**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters. The facility failed to identify a change in condition or recognize symptoms of a UTI when Resident #1, who required a catheter and had a history of UTIs, began experiencing increased bladder spasms and dysuria (painful urination) from 03/13/25 - 03/21/25. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 04/04/25 at 1:07 PM and an IJ template was given. While the IJ was removed on 04/05/25 at 1:35 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with indwelling urinary catheters at risk of pain, renal failure, urinary tract infections, and sepsis. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, obesity, overactive bladder, and personal history of urinary tract infections (an infection in any part of a urinary system, including kidneys, bladder, ureters, and urethra). Review of Resident #1's quarterly MDS assessment, dated 01/01/25, reflected a BIMS score of 14, indicating she had no cognitive impairment. Section H (Bladder and Bowel) reflected she had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 03/10/25, reflected she required an indwelling catheter related to obstructive and reflux uropathy (blockage in urinary tract) with an intervention of monitoring for signs and symptoms of infection. Review of Resident #1's physician order, dated 01/06/25, reflected oxybutynin chloride oral tablet 2.5 MG - Give 1 tablet by mouth every 4 hours as needed for bladder spasms. Review of Resident #1's MAR, February 2025, reflected she was administered oxybutynin chloride on 02/01/25, 02/03/25, twice on 02/05/25, 02/10/25, and 02/11/25. Review of Resident #1's physician order, dated 02/10/25, reflected an order for a urinalysis. Review of Resident #1's UA results, reported 02/12/25, reflected she was positive for a UTI. Review of Resident #1's physician order, dated 02/13/25, reflected Amoxicillin Oral Tablet 500 MG - Give 1 tablet by mouth three times a day for UTI for five days. Review of Resident #1's MAR, March 2025, reflected she was administered oxybutynin chloride (for bladder spasms) on 03/02/25, 03/06/25, 03/08/25, 03/10/25, 03/13/25, twice on 03/14/25, once from 03/15/25 - 03/17/25, twice from 03/18/25 - 03/21/25, and once on 03/22/25. Review of Resident #1's physician order, dated 01/06/25, reflected phenazopyridine HCl oral tablet 200 MG - Give 1 tablet by mouth every 4 hours as needed for dysuria/pain. Review of Resident #1's MAR, March 2025, reflected she was administered phenazopyridine HCl twice on 03/14/25, once from 03/15/25 - 03/18/25, once on 03/20/25, and twice on 03/21/25. Review of Resident #1's progress note, dated 03/22/25 at 3:41 PM and documented by LVN A, reflected the following: Called to room per [FM D]. [Resident #1] very lethargic she will open eyes when name is called. O2 nasal cannula was not on [Resident #1] checked o2 sats 78. Placed nasal cannula on [Resident #1] and rechecked o2 sat fluxuating [sic] between 88 and 90 at this time. She is mouth breathing and encouraged to use her nose to breath [sic] . Review of Resident #1's progress note, dated 03/22/25 at 3:58 PM and documented by LVN A, reflected the following: [Resident #1] is not responding to verbal stimuli. She remains lethargic. O2 sats are 88 to 90. Family members her [sic] requests to go to hospital . Called for ambulance. Review of Resident #1's EMS records, dated 03/22/25, reflected yellow puss was noted to be present in her foley catheter bag. Review of Resident #1's hospital records, dated 03/22/25, reflected the following: Reason for visit: Septic Shock . Assessment/Plan: Septic shock: [Resident #1] reportedly has been off for the past 3 days and became obtunded late this afternoon at her nursing home. Was found to be tachycardic to 120, febrile to 103, tachypneic, WBC of 16, lactate of 3.66. With history of recurrent UTIs and positive urinalysis positive. [Resident #1] given total of 2 L IV fluid bolus . Given initial dose of ceftriaxone (antibiotic) in ED . UTI (Urinary Tract Infection): [Resident #1] presents with acute encephalopathy without focal deficits, able to answer her name. [Resident #1]'s urinalysis positive for leukocyte esterase . Plan: ICU . HPI [FM B] said UTI and put [sic] coming out of catheter. This is an ongoing issue, has happened numerous times. Severe abdominal pain and bladder spasms, three days. Review of Resident #1's hospital discharge paperwork, dated 03/29/25, reflected her diagnosis was septic shock due to UTI and a suprapubic catheter (a tube that drains urine from the bladder through a small incision in the abdomen) had been surgically placed. During a telephone interview on 03/27/25 at 11:15 AM, Resident #1's FM C stated FM D visited Resident #1 every day. She stated FM C told her Resident #1 had been complaining of increased bladder pain and had been drowsy at least three days before hospitalization (03/22/25). She stated FM D was at the facility on 03/22/25 and FM C told her it looked like Resident #1 had a stroke and asked the nurse to check on her. She stated the nurse found her to be non-responsive and she was sent to the hospital and diagnosed with septic shock and a UTI. During a telephone interview on 03/27/25 at 11:40 AM, Resident #1's NP stated if Resident #1 had been having increased bladder pain, she would have expected to be notified and for a UA to be conducted. She stated when she saw her the previous month (February 2025), she was having similar symptoms (increased pain/burning), so she ordered a UA, and she was diagnosed with a UTI. During an interview on 03/27/25 at 12:38 PM, LVN E stated she worked with Resident #1 sometimes but was not sure if she had the week before she went to the hospital. She stated Resident #1 had been having a lot more bladder spasms over the last few months. This Surveyor showed her the MAR from March (2025) and she stated it definitely did like she had been in more pain before her hospitalization. She stated her needing an increase in pain medication could indicate an obstruction, sediment build-up, which could lead to bladder retention, which could lead to a UTI or sepsis. She stated she believed at that point, the nurses should have requested a UA from the NP. During an interview on 03/27/25 at 12:48 PM, LVN A stated she only worked one time a week, but she worked on Resident #1's hall and she was the one that had sent her to the hospital on [DATE]. She stated she did seem to be in a little more pain than usual, but when she had a change in condition, and she called 911. She did not observe any puss in her drainage bag. This Surveyor showed her Resident #1's March (2025) MAR and LVN A stated the doctor should have been made aware of her increased pain. She stated especially with the bladder problems Resident #1 had a history of, if she had increased pain, there could be a complication. She stated the catheter could have been plugged or she could have a UTI. During a telephone interview on 03/27/25 at 1:03 PM, LVN F stated she worked with Resident #1 regularly (her initials were on the MAR regularly for the pain medications during the time Resident #1 was having increased pain). She stated she had been requesting more pain medication during that time, but she believed they were effective in managing her pain. She stated she did not think that would be a reason to request a UA because of her history of bladder spasms. During an interview on 03/27/25 at 1:42 PM, the DON stated Resident #1 had chronic pain. She stated her expectations were that she be notified if she had been experiencing higher pain than normal or requesting in increase in pain medications. She stated she had not heard anything about an increase in pain. A negative outcome could be a missed infection or not having her pain controlled. She stated Resident #1's increase of requesting more pain medication could be an indication of a UTI. During a telephone interview on 03/27/25 at 4:45 PM, Resident #1's FM D stated he visited her every day. He stated for about four or five days or so before her hospitalization, her spasms and pain had been much worse. He stated he had mentioned to the nurses (could not give names) several times that it must be a UTI if she was having spasms as much as she was. He stated on 03/22/25 around 5:00 PM he could not get her to respond so he asked for her to be sent to the ER. He stated she was in the ICU for several days but now was back in a regular room. Observation on 04/04/25 at 11:20 AM revealed two CNAs performing catheter care on Resident #1's suprapubic catheter that had a dressing dated 04/04/25. Resident #1 expressed no pain, and the care was provided appropriately with no infection control issues. During an interview on 04/04/25 at 12:34 PM, Resident #1 was sitting up in her bed with her lunch tray in front of her. She stated she had recently returned from the hospital. She stated for a few days before she went to the hospital on [DATE], she was in excruciating pain. She stated she had to ask the nurses for pain medications all the time. She stated pain and bladder spasms were typical in the past when she had a UTI, but she had never felt that kind of pain before. She stated she would just lay in her bed and sob. She stated she was happy when she was sent to the hospital because she did not think she was going to make it. She stated if she had not made it, it would have been okay because at least she would not have been in pain anymore. Review of the facility's Quality of Care Policy, revised January 2023, reflected the following: Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, the resident's choices. . A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections . Review of the facility's Incontinence and Catheterization Assessment and Evaluation Policy, revised January 2023, reflected the following: The community's protocols include policies and procedures that monitor the risk, prevention, and detection of urinary tract infections. The community notifies the physician of the resident's condition or changes in the resident's continence status or development of symptoms that may represent a symptomatic UTI. Review of an online article from Web MD entitled Bladder Spasms, dated 08/13/24, reflected the following: A bladder spasm, or detrusor contraction, occurs when the bladder muscle squeezes suddenly without warning, causing an urgent need to release urine . People who have had such spasms describe them as a cramping pain and sometimes as a burning sensation. Some women with severe bladder spasms compared the muscle contractions to severe menstrual cramps and even labor pains experienced during childbirth. However, you are more likely to have bladder spasms with urine leakage if you: Are elderly or have a urinary tract infection. Some common causes of bladder spasms are: Urinary tract infection (UTI): Bladder pain and burning are a common symptom of a UTI. The ADM and DON were notified on 04/04/25 at 1:07 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/05/25 at 11:30 AM: F690 - The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. Date: 4-4-25 Corrective Action: Resident was being treated for a pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms. Was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment. Regional Nurse provided in-service to DNS/Admin/Admin in- training /ADNS regarding the following areas: 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.) 3. Notifying medical provider of the change in condition (increased pain). 4. Adhering to physician's orders and recommendations. 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report. 6. Documentation of the resident's status and delivery of care provided according to the plan of care. 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting). Comprehension of the training was verified through return demonstration and/or follow up questioning. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain. Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director on _4/4/2025____ to review plan of removal / immediate corrective action plan implemented. Date Completed: 4/4/2025 Risk Identification: All residents who have experienced a significant change in condition may be at risk. Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents; to include but not limited to residents with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms (s/s) of a change in condition and validated that the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is in place. This includes residents with bladder and bowel issues. Outcome: Change in condition on 4/4/25 on 2 residents :outcome: MD and family notified. We were provided with new orders that were implemented. Date Completed: 4/4/2025 Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place. Outcome: There were no negative outcomes identified. Date Completed: Systematic Changes: Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to the nurse working his/her next scheduled shift: Comprehension verified through follow up questions. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain. 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the significant change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the E.H.R. 3. Adhering to physician's orders and recommendations. 4. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nursing shift change report process. 5. Documentation of the resident's status and delivery of care provided according to the plan of care. 6. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 7. Nurses will conduct on-going monitoring of the resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 8. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Abuse & Neglect (ANE)- Identifying Prevention and Reporting 11. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. 12. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. 13. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record. Director of Nursing / Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) -Nurses will be in serviced prior to working their next shift. DNS/ Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires. Monitoring: Director of Nursing / Assist. Director of Nursing will review nursing 24hr reports, progress notes and SBARS/change in condition and abnormal labs during the morning clinical review meeting (5-7 days per week) and to ensure that appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR). Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff interviews to identify any Signs and symptoms (s/s) of a resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR). The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random interviews with the nursing team members to identify competency/comprehension of the following: Identifying signs and symptoms (s/s) of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented with in the electronic health record (EHR). The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. The facility will conduct a monthly Quality Assurance Performance Improvement (QAPI) meeting to review the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the Electronic Health Record (E.H.R.) Findings of audits and status of compliance will be reviewed to the Administrator and the Quality Assurance Performance Improvement (QAPI) committee during the monthly meetings for the next 2 months. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder. The Surveyor monitored the POR on 04/05/25 as followed: Observations were made on 04/05/25 from 1:04 PM - 1:10 PM of three residents' catheter tubing and bags. All three had clear drainage with no sediment noted. During interviews on 04/05/25 from 11:32 AM - 1:28 PM, three RNs, three LVNs, one MA, and five CNAs from different shifts all stated they were in-serviced before working their shift on catheter care, communication during shifts, change in conditions, and signs and symptoms of a UTI. All stated a change in condition could be increased pain, altered mental status, or anything that is out of the resident's baseline. All staff stated that any change in condition should be relayed to the NP because it could indicate a bigger issue that could be occurring that needed to be addressed. They all gave signs and symptoms of a UTI such as altered mental status, burning during urination, dark urine, or increased pain. The aides and MA stated if they noticed any of those signs and symptoms, they would notify a nurse immediately. All stated a negative outcome of not getting orders for a suspected UTI could be sepsis or hospitalization. The nurses stated during shift changes, instances of new skin integrity issues, new orders, or any change in condition with residents should be communicated to the oncoming nurse. During an interview on 04/05/25 at 12:20 PM, the ADM stated he was in-serviced by the RNC and was aware of the process for ensuring changes in conditions were identified and relayed to the MD/NP. He stated all staff were being in-serviced before working their shifts. Review of the facility's Ad Hoc Meeting agenda, dated 04/04/25, reflected the ADM, MD, DON, and AIT were in attendance. Review of an in-service conducted by the RNC, dated 04/04/25 reflected the ADM, DON, and ADON were in-serviced on the following: 1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative. 2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.) 3. Notifying medical provider of the change in condition (increased pain). 4. Adhering to physician's orders and recommendations. 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report. 6. Documentation of the resident's status and delivery of care provided according to the plan of care. 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.) 8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R). 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria. 10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly. 11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting). Review of and in-service entitled Bowel and Bladder, dated 04/04/25 - 04/05/25 and conducted by the ADM and DON, reflected all nursing staff were in-serviced on identifying bowel and bladder issues and recognizing changes in residents - increased use of PRN pain medications or increased pain with urination, and notifying the NP of those changes. Review of and in-service entitled Peri Care/Catheter Care dated 04/04/25 - 04/05/25 and conducted by the DON, reflected all nursing staff were in-serviced on the peri care audit tool and peri care steps to decrease the risk of infection. Review of assessments, dated 04/04/25, reflected all residents were assessed for pain, discomfort, or a change in condition by the DON and ADON. Two residents were determined to have a change in condition, the MD was notified, and new orders were put in place. Review of the facility's Monitoring Tool to review the 24-hour report, progress notes, SBAR/CIC, and labs daily, on 04/05/25, reflected it had been signed off as completed and they were in compliance on 04/04/25 and 04/05/25. The ADM and DON were notified on 04/05/25 1:35 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for elopement risk. Resident #1 was found lying in the grass beside his wheelchair on the opposite side of a two-lane road after he had eloped from an exit door of the facility, resulting in a laceration to his right eye and facial bruising. The noncompliance was identified as PNC. The IJ began on 06/4/2024 and ended on 06/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place all 3 residents who used a wander guard at risk for serious injuries. The findings were: Record review of Resident #1's face sheet, undated, revealed Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a disease that affects the central nervous system and makes it difficult for the brain to send signals to the rest of the body) and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's significant change MDS assessment, dated 05/20/2024, revealed a BIMS score of 04, indicating severe cognitive impairment. Record review of Resident #1's significant change MDS assessment, dated 05/20/2024, revealed Resident #1 had exhibited wandering behavior four to six days over a seven day look back time period. The MDS revealed, Resident #1 was at significant risk of getting into a potentially dangerous place (e.g., stairs, outside of the facility). Record review of Resident #1's June 2024 physician orders revealed an order check functionality and visualization of wander guard bracelet on LLE every shift with a start date 02/14/2023 and end date 06/05/2024. In addition, there was an order check functionality and visualization of wander guard every shift with a start date 06/05/2024. All dates and shifts in June 2024 were initialed as completed. Record review of Resident #1's care plan revealed a care plan, initiated 03/06/2023 and revised on 06/11/2024, I am exit seeking. I am at risk for elopement and/or wandering with unsafe boundaries r/t: History of attempts to leave community or home setting unattended, poor safety awareness r/t cognitive impairment. The care plan goal, initiated on 03/06/2023 with a target date 06/11/2024, stated my safety will be maintained, and I will demonstrate a well adjusted and content demeanor with my daily routine through my next review date. The care plan inventions included: Care plan with family regarding exit seeking behaviors, dated initiated 06/05/2024; Close monitoring in place for exit seeking behaviors, date initiated 06/05/2024; Distract me from exit seeking by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer the following: sitting in recliner in room, dated initiated 03/06/2023; I wear a wander guard device; confirm functioning of device and change device as indicated, date initiated 03/06/2023; Identify a pattern of exit seeking: intervene as appropriate in efforts to minimize behavior, date initiated 03/06/2023; Med review per NP and psych NP, and labs ordered, date initiated 06/06/2024; Room change closer to nurses' station, date initiated 05/06/2024. Record review of Resident #1's progress notes, 03/06/2024 at 7:26pm, revealed this resident attempted to elope from this facility. Resident had pushed open the emergency door exit on the 100-hall unit and set off the alarms. This nurse along with another nurse found this resident being assisted back to the building by the facility administrator. Resident did have eyes on him during the attempted elopement. Record review of Resident #1's progress notes, 04/13/2024 at 3:29pm, revealed resident wandering to door, causing alarm to sound. Pulled resident back and encouraged him to go to another area of the building. Resident wandered down hall 100 and caused the alarm to sound. Before intervention could take place, resident was halfway out the door. Resident was holding onto door frame and his hand had to be pride (s/p) off the door frame to bring him back into the building. Record review of Resident #1's progress notes, 05/05/2024 at 3:55pm, revealed resident was noted to be sitting in wheelchair on sidewalk by med nurse. Redirected resident inside without difficulty. Record review of document titled Nrsg: Exit Seeking Risk Tool TSC-v3, dated 05/06/2024 and signed by the DON, revealed Resident #1 had on one or more occasions attempted to exit or has exited the facility in effort to wander away and Resident #1 was physically able to exit on foot or by wheelchair. Record review of an in-service, dated 05/05/2024, stated the subject was checking door alarms and listed the steps to check door alarms as check which hall the alarm(s) is/are going off on, make sure that hall does not have any residents at its exit door, ensure there are no residents outside the door of the hall the alarm(s) are sounding from, visually see and count every resident that belongs on that hall and once all steps above are completed the staff may turn off the alarm. The in-service was signed by 33 employees including RN A. Record review of the facility's PIR, dated 06/12/2024, revealed on 06/04/2024 at approximately 6:45pm during change of shift report, RN A was alerted by a family member that Resident #1 was outside lying in the grass in supine (lying on back) position next to his wheelchair. RN A assessed the resident and provided first aide and out of abundance of caution, Resident #1 was sent to the emergency room for evaluation. The investigation stated Resident #1 had previously been identified as exit seeking at times and the IDT determined that a wander guard device should be used, and Resident #1 was wearing the wander guard at the time of the incident. The investigation revealed, at approximately 6:35pm, RN A indicated she heard the door alarm sounding, she proceeded to the alarm area, did not identify anything unusual and silenced the alarm. At approximately 6:40pm-6:45pm CNA D identified Resident #1 was no longer in his room and staff immediately initiated a room search and notified RN A at approximately 6:45pm. Around 6:45pm to 6:50pm, staff was notified that Resident #1 was located outside b a visitor. Resident #1 was sent to the hospital and returned to the facility around 10:22pm with a minor laceration/skin tear to forehead and no other significant injuries identified by the ER staff. The conclusion of the PIR stated it was determined, after a thorough investigation, RN A re-set the sounding alarm prior to staff confirming that all residents were accounted for. The PIR stated RN A acknowledged prematurely resetting the sounding alarm before confirming all residents were accounted for and RN A failed to adhere to the facility's elopement response policy. As a result, RN A was terminated effective 06/12/2024. Record review of Resident #1's incident report, dated 06/04/2024, revealed nurses were alerted that a resident was outside and observed lying supine in the grass next to his wheelchair. 911 was called, he was assessed for injury and tried to make resident as comfortable as possible without lifting him, to wait for EMS. The incident reported stated EMS arrived at 7:00pm to transport Resident #1 to the ER and revealed Resident #1's family member, physician, DON, ADON and Administrator were notified of the incident. Injuries observed at the time of the incident were listed as skin tear on the face. Mental status revealed Resident #1 was oriented to person and listed his mobility as wheelchair bound. Predisposing physiological factors included impaired memory, lower extremity weakness and confusion. Predisposing situation factors included active exit seeker. Record review of facility document SNF/NF to Hospital Transfer Form dated 06/04/2024, revealed Resident #1 was sent to the hospital and listed fall as the reason for the transfer. Review of the document revealed Resident #1's family member and physician were notified of the hospital transfer. Record review of weatherspark.com revealed the temperature in the city in which the facility was located on 06/04/2024 at 5:54pm was 102 degrees Fahrenheit and 100 degrees Fahrenheit at 6:54pm with mostly clear skies. Record review of Resident #1's hospital records revealed Resident #1 had a CT scan on 06/04/2024 and the findings revealed no acute intracranial abnormality. Record review of Resident #1's document titled PCC Skin & Wound-Total Body Skin Assessment, dated 06/04/2024 at 10:45pm, revealed Resident #1 had normal skin temperature and one new wound. Observation of the facility grounds, 06/19/2024 at 8:30am, revealed the facility was located along side and facing a two-lane farm to market road. Observation upon approaching the facility revealed the front door to be locked and a keypad present without an access code posted. Surveyor rang the doorbell and was let inside by the Receptionist. The front door was observed and had a delayed egress bar, keypad and a wander guard system. Observations of the facility, 06/19/2024 at 8:47am, revealed exit doors at the end of each of the 4 hallways had a delayed egress bar, STOP alarm box in the armed position and a code alert box. Exit door alarms sounded when the surveyor pressed on the delayed egress bars at all exit doors. A framed sign by the code alert alarm box, located on the wall by the nurse's station, read When door alarm sounds and ready to clear: 1. Push 1234 on keypad 1. Push green button at nurses' station. 3. Push 1234 on the keypad again. 4. Check if red light is back on all keypads. When memory alarm sounds: 1. Push 1234. 2. Push red button on wall twice. 3. Push green button once. 4. Check if red light is back on all keypads. 5. Check outside gate and doors in memory unit. Observation of the facility grounds and route Resident #1 traveled to exit the facility to the location he was found, 06/19/2024 at 9:15a.m., revealed Resident #1 propelled himself approximately 100 yards from the 300 hall exit door, through the parking lot and across the road where he was found lying in the grass. Observation of Resident #1, 06/19/2024 at 9:20am, revealed Resident #1 sitting up in a recliner in his room with a blanket covering his legs and torso. Resident #1 was watching television and was not exhibiting any signs of pain or distress. Observation revealed an approximate one-inch laceration/skin tear above Resident #1's right eye and faded brown bruising to the right side of his right eye. A wander guard was observed on Resident #1's left ankle. Resident #1 had a walker and a transport wheelchair in his room. During an interview with Resident #1, 06/19/2024 at 9:20am, Resident #1 was pleasant and was able to answer simple yes or no questions. Resident #1 denied being in pain, falling or being outside at any time. When asked how he got the laceration above his eye he said I fell and hurt my eyeball but was unable to find the correct words to give a description of how he fell. Resident #1 said he used a wheelchair to move around the room and facility. Resident #1 denied any additional injuries. During an interview with CNA A, 06/19/2024 at 9:50am, CNA A stated she was assigned to 300 hall and had provided care to Resident #1 for over a month. CNA A revealed Resident #1 was an elopement risk, was exit seeking and wandering in the facility daily and had multiple elopement attempts prior to 06/04/2024. During an interview with Resident #1's family member, 06/19/2024 at 10:52am, Resident #1's family member said she received a call from RN A around 7pm on 06/04/2024. Resident #1's family member said RN A informed her that Resident #1 got out of the facility, went across the road, fell out of his wheelchair, hit his head on the ground and was sent to the ER with a cut above his eye. Resident #1's family member stated she went up to the facility the next day, found the Administrator and told him they needed to have a meeting. Resident #1's family member said during the meeting, the Administrator told her two people driving by the facility saw Resident #1 lying by the road and one of the people went in the facility and notified the staff that Resident #1 was across the road. Resident #1's family member said the Administrator told her the facility was investigating the incident and RN A had been placed on suspension. Resident #1's family member said Resident #1 had tried to exit the facility in the past and proceeded to say when she was in the meeting with the facility staff, the Administrator told her Resident #1 was trying to get out of the facility three or four times a day and that his wander guard only works for the front door. Resident #1's family member said she was aware he was exit seeking but had no idea it was three or four times a day, that seems excessive. Resident #1's family member said she was aware Resident #1 exited the facility through a hallway exit door last month but a staff member saw him go out the door and brought him back in. Resident #1's family member said the facility had recently moved him last month to a different hall prior to the elopement on 6/4/2024 but stated she did not feel like the facility was doing enough to keep Resident #1 safe. Resident #1's family member stated the facility had not issued Resident #1 a discharge notice but had discussed Resident #1 moving to a male secured unit for safety. Resident #1's family member stated she had been touring other facilities and had found a facility she was interested in moving Resident #1 which is in a nearby town. Resident #1's family member stated, in her opinion the incident should have never happened and stated she did not think the staff were watching him appropriately. Resident #1's family member said when she went to visit Resident #1 on 06/05/2024 she observed large red and purple bruising to his cheek and right side of his eye along with a laceration above his right eye. During an interview with LVN A, 06/19/2024, LVN A stated Resident #1 had a history of exit seeking behavior. LVN A stated Resident #1 eloped out of the door on 100 hall on 05/05/2024 while she was passing medications. LVN A stated she heard the door alarm going off at the end of 400 hall and stated she finished giving a medication and then went to the 100-hall door and observed Resident #1 in the parking lot about 15 feet away from the facility. LVN A said she did not see him exit the 100 hall door. LVN A said she went outside and redirected him back into the facility through the front door and stated Resident #1 said he was looking for his family member. LVN A stated Resident #1 was moved to 300 halls after that incident. LVN A explained that the 300 halls exit door is not visible at the end of the hall like it is on 100 and 200 halls. The 300-hall door is around a corner by the therapy gym so the staff thought if Resident #1 could not see the door, it might prevent him from trying to exit. LVN A stated before the 06/04/2024 elopement, people's normal reaction was not to really react to the alarms. Record review of an undated statement, provided by the Administrator and signed by LVN A, stated On 5/5/24 [name redacted] was noted exiting the 100-hall door. This nurse was out the door in 45 seconds saw the resident at all times. Redirected back into building via front door within 5 mins. During an interview with the Administrator, 06/19/2024 at 3:59 p.m., The Administrator said was notified on the evening of 06/04/2024 before 8p.m., Resident #1 was found outside of the facility lying across the road in the grass and was being sent to the hospital. The Administrator said he immediately began an investigation into the incident and identified RN A silenced the sounding alarm at the nurse's station. The Administrator said RN A said she heard the alarm sounding, identified the alarm code to be Zone 6 which was labeled 300 hall exit door, looked down the hall and did not see anything unusual and silenced the alarm. The Administrator stated the expectation when a door alarm goes off is for staff to look at the alarm keypad and identify which exit door has been opened, go to that door and complete a search inside and outside of the facility and complete a resident head count before the alarm is deactivated. The Administrator stated a head count of all residents was conducted when the facility became aware of the incident. All staff received education on responding to door alarms, elopement and exit seeking prevention and abuse/neglect training. The Administrator stated Resident #1's family member and physician were notified of the incident, Resident #1 was placed on 15-minute checks when he returned to the facility, self-report was completed to HHSC, Resident #1's plan of care was updated, a care plan meeting was held on 06/05/2024 with Resident #1's family member, and an Ad Hoc QAPI meeting was held on 06/05/2024 with the Medical Director. The administrator also stated the facility completed 100% audit of all residents by completing a new exit seeking tool on each resident and updated plans of care based on the outcome of the assessments. The Administrator stated the facility began random elopement drills on each shift to validate staff competency. The Administrator revealed there were 3 residents (Resident #1, #3 and #4) who were at risk for elopement and wore wander guard bracelets. During an interview with RN A, 06/19/2024 at 7:12 p.m., RN A stated on the evening of 06/04/2024 she was giving report to an oncoming nurse when she heard the alarm go off. RN A said no one else knew how to respond to the alarm because they were all with the staffing agency. RN A said she looked down the hallway and did hear the door alarm from the end of the hall, so she went over to the alarm keypad and silenced the alarm. RN A said, I was going to finish my medication count and then I was going to go down to the door and check it. RN A said, about that time a family member came in from outside and said Resident #1 was outside. I called 911 and ran outside and observed him lying in the grass in a supine position on the opposite side of the road. RN A said once Resident #1 left with EMS, RN A returned to the facility and completed a head count of all the other residents. RN A stated she had received training on exit seeking residents and responding to door alarms prior to the 06/04/2024 elopement and confirmed she was terminated from her position at the facility. During an interview with CNA D, 06/19/2024 at 7:34 p.m., CNA D stated she was assigned to Resident #1 on the evening of 06/04/2024. CNA D said around 6:30 p.m., after dinner, CNA D placed Resident #1 in his room between his bed and the recliner, locked his wheelchair brakes, turned on the television and placed his call light within reach. CNA D said she worked for a staffing agency but was familiar with Resident #1 and had worked with him many times over the past month. CNA D said she was in another room talking to a family member for about five minutes and when she walked back by Resident #1's room, he was not there. CNA D said she went to the 300 hall exit door and did not see anyone outside and said she touched the delayed egress bar and the alarm sounded. CNA D then went to the nurse's station to tell RN A she could not find Resident #1 and at that time, a family member came in and said Resident #1 was outside. CNA D stated this all occurred in approximately 11 minutes. During an interview with the facility Maintenance Director, 06/20/2024 at 10:56a.m., the Maintenance Director said the door alarms were checked weekly to validate they were functioning properly. The Maintenance Director stated the last time 300 hall door was tested for functionality was 05/30/2024 and no issues were identified. The Maintenance Director stated the door alarm was triggered when a person presses on the delayed egress bar. The alarm at the door would sound for 15 seconds and then the door would open and the alarm would stop sounding. This alarm also triggers an alarm at the nurse's station that is coded by zones to identify which exit door has been opened. In addition, there is a red stop alarm on the door that is triggered when the door opens. This alarm will sound for 15 seconds. The Maintenance Director said the alarm at the nurse's station will continue to sound until the alarm is silenced or reset. The Maintenance Director stated he provided door alarm training during orientation and the training included identifying the exit door on the keypad when the alarm sounds, going to the exit door and conducting a search inside and outside of the door and completing a head count prior to deactivating the alarm. Record review of a facility document titled Work History Report listed a task doors, locks & alarms: Corridor -Doors. The task completion was marked down on time by Maintenance Director on 05/30/2024. During an interview with a facility family member, 06/20/2024 at 1:20p.m., the family member stated she was leaving the facility around 6:45p.m. on the night of 06/04/2024. When the family member was pulling out of the parking lot, she saw a man lying on the grass on the opposite side of the road tangled up in his wheelchair. The family member said she stopped her car and ran to Resident #1 and got his wheelchair off him. The family member said another person passing by stopped to help so the family member ran across the street and notified the facility staff that Resident #1 was lying out by the road. The family member said approximately five people ran out to help and said, It was like 103 degrees outside that day, who know what would of happened to him if I didn't see him. The family member also said she went to the store and bought bottled water for the staff because it was so hot outside at the time of the incident. Record Review of a facility policy titled Elopement Response & Exit Seeking Management, date implemented 2019 and date reviewed/revised January 2023, revealed if a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside the premises. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR, dated 06/12/2024, revealed an investigation was initiated on 06/04/2024 and all required notifications were made which included the Medical Director, responsible party, and physician. Record review of a facility document titled [Facility] Elopement Response, initiated date 06/04/2024, revealed the following actions: Director of Nursing/Designee will educate current team members and new hires and agency personnel prior to working the floor regarding: missing person response and elopement/exit seeking risk and proper response to missing resident/resident elopement protocol and preventing, identifying, and reporting abuse and neglect. Administrator/DNS/Designee conducted an elopement drill to ensure that team members understand and carry out an appropriate elopement response. Resident # 1 placed on close monitoring and to ensure maintain safety. Nursing notified MD and family representative of incident and resident status. The following was initiated on 06/05/2024: VP of Clinical Operations and VP of Operations conducted in-service training to the identified, Director of Nursing and Administrator regarding: missing person and elopement/exit seeking response. Addition education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: preventing, identifying and reporting abuse and neglect, facility process for identifying potential risks for elopement; implementing appropriate interventions and updating the plan of care as indicated. Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exit seeking assessment in order to identify any concerns with exit seeking or elopement risks and the IDT will review and/or will update the plan of care as indicated. Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exit seeking/elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exit seeking/elopement risk noted. Director of Nursing/Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Admin/DNS/SW/Designee will conduct random weekly audits of 1-3 new admission and/or readmission initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place. Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place. Administrator/Director Nursing/Designee will conduct elopement/missing person response drill on random shifts to identify competency of TMs or to identify additional education needs. Drills will be conducted 2-4 times per month for the next 1-2 months. This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. Record review of facility document titled Conduct and Workplace Expectation Notice revealed RN A was suspended on 06/05/2024 during the investigation and was terminated by phone from employment on 06/12/2024. The document was signed by the Administrator and DON. Record review of Resident #1's chart revealed an exit seeking risk tool assessment, completed 06/02/2024 at 10:30p.m., and skin assessment, completed 06/04/2024 at 10:45p.m., when Resident #1 returned from the hospital. Record review revealed Resident #1's care plan had been updated on 06/05/2024 to include a care plan meeting with Resident #1's family regarding exit seeking behaviors, close monitoring in place for exit seeking behaviors, medication review per NP and psych NP and labs as ordered. Record review of a facility staff roster, undated, revealed 57 employee signatures. Record review of an in-service titled Abuse and Neglect, dated 06/05/2024, with the facility abuse and neglect policy attached, revealed 62 employee names. Record Review of an in-service titled Door Alarms, dated 06/05/2024, revealed the following guidance with bullet points: Check which hall the alarm(s) is/are going off on the panel, make sure that hall does not have any residents at its exit door, ensure there are no residents outside the door of the hall the alarm(s) are sounding, visually verify and count each resident that resides on that hall and once all steps above are completed the staff may turn off the alarm. The in-service has 63 employee signatures. Record review of an in-service titled Elopement Response and Exit Seeking Management, dated 06/05/2024, revealed 61 employee signatures. Record review of an in-service titled Missing Person and Elopement/Exit Seeking Response, dated 06/05/2024 and conducted by VP of Clinical Operations and VP of Operations, was signed by the Administrator and DON. The in-service read Missing person and elopement/exit seeking response. Additional education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: Preventing, identifying and reporting abuse and neglect, Facility's process for identifying potential risk of elopement; implementing appropriate interventions and updating the plan of care as indicated. Record review of an Ad Hoc QAPI Meeting, dated 06/05/2024 at 10:15a.m., revealed 6 signatures, including the Administrator, DON and Medical Director. Record review of a facility document titled IDT: Care Plan Conference & Advanced Care Planning Review-V4, dated 06/05/2024 at 12:45p.m., revealed a care plan meeting with Resident #1's resident representative, Administrator, DON and ADON. The care plan meeting was held to discuss Resident #1's exit seeking behavior and a potential discharge to a male memory care unit. Record review of 5 resident charts revealed new elopement risk assessments completed on 06/05/2024. Record review revealed elopement drills were conducted on 06/05/2024 at 6:15p.m., 06/06/2024 at 10:10a.m., 06/07/2024 at 5:00a.m., 06/07/2024 at 5:15p.m., 06/07/2024 at 6:15p.m., 06/08/2024 at 6p.m. - 6a.m., 06/08/2024 at 8:00 a.m., 06/09/2024 at 10:15a.m., 06/09/2024 at 6p.m. - 6a.m., 06/10/2024 at 6:10p.m., 06/10/2024 at 11:35a.m. Record review of maintenance work history report revealed door locks and alarms were marked as completed on 06/04/2024, 06/13/2024 and 06/20/2024. Record review of Resident #3's face sheet revealed Resident #3 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #3's quarterly MDS assessment, dated 04/15/2024, revealed Resident #3 had a BIMS of 04, indicating severe cognitive impairment. In addition, the MDS revealed Resident #3 had no exhibited wandering behavior during the 7 day look back period. Record review of Resident #3 June 2024 physician orders revealed Resident #3 had an order to check functionality and visualization of wander guard/exit management system through wand or alarmed door, start date 09/26/2023. Record review of Resident #3's exit seeking tool, dated 06/05/2024 revealed Resident #3 was wandering and exit seeking, had verbalized the need or desire to go home or to another location, had sundown syndrome (resident experiences increased confusion, occurring specifically at dusk) and was physically able to exit on foot or by wheelchair. Record review of Resident #3's care plan revealed Resident #3 had an exit seeking care plan, initiated 06/20/2022 and revised 09/26/2023. Observation of Resident #3, 06/20/2024 at 11:00a.m., revealed Resident #3 sitting in a stationary chair in her room reading a magazine. A wander guard bracelet was observed on Resident #3's left arm. Observation of Resident #1, 06/20/2024 at 11:08a.m., revealed Resident #1 lying in his bed watching television. Resident #1 had his call light in reach and wander guard on his left leg. Resident #1 was pleasant and did not appear to be in any pain or distress. Record review of Resident #4's face sheet revealed Resident #4 is an [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #4's quarterly MDS assessment, dated 05/13/2024, revealed a BIMS score of 01, indicating severe cognitive impairment. In addition, the MDS revealed Resident #4 had exhibited wandering beh[TRUNCATED]