**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #43, Resident #47 , Resident #52, Resident #57, and Resident #67) reviewed for comprehensive care plans. These failures could place residents at risk of not having individual needs met, a decreased quality of life, causes residents not to receive needed services and death. 1. The facility failed to ensure Resident #47's care plan was comprehensive and updated to reflect he needed assistance with feeding and was a choking risk. An IT was identified on 07/16/2024 at 12:00 PM. The IT template was provided to the facility on [DATE] at 12:47 PM. The IT was removed on 07/17/2024, the facility remained in violation at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate because the facility failed to add the diagnosis of Dysphagia and Resident #47 had swallowing difficulty that required monitoring. Resident #47 passed away. 2. The facility failed to ensure Resident #52's care plan was comprehensive and updated to reflect his refusal of ADL care including interventions and timelines. 3. The facility failed to ensure Resident #57's care plan was comprehensive and updated to reflect his behaviors including interventions and timelines. 4. The facility failed to ensure Resident #43, and Resident #67's care plan was comprehensive and updated to reflect that the residents were smokers including interventions and timelines. Findings include: Record review of Resident #47's admission record dated 06/27/2024 revealed Resident #47 was a [AGE] year-old male admitted on [DATE] with diagnoses of Nausea with vomiting, depressive disorder, reflux, high level of fat particles in the blood, Urinary tract infection, brain disease, vitamin D deficiency, pre-diabetes, constipation, dementia, inflammatory disorder of the pancreas, sleeping disorder, Alzheimer's, lack of coordination, muscle weakness, and communication difficulty. Record review of Resident #47's care plan last revised 05/09/24 revealed no documented/ identified problem with swallowing or choking. Resident #47's care plan did not have any diet information and did not have the diagnosis oropharyngeal dysphagia (swallowing disorder that affect the mouth and throat). Record review of Resident #47's quarterly MDS dated [DATE] revealed that the diagnosis of dysphagia and difficulty swallowing was not added to the residents MDS or care plan. Record review of Resident #47's chart revealed that the resident had a swallow study done on 05/22/2023. The swallow study revealed that the resident had oropharyngeal dysphagia . The test also revealed that the resident was a choking risk. The resident function abilities were mild/moderate assistance- requires assistance with feeding. The swallow study report also stated that the Resident #47's dysphagia severity was severe given the risk factor for aspiration, aspiration pneumonia and/or choking. No physician orders were found by facility or in resident's chart. Record Review of the professional Imaging Physician Consult Summary dated 05/22/2023 revealed the reason swallow study was done was because of choking and swallowing issues. Recommendations were done. Resident was diagnosed with Oropharyngeal Dysphagia (swallowing difficulties). Record review of LVN C's Resident #47's progress notes dated 05/16/2024 revealed that the resident was eating supper. Resident stood up reached for his throat signs of chocking. RN started the Heimlich Maneuver to resident. Tried to take food out from his mouth and some dislodged from resident's throat. Called 911 then Resident #47 passed out RN started CPR. An interview with the DON on 06/27/2024 at 8:55 AM revealed that the DON did not report the incident. The DON stated they were back and forth on rather the facility needed to report the incident. He stated that the nurse and CNAs were in the dining room. He stated that the nurse started the Heimlich and CPR and did everything needed until EMS arrived. He stated it was not unusual for someone to die from choking. The DON also stated that an investigation was not done due to the incident being witnessed. An interview with the ADM on 06/27/2024 at 9:06 AM revealed that he did not report the incident because he was back and forth on rather it should be reported. He stated it was witnessed and it was not unusual. Interview with the DON on 06/27/2024 at 12:30 PM revealed that Resident #47 had some teeth missing, did not have dentures and that the resident was able to chew food. He stated the resident did not have issues with swallowing. An interview with RN A on 06/27/2024 at 2:26 PM revealed that he was in the dining room for dinner. He stated the Resident #47 stood up and did the universal sign of choking. He went over to the resident and started doing the Heimlich maneuver. He stated that Resident #47 then went to the floor. He stated he and LVN C swiped his mouth to get the food out. He stated he started doing CPR and that he was not sure if the resident was breathing or not at that time. He stated that he did not know if the resident had a diagnosis of swallowing difficulty. He also stated he did not know what type of diet the resident was on as he was not a resident he worked with. An interview with LVN C on 06/27/2024 at 2:39 PM revealed that Resident #47 started choking at dinner and a staff member called her to the dining room. She stated she then started helping RN. She stated she called 911 and was sweeping food out of the resident's mouth. She stated that he suddenly passed out. She stated they followed instructions from EMS and EMS took over when they got to the facility because he had expired. She stated Resident #47 was one of her regular resident's. She stated he was on a mechanical soft diet. She also stated that he had a swallow study done but was not sure what year. She stated the swallow study was normal. She stated Resident #47 would hold his food in his mouth. She also stated he was substantial risk for choking. She stated the resident did not have a diagnosis of difficulty swallowing because the test did not show anything wrong. An interview with the Speech Pathologist on 06/27/2024 at 4:12 PM revealed that the resident came in with a diagnosis of swallowing difficulties. She stated the purpose of the swallow test was to get more specific as to which type of difficulty the resident was having. She stated that he was diagnosed with Oropharyngeal Dysphagia (which is a difficulty emptying part of the throat). She stated they did make recommendations for the resident based on his results. An interview with Resident #47's Primary Doctor on 06/27/2024 at 4:31 PM revealed that the resident did not have a swallowing disorder. He stated he had been seeing the resident for two years. He stated he did not know why he ordered the swallow study. He stated the resident did not have any events of aspiration. When asked why he did not follow the recommendations of the swallow study he stated we treat the patient not the lab results. He did not have any issues swallowing. An interview with the Nurse Practitioner on 06/27/2024 at 7:25 PM revealed that she thought the swallow study was done due to the resident losing weight. She stated that when labs come back LVN A would inform her if something was abnormal. She stated if there was not something abnormal, she would see the resident on Mondays or Fridays. She stated that she did not know why the swallow study was done or the results of the test. Record review of Reporting to HHSC Policy dated July 10,2019 revealed if a death under unusual circumstances needed to be reported immediately but not later than 24 hours after the incident occurs or is suspected. Record review of Resident #52's face sheet dated 06/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of other specified diabetes mellitus with hyperglycemia (condition caused by high blood sugar), other schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), bipolar disorder (mental illness characterized by extreme mood swings)-current episode depressed-mild, impulse disorder-unspecified, and drug induced subacute dyskinesia (uncontrolled, involuntary movements of the face, arms, and legs). Record review of Resident #52's annual MDS assessment dated [DATE] revealed a BIMS score of 9 meaning moderate cognitive impairment. Resident #52 is independent with ADLs. Record review of Resident #52's care plan last revised 06/13/24 revealed bathing section requires staff assistance with the goal to bathe independently and interventions bathing: one person assist, give verbal cues to help prompt, break tasks up into smaller steps, allow rest breaks between tasks. Record review of Resident #52's care plans updated on 06/13/2024 revealed no care plan to address his resident refusing assistance with bathing. Record review of Resident #52's nurse progress notes dated 06/14/24 entered by the DON revealed: [Resident #52] attended his quarterly care plan meeting, emphasized, and reeducated the need to have a shower, have haircut and trim his fingernails- the resident denied all. When social worker talked to him about germs and how it will get him sick [Resident #52] said cannot understand the relationship despite how simple the social worker explained it to him. Also tried to incorporate bible reading on how cleanse body is good but [Resident #54] is not convinced. Asked what is in the shower/water he is afraid of; said he could not tell us. Gave a suggestion like taking a shower using a bucket, still said no. Asked if I could trim his fingernails resident said nope, will monitor for non-compliance. Record review of RN A notes of Resident #52's IDT meeting notes dated 06/18/24 revealed: Resident remains in stable condition, full code, resident ambulates without issue, extremely fast pace, brisk gait. Resident can communicate desires or requests. Generally, communication to staff evolves around the requesting of paper or foods. Resident alert and oriented to self and environment. Resident denies pain or discomfort. Resident is continent of bowel and bladder. Resident spends most of the time in room, while stationary sits and rocks back and forth in bed sometimes laughing to self. Resident suffers from delusions and hallucinations. Residents' hygiene is moderate to poor and remains challenge for staff to endorse. Resident consistently and adamantly refuses and rejects shower or management/ grooming of hair. Resident may become belligerent if he feels pressure in the forementioned areas of hygiene. Continue to manage as directed. An observation and interview on 06/25/24 at 10:17 AM with Resident #52, he was observed with unkempt hair that appeared dull and soiled, clothing both green shirt and pants appeared soiled and stained with a dark unknown dry substance. Resident #52 was not wearing shoes and had white socks on that appeared dark from dirt and his nails were observed dark underneath. A strong foul odor was also detected from Resident #52. Resident #52's mood appeared well and pleasant, he stated he was getting ready to go for a smoke break. Resident #52 stated that he gets the help that he needs from staff and when asked about showers/ baths he stated he did not want any. Resident #52 stated that he did not like baths or showers and did not want to receive one. He stated that he can change his own clothing and did not want to change it. An observation on 06/26/24 at 09:00 AM Resident #52 was wearing the same soiled green shirt and pants observed on 06/25/24. Resident #52 was observed during his morning smoke break and mood appeared well. An observation and interview on 06/27/24 at 04:21 PM Resident #52 were still wearing the same green shirt and pants he was observed in on 06/25/24 and 06/26/24. Resident #52 was observed ambulating in the hall and into his room, his mood appeared pleasant and when asked if he wanted to shower Resident #52 stated no. An interview on 06/27/24 at 02:31 PM with LVN B, she stated all staff have encouraged Resident #52 to take a shower and change his clothing and he refuses. LVN B stated the resident's guardian was aware and has been a part of the meetings in the past. LVN B stated that she has asked Resident #52 why he does not like showers or water, and she said he alluded to something happening in his past. She stated they do not pressure him into showering because it was his right not to if he decides and he will also become aggressive if staff push too hard on the subject. Record review of Resident #57 face sheet dated 06/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), opioid dependence with unspecified opioid induced disorder, altered mental status-unspecified, and unspecified dementia (a group of symptoms that affects memory thinking and interferes with daily life)- unspecified severity-with other behavioral disturbance. Record review of Resident #57's admission MDS assessment dated [DATE] revealed BIMS section C0100: should resident interview be conducted was marked No. (resident is rarely/ never understood). Resident's BIM score was a 99 indicating resident was rarely/never understood. MDS assessment section GG- toileting revealed setup or cleanup assistance- helper sets up or cleans up; resident completes activity. Helper assists only prior to or following activity. Toilet transfer section revealed, independent- resident completes the activity themselves with no assistance from helper. Record review of Resident #57's care plan last revised 06/04/24 revealed no documented/ identified problem with mood/ behavior or interventions. Record review of LVN E's notes for Resident #57's IDT note dated 06/06/24 08:02 AM revealed, resident up walking in his room after disrobing, made several attempts to put his clothes back on but became combative; redirected but resident became combative and started hitting at the staff will continue to monitor. Record review of LVN E's notes for Resident #57's IDT note dated 06/06/24 08:13 AM revealed resident taken to the bathroom, voided without difficulty- approximately 20 minutes later resident went into a female resident's room pulled his pants down and brief down and voided on the floor. When instructed that he could not go into the females' room he told staff to kiss his ass. Attempt to put him in bed he would not allow it. Record review of RN A's notes for Resident #57's IDT note dated 06/06/24 06:02 PM revealed, while resident was outside on the scheduled smoke break without warning resident stood up out of wheelchair and urinated on sidewalk. When staff suggested that the bathroom inside be used as it was the policy, resident stated, 'I can do whatever the hell I want' resident then sat back in wheelchair and ignored staff prompting. Record review of RN A's notes for Resident #57's IDT note dated 06/11/24 at 11:00 PM revealed, residents behavior remains challenging to manage. At the beginning of the shift resident refused assistance while in the room lying on padded floor. Record review of LVN E's notes for Resident #57's IDT note dated 06/13/24 at 12:39 AM revealed, resident in bed attempting to get out unassisted, removed is brief and threw it on the floor; when trying to clean him up put on another brief and resident started striking out at the aides. Record review of LVN B's notes for Resident #57's IDT note dated 06/19/24 08:43 AM revealed, resident not easily redirectable, went into two rooms and voided on the floor .refuses assistance to bathroom, began cussing when attempted to assist. An observation and interview on 06/25/24 at 12:47 PM in Resident #57's room, he was observed standing near his bedside with a puddle of what appeared to be urine, and which had an ammonia/ urine smell that was detected when walking into the room. LVN B was notified, and she stated that was a behavior that he frequently exhibited where he urinates in the room or in the hall. An interview on 06/27/24 with LVN B she stated that Resident #57 was new, and the physicians have adjusted his medications trying to get the correct therapeutic dose to control his behaviors. LVN B stated that she would expect his behaviors to be mentioned in the care plan because he does have behaviors of being combative to staff, refusing care, and urinating on the floor. She stated that the DON would be responsible for making any care plan updates or ensuring it was individualized. Record review of Resident #43's admission record dated 6/26/2024 revealed a [AGE] year-old female who was admitted on [DATE]. Resident #43's diagnoses included schizoaffective disorder (mental health mood disorder), other mental disorders, muscle wasting, lack of coordination, sleep disorder, alcohol abuse with alcohol-induced sexual dysfunction, vitamin D deficiency, dementia (forgetfulness, limited social skills and thinking ability), long term use of birth control (current), restlessness and agitation, marijuana abuse, carbuncle of chest wall (boils under the skin that are connected to each other), Hyperlipidemia (high levels of fat particles in the blood), psychosis (disconnection from reality), diabetes, hypercholesterolemia (high levels of cholesterol in the blood), hypertension (high blood pressure), cocaine abuse, abnormalities of gait and mobility. Record review of Resident #43's care plan, dated 05/22/23, did not reflected Resident #43 was a smoker. Record review of Resident #43's quarterly MDS dated [DATE] revealed Resident #43 had a BIM score of 15, indicating the resident could understand and make self-understood. Resident #47's MDS did not reveal she was a smoker. Record review of Resident #43's smoking assessment dated [DATE] revealed resident was able to smoke with staff supervision. The assessment also has that the care plan has been updated as appropriate. Record review of Resident #67's admission record dated 06/26/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #67's diagnoses included impulse disorder, insomnia (sleep difficulty), psychosis (disconnection from reality), schizoaffective disorder (mental health mood disorder), adjustment disorder with mixed anxiety and depressed mood, brain damage. Record review of Resident #67's care plan, dated 06/04/24, did not reflected Resident #67 was a smoker. Record review of Resident #67's quarterly MDS dated [DATE] revealed that Resident #67 had a BIMs score of 5, indicating Resident #67 rarely understands and is not able to make self-understood. Record review of Resident #67's smoking assessment dated [DATE] revealed resident was able to smoke with staff supervision. The assessment also has that the care plan has been updated as appropriate. An interview on 06/27/24 at 02:54 PM with the DON , he stated it was his responsibility to update the care plans. He stated that Resident #57's behavior has gotten better since the last adjustment on his medications. He stated that they have implemented interventions that were a part of the IDT meeting and in the IDT notes and did not think it needed to be added to the care plan. The DON said that Resident #52 has been spoken to many times about showers, but he refuses them, and it was his right to refuse. He stated that they still try to recommend many ways to get him clean and that sometimes he does agree to use wet wipes to clean his body. The DON then stated that his expectations were that the care plans were holistic and should reflect behavioral issues and the individualized needs of the residents. The DON said that if care plans were not updated there was potential for residents to not have their needs met. An interview on 06/27/24 at 03:30 PM with the ADM he stated it was his expectation that care plans were patient centered, he said if there was a pattern of repeated behaviors or have other needs that staff should be aware of that information should be care planned. The ADM said the IDT contributes to the care plan, but it was ultimately the responsibility of the DON to finalize it and update it as needed. The ADM said that a negative outcome of not having the care plan updated would be that care staff would not know the whole picture and be able to treat the resident. He said once something was addressed on the care plan it was addressed appropriately and you can meet the needs of the resident. Review of the facility care planning policy dated 12/13/20 revealed: Policy: to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The facility will develop a person-centered baseline care plan for each resident. The care plan will be updated to reflect changes in the residents' condition or needs occurring prior to the development of the comprehensive care plan. Care plan will include measurable objectives and timetable to meet a resident medical, nursing, mental, and psychosocial needs. IT was removed on 07/17/2024 at 6:00 PM and ADM was informed IT was removed. However, the facility remained out of compliance at a severity of no at no actual harm with the potential for more than minimal harm due that is not immediate jeopardy at a scope of isolated. The facility's plan of removal was accepted on 7/17/2024 at 08:26 AM and reflected the following: On 06/27/2024 a survey was initiated at facility. On 07/16/2024 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F656- The facility failed to ensure Resident #47's care plan was comprehensive and updated to reflect he needed assistance with feeding and was a choking risk. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. -Action: A care plan audit was conducted and completed by DON for all residents with swallowing difficulties who have had a barium swallow test done and triggered for needing assistance with feeding or for choking risk to ensure no additional residents are at risk. Five residents triggered. Care Plans will be updated to reflect appropriate diet and interventions are in place and MDS will be checked to ensure swallowing issues and any modified diets are reflected accurately for those residents as well that trigger. Start Date: 07/16/2024. Completion Date: 07/16/2024 Responsible: DON -Action: DON was reeducated by Clinical Nurse Consultant on care plans and ensuring they are kept updated as needed to reflect appropriate diet and interventions are in place. Start Date: 7/16/24. Completion Date: 7/16/24 Responsible: Clinical Nurse Consultant -Action: Care Plans will be reviewed weekly by IDT and monitored weekly by DON to ensure reflective of resident's current clinical status and updated and communicated accordingly. The monitoring will be reported by the DON to the QAPI monthly for 3 months and as needed thereafter. Start Date: 07/16/2024. Completion Date: 07/16/2024 Responsible: DON -Action: An Ad-hoc QAPI meeting was held by DON, MD, and Administrator regarding auditing and updating comprehensive care plans for residents that trigger for needing assistance with feeding and choking risk as well as monitoring of these residents during mealtime. Start Date: 07/16/2024. Completion Date: 07/16/2024 Responsible: DON Monitoring Included: An interview with CN on 07/17/2024 at 1:13 PM revealed she in serviced the DON covered care plan diets, swallow studies, residents risk of choking, training the staff, interventions, and responsibilities. She stated she also trained him to train the other staff. An interview with ADM on 07/17/2024 at 2:00 PM revealed that the ADM and DON went through the residents charts. The ADM stated they checked the residents charts to ensure if they were triggered for swallowing difficulties he could look and see if they needed assistance or supervision. He stated he made sure the DON added the risks and appropriate supervision on the resident's chart. He stated that was the process they did for the audit of the care plans. An interview with the DON on 07/17/2024 at 2:10 PM revealed that he was trained on choking hazard, interventions, and responsibilities. He stated if a resident is choking staff are to do the Heimlich maneuver. He stated staff and himself are to monitor the residents who triggered for choking closely. He stated all care plans for those residents who triggered for choking hazard or swallowing difficulties have been updated to reflect the issue. Record Review of Resident's who triggered for swallowing difficulties and choking hazards revealed that their charts reflected the swallowing difficulty and choking risk. Record review of in-serviced training done for the DON revealed he had been trained on choking hazards and responsibilities. Record Review of QAPI revealed the facility did have a meeting and addressed the choking, and care plans. Record review of daily monitoring of residents of high-risk choking log dated July 2024 revealed the facility started monitoring on 07/16/2024 at dinner. Record Review of the resident's charts that triggered for high-risk of choking were reviewed to ensure they had the correct diagnosis, choking difficulty and that they needed assistance with feeding. Record review of in-serviced training done by the DON revealed he had trained 27 of 38 staff on choking hazards and responsibilities. He stated that the remaining staff will be trained before they are allowed to work their next shift. IT was removed on 07/17/2024 at 6:00 PM and ADM was informed IT was removed. However, the facility remained out of compliance at a severity of no at no actual harm with the potential for more than minimal harm due that is not immediate jeopardy at a scope of isolated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #47) of 5 residents reviewed for accidents. The failed to ensure resident #47 was being monitored during meal intake resulting Resident #47 choking and ultimately passing away. This failure could result in other residents not getting the assistance or the supervision needed when they have swallowing difficulties and could also lead to severe injury and/or death. An IT was identified on 07/16/2024 at 12:00 PM. The IT template was provided to the facility on [DATE] at 12:47 PM. The IT was removed on 07/17/2024, the facility remained in violation at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate because the facility failed to Findings included: Record review of Resident #47's face sheet dated 06/27/2024 revealed Resident #47 was a [AGE] year-old male admitted on [DATE] with diagnoses of Nausea with vomiting, depressive disorder, reflux, high level of fat particles in the blood, Urinary tract infection, brain disease, vitamin D deficiency, pre-diabetes, constipation, dementia, inflammatory disorder of the pancreas, sleeping disorder, Alzheimer's, lack of coordination, muscle weakness, and communication difficulty. Record review of Resident #47's quarterly MDS dated [DATE] revealed resident did not have a swallowing issue. The MDS also revealed the resident was on a mechanically altered diet (chopped/cut up food that are soft and easy to eat) Resident #47's MDS also revealed that resident was independent when feeding. Record Review of Resident #47's care plan dated 05/09/2024 revealed no information as to Resident #47 having dysphasia (swallowing difficulty), needing assistance with feeding, or was at risk of choking. Record review of a professional Imaging Physician Consultation Evaluation and Management report dated 05/22/2023 for Resident #47 revealed the chief complaint was choking, feeding difficulties, difficulty swallowing, poor intake and weight loss. The report also revealed the resident had the issues for weeks and the intensity was moderate. The evaluation also revealed that the resident was at risk for choking episodes and a diagnosis of oropharyngeal dysphagia (swallowing difficulty) was given. The report also stated that the resident needed assistance with feeding. Record review of the Dietary orders dated 02/28/2022 revealed that Resident #47 was on a mechanical soft diet. No doctor orders for mechanical soft diet were received up on exit. Record review of Resident #47's care plan dated 05/09/2024 did not have any information on his diet. Record review of LVN F's progress notes for Resident #47 dated 05/03/2024 at 12:44 PM revealed requesting diet change. Appearing to be having problems swallowing. Consult with physician. Record review of LVN G's progress notes for Resident #47 dated 05/04/2024 at 5:13 AM revealed request for diet change due to swallowing problems. Record review of LVN C progress notes for Resident #47's dated 05/16/2024 revealed that the resident was eating supper. Resident stood up reached for his throat signs of chocking. RN started the Heimlich Maneuver to resident. Tried to take food out from his mouth and some dislodged from resident's throat. Called 911 then Resident #47 passed out RN started CPR. She stated that EMS pronounced the resident dead. Interview with the DON on 06/27/2024 at 12:30 PM revealed that Resident #47 had some teeth missing, did not have dentures and that the resident was able to chew food. He stated the resident did not have issues with swallowing . He stated he had been the DON for a little over a year. He stated the nurse would let the doctor know when results come in and inform the doctor. He stated he did not know why the swallow study showed he had swallowing difficulties because he did not have any issues with swallowing. An interview with RN on 06/27/2024 at 2:26 PM revealed he had been working at the facility for one year. He stated that he was in the dining room for dinner on 05/16/2024 at approximately. 5:00 PM . He stated Resident #47 stood up and did the universal sign of choking. He went over to the resident and started doing the Heimlich maneuver. He stated that Resident #47 then went to the floor. He stated he and LVN swiped his mouth to get the food out . He stated a little chunk that was mushy came out. He stated he started doing CPR and that he was not sure if the resident was breathing or not at that time. He stated that he did not know if the resident had a diagnosis of swallowing difficulty. He also stated he did not know what type of diet the resident was on as he was not a resident, he worked with . He stated Resident #47 was given a mechanical soft diet that day. An interview with LVN on 06/27/2024 at 2:39 PM revealed that Resident #47 started choking at dinner on 05/16/2024 and a staff member called her to the dining room. She stated she then started helping RN. She stated she called 911 and was sweeping food out of the resident's mouth. She stated it was a ball of mush She stated that he suddenly passed out. She stated they followed instructions from EMS and EMS took over when they got to the facility. She stated Resident #47 was one of her regular resident's. She stated he was on a mechanical soft diet and given a mechanical soft diet the day he choked. She also stated that he had a swallow study done but was not sure what year. She stated the swallow study was done because the family was concerned . She stated the swallow study was normal. She stated Resident #47 would hold his food in his mouth. She stated she did not know how long he had been holding food in his mouth. She also stated he was high risk for choking. She stated the resident did not have a diagnosis of difficulty swallowing because the test did not show anything wrong. An interview with the Speech Pathologist on 06/27/2024 at 4:12 PM revealed that the resident came in with a diagnosis of swallowing difficulties. She stated the purpose of the swallow test was to get more specific as to which type of difficulty the resident was having. She stated that he was diagnosed with Oropharyngeal Dysphagia (which is a difficulty emptying part of the throat). She stated they did make recommendations for the resident based on his results. An interview with Resident #47's Primary Doctor on 06/27/2024 at 4:31 PM revealed that the resident did not have a swallowing disorder. He stated he had been seeing the resident for two years. He stated he did not know why he ordered the swallow study. He stated the resident did not have any events of aspiration. When asked why he did not follow the recommendations of the swallow study he stated we treat the patient not the lab results. He did not have any issues swallowing. An interview with the Nurse Practitioner on 06/27/2024 at 7:25 PM revealed that she thought the swallow study was done due to the resident losing weight. She stated that when labs come back LVN A would inform her if something was abnormal. She stated if there was not something abnormal, she would see the resident on Mondays or Fridays. She stated that she did not know why the swallow study was done or the results of the test. Record review of laboratory protocol and procedures dated 06/14/2014 revealed that laboratory procedures will be done in accordance with facility policy and procedures. Requested policy for following up on swallow study results and notifying doctor and policy for supervising resident with swallowing difficulties who are at risk of choking, from the ADM and DON on 06/27/2024 at 2:30 PM no policy was provided at the time of exit. The facility's plan of removal was accepted on 7/17/2024 at 08:26 AM and reflected the following: On 06/27/2024 a survey was initiated at facility on 07/16/2024 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F689 - The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that: They failed to ensure resident was being monitored during meal intake resulting in severe injury, and death. -Action: An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on monitoring residents during meal service who need assistance with feeding and that trigger for choking risk as well as communicating updated interventions and staff responsibilities, prior to them working the floor. All staff were re-educated on the regulatory guidelines and facility policy and procedures regarding Abuse, Neglect and Exploitation. Start Date: 07/16/2024. Completion Date: 07/16/2024 Responsible: DON -Action: DON was reeducated on monitoring residents during meal service who need assistance with feeding and that trigger for choking risk as well as communicating updated interventions and staff responsibilities, prior to them working the floor. Start Date: 7/16/24. Completion Date: 7/16/24 Responsible: Clinical Nurse Consultant -Action: DON or designee will do weekly checks during meals to ensure staff are monitoring residents who need assistance with feeding and that trigger for choking risk. This will be documented on a QAPI monitoring form and reported to QAPI monthly for 3 months and as needed thereafter. Start Date: 07/16/2024. Completion Date: 0716/2024 Responsible: DON -Action: An Ad-hoc QAPI meeting was held by DON, MD, and Administrator regarding auditing and updating comprehensive care plans for residents that trigger for needing assistance with feeding and choking risk as well as monitoring of these residents during mealtime. Start Date: 07/16/2024. Completion Date: 07/16/2024 Responsible: DON Monitoring included. An interview with CN on 07/17/2024 at 1:13 PM revealed she in serviced the DON covered care plan diets, swallow studies, residents risk of choking, training the staff, interventions, and responsibilities. She stated she also trained him to train the other staff. An interview with ADM on 07/17/2024 at 2:00 PM revealed that the ADM and DON went through the residents charts. The ADM stated they checked the residents charts to ensure if they were triggered for swallowing difficulties he could look and see if they needed assistance or supervision. He stated he made sure the DON added the risks and appropriate supervision on the resident's chart. He stated that was the process they did for the audit of the care plans. Interview with RN A on 07/17/2024 at 2:50 PM revealed he had been trained on hazards of choking on 07/16/2024. He stated the training covered choking monitoring and risk for choking. He stated that if someone is choking, they would naturally reach for their throat. He stated it is important to ensure the resident has oxygen and can breathe during the choking and after. He also stated if a resident is choking it is important to try to get their airway clear. He stated he was trained on abuse and neglect and resident rights. He stated the training covered the rights of the resident and who to report abuse and neglect to and how to identify abuse. An interview with LVN C on 07/17/2024 at 3:02 PM revealed that she had been trained on choking and hazard of choking on 07/16/2024. She stated the training covered what to do if a resident is choking. She stated there were to be a nurse in the hall and a nurse in the dining room monitoring the residents. she stated if a resident was choking staff were to do the Heimlich maneuver and remove the food from their throat. She stated she had been trained on resident rights and abuse. She stated that the training covered who to report abuse to what to do if you suspect abuse and making sure staff are meeting the needs of the resident. An interview with CNA H on 07/17/2024 at 3:10 PM revealed he had been trained on choking hazards and monitoring on 07/16/2024. He stated the training covered watching the residents during mealtime, watch the way the resident is eating and ensure resident are not having issues. He stated that if a resident were choking, he would help the resident and let the nurse know. He stated he was trained on resident rights and abuse. He stated the training covered the residents rights to refuse care and move around the facility. He stated if a resident is being abused, he would report it to the administrator. An interview with the Dietary manager on 07/17/2024 at 3:38 PM revealed due to active COVID in the building, she brings the residents from one side of the building to the dining room at a time. She stated the residents that come to the dining room are the ones who need assistance. She stated for the residents who are at risk of choking she puts a red mark on their tray to let staff know they are at risk of choking. She stated those residents are the only ones brought to the dining room. Observation of dining services on 07/17/2024 at 4:45 PM revealed that all resident that triggered for swallowing difficulties was in the dining room for observation while eating. One resident had COVID and was eating in his room, a staff member stood outside residents room to watch him. All residents who were triggered for choking risk were given the proper diet. Record review of in-serviced training done by the DON revealed he had trained 27 of 38 staff on choking hazards and responsibilities. He stated that the remaining staff will be trained before they are allowed to work their next shift. Record Review of QAPI revealed the facility did have a meeting and addressed the choking, and care plans. Record review of daily monitoring of residents of high-risk choking log dated July 2024 revealed the facility started monitoring on 07/16/2024 at dinner. IT was removed on 07/17/2024 at 6:00 PM and ADM was informed IT was removed. However, the facility remained out of compliance at a severity of no at no actual harm with the potential for more than minimal harm due that is not immediate jeopardy at a scope of isolated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accident hazards/supervision. Resident #1 walked out of the facility unattended on 04/01/24 at 8:08PM and remained missing as on 04/10/24 at 3:00PM. LVN B failed to physically check during the two-hour monitoring to ensure Resident #1 was in the building during and after his elopement. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/05/24 at 9:12AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual ham but potential for harm as the resident was missing as on 04/10/24. This failure could affect residents and place them at risk of not receiving the appropriate level of supervision to prevent physical harm, pain and accidents. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Schizoaffective Disorder (a type of mental illness), Repeated Falls, Muscle weakness, Disorder of Kidney and Ureter and Hypertension (High blood pressure). Record review of Resident #1's MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. Record review of Resident #1's care plan dated 01/18/2024 revealed Resident #1 had the habit of intruding into other resident's privacy and the intervention was placing Resident #1 in area where frequent observation was possible. Record review of Resident #1's Elopement Risk Evaluation dated 01/18/24 reflected a score of 7 indicating Resident #1 was at no risk for elopement. Record review on 04/03/24 of Resident #1's medication order revealed resident was on the following medications: Clozapine Immediate Release 200MG daily at bedtime Clozapine 100MG tablet in the morning Haloperidol 5mg at night Haloperidol 5mg at noon Donepezil HCL 10MG daily Trazadone 25MG at night Simvastatin 5MG every night Gemfimbrozil 600MG twice a day Metoprolol Tartrate 37.5MG Twice a day Record review on 04/03/24 of Resident #1's MAR for the month of April revealed that on 04/01/24 all his medications scheduled for 9:00PM, were administered by CNA D. Record review of facility's incident report to HHSC dated 04/02/24 reflected, on 04/02/24 at 7:30AM staff noticed Resident #1 was missing and not on the property. CC camera review showed Resident #1 eloped from facility through a secured exit gate on 04/01/24 at 8:08PM. Record review on 04/03/24 of Facility's Monitoring Sheet Every Two Hours' dated 04/01/24, documented by LVN B, reflected resident was at the facility at 5PM,7PM,9PM,11PM,1AM,3AM and 5AM and Monitoring Sheet Every Two Hours' dated 04/02/24 reflected Resident #1 was absent at the facility since 7AM. Observation on 04/03/24 at 11.45AM of the CC camera footage revealed Resident #1 exited through one of the facility's three locked fence gates around the facility on 04/01/24 at 8:08PM by opening forcefully. Observation of Resident #1's room on 04/03/24 at 11:00AM revealed he was sharing the room with another resident. Resident #1's bed was towards the window, away from the door. His privacy curtain was fully drawn so that his bed was not visible from the door. During an interview on 04/03/24 at 11:30 AM, LVN A stated she knew Resident #1 very well since his admission a few years ago. She said on 04/01/24 she did overtime and left the facility at about 7:30PM. LVN A stated Resident #1 was in the facility at around 7:00PM and she marked his presence on the two hour's monitoring sheet. LVN A stated she came to know Resident #1's elopement on 04/02/24 at about 8:00AM when she arrived for work and observed staff and police were on the lookout for Resident #1. During an interview on 04/03/24 at 2:30PM CNA D stated he is a Med Aide and works the afternoon shifts. He stated he had administered Resident #1's evening medications at 8:00PM on 04/01/24. CNA D said Resident #1 did not voice any concerns at that time and was appeared in his usual presentation. During a telephone interview on 04/03/24 at 6:00PM, LVN B stated she was the night nurse at the facility. She said she started her shift at 8:00PM on 04/01/24 and finished at 7:00AM on 04/02/24. LVN B stated she had the task of checking on residents every two hours and marked Resident #1 on the 'Two Hour's Monitoring Sheet' as present at the facility in the whole night, without physically seeing him. LVN B said she assumed Resident #1 would be at the facility since he was one of the residents with very low elopement risk, over the years. She stated to ensure the residents were present at the facility, she should have observed all of them physically at every two hours instead of assuming. During an interview on 04/04/24 at 7:00AM, LVN C stated she was the night nurse at the facility. She stated she worked on 04/01/24 in the East Hall where Resident #1 was not living. LVN C stated, in the nights she physically checked all the residents every two hours by entering in their rooms unlike, as observed, LVN B who used flashlight from the door for observation, without entering their rooms. During a telephone interview on 04/03/24 at 3:00PM the NP at the facility stated since Resident #1 had eloped, there was risk of relapsing his mental illness due to the lack of medication. She stated this would make him more vulnerable in the community and could be a threat to the safety of his and/or of the community. NP stated Resident #1 has long history of mental illness and even if he returned to the facility after few days, it would take some time to build up a therapeutic level of medications in the blood to make him mentally stable. During a telephone interview on 04/08/24 at 10:35AM the LEO stated Resident #1 was still missing. He stated the department was on a [NAME] to trace him down and the facility also was making efforts to find him. LEO stated he was one of the three officers who responded to the 911 call from the facility on 04/02/24 at about 7:30AM. He said the observation of the CC camera footage revealed the resident exited the facility by breaking open the gate forcefully. LEO stated, while he could not find any remarkable noncompliance of the facility, the Two Hour's Check Sheet did not make any senses as Resident #1 was marked in it as present at the facility throughout the night on 04/01/24. He said, it was clear from the CC camera footage that he exited the facility at about 8:00PM. LEO stated the earlier the search for a missing person the higher the chances of success in finding them. During an interview on 04/03/24 at 5:00PM the DON stated, he came to know about the elopement of the resident from a phone call by the staff on 04/02/24 at about 8:00AM, on his way to work. He stated Resident #1 was on low risk of elopement and on 2 hours observation whereas a resident with high risk of elopement were on 30minutes check. The DON stated staff who do the checks should make sure that they physically observed the resident before signing off the monitoring sheet in order to eliminate issues like elopement. The DON stated there was no system at the facility in place to check the accuracy of these observations. During an interview on 04/03/24 at 5:30PM the ADM stated the facility had no right to stop Resident #1 from leaving the facility as he was the responsible party for himself. When the investigator asked ADM if Resident #1 discussed with him or staff about leaving the facility and signed or refused to sign any documents like AMA, ADM stated Resident #1 did not do so any time before eloping. the ADM also stated Resident #1 had not taken any medication with him as well, as all his medications were stored and managed by the facility. Review of facility policy 2 hr Resident Monitoring dated 09/10/2016 reflected: Policy: Resident who score 0-8 on the Elopement /Wandering Risk Assessment will be checked physically present Q2 hours. 1.Nursing staff will conduct rounds Q 2 hours on their assigned residents. 2.Nursing staff will use assigned 2 hrs monitoring checklist to document their checks. 3.Nursing staff must confirm time checked and initial checklist. 4.Nursing staff must report any resident that is not accounted for during their checks immediately to their supervisor in order to initiate a possible elopement protocol. 5.If an elopement protocol is initiated, the nurse supervisor must contact the Administrator and DON immediately for assistance. Indicate that a plan of removal was requested; when it was received and accepted. The notification of Immediate Jeopardy states as follows: The facility failed to ensure all the residents were present in the facility by doing routine checks accurately, resulted in the elopement of Resident #1 unnoticed Action: All residents were re-assessed for elopement risk with no new residents identified on 4/02/2024. All Nursing Staff Inservice to include PRN and New Hires on doing routine checks accurately to ensure residents are in facility and accounted for as per our 2-hour monitoring checklist. (No Agency in Use). Per checklist, Residents who score 0-8 on the Elopement/Wandering risk Assessment must be checked physically present by setting eyes on resident to ensure present Q 2 hours. Inservice of all nursing staff to ensure the 2 hr monitoring checks are being completed and that staff must set eyes on resident to ensure they are physically present, as per updated policy. All new admissions will continue to be assessed for elopement risk per policy. Start Date: 4/02/2024. Completion Date: 4/04/2024 Responsible: DON Action: The charge nurse for the given shift will be the primary monitor and will ensure staff are completing checks by monitoring and signing-off on the checklist for their assigned shift. The DON will monitor the 2-hour checks for compliance through QAPI checks weekly. Administrator will be secondary QAPI monitor as needed. The DON is responsible for the training of staff. The DON has been inserviced by Regional Nurse Consultant on 4/03/2024. Administrator has been trained by DON 4/04/2024. Start Date: 4/03/2024. Completion Date: Ongoing checks per policy 2 hour resident monitoring policy. QAPI will monitor for 3 months or as necessary thereafter. Responsible: DON Action: Inservices for all nursing staff will include on explaining the difference between a resident elopement and resident right to leave. Start Date: 4/04/2024 Completion Date: 4/04/2024 Responsible: DON Action: Adhoc QAPI to discuss the plan and monitoring for effectiveness. Monitoring for effectiveness will be done weekly and reported to QAPI for review. DON or designee will review checklist being used and do random checks, follow up with staff, and educate as needed. Progress or concerns reported to QAPI. Start Date: 4/03/2024 Completion Date: QAPI will monitor for 3 months or as necessary thereafter to ensure compliance. Responsible: Administrator/DON Action: The exit gates have been reinforced for safety and security immediately following the incident. Hinges were reinforced by adding an additional bolt to secure hinge mechanisms in place. Maintenance Supervisor will be responsible and will monitor and log compliance weekly. Administrator will ensure ongoing compliance weekly. Start Date: 4/03/2024. Completion Date: Ongoing weekly Responsible: Maintenance Supervisor The surveyor confirmed the facility implemented their plan of removal sufficiently from 04/03/24 through 04/05/24 to remove the IJ by: 1. New Elopement risk assessment for all residents were reviewed. No additional residents with risks were noticed. There are 9 high risk residents at the facility. Risk management plan is in place and implementation is continuing without any issues at this time. 2. The updated policy 2hr Resident Monitoring reviewed. The sentence by setting eye on resident to ensure present' is added to the existing policy. 3. Inservice records reviewed. All staff members were in serviced. This includes DON and ADM. The following staffs were interviewed, and they were able to explain the new policy and procedure with the importance of ensuring that the residents are physically present. LVN C (Night Shift) LVN A (Morning shift), CNA E (Afternoon shift) , AD ( day shift) and DON(Day shift). 4. During an interview on 04/05/24 at 11:00AM, the DON explained the facility plan to reduce the risk of elopement by close and efficient observation. The ADM elaborated his role of supervision was to ensure the plan was executed correctly and consistently. 5. Record review revealed the QAPI meeting conducted on 04/03/24. During an interview on 04/05/24 at 12:00PM, the ADM stated QAPI meeting conducted and as per plan the facility will monitor for 3 months or as necessary thereafter to ensure compliance. 6. The exit gates observed and confirmed that the reinforcement done to make it more secure. MS during the interview on 04/05/24 at 11:25am stated she tried to open the gate with the paddle lock in place like how Resident #1 did and it was difficult to open initially however with a powerful push the gate opened. She stated, she added additional nut and bolt on the existing lock to secure the system with good effect. She said her current plan is to do a daily check on fence, gates, and locks. She stated she maintains a work logbook and review of the log book revealed documentation of her daily inspection. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/05/24 at 9:12AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual ham but potential for harm as the resident was missing as on 04/10/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards, in that: The facility failed to: 1. Ensure the fence surrounding the facility was secured. 2. Ensure functioning door alarms were installed. 3. Follow Resident #1's care plan by physically checking on him every two hours. Resident #1 eloped from the facility on 11/09/22 and was found 14-16 hours later and five miles away on a high-trafficked highway. These deficient practices placed residents at risk for unsafe elopements, falls, injuries, and hospitalization. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/28/22 at 5:45 PM. While the IJ was removed on 12/03/22 at 3:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including insomnia (trouble falling/staying asleep), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), bipolar disorder (a mental health condition that causes extreme mood swings), impulse disorder, and anxiety disorder. Review of Resident #1's quarterly care plan, reviewed 11/08/22, reflected he was deemed at risk of wandering/elopement as evidence by him having a history of elopement at his previous facility with interventions of observing and documenting [Resident #1's] location every two hours. It further reflected Resident #1he was at risk of wandering with an intervention to implement facility protocol for locating an eloped resident. Review of Resident #1's quarterly MDS assessment, dated 11/11/22, reflected a BIMS of 6, indicating a severe cognitive impairment. MDS further reflected a wandering behavior had occurred one - three days within the quarter. Additionally, it reflected he required no assistance with ambulation. Review of Resident #1's Elopement Risk Assessment, dated 08/03/22, reflected a score of 10, indicating he was a high elopement risk. Review of Resident #1's Elopement Risk Assessment, dated 11/10/22, reflected a score of 19, indicating he was a high elopement risk. Review of Resident #1's progress notes located located in the resident's EMR, dated 08/08/22, reflected RN D documented Resident #1 eloped from the facility by climbing over the fence. Resident #1 was found not to be in his room around 6:15 AM and was brought back to the facility by law enforcement around 12:00 PM without injury. Review of Resident #1's progress notes located in the residents' EMR, dated 11/09/22, reflected RN E documented Resident #1 was found not to be in his room and missing from facility by CNA A around 1:00 AM. Around 2:45 AM ADM and DON were in the facility checking the surveillance cameras when they saw on the footage that [Resident #1] climbed over the fence on the East side of the facility left of an air conditioning unit. Review of Resident #1's progress notes located in the EMR, dated 11/15/22 (late entry), reflected DON documentation reflecting, Resident #1 had eloped from the facility on 11/09/22 at 9:30 PM and was found the next day five miles away by the police department around 12:00 PM without injury. Resident #1 was sent to the hospital by EMS for evaluation. Resident #1 returned to the facility around 3:00 PM. Review of Resident #1's Incident Statement documented by CNA A, dated 11/10/22, reflected: Date of Incident: 11/10/22, Time of Incident: 1:00 AM. It was around 1:00 AM when I was checking the resident; he was not in his room. I reported to the nurse. Review of Resident #1's Incident Statement documented by CNA B, dated 11/10/22, reflected: Date of Incident: 11/10/22, Time of Incident: 1:00 AM. At about 1:00 AM I was making rounds and that's when I noticed [Resident #1] was not in his bed . I checked outside the building and notified the nurse in charge. Review of Resident #1's Incident Statement documented by DON, dated 11/10/22, reflected: Date of Incident: 11/10/22, Time of Incident: 1:10 AM. The steps to prevent occurrence of incident: 1:1 Q 15-30-minute whereabouts. Review of Resident #1's ER Discharge Paperwork, dated 11/10/22 at 12:29 PM, reflected the following: [Resident #1] came in by ambulance due to [Resident #1] found walking after being missing 12 - 16 hours from nursing home, [facility], and needing medical clearance to return to NH. [Resident #1] a&o to name only and is his norm per NH. Review of staffing sheets, dated 11/09/22 and 11/10/22, reflected CNA C was scheduled on Resident #1's hall from 3 PM - 11 PM and on 11/09/22. CNA B and CNA A were scheduled on Resident #1's hall from 11 PM - 7 AM on 11/10/22. Review of Resident #1's EMR, dates 08/09/22 - 11/28/22, reflected no documentation of required Q 2-hour checks. Observations made on 11/28/22 from 8:30 AM - 3:45 PM revealed none of the facility exit doors were equipped with door alarms. Observation and interview on 11/28/22 beginning at 10:15 AM with ADM, she showed this Surveyor where Resident #1 eloped on (the first time) on 08/09/22. Observations were made of the facility being surrounded by a 12-foot chain-link fence with chicken wire over the top of the fence. ADM pointed to a corner of the fence and stated, The chicken wire at that spot had become loose due to weather and age. ADM stated Resident #1 must have climbed the fence and got his body through the loose chicken wire. ADM stated after that elopement (08/09/2022), her MAINTD had replaced the chicken wire and tightened up any loose areas. ADM then took this Surveyor to the other side of the facility where Resident #1 eloped the second time, on 11/09/22. There was a large AC unit about 10-feet off the ground with a metal elevated platform under it. ADM stated, There had been a gap approximately one foot between the chicken wire and the AC unit and stated, I never thought anyone could fit through it. ADM stated a surveillance camera happened to catch his movements during the second elopement. ADM stated he climbed the fence onto the elevated platform and then pushed himself through the gap. ADM stated they had scheduled a [NAME] company to come in the next few days to solder off the metal platform but MAINTD had already tightened the chicken wire so there was no longer a gap. ADM stated they had placed alarms on all exit doors after the first time Resident #1 eloped, but the residents had pulled them off. ADM stated Resident #1 was put on Q 15-minute checks for 72 hours after each elopement. ADM stated it was her expectation that all residents were physically checked every two hours - preferably even more often since their resident population had a high-elopement risk. ADM stated it was unacceptable that Resident #1 left the facility at 9:30 PM and his absence was not discovered until approximately 1:30 AM the following morning. ADM stated she was aware he was exhibiting exit-seeking behaviors at the group home he lived prior to living at the facility, but before he was admitted , when Resident #1 he was in the hospital, she was reassured by hospital staff that Resident #1 showed no such behaviors. A telephone interview was attempted with CNA C on 11/28/22 at 1:41 PM and 2:37 PM. A message was left requesting a call back. This Surveyor was not able to interview CNA C. During an interview on 11/28/22 at 1:44 PM with CNA B, he stated he was a floater on the night of 11/09/22 and CNA A was Resident #1's main aide. CNA B stated sometime after 1:00 AM he realized Resident #1 was not in his bed. CNA B stated CNA A told him she did not check on him because there was a pillow and sheets under his blanket, and she thought he was sleeping. CNA BHe stated all residents should be checked on every two hours to ensure their safety. During a telephone interview on 11/28/22 at 2:51 PM with CNA A, she stated she thought Resident #1 was sleeping in his bed on the night of 11/09/22. CNA A stated she did not think to go in his room to physically ensure he was in there or place eyes on him. CNA A stated she had been in-serviced on ensuring all residents are checked on every two hours. During an Iinterview on 11/28/22 at 3:02 PM with DON, he stated he expected all residents to be checked on every two hours. DON stated if residents were not physically checked on, it could lead to outcomes of elopement or injury. Review of the facility's Elopement Policy, revised 08/06/21 reflected the following: Policy: The facility is committed to providing an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents, such as elopement. This includes: - Identifying hazard(s) and risk(s) - Evaluating and analyzing hazard(s) and risk(s) - Implementing interventions to reduce hazard(s) and risk(s) - Monitoring for effectiveness and modifying interventions when necessary Elopement is defined as the unplanned leaving of the facility grounds. Review of the facility's undated Elopement Prevention and Search Policy reflected the following: Knowing the whereabouts of residents in the facility is the responsibility of every staff person. Residents who have the tendency or history of wandering are identified in the assessment and reassessment process. Residents must be identified as at risk for attempting to wander outside the facility. In addition, the following features, practices and procedures will assist in preventing a resident from eloping or attempting to leave the facility unaccompanied: . Alarms must be maintained and monitored for accurate operation on a daily, weekly, and monthly basis. ADM was notified on 11/28/22 at 5:45 PM, that an Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the ADM on 11/28/22 at 5:45 PM. A Plan of Removal was first submitted by ADM on 11/29/22 at 1:30 PM and the following POR was accepted on 12/03/22 at 9:04 AM and read as follows: Date: 11/29/22 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Impact Statement On 11/28/2022 an abbreviated survey was initiated at [facility]. On 11/28/22 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility neglected to provide adequate supervision to 1 of the 13 residents at risk for elopement. Resident #1 eloped from the facility on 11/09/22 and was missing for 14 hours. Free from Accident Hazards F689-The facility failed to have adequate supervision to prevent potential accidents. Identify residents who could be affected - 13 High-Risk Elopement Resident. Problem - The facility failed to supervise to prevent an elopement. - Monitoring the outside areas as well as the inside. Action Taken - Current Elopement Risk Assessments have been conducted on all current residents. Elopement Risk Assessments were completed on 11/30/22 and finished on 12/01/22 in the am. Thirteen residents are at high risk for elopement. - MDS Nurse and DON will review and be responsible for completing the new Elopement Risk Assessments Start Date 11/30/2022 and ongoing with each MDS assessment cycle. - Reviewed and Monitored by Administrator and DON Start Date 11/30/2022 and ongoing. - Elopement Risk Assessment will be completed within 2 hours upon admission by Charge Nurse that has received the admission. - Admitting Charge Nurse is responsible Start Date: Will begin with the next admission and ongoing. - Reviewed and Monitored by the Administrator and DON within 24 hours during the audit on the admission chart. The start date will begin with the next admission and ongoing. - Elopement Risk Assessments will be done quarterly and PRN (as needed) with the change of condition done during the care plan and with the MDS cycle. - MDS Nurse will complete the Elopement Risk Assessments Quarterly and PRN Start Date 11/29/2022 and ongoing with the MDS Assessment Cycle. - DON and Administrator will monitor to ensure compliance. Start Date 11/29/22 and ongoing. - In-service conducted on 11/28/2022 with all staff on elopement/wandering. New hires and/or agency staff will be educated on elopement/wandering during orientation before starting the shift. An elopement posttest was given and completed by 11/29/2022. All staff will be tested before their next working shift. New hires and/or agency staff will be educated on elopement and those residents at high risk for elopement during orientation before starting the shift. - DON conducted the Inservice for current staff Start Date 11/28/2022 and completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation). - Reviewed and Monitoring by the Administrator Start Date 11/28/2022 and ongoing. - Education on Elopement Assessment on 11/29/2022 was completed with all charge nurses (at a mandatory meeting) that will be utilizing the tool upon admission and how to understand to get the correct score. Any resident that is from 8-10 are considered high risk for elopement and they will be checked on every 30 min with eye-to-eye contact per shift. The Charge Nurse will sign off on each elopement monitoring sheet per shift for high-risk residents. Then pass to the next shift stating those residents are still at the facility. - Charge Nurse of each shift is responsible Start Date of 11/29/2022 and is ongoing on each shift. The facility schedule 3 - 8 hours shifts. - DON or Administrator will review monitoring sheets on high-risk residents and sign off daily. Start Date 11/29/2022 and ongoing. - All Staff in service on 11/29/2022 about door alarms that were reapplied on 11/28/2022 by maintenance to alert staff that someone has gone out that exit door to ensure they return to the facility safely. New hires and agency staff will be educated on door alarms during orientation as for the purpose of it. - Administrator conducted the Inservice for current staff Start Date 11/29/2022 completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation). - Administrator will be responsible for monitoring the Start Date - 11/29/2022 and ongoing. - All Staff have been educated on 11/30/2022 that doors will be locked from the hours of 9 PM to 5 AM with the door alarm set at 6 PM after the last smoke break after dinner time. Staff will instruct that they will need to go to that exit door and observe residents' whereabouts and status. New hires and agency staff will be educated on door locking and door alarms during orientation before their first shift. - Administrator conducted the Inservice for current staff Start Date 11/30/2022 completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation) o Administrator will be responsible for monitoring Start Date - 11/30/2022 and ongoing (with each new employee hired and or agency staff during orientation). - Established Red Shoe Society on 11/30/2022- this program will identify those residents at high risk for elopement. After a review and completion of the Elopement Risk Assessments, a red shoe symbol will be placed on the resident's door to indicate that they are at a higher risk for elopement. An In-service will be held for new staff where this information will be shared. The break room will have a poster explaining the Red Shoe Society - posted on 12/01/22 New Hires and/or agency staff will be educated on the Red Shoe Society during orientation. - admission Coordinator, Activities, and/or DON will make sure that current and new residents with a score of 8 or above will have a red shoe placed on their door. Start Date 11/30/2022 for current staff completed on 12/01/22 and ongoing (with each new employee hired and or agency staff during orientation). - Administrator will be responsible for monitoring -Start Date -11/30/2022 and ongoing- will check for compliance weekly for four weeks, bi-weekly for a month, and then monthly thereafter. - The area of the elopement was secured with extra reinforcement with chicken wire on 11/29/2022 by the Maintenance Director. The Maintenance Director and Administrator walked the premises to secure any other area that looked large enough that the administrator could fit through. If the Administrator was able to fit into an area it was reinforced and secured by using chicken wire to fill in the gaps of the 10-foot-tall chain link fence. The elevated platform was removed by a [NAME]. (This platform is about 10 feet off the ground). - Maintenance will walk premises weekly for four weeks, bi-weekly for a month, and then monthly thereafter. To ensure no areas have been tampered with or any resident has tried to get out. Start Date 11/29/2022 and ongoing. If a new maintenance director is hired, they will be educated on the process on the 1st day of employment. - Administrator will be responsible for monitoring the Start Date of 11/29/2022 and ongoing. - On 12/1/2022 a [NAME] will come to the facility and remove the metal platform down from the elopement site. - Outside Contractor is responsible for removing the metal platform Completed on 12/01/2022. - Administrator will be responsible for monitoring the Start Date -12/01/2022 and ongoing. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 11/29/2022. The Director of Nursing will review the weekly elopement and report with the Medical Director. Involvement of QA On 11/29/22 an Ad Hoc QAPI meeting has been held with the Medical Director, Facility Administrator, Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the New Process. The New Process/ system was started on 11/29/22. Who is responsible for monitoring the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 11/28/22. The Surveyor monitored the Plan of Removal from 11/29/22 - 12/03/22 as follows: Observation on 11/29/22 at 1:02 PM revealed the fence surrounding the facility to be intact, and all outdoor gates were locked. Observation on 11/30/22 at 3:40 PM revealed all facility gate to be locked. Observation on 11/30/22 at 3:38 PM revealed approximately 30 residents in the dining room enjoying music. Noted three staff members were present. Each nurse's station at the end of each hallway was manned with one charge nurse monitoring the hall. During an Oobservation and interview beginning on 11/30/22 at 4:00 PM, ADM and this Surveyor walked the outdoor property and she pointed out the changes that had been made to the fence to ensure safety of the residents. Reviewed in-services (training material) that had been started with staff, post-in-service tests, and Red Shoe Program ideas. Observation on 12/01/22 at 12:10 PM revealed all gates around the facility were locked. There were no residents outside. Observed alarms on all exit doors. During an Iinterview on 12/01/22 at 12:32 PM with ADM, she stated the alarms had been placed on the doors and would be turned on every day from 6:00 PM to 5:00 AM. ADM stated an in-service on the alarms had been started. During an Iinterview on 12/01/22 at 12:58 PM with MAINTD, she stated she will be conducting rounds and of the property fencing weekly for a month, then biweekly for a month, and would continue to do so each month. MAINTD stated any modifications that were made/needed to be made will be documented. Observation on 12/01/22 from 1:05 PM - 2:22 PM revealed all alarms on exit doors were working properly when turned on. Observation on 12/02/22 at 2:20 PM revealed the metal platform that Resident #1 had used to aide in his elopement had been soldered off (removed). Reviewed all in-services records dated 11/29/22 and 11/30/22 t o ensure staff had been trained in-serviced on the Q 30-minute checks for residents that were a high-risk of elopement, Red Shoe Program , door alarms, physically seeing each resident every two hours and abuse and neglect. Reviewed binders at both nurse's station which contained Q 30-minute checkoffs for the eight deemed high-elopement risk residents. They had been completed appropriately. Review of ed each new Elopement Risk Assessments, completed 11/30/22, for each resident. Observation on 12/02/22 at 2:56 PM revealed a nurse checking to see if a resident exited the facility in less than a minute once this Surveyor turned on an alarm (testing the alarm) on the East Hall and stepped outside. Observation on 12/02/22 at 3:02 PM revealed DON in-servicing and testing a PRN CNA before she started her shift. During interviews on 12/02/22 between 3:06 PM and 4:10 PM, three aides, two nurses, and two housekeepers all stated they had been in-serviced. All were able to state indicators to look out for regarding elopement such as agitation and wandering. All knew the alarms on the doors were to be turned on at 6:00 PM and turned off at 5:00 AM. All knew that all residents were to be seen at least every 2 hours, and the 8 high-risk residents were to be seen and accounted for every 30 minutes. Observation on 12/03/22 at 1:42 PM revealed four residents on the elopement high-risk list, including Resident #1, outside and being closely monitored by an aide. Review of the facility's undated Door Alarms Policy reflected the following: It is the policy of [facility] to protect each resident from harm. Door alarms are throughout the facility on each exit door to help facilitate the effort of protection. Door alarms will be set between the hours of 6PM and 5AM. The following procedure is to be followed when a door alarm sounds: 1. When the alarm sounds, all staff within auditory range is to respond to the alarm. ADM was notified on 12/03/22 at 3:00 PM that the IJ had been lowered. While the IJ was lowered on 12/03/22 at 3:00 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.