:40 AM, revealed the Facility Maintenance Director and Maintenance Chief Engineer (MCE) showed the surveyor the number code to access the elevator on the second floor was written on plastic next to the elevator door. The MCE stated, .any resident could punch in the code and have access to the elevator [to exit the 2nd floor] . The Facility Maintenance Director replied, .Dementia residents can read that [access code] and get on the elevator . During a telephone interview on 8/24/2023 at 11:29 AM, Family Member #4 (Resident #201's representative) stated he was aware of (Resident #201) being found outside an exit door sitting on the curb. Family Member #4 stated, I had to demand a meeting to discuss (Resident #201)'s care. No one was telling me anything. The staff would say just pop your head in on therapy and find out about [Resident #201's] progress. The facility didn't call me when [Resident #201] was transferred from the hospital. If they had called me I could have told them [Resident #201] walked away from [Assisted Living Facility #3]. [Resident #201] crossed a busy street walked a 30 % grade up a hill off [roadway #4], ended up at a pizza place and staff had to go get him and bring him back. I have [Resident #201] at home with me now he is walking up to 150 feet now. During an interview on 8/28/2023 at 9:35 AM the admission Director and Community Clinical Liaison, revealed Resident #201 was not evaluated prior to admission. The admission Director stated, [Resident #201] was not on the list to be evaluated. We didn't go out to speak to him, we just decided to place him. Both the admission Director and Community Clinical Liaison stated they do not call the families before they admit a resident to obtain a history on the resident. 2. Review of the medical record revealed Resident #200 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Nicotine Dependence, Depression, and Unspecified Dementia, Unspecified Severity. Review of the After Visit Summary (Hospital Discharge Orders sent with transport on 7/26/2023) for Resident #200 revealed, .Referral to Behavioral Health .Vascular Dementia of Acute Onset With Behavioral Disturbance .Delirium Due to Multiple Etiologies .Recurrent Major Depressive Disorder .having hallucinations at home .smoking status .Every Day Packs/day 1 . Medications given in hospital included QUEtiapine (Seroquel-antipsychotic), mirtazapine (Remeron-antidepressant), and nicotine (transdermal patch used to treat nicotine withdrawal) and Lorazepam (antianxiety medication). Review of the Elopement Risk Tool for Resident #200 dated 7/29/2023 revealed, .cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? Yes .diagnosis that may increase the risk of elopement? .Dementia [Resident #200's diagnoses included; Depression, Nicotine Dependence, Hallucinations, and Metabolic Encephalopathy (chemical imbalance that can cause delirium and illusions) which can increase elopement risk] Resident has not been found to be a risk for elopement . (Resident #200 required a sitter while hospitalized prior to placement in facility #1. Family member #3 stated he told the nurse that called him on 7/26/2023 Resident #200 had behaviors and episodes of Psychosis (loss of contact with reality) which made it necessary for placement in a secured area.) Review of the Elopement Risk Tool for Resident #200 dated 8/13/2023 revealed, .cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? Yes .diagnosis that may increase the risk of elopement? .Depression .Dementia .Has the resident ever left the facility without informing staff? .No .Additional details: Patient has not left the building or walked all the way up the hallway to an exit by herself until this A.M. [Morning] [Resident attempted to exit the building the previous shift] .Has the resident verbally stated that they wish to go home, packed their belongings, remained in close proximity to an exit door, or displayed exit-seeking behavior? .Yes .Additional Details: Patient has stated that she wanted to go home after she gets better previously but never packed her belongings or headed towards an exit .pattern of wandering throughout the facility including wandering into other resident rooms? .Yes .Additional Details: Patient will walk from her room to nurses station and back to room [Interviews with staff revealed Resident #200 wandered looking for her husband or wanting to get a prescription filled, days prior to her elopement from the facility's] .Will walk to dining room or therapy gym [both areas with unarmed exit doors in close proximity] .Does the resident's wandering behavior affect his/her safety and well-being? .Yes .Resident has been found to be at risk for elopement . Review of the therapy summary notes for Resident #200 revealed, .7/27/2023 .Impulsive behaviors leading to increased fall risk . Review of the Medicare Skilled Daily Notes for Resident #200 revealed, .7/30/2023 .Altered level of consciousness .Inattention, difficult focusing, easily distracted, difficulty keeping track of what was being said .8/1/2023 .Confused at times .mood indicators? .Yes .Feeling down, depressed, or hopeless .worse than usual? .Yes . Review of the admission MDS assessment dated [DATE] revealed Resident #200 had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #200 required supervision with walk in room and locomotion on unit. Review of the facility document Vital Signs Grid for Resident #200 revealed there was no documented assessment of vital signs on 8/13/2023 at 9:30 AM. Resident #200 returned to the facility on 8/13/2023 at 9:30 AM, after being outside an undetermined amount of time, in temperature approximately 84 F. Symptoms of heat illness in older adults include high body temperature and strong, rapid pulse. (nurse documented head to toe assessment after elopement-no vital signs included) During an interview in the Administrator's office on 8/17/2023 at 9:55 AM, the Administrator stated there had not been consistent education provided to staff related to elopement risk prior to the recent elopements on 8/12/2023 and 8/13/2023. During an interview on 8/17/2023 at 10:05 AM, the EDON stated she was unable to find documentation of education that had been provided to nursing staff related to elopements, risk of elopements, and use of the Elopement Risk Tool for assessment. The EDON stated, .I audited the wandering residents after the elopements, and found the elopement risk assessments were all over the place .some residents with wander guards had assessments that said they were not at risk to elope .most assessments were inconsistent with the previous assessment .no documentation of wandering . The EDON stated the Unit Managers were responsible for monitoring the documentation and assessments. The EDON stated, .it appears that no one has been supervising the nurses . During an interview on 8/21/2023 at 11:20 AM, CNA #7 (agency staff) stated, Today is my first day in the facility. I do not know the code for elopement, I didn't get in-service on elopement prior to working this morning. During an interview on 8/21/2023 at 11:25 AM, CNA #8 (agency staff) stated she had not had an elopement in-service prior to working today. She did not know what the elopement code was for the facility. During an interview on 8/21/2023 at 11:40 AM, the Infection Control Preventionist stated she had provided elopement risk in-service to all employees on the schedule for 8/21/2023 that had not been previously in-serviced. She presented a roster of 4 employees she had in-serviced and stated it included the agency staff on the schedule for today (8/21/2023). The roster of in-serviced employees did not include agency staff CNA #7 and #8. During an interview on 8/21/2023 at 11:55 AM Licensed Practical Nurse (LPN) #9 stated, .[Resident #200] walked independently and would occasionally say she was going to visit her friend .[Resident #200] would come to the nurse station and start picking up things. When asked what she was looking for [Resident #200] usually didn't know, just things .anxious all the time and looking for her husband. During an interview on 8/22/2023 at 9:30 AM, The Clinical Director stated, .on Sunday morning around 8:44 AM [Resident #200] left the building. The night shift nurse says she reported to the oncoming shift that [Resident #200] had to be redirected all night because she kept trying to exit the building. The nurse didn't move [Resident #200] to another secured area in the building and she didn't notify management. We don't have any documentation of routine checks for (Resident #200) while the alarm was not working. I am not sure who went and got [Resident #200], I know someone from Cottage #13 called and said a resident was at the cottage. [Resident #200] was assessed, a wanderguard was applied, and [Resident #200] was moved to the second floor . During an interview on 8/23/2023 at 2:45 PM CNA #5 stated, .[Resident #200] was upset and anxious repeating different lists, and saying she was missing things the week before she left the building .[Resident #200] was agitated and hard to redirect .looking for her husband . I told [Unit Manager #1] [Resident #133, #200, #201, and #29] were at risk for wandering .not appropriate for this unit because of all the doors available to exit from the facility .went to cottage #13 to bring [Resident #200] back to the facility the day she was out [8/13/2023] .Resident was sweating and had a red face . During a telephone interview on 8/23/2023 at 3:58 PM Family Member #3 stated, .[Resident #200] was not happy about being in the facility, she wanted to be home with me .had a lot of behaviors in the past .getting worse to the point I felt like [Resident #200] needed a lock down unit .received a phone call after [Resident #200] was brought to the facility and was told what items she needed in the facility .I asked them if they had a lock down unit for [Resident #200] and was told no but they could watch [Resident #200] .told them she needed a lock down unit because she has episodes of Psychosis, especially during the evening . During an interview on 8/24/2023 at 9:40 AM the live in caretaker for Cottage #13 stated, .The Home Health Agency [HHA] caregiver told me a woman she had found in the yard was inside the cottage .[Resident #200] sitting on the sofa .had bruising all over and her feet were swollen .I called the towers [facility receptionist area] and the woman that answered said she would send someone to get the resident . During an interview on 8/24/2023 at 10:22 AM, the MCE stated Maintenance Assistant (MA) #3 had left a text message on his phone the night of 8/12/2023 indicating the 1 North-North door alarm was not working properly. He stated when he saw the message on 8/13/2023 he called the Environmental Services Director and was told the alarm had not been repaired and was not attached to the door. [MA #3] could not reset the alarm on 8/12/2023 because his key was worn and would not work in the alarm. The MCE stated he had the same problem with a worn alarm key about a year prior to the incident on 8/12/2023. During a telephone interview on 8/24/2023 at 5:42 PM the HHA caregiver stated, I saw [Resident #200] walking across the yard [Cottage #13] .[Resident #200] fell and I went out to see if she needed help .[Resident #200] said she did need help and kept repeating she was hot .[Resident #200] was red faced and sweating .had bruises all over her arms, legs, and hands . [Resident #200] couldn't figure out how to use her cell phone .took her inside .[live in caregiver] called [facility #1]. During an interview on 8/24/2023 at 6:01 PM, MA #3 stated, .received a call from the 1 North Hall nurse on 8/12/2023 around 11:30 PM requesting assistance to turn off 1 North-North exit door alarm .could not get the alarm to reset with his key .sent the MCE a text message around 12:00 AM .could not get the alarm to reset and I took the batteries out to silence the alarm . told the nurses on 1 North Hall that the alarm was not working and the nurses [MA #3 did not know the names of the nurses] said they would keep an eye on the door . During an interview on 8/28/2023 at 11:47 AM, the Community Clinical Liaison (CCL) stated the facility receives the referral for an admission and she evaluates the resident for appropriate placement in the facility. The CCL stated if the prospective resident is in another facility she meets with the family and then goes to the transferring facility for the evaluation. The CCL stated she did not meet with Family Member #3. The CCL stated she spoke to Resident #200's case manager at the hospital. The CCL stated, .I was told [Resident #200] was very lonely, cried a lot, and was confused during her stay .gave her medications and she evened out but still had some confusion .had a sitter to keep her company and prevent her from being lonely .I have not received training for psychiatric behaviors and dementia patients . During a telephone interview on 8/28/2023 at 2:41 PM, LPN #10 stated, .[Resident #200] attempted to open the exit door about 11 [11:00 PM] on [8/12/2023] .had to call maintenance to turn alarm off .he couldn't get it to turn off, so he took the battery out of it .[Resident #200] didn't try to get out anymore that night .reported to [Unit Manager #1] the next morning during count that the door was unlocked and the battery was out of the alarm .told [Unit Manager #1] [Resident #200] was anxious all night, wanting to go pay a credit card bill and when she tried to go out the door, [Resident #200] said she was going to type a paper .the supervisor was sitting at the desk listening to report at that time . During a telephone interview on 8/28/2023 at 3:18 PM, CNA #11 stated, .the dayshift [8/12/2023] CNA [CNA #5] reported [Resident #200] wandered a lot and had been anxious and hard to redirect for several days .walked around looking for her phone and other items .didn't want to go to bed .mumble jumble speech .told nurse .very anxious . During a telephone interview on 8/28/2023 at 3:18 PM, CNA #34 stated, .after report on [8/12/2023] the nurse told me to keep an eye on [Resident #200] because she had been wandering and was anxious .[Resident #200] tried to go out the end door [1 North-North] 3 times total before morning .the door alarm was off and maintenance couldn't fix it .didn't sleep at all .very confused trying to walk down East Hall to get prescription filled .gave report to [CNA #5] and [Unit Manager #1] the next morning . During an interview on 8/28/2023 at 5:18 PM, Unit Manager #1 stated, .[Resident #200] walked to the nurse station and dining area, more often when she was anxious .knew the nurse had said [Resident #200] had not slept all night .completed elopement risk assessments but had not received guidance for completing the assessments .I know [Resident #200] wore a nicotine patch, but I didn't know she still smoked before she came here . Unit Manager #1 reviewed Resident #200's medical record and stated, I suppose having dementia, anxiety, and smoking would make [Resident #200] an elopement risk. Unit Manager #1 stated she had not been in-serviced on completing the Elopement Risk Tool. The determination of Elopement Risk was left up to the nurse completing the assessment. During an interview on 8/29/2023 at 2:25 PM, the Director of Nursing (DON) stated, .he had provided in-services since 1/2022 .had not been trained on elopement risk assessment .had not provided an in-service to the nursing staff related to recognizing/assessing elopement risk . During an interview on 8/29/2023 at 3:16 PM, the Director of Clinical Operations (DOC) stated Resident #200 and #201 had not been assessed correctly on admission for elopement risk and staff had failed to recognize elopement risk factors. The DOC stated the Administrator conducted ad hoc (when needed) QAPI (Quality and Performance Improvement) meeting on 8/14/2023 to discuss the root cause analysis of the elopements and put additional interventions in place to prevent further elopements. The DOC stated QAPI attendees concluded that nursing staff failed to recognize elopement risk and put interventions in place and maintenance failed to ensure the door alarm was working properly on the 1 North-North exit door. Continued interview the DOC stated she did not locate documentation of care plan meetings with Resident #200 and Resident #201's family and could not find documentation from previous SSD related to 72 hour meetings. Observation of facility property and interview on 8/22/2023 at 8:44 AM, revealed 1 North-North exit door facing roadway #1 with a sidewalk and 11 inch curb on the edge of the roadway approximately 4 feet (ft.) from the door. Roadway #2 measured 642 ft. from 1 North-North exit door and roadway #3 measured 278.4 ft from the exit door. The pathway Resident #200 was seen on camera walking along measured 517 ft. from 1 North-North exit door to Cottage #13 [where Resident #200 was located]. The MCE verified the measurements with a rolling measuring tool. The Facility Maintenance Director stated an individual exiting the 1 North-North door and turning to the left would not be seen immediately on any of the cameras outside the facility. 3. Observation and interview on 9/22/2023 at 10:55 AM, revealed, Registered Nurse (RN) #11 reviewed the Elopement Book at 1 North Nurse Station and stated, .The residents listed in the book with wander guards have a picture and facesheet in the book and the residents on the wandering only list do not have pictures with facesheets in the book . When asked if she would recognize each resident on the wander only list, she replied, I do not know [Resident #144 and Resident #253] and I am not really sure about [Resident #112]. Observation and interview on 9/22/2023 at 11:00 AM, revealed, CNA #24 (agency staff) reviewed the Wandering Only List found in the Elopement Book at 1 North nurse station. CNA #24 stated she did not recognize any of the residents on the wandering only list. Observation and interview on 9/22/2023 at 11:08 AM, revealed, CNA #6 reviewed the Wandering Only List found in the Elopement Book at 1 North nurse station. CNA #6 stated she did not recognize any of the residents on the wandering only list. Observation and interview on 9/22/2023 at 11:16 AM, revealed CNA #8 (agency staff) reviewed the Wandering Only List found in the Elopement Book at 2 East nurse station. CNA #8 stated she had only been assigned to the faciltiy for two weeks was not able to identify any of the residents on the wandering only list. Observation and interview on 9/22/2023 at 11: 20 AM, revealed CNA #23 reviewed the Wandering Only List found in the Elopement Book at 2 East nurse station. CNA #23 stated she was unable to identify 5 of the 9 residents on the wandering only list. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Atherosclerotic Heart Disease of Native Coronary Artery, Unspecified Dementia, mild, with Anxiety, and Unspecified Atrial Fibrillation. Review of the current care plan for Resident #11 revealed, .Problem Onset: 8/14/2023 I tend to wander aimlessly . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #11 had a BIMS score of 0, which indicated the resident was unable to complete the interview. Staff Assessment for Mental Status was coded 1 Memory OK and Cognitive Skills for Daily Decision Making was coded 2 Moderately impaired. Behaviors Wandering was coded 0 Behavior not exhibited. Review of the progress notes for Resident #11 revealed, .9/13/2023 .At 4:08am resident came out of room walking behind wheel chair .stated she was lost and looking for her room . Review of the Elopement Risk Tool for Resident #11 revealed elopement risk assessments documented between 11/16/2022 and 9/26/2023. The elopement risk assessments were inconsistent with risk factors such as history of elopement, and patterns of wandering, and final determination of elopement risk. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Schizophrenia, Unspecified Psychosis, and Major Depressive Disorder. Review of the current care plan for Resident #22 revealed, .Problem Onset: 2/28/2023 Wandering due to exit seeking behaviors at times .Problem Onset: 8/14/2023 .I tend to wander aimlessly . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #22 had a BIMS score of 0 which indicated the resident could not complete the interview. Staff Assessment for Mental Status was coded 0 Memory OK. Cognitive Skills for Daily Decision Making was coded 1 Modified independence. Behavior Wandering was coded 0 Behavior not exhibited. Review of the progress notes for Resident #22 dated 11/1/2022-9/27/2023 revealed there was no documentation of wandering/elopement/exit seeking behavior. Resident #22 was listed in the Elopement Book as a wandering resident and care planned for wandering. Review of the Elopement Risk Tool for Resident #22 revealed elopement risk assessments documented between 1/4/2023 and 9/20/2023. The elopement risk assessments were inconsistent with risk factors such as history of elopement, and patterns of wandering, and final determination of elopement risk. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Multiple Fractures of Ribs, Depression, and Dementia. Review of the Elopement Risk Tool for Resident #29 revealed, .8/15/2023 .intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills? Yes .diagnosis that may increase the risk of elopement? other Dementia .Dementia .Has family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? No [family interview revealed staff was informed of wandering behavior at home] .has not been found to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure a safe environment that prevented an incident of entrapment for 1 (Resident #145) of 77 sampled residents reviewed for assist bar use. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ-a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #145, a vulnerable resident assessed to be cognitively impaired, became entrapped between the assist bar and mattress. The facility also failed to try an appropriate alternative prior to installing an assist bar, failed to perform side rail assessments and failed to obtain informed consent prior to installation of the assist bars for Resident #1, #3, #5, #8, #13, #14, #20, #23, #25, #26, #27, #28, #31, #33, #36, #38, #39, #41, #42, #43, #44, #45, #46, #50, #51, #52, #54, #56, #57, #58, #60, #62, #64, #68, #69, #70, #71, #74, #77, #80, #83, #84, #93, #94, #96, #97, #98, #100, #102, #106, #110, #111, #113, #115, #116, #118, #119, #122, #133, #134, #135, #136, #137, #139, #141, #142, #143, #144, # 145, #146 , #253, #255, #257, #258, #259, #300, and #400. The Administrator, Executive Director, and Regional Nurse were notified of the IJ on 8/30/2023, in the Administrator's office. The facility was cited IJ at F-700. The facility was cited at F-700 at a scope and severity of k which is Substandard Quality of Care. The IJ was effective from 8/7/2023 through 9/14/2023. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was verified onsite by the survey team on 9/14/2023. The facility's noncompliance at F-700 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings included: Review of the undated facility's policy titled, Proper Use of Bed Rails, revealed, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensure correct installation, use, and maintenance of the rails .Bed Rails are adjustable metal or rigid plastic bars that attach to the bed .available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths .some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed .Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars .Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail .Resident Assessment .as part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs .Medical diagnosis .size and weight .existence of delirium .ability to toilet self safely .cognition .mobility (in and out of bed) .Risk of falling .The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs .The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include .a. Accident hazards ( .falls, entrapment .attempts to climb over, around, between, or through the rails, or over the footboard) b. Barrier to residents from safely getting out of bed c. Physical restraint .d. Decline in resident function .e. Skin integrity issues f. Decline in other areas of activities of daily living such as using the bathroom, continence, eating, hydration, walking and mobility g. Other potential negative psychosocial outcomes such as an undignified self-image, altered self-esteem, feelings of isolation, or agitation/anxiety .resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself .Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails .Appropriate Alternatives .facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include, but are not limited to: a. Roll guards b. Foam bumpers c. Lowering the bed d. Concave mattresses .The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes .Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible .Checking bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time .For bed rails that are incorporated or pre-installed, the facility will determine whether or not disabling the bed rail poses a risk for the resident .Ongoing assessment to assure that the bed rail is used to meet the resident's needs .Ongoing evaluation of risks .Responsibilities of ongoing monitoring and supervision are specified as follows .A nurse assigned to the resident will complete assessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail . 1. Review of the medical record revealed Resident #145 was admitted to the facility on [DATE] with diagnosis which included Neoplasm of uncertain behavior of Cerebral Meninges, Long term use of anticoagulants, Lack of coordination, and muscle weakness . Review of the Annual Minimum Data Set, dated (MDS) 7/28/2023 revealed Resident #145 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the comprehensive care plan for Resident #145 revealed, .problem onset .potential for injury R/T [related to] fall - muscle weakness .lack of coordination .falls in the past .7/28/2023 - use total mechanical lift with transfers .fall mats on each side of bed to prevent injury related to falls .7/28/2023-bolsters applied to bed . Review of fall documentation for Resident #145 dated 8/7/2023 revealed .was found a second time on the floor at approximately 10-11 PM, a family member visiting across the hall came to me .saying that she heard someone yelling for help .went with her immediately to see who it was .[Resident #145] had her arm (R) [right] between the railing and mattress . Review of the medical record for Resident #145 revealed no side rail assessment was performed for the resident and no consent for the use of the assist bar. Observation in Resident #145's room on 8/16/2023 at 4:00 PM revealed C- rails (8 inch wide assist bar noted with bed controls to center of rail) to both sides of the bed. During an interview on 8/16/2023 at 4:38 PM, Licensed Practical Nurse (LPN) #6 confirmed Resident #145's right forearm was entrapped between the assist bar and mattress. LPN stated, I had to help her get her arm out of the space when I found her on the floor after she fell from the bed. A visitor heard a resident yelling for help, so I went down the hall and found her in the floor. LPN stated, (Resident #145) was often confused and tried to get up without assistance. LPN #6 stated, Resident #5 had a standard mattress to her bed leaving a gap between mattress and the assist bar. During an interview on 8/17/2023 at 9:45 AM, Executive Director of Nursing (EDON) was unaware of fall on 8/16/2023 which involved Resident #145's right arm being entrapped between her assist bar and the air mattress. EDON confirmed the facility does not perform side rail assessments since the facility only had assist bars. The EDON reviewed the facility policy for proper use of bed rails and confirmed assist bars are included as a side rail. The EDON confirmed a resident assessment for the use of the assist bar should have been completed. The EDON, stated, I did not go to [Resident #145's] room when this incident occurred or later to assess her bed or assist bar. During an interview on 8/17/2023 at 10:02 AM, Certified Nursing Assistant (CNA) #6 confirmed Resident #145 required 2 persons assist with a lift for transfers. CNA #6 stated, She requires max assistance to sit up on side of bed and confirmed Resident #145 uses the assist bar for bed mobility. During an interview on 8/17/2023 at 10:45 AM, the Maintenance Supervisor and Facility Director stated, We removed all the side rails from the beds back in 2020. The beds only have assist bars now and most of those rails have the bed controls included. We don't do any routine checks with the assist bars. We have two main assist bars one is a C-rail [8-inch-wide rail with bed controls in the center attached to the bed frame] and a transfer bar [9-inch rail attached to bed frame]. During an interview on 8/21/2023 at 5:15 PM, LPN #7 stated, I never had training on side rails, we just have assist bars. I have never seen any consents that family signs for the use of side rails. 2. Review of the medical record for Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Personal History of Traumatic Brain Injury, Disorganized Schizophrenia, Anxiety Disorder, and Repeated Falls. Observation on 8/23/2023 at 9:25 AM, revealed transfer bars to Resident #1's bed. Review of the medical record for Resident #3 was admitted to the facility on [DATE] with diagnoses which included Unspecified lack of coordination and Difficulty in walking. Observation on 8/22/2023 at 2:40 PM, revealed transfer bars to Resident #3's bed. Review of the medical record for Resident #5 was admitted to the facility on [DATE] with diagnoses which included Hallucinations, Altered Mental Status, Anxiety Disorder, Need for Assistance with Personal Care, Dizziness and Giddiness, Other Lack of Coordination, and Repeated Falls. Observation on 8/23/2023 at 9:05 AM, revealed C-rails to Resident #5's bed. Review of the medical record for Resident #8 was admitted to the facility on [DATE] with diagnoses which included Dementia with Lewy Bodies, Vascular Dementia, and History of Falling. Observation on 8/22/2023 at 3:05 PM, revealed transfer bars to Resident #8's bed. Review of the medical record for Resident #13 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Altered Mental Status, Muscle Weakness, Visual Hallucinations, Nightmare Disorder, Epilepsy, and Restless Legs Syndrome. Observation on 8/23/2023 at 11:00 AM, revealed C-rails to Resident #13's bed. Review of the medical record for Resident #14 was admitted to the facility on [DATE] with diagnoses which included Wedge Compression of Fracture of T11-T12 Vertebra, Other Abnormalities of Gait and Mobility, Unsteadiness on Feet, Muscle Weakness, and Need for Assistance with Personal Care. Observation on 8/22/2023 at 1:00 PM, revealed transfer bars to Resident #14's bed. Review of the medical record for Resident #20 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction. Observation on 8/22/2023 at 2:26 PM, revealed C-rails to Resident #20's bed. Review of the medical record for Resident #23 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Lack of Coordination, Unspecified Dementia, History of Falling, Repeated Falls and Morbid Obesity. Observation on 8/22/2023 at 3:12 PM, revealed transfer bars to Resident #23's bed. Review of the medical record for Resident #25 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Other Abnormalities of Gait and Mobility, and Restless Legs Syndrome. Observation on 8/22/2023 at 1:45 PM, revealed transfer bars to Resident #25's bed. Review of the medical record for Resident #26 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Other Seizures, Muscle Weakness, Other abnormalities of Gait and Mobility. Observation on 8/22/2023 at 1:35 PM, revealed transfer bars to Resident #26's bed. Review of the medical record for Resident #27 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Metabolic Encephalopathy, Unspecified Abnormalities of Gait and Mobility, Muscle Weakness, and Unspecified Lack of Coordination. Observation on 8/22/2023 at 1:30 PM, revealed C-rails to Resident #27's bed. Review of the medical record for Resident #28 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Unspecified Fall, and Morbid Obesity. Observation on 8/22/2023 at 1:40 PM, revealed C-rails to Resident #28's bed. Review of the medical record for Resident #31 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Aftercare following Joint Replacement Surgery, Pain in Right hip, Cognitive Communication Deficit, Other Seizures, Other Chronic Pain, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, and Bipolar Disorder. Observation on 8/23/2023 at 9:45 AM, revealed C-rails to Resident #31's bed. Review of the medical record for Resident #33 was admitted to the facility on [DATE] with diagnoses which included Morbid Obesity, Unsteadiness on Feet, Other Lack of Coordination, Weakness, and Anxiety Disorder. Observation on 8/23/2023 at 10:45 AM, revealed transfer bars to Resident #33's bed. Review of the medical record for Resident #36 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Lack of Coordination, Difficulty in Walking, Unspecified Dementia, and History of Fall. Observation on 8/23/2023 at 9:40 AM, revealed transfer bars to Resident #36's bed. Review of the medical record for Resident #38 was admitted to the facility on [DATE] with diagnoses which included Essential Tremor. Observation on 8/23/2023 at 1:55 PM, revealed transfer bars to Resident #38's bed. Review of the medical record for Resident #39 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Difficulty in walking, and Muscle Weakness. Observation on 8/23/2023 at 11:08 AM, revealed C-rails to Resident #39's bed. Review of the medical record for Resident #41 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Need for Assistance with Personal Care, Other Muscle Spasm, and Contracture, Left Elbow. Observation on 8/22/2023 at 3:00 PM, revealed transfer bars to Resident #41's bed. Review of the medical record for Resident #42 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Lack of Coordination, Displaced Fracture of Olecranon Process with Intraarticular Extension of Right Ulna (fracture of the bony portion of the elbow), Altered Mental Status, Other Seizures, History of Fall, Need for Assistance with Personal Care, and Anxiety State. Observation on 8/22/2023 at 3:20 PM, revealed C-rails to Resident #42's bed. Review of the medical record for Resident #43 was admitted to the facility on [DATE] with diagnosis which included Blindness, One Eye, Low Vision Other Eye, Unspecified Eyes, Difficulty in Walking, Transient Alteration of Awareness, Morbid Obesity, Muscle Weakness, Unsteadiness of Feet, Other Abnormalities of Gait and Mobility, and Need for Assistance with Personal Care. Observation on 8/22/2023 at 2:14 PM, revealed transfer bars to Resident #43's bed. Review of the medical record for Resident #44 was admitted to the facility on [DATE] with diagnoses which included Other Convulsions and Hemiplegia. Observation on 8/22/2023 at 2:22 PM, revealed transfer bars to Resident #44's bed. Review of the medical record for Resident #45 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Restless Legs Syndrome, Unspecified Dementia, Tremor, Claustrophobia, and Muscle Weakness. Observation on 8/23/2023 at 9:18 AM, revealed transfer bars to Resident #45's bed. Review of the medical record for Resident #46 was admitted to the facility on [DATE] with diagnoses which included Rheumatoid Arthritis, Chronic Pain, Muscle Weakness, and Lack of Coordination. Observation on 8/23/2023 at 10:15 AM, revealed C-rails to Resident #46's bed. Review of the medical record for Resident #50 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Unspecified Lack of Coordination, and Difficulty in Walking. Observation on 8/22/2023 at 2:10 PM, revealed C-rails to Resident #50's bed. Review of the medical record for Resident #51 was admitted to the facility on [DATE] with diagnoses which included Morbid Obesity and Spinal Stenosis. Observation on 8/23/2023 at 1:08 PM, revealed transfer bars to Resident #51's bed. Review of the medical record for Resident #52 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Difficulty in walking, and Lack of coordination. Observation on 8/22/2023 at 2:32 PM, revealed C-rails to Resident #52's bed. Review of the medical record for Resident #54 was admitted to the facility on [DATE] with diagnoses which included Dementia, Alzheimer's disease, Unspecified Psychosis, Extrapyramidal and movement disorder, and Essential Tremor. Observation on 8/22/2023 at 2:57 PM, revealed an assist bar on the left side was not connected to the bed. The assist bar was stabilized under Resident #54's mattress. Review of the medical record for Resident #56 was admitted to the facility on [DATE] with diagnoses which included Need for Assistance with Personal Care, Unspecified Spina Bifida with Hydrocephalus, Epilepsy, Legal Blindness, and Difficulty in Walking. Observation on 8/23/2023 at 9:00 AM, revealed transfer bars to Resident #56's bed. Review of the medical record for Resident #57 was admitted to the facility on [DATE] with diagnoses which included Unsteadiness of Feet and Difficulty in Walking. Observation on 8/22/2023 at 3:16 PM, revealed transfer bars to Resident #57's bed. Review of the medical record for Resident #58 was admitted to the facility on [DATE] with diagnoses which included Cognitive communication deficit, Generalized Anxiety disorder, Difficulty in walking, Muscle Weakness, Need for Assistance with personal care, and Unspecified Dementia. Observation on 8/23/2023 at 10:50 AM, revealed C-rails to Resident #58's bed. Review of the medical record for Resident #60 was admitted to the facility on [DATE] with diagnoses which included Unspecified Lack of Coordination, Need for Assistance with Personal Care, Dementia, Muscle Weakness, and Repeated Falls. Observation on 8/22/2023 at 2:45 PM, revealed transfer bars to Resident #60's bed. Review of the medical record for Resident #62 was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder, Morbid Obesity, Need for Assistance with Personal Care, Other Abnormalities of Gait and Mobility, Muscle Weakness, and Other Seizures. Observation on 8/23/2023 at 9:55 AM, revealed C-rails to Resident #62's bed. Review of the medical record for Resident #64 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Muscle Weakness, Amputation of Limbs, and Need for Assistance with Personal Care. Observation on 8/22/2023 at 3:08 PM, revealed C-rails to Resident #64's bed. Review of the medical record for Resident #68 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Muscle Weakness, and Other Alzheimer's disease. Observation on 8/23/2023 at 9:15 AM, revealed transfer bars to Resident #68's bed. Review of the medical record for Resident #69 was admitted to the facility on [DATE] with diagnoses which included Wedge Compression Fracture of third Lumbar Vertebra, Unspecified Fracture of Sacrum, and Repeated Falls. Observation on 8/22/2023 at 2:34 PM, revealed C-rails to Resident #69's bed. Review of the medical record for Resident #70 was admitted to the facility on [DATE] with diagnoses which included Need for assistance with personal care, Anxiety disorder, Muscle weakness, and Unsteadiness of feet. Observation on 8/22/2023 at 1:48 PM, revealed C-rails to Resident #70's bed. Review of the medical record for Resident #71 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Unspecified Dementia, History of Falling, and Muscle Weakness. Observation on 8/23/2023 at 9:10 AM, revealed transfer bars to Resident #71's bed. Review of the medical record for Resident #74 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, History of falling, Muscle Weakness, and Difficulty in walking. Observation on 8/22/2023 at 2:53 PM, revealed C-rails to Resident #74's bed. Review of the medical record for Resident #77 was admitted to the facility on [DATE] with diagnoses which included Chronic Pain, Need for Assistance with Personal Care, Difficulty in Walking, Anxiety Disorder, and Dementia. Observation on 8/22/2023 at 2:00 PM, revealed C-rails to Resident #77's bed. Review of the medical record for Resident #80 was admitted to the facility on [DATE] with diagnoses which included Pathological Fracture, hip, Unspecified Fracture of Unspecified Lumbar Vertebra, Muscle Weakness, and Difficulty in Walking. Observation on 8/23/2023 at 11:05 AM, revealed C-rails to Resident #80's bed. Review of the medical record for Resident #83 was admitted to the facility on [DATE] with diagnoses which included Other Specified Anxiety Disorder, Pain, Wedge Compression Fracture of Second Lumbar Vertebrae, and Repeated Falls. Observation on 8/23/2023 at 2:20 PM, revealed C-rails to Resident #83's bed. Review of the medical record for Resident #84 was admitted to the facility on [DATE] with diagnoses which included Idiopathic Normal Pressure Hydrocephalus, Unsteadiness of Feet, Muscle Weakness, Difficulty in Walking, Unspecified Lack of Coordination, Unspecified Dementia, Contracture of Muscle of Right and Left Lower Leg. Observation on 8/22/2023 at 1:20 PM, revealed transfer bars to Resident #84's bed. Review of the medical record for Resident #93 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Unspecified Dementia, Multiple Sclerosis, Parkinson's Disease, Anxiety Disorder, Muscle Weakness, and Difficulty in Walking. Observation on 8/23/2023 at 1:00 PM, revealed C-rails to Resident #93's bed. Review of the medical record for Resident #94 was admitted to the facility on [DATE] with diagnoses which included Fracture of Unspecified Part of Neck of Left Femur, Need for Assistance with Personal Care, Post Traumatic Seizures, Repeated Falls, Unsteadiness on Falls, Other Lack of Coordination, Cognitive Communication Deficit, Ataxic Gait, and Altered Mental Status. Observation on 8/23/2023 at 9:32 AM, revealed C-rails to Resident #94's bed. Review of the medical record for Resident #96 was admitted to the facility on [DATE] with diagnoses which included Morbid Obesity, Difficulty in walking, and Muscle Weakness. Observation on 8/23/2023 at 9:53 AM, revealed C-rails to Resident #96's bed. Review of the medical record for Resident #97 was admitted to the facility on [DATE] with diagnoses which included Epidemic Vertigo, Metabolic Encephalopathy, Cognitive Communication, and Unspecified Dementia. Observation on 8/22/2023 at 1:25 PM, revealed C-rails to Resident #97's bed. Review of the medical record for Resident #98 was admitted to the facility on [DATE] with diagnoses which included Unspecified displaced fracture of sixth cervical vertebra, Fracture of nasal bones, Generalized Anxiety disorder, Repeated falls, Contracture, right hand and right shoulder, and Muscle Weakness. Observation on 8/22/2023 at 1:52 PM, revealed C-rails to Resident #98's bed. Review of the medical record for Resident #100 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction and Cognitive Communication Deficit. Observation on 8/22/2023 at 2:18 PM, revealed C-rails to Resident #100's bed. Review of the medical record for Resident #102 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy and Altered Mental Status. Observation on 8/22/2023 at 2:50 PM, revealed C-rails to Resident #102's bed. Review of the medical record for Resident #106 was admitted to the facility on [DATE] with diagnoses which included Chronic Pain Syndrome, Morbid Obesity, Muscle Weakness, and Unspecified Lack of Coordination. Observation on 8/22/2023 at 2:05 PM, revealed C-rails to Resident #106's bed. Review of the medical record for Resident #110 was admitted to the facility on [DATE] with diagnoses which included Repeated Falls, Vascular Dementia, Muscle Weakness, and Difficulty in Walking. Observation on 8/23/2023 at 9:35 AM, revealed C-rails to Resident #110's bed. Review of the medical record for Resident #111 was admitted to the facility on [DATE] with diagnoses which included Fall on same level from slipping, tripping, and stumbling with subsequent striking against unspecified sharp object, Unspecified Dementia, Muscle Weakness, and Need for Assistance with Personal Care. Observation on 8/23/2023 at 9:43 AM, revealed transfer bars to Resident #111's bed. Review of the medical record for Resident #113 was admitted to the facility on [DATE] with diagnoses which included Disorientation, Chronic Pain Syndrome, Muscle Weakness, Other Abnormalities of Gait and Mobility, and Cognitive Communication Deficit. Observation on 8/23/2023 at 9:30 AM, revealed C-rails to Resident #113's bed. Review of the medical record for Resident #115 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Pain, Hemiplegia and Hemiparesis, Anxiety Disorder, and Repeated Falls. Observation on 8/23/2023 at 9:50 AM, revealed C-rails to Resident #115's bed. Review of the medical record for Resident #116 was admitted to the facility on [DATE] with diagnoses which included Difficulty in Walking, Presence of Right Artificial Knee Joint, Obsessive-Compulsive Disorder, Repeated Falls, Unspecified Lack of Coordination, and Need for Assistance with Personal Care. Observation on 8/23/2023 at 1:25 PM, revealed transfer bars to Resident #116's bed. Review of the medical record for Resident #118 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness and Vascular Dementia, Observation on 8/23/2023 at 9:22 AM, revealed transfer bars to Resident #118's bed. Review of the medical record for Resident #119 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy and Unspecified Dementia. Observation on 8/22/2023 at 1:10 PM, revealed C- rails to Resident #119's bed. Review of the medical record for Resident #122 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Generalized Anxiety Disorder, and Morbid Obesity. Observation on 8/23/2023 at 9:47 AM, revealed transfer bars to Resident #122's bed. Review of the medical record for Resident #133 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Unspecified Dementia, Muscle Weakness, and Difficulty in Walking. Observation on 8/23/2023 at 1:15 PM, revealed C-rails to Resident #133's bed. Review of the medical record for Resident #134 was admitted to the facility on [DATE] with diagnoses which included Cerebral Edema, Unspecified Convulsions, Hemiplegia and Hemiparesis, Difficulty in Walking, and Muscle Weakness. Observation on 8/23/2023 at 1:10 PM, revealed C-rails to Resident #134's bed. Review of the medical record for Resident #135 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Disorder of Brain, Muscle Weakness, and Difficulty in Walking. Observation on 8/23/2023 at 10:18 AM, revealed C-rails to Resident #135's bed. Review of the medical record for Resident #136 was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Intracranial Hemorrhage, Cerebral Infarction, Difficulty in Walking, Need for Assistance with Personal Care, Other Fall on same level, and Other Seizures. Observation on 8/23/2023 at 2:25 PM, revealed C-rails to Resident #136's bed. Review of the medical record for Resident #137 was admitted to the facility on [DATE] with diagnoses which included Other Muscle Spasm, Difficulty in Walking, and Muscle Weakness. Observation on 8/23/2023 at 10:05 AM, revealed C-rails to Resident #137's bed. Review of the medical record for Resident #139 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Other Seizures, Anoxic Brain Damage, and Muscle Weakness. Observation on 8/23/2023 at 9:28 AM, revealed transfer bars to Resident #139's bed. Review of the medical record for Resident #141 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Anxiety Disorder, and Muscle Weakness. Observation on 8/23/2023 at 10:00 AM, revealed 1/4 rails to Resident #141's bed. Review of the medical record for Resident #142 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Difficulty in walking, and Muscle weakness. Observation on 8/23/2023 at 10:08 AM, revealed C-rails to Resident #142's bed. Review of the medical record for Resident #143 was admitted to the facility on [DATE] with diagnoses which included Wedge Compression Fracture of fifth lumbar vertebra, Restlessness and Agitation, Generalized Anxiety disorder, Fracture on one rib, left side, Difficulty in walking, and Muscle Weakness. Observation on 8/23/2023 at 10:12 AM, revealed C-rails to Resident #143's bed. Review of the medical record for Resident #144 was admitted to the facility on [DATE] with diagnoses which included Underweight and Unspecified Dementia. Observation on 8/23/2023 at 10:25 AM, revealed C-rails to Resident #144's bed. Review of the medical record for Resident #146 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Muscle Weakness, and Difficulty in walking. Observation on 8/23/2023 at 1:05 PM, revealed C-rails to Resident #146's bed. Review of the medical record for Resident #253 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, Dementia with Lewy Bodies, Vis

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility document review, hospital medical record review, observations, and interviews, the facility failed to implement a care plan for risk of choking for 1 of 36 sampled residents (Resident #28) reviewed. The facility's failure to implement the care plan and interventions for Resident #28 placed her in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) which resulted in the resident choking and expiring. The facility also failed to implement care plan interventions for 1 of 3 sampled residents (Resident #23) which caused a fall that resulted in 18 sutures which caused harm to the resident and failed to develop interventions regarding Resident #23's primary language and how to communicate with the resident. The facility also failed to develop and implement a comprehensive person-centered care plan to meet medical, nursing, mental and psychosocial needs for 1 of 36 sampled residents (Resident #10) reviewed. The Administrator was notified of the Immediate Jeopardy on 12/6/2022 at 3:05 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of J. The Immediate Jeopardy was removed onsite. The IJ began on 4/19/2022 and ended on 12/6/2022 PM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 12/6/2022 at 8:44 PM. The corrective actions were validated onsite by the surveyors on 12/6/2022 at 9:45 PM. The facility's noncompliance at F-656 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The IDT must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD,) and Cerebrovascular Accident (CVA.) Review of the Physician's Orders for Resident #28 revealed she was admitted on [DATE] with an order for NPO (Nothing by Mouth) with a tube feeding of Osmolite 1.5 Bolus 237 ml [milliliters] 5 times a day. Continued review of the Physician's Orders dated 2/18/2022 for Osmolite 1.2 237 ml 5 times a day, 4/14/2022 Nepro 1.8 237 ml bolus TID [three times a day], and 4/29/2022 Pureed diet with Honey thick liquids. Review of the hospital admissions and discharges revealed Resident #28 was admitted to the hospital on [DATE] with a diagnosis of Aspiration Pneumonia, on 3/14/2022 with Severe Sepsis and Pneumonia, on 4/2/2022 with Anemia which required a blood transfusion, and on 4/20/2022 with Leukocytosis and Urinary Tract Infection. Review of the care plan for Resident #28 revealed, .2/19/2022 Resident receives nutrition/hydration per peg tube. Non-compliant with food consistency and nectar liquids .4/19/2022 Pt non-compliant with NPO status, cont [continues] to drink liquids from bathroom sink . Interventions included, .redirect pt when non-compliant with diet. 4/19/2022 Staff will cont to offer verbal encouragement with NPO status . Review of the Physician's Progress Note for Resident #28 dated 4/22/2022 revealed, .Patient continues to be NPO d/t [due to] dysphagia however patient is caught drinking and eating often . Review of the 5-Day MDS assessment for Resident #28 with an Assessment Reference Date (ARD) of 5/6/2022 revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of the Nurses' Notes for Resident #28 revealed, .4/19/2022 pt [patient] is non-compliant with NPO status; lungs sound congested, throat is gurgly; WBC [white blood cells] count is over 25 .5/4/2022 [Named resident] was moved to [room number] on 4/30/2022. She is frustrated due to being tube fed but states she is hungry and wants to eat. She is taking food off other trays. She has now been changed to a pureed diet with honey thick liquids .5/13/2022 2pm: staff noted patient to be choking at lunch. Performed Heimlich maneuver resulting in removal of cake from patient mouth. Patient on pureed diet but often non-compliant with diet and takes food and drink from other resident's food trays. Patient place on the floor in the dining room by staff, finger sweep performed. Patient noted to not be breathing and no pulse. CPR [Cardiovascular Pulmonary Resuscitation] started. 911 called. Staff performed CPR for 13 minutes until arrival of EMS [Emergency Medical Services]. EMS took over CPR and continued CPR for 20 minutes. EMS pronounced patient dead at 2:23 pm . During an interview on 12/6/2022 at 10:55 AM, the Director Of Nursing (DON) stated, The resident was admitted to the facility on a tube feeding. She was hospitalized several times. The last hospitalization she was put on a pureed diet with honey thick liquids. She was non-compliant with her diet. The staff had to keep re-directing her. The staff called me to the Main Dining room. She was on the floor and CPR was in progress. There were other residents in the dining room at the time. She ate in the dining room. She had been drinking out of the sink in her room. The Social Service Director [SSD] told me we need to keep her locked up in her room during mealtimes. There were nurses and CNAs [Certified Nursing Assistants] in the dining room supervising the residents. She fed herself. Continued interview during review of the Care Plan, there was a problem/assessment for, .2/19/2022 Resident receives nutrition/hydration per peg tube . The DON confirmed that care plan problem should have been resolved because she readmitted from the hospital on 4/29/2022, and was not on a tube feeding. Continued interview, she stated the interventions, which were .redirect pt when non-compliant with diet .Staff will cont to offer verbal encouragement with NPO status . were inappropriate interventions for a resident with a BIMS of 6. During an interview on 12/6/2022 at 11:40 AM, CNA #8 stated he was in the dining room the day Resident #28 choked. He stated it was after lunch and the resident usually ate in the dining room. He stated, I don't know who she was sitting with that day. She was on a pureed diet with thick liquids. She had a swallowing problem. We have many assisted diners in the dining room, and we all pitch in to help. There were probably 4 or 5 residents that needed assistance that day. I was standing in the middle of the dining room. My back was turned to the resident [Resident #28], and she patted me on the back. I turned around and saw she was choking. I immediately started doing the Heimlich. The nurse was at the nurse's station and she came over and started to help me. The resident would randomly take food from trays, and I have stopped her many times. I would tell her it wasn't good for her to eat that kind of food, and she would say she wasn't taking food. During an interview on 12/6/2022 at 12:30 PM, CNA #9 stated, We were picking up trays after lunch. I fed in the dining room that day. Me and [Named CNA #8] and a nurse were in the dining room for lunch. She ate her lunch, and it was a pureed diet, which is what was ordered for her. She got cake off someone's tray. I had to intervene all the time with her taking food off other trays; almost daily. I would tell her she wasn't supposed to eat regular food and she would give me attitude. During breakfast that morning, she took food and I had to stop her. We observed her as best we could, but she was fast with grabbing food. During an interview on 12/7/2022 at 9:03 AM, the Speech Therapist (ST) stated she assisted with Resident #28's care. She stated, She was seen for post CVA. Her deficits were cognitive impairment, Dysphasia [difficulty talking,] Dysphagia [difficulty swallowing,] and she was very impulsive. She had a severe dysphagia impairment which caused her to stay on pureed diet with thickened liquids. She was on a tube feeding until she went to the hospital in April and came back on a pureed diet. She had many swallow studies done. She tolerated her pureed diet well, but she was so impulsive. She tried continuously to grab other people's food. All of the staff were very aware she grabbed food that she shouldn't have. She needed 1:1 personal care. The CVA affected her reasoning. The surveyors verified acceptable Immediate Action Removal Plan on 12/6/2022 at 9:45 PM by: 1. Residents with current orders for a pureed diet or thickened liquids were reviewed by the DON or designee to determine if any of the residents have a history of being non-compliant with their diet and are in need of additional interventions to maintain their safety. 2. The DON or designee reviewed the care plans of any residents that were identified as being non-compliant with their diet orders to assure that appropriate safety measures were in place. The care plans for these residents will be updated as needed. Two residents were identified as non-compliant with diet order due to family providing them with non-compliant food. These resident's care plans were updated to reflect this non-compliant practice. Additionally, the Unit Manager educated the families to reflect the non-compliance and one responsible party had signed a diet waiver. 3. Licensed nursing and CNA staff will be in-serviced by the DON or designee. the in-service was completed for current staff in the building on 12/6/2022 and on going. The DON or designee will educate all licensed nurses and other staff prior to their starting work until all staff education is completed. New staff will be educated during their orientation. The education will include the following: Review of the CMS (Centers for Medicare/Medicaid Services) regulation #656, the statement of deficiency, the plan of correction, the policy regarding care plans, and the policy regarding therapeutic diets. 4. Beginning 12/7/2022 the Administrator, DON or designee will monitor for continued compliance through Quality Improvement audits. The audits will be completed weekly for 4 weeks, monthly for 3 months. The Administrator or designee will report to the QA (Quality Assurance)/QI (Quality Improvement) committee who will determine additional actions that may be taken and/or frequency of further monitoring. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with a diagnosis which included Epilepsy and Blindness. Review of the Care Plan dated 2/14/2022 revealed .[named Resident #23] is a risk for falls secondary to impaired balance during transitions and weakness .Interventions: Keep resident area free of clutter . Continued review revealed .[named Resident #23] has a potential for changes in mood and behavior rt [related to] dx [diagnoses] of depression, seizure disorder, and language barrier . No interventions were found which addressed on how to communicate with Resident #23, or what his primary language was. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #23 had a BIMS score of 6, indicating severe cognitive impairment. Continued review revealed Resident #23 required supervision and setup for walking in the room. Resident #23 required limited assistance with one staff for toileting. Review of the Facility's Report dated 7/31/2022 revealed Resident #23 had a fall in his room on 7/31/2022 at 5:00 PM. Continued review revealed Resident #23 was found by a family member. Resident #23 had a laceration to the right arm and received first aid while in the facility. The nurse obtained an order to send Resident #23 to the emergency room. Review of the SBAR (Situation, Background, Appearance, Review and Notify) Communication Form dated 7/31/2022 revealed .pt [patient] wt [with] a deep laceration, open wound edged jagged and damaged with a lot of bleeding. NP [Nurse Practitioner] notified to send pt to the hospital for evaluations and sutures . Review of the History and Physical at [name Hospital] dated 7/31/2022 revealed .Patient history obtained via computer translator .Patient brought by EMS from nursing home for ground level fall and right forearm laceration. Patient is blind and lives in a nursing home. Patient stated he was using his cane to ambulate from the bathroom when he tripped and fell. Patient is unsure if he struck his head but denies any loss of consciousness. Patient complaining of pain and wound to right forearm .Procedure: R [Right] Proximal Dorsal Forearm. 18 sutures .Antibiotic ointment applied, dressing applied . Review of the wound assessment dated [DATE] revealed .Incision, right lower forearm. 19 sutures Closed healing. Sutures present and intact . During an interview on 11/28/2022 at 12:30 PM, Family Member #3 stated on the day Resident #23 had fallen, she had found him and noticed a lot of blood on Resident #23. Resident #23 had told Family Member #3 he had fallen and no one had come to help him. Family Member #3 stated she believed Resident #23 had gone to the restroom and then left and somehow fallen or hit his hand on the transport wheelchair. During a telephone interview on 11/28/2022 at 2:27 PM, CNA #13 stated there was a transport chair in Resident #23's room and she believed it was the cause of the laceration to Resident #23's arm. Family Member #3 had taken Resident #23 outside that day and left the chair in the middle of the floor. During a telephone interview on 11/28/2022 at 3:01 PM, Registered Nurse (RN) #1 stated she and Family Member #3 arrived at Resident 23's room at the same time. RN #1 walked in the room and noticed blood on his hand. Resident #23 could not tell her what happened because of the language barrier. There was a transport chair which was used for when he was taken on outings in the room and RN #1 thought he could have hit his hand on the transport chair. RN #1 applied first aide to Resident #23's outer right arm and then called the physician. RN #1 did not remember Resident #23 having a fall. During an interview on 11/28/2022 at 3:22 PM, the Assistant Director of Nursing (ADON) stated he thought Resident #23 had tripped over the transport wheelchair because Resident #23 told him chair and fell. Resident #23 usually did not have chairs in his rooms because he had a walking guide to help him maneuver safely in his room. The fall was an unwitnessed fall. The ADON confirmed the cause of the fall was due to the transport chair. The ADON confirmed the staff should have removed the transport chair if they knew it was in the middle of the floor. During an interview on 12/7/2022 at 3:22 PM, the MDS Coordinator confirmed there were no interventions on the care plan for Resident #23 addressing his primary language and how to accommodate his language barrier. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Anxiety Disorder, Conversion Disorder with seizures or convulsions, Hepatitis A, Unspecified Viral Hepatitis C, and Other Psychoactive Substance Abuse. Review of the Medication Administration Record (MAR) for Resident #10 dated 10/2022, revealed, .10/12/2022 .Adderall 30 mg [milligram] tablet .Attention-deficit hyperactivity disorder . Review of the Psychiatric Evaluation for Resident #10 dated 11/3/2022 and 11/11/2022, revealed diagnoses which included PTSD (Post-Traumatic Stress Disorder,) Bipolar 2 Disorder, Adult ADHD (Attention-Deficit/Hyperactivity Disorder,) and Polysubstance Abuse. During an interview on 12/6/2022 at 6:23 PM, the DON reviewed the medical records for Resident #10 and confirmed her diagnoses which included Substance Abuse, Bipolar, Depression, Conversion Disorder with seizures or convulsions, Hepatitis A, Unspecified Viral Hepatitis C, and PTSD, were not included in the plan of care with interventions in place. She stated she expected the care plan to be person centered and include the pertinent diagnoses with interventions. During an interview on 12/7/2022 at 3:22 PM, the RN/MDS Coordinator reviewed Resident #10's current Comprehensive Care Plan and confirmed there was no focus/care plan for diagnoses of Substance Abuse, Bipolar, Depression, Conversion Disorder with seizures or convulsions, Hepatitis A, Unspecified Viral Hepatitis C, and PTSD. She stated she expected the diagnoses to be included in the care plan with interventions in place. She confirmed the care plan did not meet the requirements of being person centered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility document review, hospital medical record review, observations, and interviews, the facility failed to adequately supervise 1 of 36 residents (Resident #28), a cognitively impaired resident, who was noncompliant with her prescribed diet and food consistency restrictions, which resulted in a choking incident that caused the death of the resident. The facility's failure to provide adequate supervision placed her in Immediate Jeopardy IJ (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.) The facility also failed to implement care plan interventions for 1 of 3 sampled residents (Resident #23) which caused a fall that resulted in 18 sutures which caused harm to the resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 12/6/2022 at 2:27 PM in the Administrator's office. The facility was cited an Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite. The IJ began on 4/19/2022 and ended on 12/6/2022. An acceptable Immediate Removal Action Plan, which removed the immediacy of the jeopardy, was received on 12/6/2022 at 8:44 PM. The corrective actions were validated onsite by the surveyors on 12/6/2022 at 9:45 PM. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Therapeutic Diets, revised 10/2017, revealed, .Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet .If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD,) and Cerebrovascular Accident (CVA.) Review of the Physician's Orders for Resident #28 revealed she was admitted on [DATE] with an order for NPO (Nothing by Mouth) with a tube feeding of Osmolite 1.5 Bolus 237 ml [milliliters] 5 times a day. Continued review of the Physician's Orders dated 2/18/2022 for Osmolite 1.2 237 ml 5 times a day, 4/14/2022 Nepro 1.8 237 ml bolus TID [three times a day], and 4/29/2022 Pureed diet with Honey thick liquids. Review of the hospital admissions and discharges revealed Resident #28 was admitted to the hospital on [DATE] with a diagnosis of Aspiration Pneumonia, on 3/14/2022 with Severe Sepsis and Pneumonia, on 4/2/2022 with Anemia which required a blood transfusion, and on 4/20/2022 with Leukocytosis and Urinary Tract Infection. Review of the care plan for Resident #28 revealed, .2/19/2022 Resident receives nutrition/hydration per peg tube [a tube to provide food, liquids and medications directly into the stomach] .Non-compliant with food consistency and nectar liquids .4/19/2022 Pt non-compliant with NPO status, cont [continues] to drink liquids from bathroom sink . Interventions included, .redirect pt when non-compliant with diet. 4/19/2022 Staff will cont to offer verbal encouragement with NPO status . Review of the Physician's Progress Note for Resident #28 dated 4/22/2022 revealed, .Patient continues to be NPO d/t [due to] dysphagia however patient is caught drinking and eating often . Review of the 5-Day Minimum Data Set (MDS) assessment for Resident #28 with an Assessment Reference Date (ARD) of 5/6/2022 revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of the Nurses' Notes for Resident #28 revealed, .4/19/2022 pt [patient] is non-compliant with NPO status; lungs sound congested, throat is gurgly; WBC [white blood cells] count is over 25 .5/4/2022 [Named resident] was moved to [room number] on 4/30/2022. She is frustrated due to being tube fed but states she is hungry and wants to eat. She is taking food off other trays. She has now been changed to a pureed diet with honey thick liquids .5/13/2022 2pm: staff noted patient to be choking at lunch. Performed Heimlich maneuver resulting in removal of cake from patient mouth. Patient on pureed diet but often non-compliant with diet and takes food and drink from other resident's food trays. Patient place on the floor in the dining room by staff, finger sweep performed. Patient noted to not be breathing and no pulse. CPR [Cardiovascular Pulmonary Resuscitation] started. 911 called. Staff performed CPR for 13 minutes until arrival of EMS [Emergency Medical Services]. EMS took over CPR and continued CPR for 20 minutes. EMS pronounced patient dead at 2:23 pm . During an interview on 12/6/2022 at 10:55 AM, the Director Of Nursing (DON) stated, The resident was admitted to the facility on a tube feeding. She was hospitalized several times. The last hospitalization she was put on a pureed diet with honey thick liquids. She was non-compliant with her diet. The staff had to keep re-directing her. The staff called me to the Main Dining room. She was on the floor and CPR was in progress. There were other residents in the dining room at the time. She ate in the dining room. She had been drinking out of the sink in her room. The SSD [Social Services Director] told me we need to keep her locked up in her room during mealtimes. There were nurses and CNAs [Certified Nursing Assistants] in the dining room supervising the residents. She fed herself. Continued interview during review of the care plan with the DON, revealed a problem/assessment for, .2/19/2022 Resident receives nutrition/hydration per peg tube . The DON confirmed the care plan problem should have been resolved when she was readmitted from the hospital on 4/29/2022 not on a tube feeding and with a pureed diet and thickened liquids, but it was not. Continued interview, the DON confirmed the interventions, .redirect pt when non-compliant with diet .Staff will cont to offer verbal encouragement with NPO status . were not appropriate interventions for a resident with a BIMS of 6. During an interview on 12/6/2022 at 11:40 AM, CNA #8 stated he was in the dining room the day Resident #28 choked. He stated it was after lunch and the resident usually ate in the dining room. He stated, I don't know who she was sitting with that day. She was on a pureed diet with thick liquids. She had a swallowing problem. We have many assisted diners in the dining room, and we all pitch in to help. There were probably 4 or 5 residents that needed assistance that day. I was standing in the middle of the dining room. My back was turned to the resident [Resident #28], and she patted me on the back. I turned around and saw she was choking. I immediately started doing the Heimlich. The nurse was at the nurse's station, which is in the dining room, and she came over and started to help me. The resident would randomly take food from trays, and I have stopped her many times. I would tell her it wasn't good for her to eat that kind of food, and she would say she wasn't taking food. During an interview on 12/6/2022 at 12:30 PM, CNA #9 stated, We were picking up trays after lunch. I fed in the dining room that day. Me and [Named CNA #8] and a nurse were in the dining room for lunch. She ate her lunch, and it was a pureed diet, which is what was ordered for her. She got cake off someone's tray. I had to intervene all the time with her taking food off other trays; almost daily. I would tell her she wasn't supposed to eat regular food and she would give me attitude. During breakfast that morning, she took food and I had to stop her. We observed her as best we could, but she was fast with grabbing food. During an interview on 12/7/2022 at 9:03 AM, the Speech Therapist (ST) stated she assisted with Resident #28's care. She stated, She was seen for post CVA. Her deficits were cognitive impairment, Dysphasia [difficulty speaking], Dysphagia [difficulty swallowing], and she was very impulsive. She had a severe dysphagia impairment which caused her to stay on pureed diet with thickened liquids. She was on a tube feeding until she went to the hospital in April and came back on a pureed diet. She had many swallow studies done. She tolerated her pureed diet well, but she was so impulsive. She tried continuously to grab other people's food. All the staff were very aware she grabbed food that she shouldn't have. She needed 1:1 personal care. The CVA affected her reasoning. The surveyors verified an acceptable Immediate Action Removal plan on 12/6/2022 at 9:45 PM by: 1. Residents with current orders for a pureed diet or thickened liquids were reviewed by the DON or designee to determine if any of the residents had a history of being non-compliant with their diet and were in need of additional interventions to maintain their safety. 2. The DON or designee reviewed the care plans of any residents that were identified as being non-compliant with their diet orders to assure that appropriate safety measures were in place. The Care Plans for those residents will be updated as needed. Two residents were identified as non-compliant with diet orders due to their family providing them with non-compliant food. The resident's care plans were updated to reflect the non-compliance. The Unit Manager educated the families of the risk for non-compliance and one responsible party has signed a diet waiver. 3. Licensed nursing and CNA staff were in-serviced by the DON or designee. The in-service was completed for current staff in the building on 12/6/2022 and on going. The DON or designee will educate all other staff prior to their starting work until all staff education is completed. New staff will be educated during their orientation. The education will include the following: Review of the regulation #689, the statement of deficiency, the plan of correction, the policy regarding Safety and Supervision of Residents, and the policy regarding Therapeutic Diets. 4. Beginning 12/7/2022 the Administrator or designee will monitor for continued compliance through Quality Improvement audits. The audits will be completed weekly for 4 weeks, monthly for 3 months. The Administrator or designee will report to the QA [Quality Assurance]/QI [Quality Improvement] committee who will determine additional actions that may be taken and/or the frequency of further monitoring. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with a diagnosis which included Epilepsy. Review of the Care Plan dated 2/14/2022 revealed .[named Resident #23] is a risk for falls secondary to impaired balance during transitions and weakness .Interventions: Keep resident area free of clutter . Continued review revealed .[named Resident #23] has a potential for changes in mood and behavior rt [related to] dx [diagnoses] of depression, seizure disorder, and language barrier . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #23 had a BIMS score of 6, indicating severe cognitive impairment. Continued review revealed Resident #23 required supervision and setup for walking in the room. Resident #23 required limited assistance with one staff for toileting. Review of the Facility's Report dated 7/31/2022 revealed Resident #23 had a fall in his room on 7/31/2022 at 5:00 PM. Continued review revealed Resident #23 was found by a family member. Resident #23 had a laceration to the right arm and received first aid while in the facility. The nurse obtained an order to send Resident #23 to the emergency room. Review of the SBAR (Situation, Background, Appearance, Review and Notify) Communication Form dated 7/31/2022 revealed .pt [patient] wt [with] a deep laceration, open wound edged jagged and damaged with a lot of bleeding. NP [Nurse Practitioner] notified to send pt to the hospital for evaluations and sutures . Review of the History and Physical at [name Hospital] dated 7/31/2022 revealed .Patient history obtained via computer translator .Patient brought by EMS [Emergency Medical Services] from nursing home for ground level fall and right forearm laceration. Patient is blind and lives in a nursing home. Patient stated he was using his cane to ambulate from the bathroom when he tripped and fell. Patient is unsure if he struck his head but denies any loss of consciousness. Patient complaining of pain and wound to right forearm .Procedure: R [Right] Proximal Dorsal Forearm. 18 sutures .Antibiotic ointment applied, dressing applied . During an interview on 11/28/2022 at 12:30 PM, Family Member #3 stated on the day Resident #23 had fallen, she had found him and noticed a lot of blood on Resident #23. Resident #23 had told Family Member #3 he had fallen and no one had come to help him. Family Member #3 stated she believed Resident #23 had gone to the restroom and then left and somehow fallen or hit his hand on the transport wheelchair. During a telephone interview on 11/28/2022 at 2:27 PM, CNA #13 stated there was a transport chair in Resident #23's room, and she believed it was the cause of the laceration to Resident #23's arm. CNA #13 stated she believed Family Member #3 had taken Resident #23 outside that day and left the chair in the middle of the floor. During a telephone interview on 11/28/2022 at 3:01 PM, Registered Nurse (RN) #1 stated she and Family Member #3 arrived at Resident 23's room at the same time. RN #1 walked in the room and noticed blood on his hand. Resident #23 could not tell her what happened because of the language barrier. There was a transport chair which was used for when he was taken on outings in the room and RN #1 thought he could have hit his hand on the transport chair. RN #1 applied first aide to Resident #23's outer right arm and then called the physician. RN #1 did not remember Resident #23 having a previous fall. During an interview on 11/28/2022 at 3:22 PM, the Assistant Director of Nursing (ADON) stated he thought Resident #23 had tripped over the transport wheelchair because Resident #23 told him chair and fell. The ADON stated Resident #23 usually did not have chairs in his rooms because he had a walking guide to help him maneuver safely in his room. The ADON stated the fall was an unwitnessed fall. The ADON confirmed the cause of the fall was due to the transport chair, and the staff should have removed the transport chair if they knew it was in the middle of the floor.

Based on job description review and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well being of the residents. Administration failed to provide oversight to ensure a resident (Resident #28), who was noncompliant with a pureed diet, was prevented from obtaining regular texture foods that resulted in choking, and her death. The Administration also failed to conduct an Ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting that identified other residents who were on pureed/therapeutic diets, and who could obtain regular texture foods which could result in choking and death. Administration also failed to ensure all resident therapeutic diets were appropriate for them and failed to educate all staff on interventions for residents who did not follow therapeutic diet orders and safety measures, and failed to update the care plans for any and all residents identified. The facility's failure to provide adequate supervision, ensure the care plans were followed, and conduct an Ad hoc meeting after the choking incident occurred, placed all other residents who were at risk for choking in Immediate Jeopardy IJ (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.) The Administrator was notified of the Immediate Jeopardy on 12/6/2022 at 2:27 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-835 at a scope and severity of J. The Immediate Jeopardy was removed onsite. The IJ began on 4/19/2022 and ended on 12/6/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 12/6/2022 at 8:44 PM. The corrective actions were validated onsite by surveyors on 12/6/2022 at 9:45 PM. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The findings include: Review of the job description for the Administrator revealed, .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Administrative Functions include: Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures .Make routine inspections of the facility to assure that established policies and procedures and coordinate those are being implemented and followed .Assist with the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified deficiencies . Accidents: Failure to ensure adequate supervision for 1 of 36 sampled residents (Resident #28), when a cognitively impaired resident with severe swallowing problems, was able to obtain and ingest a piece of cake, which resulted in her death related to choking. Refer to F-689. Care Plans: Failure to ensure care plan interventions were followed for 1 of 36 residents (Resident #28) reviewed for therapeutic diets. Failure to follow the Care Plan interventions resulted in choking and death. Refer to F-656. QAPI: Failure to identify other residents in the facility on therapeutic diets who were noncompliant, which could result in choking and death. Refer to F-867 During an interview on 12/5/2022 at 1:35 PM, the Administrator stated she was not the Administrator at the time the choking incident occurred. She stated she was told a QAPI meeting was held after the incident, but she was unable to locate the document. The surveyors verified acceptable Immediate Action Removal Plan on 11/4/2022 at 7:40 PM by: 1. The Administrator employed at the time of the occurrence is no longer with the facility. 2. The current Administrator has been in-serviced by the Regional [NAME] President of Operations. The in-service included: Review of the regulations #656, #689, #835, the statement of deficiency, the plan of correction, the policy regarding care plans, the policy regarding safety and supervision of residents, and the policy regarding therapeutic diets. 3. Beginning 12/7/2022 the Executive Director of designee will monitor for continued compliance through Quality Improvement audits. The audits will be completed weekly for 4 weeks, monthly for 3 months. The Executive Director or designee will report to the QA (Quality Assurance)/QI (Quality Improvement) committee who will determine additional actions that may be taken and/or the frequency of further monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility's Quality Assurance Performance Improvement (QAPI) failed to identify residents in the facility who were at risk for choking, and failed to ensure care plans were updated and interventions were appropriate. The facility's failure to conduct a QAPI meeting after a choking incident which resulted in death, failure to assure any other residents in the facility were not at risk for choking, and failure to ensure anyone at risk for choking had appropriate interventions, placed those identified residents in Immediate Jeopardy, IJ (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) at a scope and severity level of J. The facility also failed to identify potential negative risk related to residents admitted to the facility with diagnoses which included Substance Abuse for 1 of 36 sampled residents (Resident #10) reviewed. The Administrator was notified of the Immediate Jeopardy on 12/13/2022 at 11:27 AM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-867. The facility was cited at F-867 at a scope and severity of J. The Immediate Jeopardy was removed onsite. The date the IJ began was 5/13/2022 and ended 12/13/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 12/13/2022 at 3:05 PM. The corrective actions were validated onsite by the surveyors on 12/13/2022 at 3:25 PM. The facility's non-compliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, revised 7/2016, revealed, .This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program .The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program . Accidents: Failure to ensure adequate supervision for 1 of 36 sampled residents (Resident #28), which resulted in the resident choking, causing her death. Failure to ensure safety and supervision during mealtimes for residents who have swallowing difficulties, placed those residents at risk. Refer to F-689. Care Plans: Failure to ensure care plans interventions were developed and implemented to prevent choking, which resulted in death for 1 of 36 sampled residents (Resident #28) reviewed. Refer to F-656. Administration: Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well being of the residents. Administration failed to provide oversight to ensure a resident (Resident #28), who was noncompliant with a pureed diet, was prevented from obtaining regular texture foods that resulted in choking, and her death. The Administration also failed to conduct an Ad hoc QAPI Committee meeting that identified other residents who were on pureed/therapeutic diets, and who could obtain regular textured foods, which could result in choking and death. Administration failed to ensure all resident therapeutic diets were appropriate for them and failed to educate all staff on interventions for residents who did not follow therapeutic diet orders and safety measures, and failed to update the care plans for any and all residents identified. Refer to F-835 During an interview on 12/5/2022 at 1:35 PM, the Administrator stated she was told the facility had a QAPI meeting after the choking incident involving Resident #28, but was unable to locate the document. The surveyors verified the acceptable Immediate Action Removal Plan on 12/13/2022 at 3:25 PM by: 1. The care plans of residents on pureed diets or thickened liquids were reviewed by the Director Of Nursing (DON) or designee to determine if any of the residents have a history of being non-compliant with their diet and are in need of additional interventions to maintain their safety. All residents who were ordered a pureed diet were reviewed. 2. The DON or designee reviewed the care plans of any residents that were identified as being non-compliant with their diet orders to assure that appropriate safety measures were in place. Two residents were identified as non-compliant and their care plans were updated to reflect the non-compliant practice. 3. The Unit Manager educated the families of the risk of non-compliance and one responsible party signed a diet waiver. 4. The facility conducted a QAPI meeting on 12/6/2022. During the meeting the facility reviewed the plan of correction for residents with current orders for a pureed diet or those on thickened liquids. The review included appropriate care planning for residents with pureed diets, thickened liquids and those who are non-compliant with their special needs diets and safety of residents on therapeutic diets. 5. The Nursing Home Administrator, DON, and Assistant Director Of Nursing (ADON) were in-serviced by the Regional [NAME] President of Operations or Executive Director. The education included the following: Review of regulation #867, the statement of deficiency, the plan of correction, the policy regarding Quality Assurance and Performance Improvement, promptly convening a QAPI meeting to review significant safety events and develop appropriate follow up actions to prevent other occurrences. 6. Beginning 12/14/2022, the Executive Director or designee will monitor for continued compliance through Quality Improvement audits. The audits will be completed weekly for 4 weeks, monthly for 3 months. The Administrator or designee will report to the QA (Quality Assurance)/QI (Quality Improvement) committee who will determine additional actions that may be taken and/or the frequency of further monitoring. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Anxiety Disorder, and Other Psychoactive Substance Abuse. During an interview on 12/7/2022 at 10:28 PM, the Medical Director confirmed he attends all QAPI meetings either in person or by phone. He stated during the meetings the team discusses incidents that have occurred in the facility. He stated, We do not always identify potential risk in the meetings. He confirmed there had not been a QAPI meeting to discuss potential risk of resident's admitted with diagnoses of Substance Abuse or PTSD (Post Traumatic Stress Disorder).