**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 6 residents reviewed for quality of care. The facility failed to ensure CR #1, who was cognitively impaired received adequate supervision when the facility sent her to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of the building next to a major freeway feeder road by the doctor's office manager. On 5/16/24 at 4:13 p.m. an immediate jeopardy (IJ) was identified. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed facility residents with dementia and impaired cognition at risk of neglect and elopement for lack of supervision during any appointment. Findings included: Record review of CR #1's face sheet dated 5/16/24 revealed a [AGE] year-old female admitted originally 7/9/20 and most recently 5/25/23. Her diagnoses were: Cerebral infarction (of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue), Glaucoma (group of eye conditions that damage the optic nerve and can cause vision loss), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified disorientation, hallucinations, unsteadiness of feet, history of falling, anemia (condition of low red blood cells or hemoglobin that can cause fatigue), and congestive heart failure. Record review of CR #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Section E- Behaviors revealed CR #1 had hallucinations. Section GG0170 - Mobility Devices revealed CR #1 used a manual wheelchair. CR #1 required substantial/maximal assistance (helper does more than half the effort) with ADLs. Record review of CR #1's care plan last revised 5/10/24 revealed the following in part: Problem: Communication - CR #1 has impaired communication as evidenced by: Reduced ability to understand others. Impaired daily decision-making ability. Goal: Staff will anticipate and meet all needs. CR #1 is not able to communicate effectively over the next 90 days. Approach: Reduce or remove all interfering environmental stimuli. Problem: Cognitive Loss/ Dementia - CR #1 appeared to have impaired ability to understand others at times and has impaired ability to make daily decisions. Goal: CR #1 will accept helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. Approach: Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Record review of CR #1's nursing note dated 5/14/24 at 9:34 a.m. written by LVN A revealed CR#1 was picked up by EMS via wheelchair for a scheduled appointment at 9:00 a.m. Record review of CR #1's nursing note dated 5/14/2024 at 4:57 p.m. written by the ADON revealed CR #1 returned vial EMS. The nursing note did not reflect CR #1's elopement from the doctor's office. Attempted interview on 5/17/24 at 9:40 a.m. in CR #1's room. CR #1 was asleep. CR #1's name was called she rolled over and did not wake up. In an interview on 5/16/24 at 11:21 AM with the Doctor's Office Manager, she said CR #1 had an appointment on 5/14/24 and had finished at approximately 11:43 a.m. She said the resident was placed in a waiting room with a T.V. until transportation picked her up. She said CR #1 had been dropped off by transportation unaccompanied. The Doctor's Office Manager said she received a call, at 2:29 p.m., from the ADMIN, who inquired if CR #1 was still at the appointment. She said the staff looked for the resident inside the building and CR #1 was found at the sidewalk, stuck in the mud next to a major freeway feeder road, in her wheelchair at 3:00 p.m. She said CR #1 was soiled through her pants, sweating, thirsty, and hungry. She said the resident asked for water and peanuts. The Doctor's Office Manager said she notified the ADMIN, and transportation picked up the resident approximately 3:55 p.m. In an interview on 5/16/2024 at 11:34 a.m. with the ADMIN, she said CR #1 went to the doctor's appointment, on 5/14/24, without an escort because the staff that set up transportation thought CR #1's family member was supposed to meet her. The ADMIN said she received a call from the transportation company at approximately 2:00 p.m. and they said CR #1 could not be located. The ADMIN said she called the doctor's office and asked if they knew where CR #1 was. The ADMIN said she called the doctor's office staff and asked them to check the building. She said she did not know how long the doctor's office searched for CR #1, but the doctor's office manager called at approximately 3:00 p.m. and said that the resident had been found. The ADMIN said she was told the resident was thirsty and asked for peanuts. She said the resident returned to the facility between 4:00 p.m. - 5:00 p.m. She said the resident's brief and clothing needed to be changed. She said the resident should have either had an escort from the facility or a family member should have been confirmed that they would be in attendance. She said the resident was at risk because her level of cognition would prevent her from making safe decisions. In an interview on 5/16/24 at 12:15 p.m. with the DON, she said when a doctor's appointment was scheduled, the facility nurses set up transportation and should have called the RP to verify if they will be in attendance. She said a resident's cognitive ability to make decisions was what determined if an escort was needed for a doctor's appointment. She said it was rare that a resident would be sent alone to an appointment. The DON said the transportation company will bring the resident into the doctor's office, leave a card, and advise the doctor's office to call when the appointment was completed for the return pickup. The DON said she was notified by the ADMIN and the transportation company that they were not able to locate CR #1 at approximately 2:00 p.m. The DON said the ADMIN called the doctor's office and asked them to look for CR #1. She said the doctor's office manager said that CR #1 had been placed in a TV room while she waited for pick up. She said the doctor's office manager called about an hour later and said CR #1 had been found near a sidewalk. The DON said CR #1 was transported back to the facility by the transportation company. She said CR #1 was cleaned up and provided dinner. The DON said she was not sure if CR #1 was able to navigate safely in the community alone. She said if the resident was not able to make safe decisions and could not navigate her surroundings, she would be at risk for possible injury. In an interview on 5/16/24 at 12:55 p.m. with the ADON, she said the appointment was scheduled by the NP with the doctor's office. The NP would notify the nursing staff of the scheduled appointment and the nursing staff were responsible for the transportation set-up. She said if family was not able to attend the visit, then facility staff would attend. The ADON said she along with LVN A received CR #1 when she returned. The ADON said CR #1 received a brief change, but stated it was not because she was soiled. She said she did a quick head to toe assessment and checked her blood sugar and it was in normal limits. The ADON said CR #1 did not discuss the details of the visit. In an interview on 5/17/2024 at 1:12 p.m. with the NP, she said she scheduled the orthopedic doctor's appointment for CR #1 and notified LVN B who was responsible for transportation. She said the facility staff that set up transportation was responsible for notifying the family member and should have verified if they would be in attendance at the visit. The NP said CR #1's cognition was in and out and becomes confused. The NP said she would be concerned for CR #1's safety if she was alone in the community. In an interview on 5/17/2024 at 2:16 p.m. with LVN B, she said the nurses were responsible for scheduling resident transportation to doctor visits. She said she notified CR #1's family member about the 5/14/24 doctors' appointment. LVN B said the family answered OK to the notification of the visit, but LVN B said she did not verify if the family member was going to attend the doctor's appointment. She said she was not sure if the family member would meet CR #1 at the doctor's office. LVN B said she did not feel CR #1 was confused and communicate to nursing staff if a resident needed an escort. She said she was not present on the day of the appointment for CR #1. LVN B said she did not recall a training on determining if a resident needed an escort or to verify if a family member would be in attendance. In an interview on 5/17/24 at 2:32 p.m. with LVN A, he said he was the nurse on duty when CR #1 left for her doctor's appointment on 5/14/24. He said he was told by LVN B, CR #1's family member would meet her at the doctor's office. He said CR #1's baseline was that she was confused. He said he had not received training on verifying if a resident needed an escort or had a family member that would meet the resident at a doctor's appointment. He said the ADON received CR #1 when she returned from the doctor's appointment at approximately 5:00 p.m. and the ADON made sure she was cleaned up. He said he did assist with the clean up and did not know if the resident was soiled through her clothing. In an interview on 5/16/24 at 3:01 p.m. with the Transportation Manager, he said CR #1 was dropped off at the doctor's office and wheeled inside of the office on 5/14/24 at 8:57 a.m. He said a card was left with the doctor's office staff to call when the resident needed to be picked up. He said dispatch received a return pick up at 11:48 a.m. He said the driver was not able to locate the resident and the driver was unassigned and left the doctor's office at 12:42 p.m. He said a second driver was assigned to pick up the resident at 3:04 p.m. He said the resident was returned back to the nursing facility at 4:56 p.m. In an interview on 5/16/24 at 3:40 p.m. with CR #1 she said, she did not remember a doctor appointment. She was asked if she knew her family members names and she said, I don't remember do you. She appeared confused and asked this State Surveyor if she knew she had an appointment. She said she did not remember waiting for transportation at her doctor's visit this week. Record review of the doctor's office timestamped video from 5/14/2024 revealed the following: 11:43 a.m. - 1:00 pm 11:43 a.m. - CR #1's doctor's visit was completed. 12:46 p.m. - CR #1 seen waiting at second floor elevator doors. 12:48 p.m. - CR #1 seen exiting the first-floor elevator doors. 12:49 p.m. - CR #1 seen speaking to security guard. 1:00 p.m. - CR #1 seen propelling herself from the parking garage camera towards the major freeway feeder road. In an interview on 5/16/24 at 11:34 a.m. with the ADMIN, a facility policy on transportation and the determination if a resident required an escort to a doctor visit was requested. The ADMIN said the facility did not have policy. Record review of accuweather.com revealed on 5/14/24 the temperature was a high of 88 degrees and a low of 68 degrees. Record review of facility policy on Activities of Daily Living, Optimal Function (revision date 5/5/23) revealed the following in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own. Record review of facility Elopement policy dated 11/1/2017 revealed the following in part: Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . .5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, the Administrator and/or designee contact the appropriate community agencies (Police, Local Health Department) and Administration, the patient's/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing, if known . This was determined to be an Immediate Jeopardy (IJ) On 5/16/24 at 4:13 p.m. The ADMIN and the DON were notified. The Administrator was provided with the IJ template on 5/16/24 at 4:13pm. The following Plan of Removal (POR) was submitted by the facility and accepted on 5/17/24 at 9:26 a.m.: PLAN OF REMOVAL F689 Name of facility: The facility Date: 5/16/24 Facility failed to ensure CR#1 had adequate supervision when the facility sent her to the doctor's office unsupervised. Immediate action: CR #1 returned to the facility. Resident was assessed by the Assistant Director of Nursing at 4:57pm on 5/14/24 with no injuries identified. Physician and responsible party notified. Review of upcoming appointments were completed by the Director of Nursing/Designee on 5/16/24 to identify upcoming appointments for cognitively impaired residents with a BIMS score of 12 or less. 4 residents identified with a BIMS score less than 12 scheduled for appointments. Those 4 identified residents have someone scheduled to accompany them. Review of resident's recent BIMS scores completed by the Social Services Director on 5/16/24. The cognitively impaired residents with a BIMS score of less than 12 will have their care plan updated by 5/17/274 to include need for accompaniment for outside appointments. The Social Worker will update the care plan for current residents who have a change in BIMS score and new residents who admit who are cognitively impaired with BIMS score <12 beginning 5/17/24. Reeducation provided to the Director of Nursing and the Administrator by the Clinical Consultant on 5/16/24 on need for family/Responsible Party or facility staff to accompany cognitively impaired residents with a BIMS score of less than 12 to outside appointments. Re-education provided to licensed nurses and certified nursing assistants on need for cognitively impaired residents with BIMS score of less than 12 to have a family member/Responsible Party or facility staff accompany them to outside appointments. This education was completed by 5/16/24 by the Director of Nursing. Any licensed nurse or certified nursing assistant not receiving this education by the target date will receive prior to their next scheduled shift. A review of the days outside appointments will be completed in clinical morning meeting Monday - Friday by the Administrator to validate any cognitively impaired resident with a BIMS score of less than 12 has a family member/Responsible Party or facility staff member scheduled to accompany them. This will begin on 5/17/24 and continue Monday - Friday during the morning meeting process. The Nurse Managers will communicate to the licensed nurse verbally and by writing on the 24-hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Licensed Nurses will validate cognitively impaired residents with a BIMS score of less than 12 have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Should a cognitively impaired resident with a BIMS score less than 12 have an outside appointment on the weekend, the licensed nurse will validate the resident has as escort to the appointment. Licensed Nurses will validate prior to the end of their shift any resident who has left for an appointment without an accompaniment has returned. If the resident has not returned, the licensed nurse will follow up with the office staff at the appointment for an update on the resident and this will be communicated to the next shift. Elopement Policy was reviewed on 5/16/24 by the Administrator and the Director of Nursing and no changes were indicated. Ad Hoc QAPI was held on 5/16/24 to review the contents of this plan. The Medical Director was notified on 5/16/24 of the Immediate Jeopardy and the contents of this plan. MONITORING Record review of the facility list of 4 residents with upcoming doctor visits via transportation service revealed the following: Interview on 5/17/2024 at 12:38 p.m. with CNA A said she had been trained on 5/16/24 on when a resident should be escorted to a doctor's visit. She said she had to be present with the resident the entire time of the visit. She said she was informed she would escort a resident of (Resident #2) on 5/22/24 to an appointment. She said she was trained to inform family members who took residents to doctor's appointments that they must remain with the resident throughout the entire visit. In an interview on 5/17/24 at 11:57 a.m. with RP of Resident #3 said she was currently at visit with the resident. The RP said the DON had informed her that a family member must remain with a resident throughout a doctor's visit until they return to the facility or are with transportation. In an interview on 5/17/24 at 12:05 p.m. with RP of Resident #4 said she was aware and always stayed with the resident throughout the visit and returned her back to the facility. She was aware to never leave the resident alone. She was aware of the next 4 visits (5/22/24, 5/28/24, 6/5/24, 6/13/24) and would be present. Interview on 5/17/24 at 12:33 p.m. with RP of Resident #5 said she was aware and informed by the facility that she would meet the resident for her doctor's visit and be with her until transportation picked her up. Interviews with the following Nurses and CNA's revealed the following: Nurses and CNA's confirmed they had been educated on the need for cognitively impaired residents with a BIMS score of less than 12 to have a family member/Responsible Party or facility staff accompany them to outside appointments. The Nurses said they would communicate to the licensed nurses verbally and by writing on the 24-hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Nurses confirmed they would validate cognitively impaired residents with a BIMS score of less than 12 have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Nurses and CNAs confirmed the same process would be required for weekend appointments. LVN C (day shift) - Interviewed on 5/17/24 at 12:58 p.m. RN A (day shift)- Interviewed on 5/17/24 at 1:10 p.m. LPN A (day shift) - Interviewed on 5/17/24 at 1:22 p.m. LVN D (night shift) - Interviewed on 5/17/24 at 1:37 p.m. CNA D (day shift) - Interviewed on 5/17/24 at 1:48 p.m. LVN E (night shift) - Interviewed on 5/17/24 at 2:08 p.m. PRN CNA B (night shift) - Interviewed on 5/17/24 at 2:42 p.m. LVN F (night shift) - Interviewed on 5/17/24 at 2:55 p.m. CNA C (night shift) - Interviewed on 5/17/24 at 3:01 p.m. In an interview on 5/17/2024 at 2:00 pm with the nurses that were ending their shifts revealed they had verified the residents who had gone out for appointments today had returned by making physical observations. In an interview on 5/17/2024 at 2:26 pm with the SW, she said she had updated all residents with BIMS score of less than 12 to have staff or family member accompany the resident to appointments throughout the visit. Record review of facility audit of resident's recent BIMS scores completed by the Social Services Director on 5/16/24. Cognitively impaired residents with a BIMS score of less than 12 will have their care plan updated by 5/17/274 to include need for accompaniment for outside appointments. Record review of 10 sampled residents revealed their care plans had been updated to reflect the following This resident will need to be accompanied by responsible party or staff for all appointments due to BIMS score less than 12). In an interview on 5/17/2024 at 11:36 AM with ADMIN and DON, the DON said she was reeducated by the Clinical Consultant on 5/16/2024 on the need for family/Responsible Party or facility staff to accompany cognitively impaired residents with a BIMS score of less than 12 to outside appointments. The ADMIN said she was aware that residents with a BIMS score less than 12 had to be escorted to appointments with family members or facility staff. The ADMIN said she would review on the day of the outside appointments in the clinical morning meeting Monday - Friday to validate any cognitively impaired resident with a BIMS score of less than 12 has a family member/Responsible Party or facility staff member scheduled to accompany them. Record review of Ad Hoc QAPI held on 5/16/2024 was completed with the following participants: Medical Director, the DON, the ADMIN, the ADON. The ADMIN was informed the IJ was removed on 5/17/24 at 3:31 p.m. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to allow adequate equipment for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 36 Resident rooms (102, 104, 110, 111, 112, 113, 114, 115, 117, 118, 119, 123, 125, 201, 202, 203, 205, 206, 207, 208, 209, 210, 211, 213, 215, 217, 218, 219, 303, 309, 311, 313, 314, 315, 317 and 319) out of 37 resident rooms reviewed for environment. The facility failed to ensure all portions of the call system were functioning after loss of power by verifying that each resident room call lights were functioning effectively after repairs were made and verifying monthly thereafter. The facility failed to provide alternate means of communication with the staff that was always accessible to all residents while in their beds and in resident bathrooms to allow residents to call when needing staff assistance. An Immediate Jeopardy (IJ) was identified on 11/10/2023. While the immediacy was removed on 11/13/2023, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and of not being able to obtain assistance or care as needed. The findings included: Record review of the facility's undated Resident Room roster received on 11/09/2023 revealed there were 61 resident rooms in the building. Record review of Resident #1's electronic face sheet dated 11/10/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included the following: brain stroke, weakness to one side of body following the stroke, abnormal gait and mobility, fracture to the spine, shortness of breath, muscle weakness, unsteady on feet, history of falling, need for assistance with personal care, seizures, elevated blood pressure and disorientation. Record review of Resident #1's annual MDS assessment dated [DATE], revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. His vision was moderately impaired. He required supervision with set up help for transfers. He required supervision with one person assist for bed mobility, toilet use and personal hygiene. He had impairment to one side of his upper and lower extremity that interfere with daily function or placed the resident at risk of injury. He used a wheelchair for mobility. He was always incontinent of bowel and bladder. Resident #1 had a fall since reentry prior to assessment. Further review revealed Resident #1 did not have any injury from the fall. Record review of Resident #1's care plan revised on 08/22/2023 revealed: Problem - Resident #1 was at risk for falls d/t impaired cognition, impaired mobility. He had a fall on 06/28/2023 while trying to use the restroom without assistance which resulted in a back fracture. He had a fall on 8/18/2023 trying to use the restroom without assistance, no injury noted. The long-term goal was, Resident #1 will remain free from injury. Approach - place resident in a fall prevention program. Observe frequently and place in supervised area when out of bed. Provide with safety device/appliance if applicable. Provide toileting assistance when needed. Problem - Resident #1 had diagnosis of seizures and at risk for injury. Medication: Levitiracetam. Goal - Resident #1 will not injure self secondary to seizure disorder. Approach included: keep call light within reach. Resident #1 had diagnosis of CVA (brain stroke) with hemiplegia (weakness to one side of the body) and was at risk for decreased cardiac output. Goal - Resident #1 will participate in exercises necessary to maintain muscle strength and tone. Approach included - Place objects (e.g. call bell, tissues) on unaffected side and approach from that side. Problem - Resident #1 required assistance with ADLs and transfers. Goal - Resident #1 will maintain a sense of dignity, being clean, dry, odor free and well groomed. Approach included: toileting - extensive assist with one person assist, transfers - limited/extensive assist with one person assist. Record review of Resident #2's electronic face sheet dated 11/11/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included dementia, cellulitis (bacterial infection) of toe, abnormal gait and mobility, Atherosclerosis (narrowing of arteries' walls d/t buildup of plaques), muscle wasting, lack of coordination, assistance with personal hygiene, depression, anxiety, high blood pressure, chronic pain, heart failure, diabetes and end stage renal disease. Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating intact cognition. He used a walker and wheelchair for mobility. Section GG of the MDS revealed he required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, toilet transfers and walking. His primary medical condition was progressive neurological conditions. Record review of Resident #2's care plan revised on 11/06/2023 revealed: Problem included - Resident #2 had a fall 5/26/23 while attempting to get up from toilet. Goal - Resident #2 will remain free from injury and notify staff of any falls. Approach included -give verbal reminders not to ambulate/transfer without assistance when feeling weak/unsteady. Problem - Resident #2 at risk for falling r/t unsteady gait, diabetes and ESRD. Goal - Resident #2 will remain free from injury. Approach included - Resident #2 on the Falling Star program, identified by a yellow name plate. Keep bed in lowest position with brakes locked. Keep call light in reach at all times. Record review of Resident #3's electronic face sheet dated 11/10/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, abnormalities of gait and mobility, intermittent explosive disorder, anxiety, cellulitis, UTI, muscle wasting, need for personal care, psychosis, hallucinations, and osteoporosis. Record review of Resident #3's annual MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. She had minimal difficulty with hearing. She required extensive two person assist for toilet use and personal hygiene. She required extensive one person assist for bed mobility, transfers, and dressing. She used a wheelchair for mobility. She was occasionally incontinent of bowel and bladder. Record review of Resident #3's care plan revised on 07/19/2023 revealed: Problem included - Resident #3 at risk for falls r/t impaired cognition, impaired mobility, incontinence of bowel and bladder and use of psychotic medications. Goal - Resident #3 will remain free from major injury through the next review date. Approach included - Encourage to use environmental devices such as hand grips, handrails, etc. Give verbal reminders not to ambulate/transfer without assistance. Observe frequently and place in supervised area when out of bed. Problem - Resident #3 at risk for pain r/t Osteoporosis, neuropathy, and lumbago (persistent discomfort in lower back). Goal - Resident #3 will not experience unaddressed pain r/t osteoporosis and lumbago through the next 90 days. Approach included - encourage resident to request pain medication if not getting relief from what she was currently taking. Further review of the care plan revealed no approach to include placement of call light within reach of Resident #3. Record review of Resident #4's electronic face sheet dated 11/11/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included Rhabdomyolysis (rapid muscle breakdown), Glaucoma (eye disease), abnormalities of gait and mobility, need for assistance with personal care, localized edema (fluid retention), high blood pressure, epilepsy (seizures), low blood pressure, pain and osteoarthritis. Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. She had impaired vision. She required partial/moderate assistance with the following: rolling left and right from lying on back, moving from sit to lying, lying to sitting, sit to stand, chair/bed-to chair transfer. She required substantial/maximal assistance with toilet transfer. She was occasionally incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #4's care plan revised on 11/08/2023 revealed: Problem included - Resident #4 at risk of falling r/t unsteady gait at times. Resident #4 had a fall on 11/07/2023, while trying to transfer self. Goal - Resident #4 will be free of falls. Approach included - educate resident on asking for assistance. Further review of the care plan revealed no approach to include placement of call light within reach of Resident #4. Record review of Resident #5's electronic face sheet dated 11/09/2023, revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included diabetes, intermittent explosive disorder (behavioral disorder characterized by explosive outbursts of anger/or violence), history of abdominal pain, UTI, insomnia, lack of coordination, legal blindness, high blood pressure, anxiety, abnormalities of gait and mobility. Record review of Resident #5's annual MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate impaired cognition. She had severely impaired vision. She required total assistance with one-person physical assist for walking. She required extensive assistance with one-person physical assist for bed mobility, transfers, locomotion on or off unit, dressing, eating, toilet use and personal hygiene. She used a wheelchair for mobility. She was always incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #5's care plan revised on 09/11/2023 revealed: Problem included - Resident #5 experienced a witnessed fall on 09/16/23 and on 09/17/23 with no apparent injuries. Resident #5 had an unwitnessed fall on 10/21/23 with no apparent injuries. Long term goal - Resident #5 will remain injury free. Approach included - fall mats in place, increased frequent rounding on resident. Problem - Resident #5 at risk for falling r/t unsteady gait and use of psychotropic medication. Long term goal - Resident #5 will remain free from injury. Approach included - keep call light in reach at all times. Observe frequently and place in supervised area when out of bed. Provide toileting assistance when needed. During an observation and interview on 11/09/2023 beginning at 7:45 AM, Resident #6 and Resident #3 were in their room. Resident #3 was sitting in a wheelchair next to the bed and stated the call light was not working. Resident #3 said she was given a bell, but it was not effective as it was not loud enough. She stated the call lights have not been working for about 3 months. She stated when she needed her brief changed, she would holler loudly. She stated that it was aggravating to have to yell and that she had a low tone to her voice and was afraid no one could hear her because of her soft voice. She stated the staff would come after about an hour of her calling out. She stated she was changed recently and was currently dry. Resident #3 pressed the call light. The call light cord was connected to the box mounted to the wall and it did not light up. The lighting fixture above the resident room in the hallway did not light up. There were no bells observed within reach for Resident #3 or Resident #6 anywhere in the room. During an observation and interview on 11/09/2023 beginning at 10:15 AM in room [ROOM NUMBER], Resident #4 stated the call light did not work for a long time. Resident #4 stated she must holler for help or bang on the wall. She stated she and her roommate Resident #5 were not given anything to use like bells. She stated her roommate was blind and if she needed help, Resident #4 would holler for the staff to come. She stated, If we don't have working call lights, I guess they just don't come. Observation of Resident #4 pressing the call light and no light turned on outside the room. Resident #5 was sitting in a wheelchair next to the bed and was holding the call light box. There were no bells anywhere in the room or within reach of either residents. During an observation and interview on 11/09/2023 beginning at 10:30 AM in room [ROOM NUMBER], Resident #1 was sitting in a wheelchair and Resident #2 was reclining in the bed. Resident #1 pressed call light and it did not light up in the hallway. Resident #2 pressed the call light, and it did not light up in the hallway. Resident #2 stated he did not use the call light, that he would get up and go get a nurse if he needed anything. Resident #1 stated he was able to wheel himself to the nurse station if he needed anything. Resident #2 stated he was not given a bell to use. There were no bells observed in the room or within reach of either resident. During an interview on 11/09/2023 at 10:35 AM, CNA C stated she was new and started working at the facility 11/01/2023. CNA C stated she was assigned to 200 hall and was not aware of any rooms with call lights that were not working. During an interview on 11/09/2023 at 10:40 AM, CNA D stated she was floating in 200 Hall and 400 Hall at the time . CNA D stated as far as she knows there were no rooms with call lights that were not working. CNA D stated if she found a call light that did not work, she would put a work order in the computer system so the Maintenance man could work on it and would give the resident bells to use. During an interview on 11/09/2023 at 10:45 AM, LVN E stated he was in charge of 200 Hall. LVN E stated he put bells out yesterday (11/08/2023) but did not remember which rooms and did not have a list of the rooms. LVN E stated he was unaware of call lights not working in rooms 201, 202 and 213. He stated he did not know why they did not have bells but would make sure residents in 201, 202 and 213 received bells. LVN E stated since the big thunderstorm in September 2023, there had been issues with the call lights. LVN E stated there was no documentation on resident monitoring for residents without working call lights. He stated the documentation logs were more for the exit doors that were not locking after the lightning strike, which had since been repaired. LVN E stated rounds were made on all residents with call lights not working and the CNAs, charge nurses and ADON were all monitoring residents; LVN E did not specify the monitoring schedule. During an interview on 11/09/2203 at 10:58 AM the Maintenance Director stated in September 2023, lighting struck the whole building and knocked out the fire panel system and call light system. He stated currently he did not remember which resident rooms had call lights that were not working and that some may not light up in the hallway but may ring at the nurse station. Maintenance Director stated he was not aware that rooms 201, 202 and 213 call lights were not working but he would check them. During an interview on 11/09/2023 at 11:20 AM, the Maintenance Director stated room [ROOM NUMBER] did light up at the nurse station, 201 and 213 needed new boxes for the wall and that he would be able to replace those. He stated as far as he knew the Service Company told him the call light system was fixed when they replaced the main board in September 2023. He stated he did not have paperwork from the Service Company stating all the call lights were checked. He stated he would not know the call lights were not working unless someone told him. He stated he routinely checks the call light system monthly. He stated he did not check call lights in October 2023. When asked why, he stated, I don't know, I was busy. During an interview on 11/09/2023 at 2:40 PM, LVN E stated residents in rooms 201, 202, 213 had handbells. He stated since the contingency, the bells were put into place, the nursing staff had been checking on residents frequently by walking up and down the halls and checking the rooms. LVN E stated it was the Maintenance Director's responsibility to ensure the call lights were working. During an interview on 11/09/2023 at 2:50 PM, the Administrator stated all the employees were responsible to ensure the call light system was working. The Administrator stated the expectation was that Maintenance Director check the system monthly. The Administrator stated she knew the Maintenance Director did an informal random check of the resident call light system during the first week in October 2023, but that he probably did not have any documentation. The Administrator stated she knew there were issues with the call light system and had several call lights that were not working. The Administrator stated the staff ensure the residents have bells and staff increase monitoring of residents. The Administrator stated the service company technician was supposed to come out to the facility but did not know exactly when so today she contacted the representative and that he was coming out tomorrow (11/10/2023). Surveyor requested email verification of the communication with Service Company. Requested verification was not provided by exit date . During an observation on 11/09/2023 at 3:00 PM, Resident #3 was in her room and had a handheld bell within reach. She stated the technicians were working on the call lights. The light fixture outside the room was flashing . Resident #5 in room [ROOM NUMBER] had a handheld bell on the overbed table that was not in reach of the resident who was lying in bed asleep. Resident #4 stated, look where they put the bell on her table, she cannot reach it. There was no bell near Resident #4. Resident #4 stated she was not given a bell. During an interview on 11/10/2023 at 7:15 AM, the Maintenance Director was asked for a copy of work orders for call lights between the time the Service technicians fixed the call light system on 09/26/2023 and 11/09/2023. The Maintenance Director stated honestly, he did not receive any work orders. He stated if he there were work orders, he would have seen the work orders on his phone and his desk computer. During an observation and interview on 11/10/2023 beginning at 8:20 AM the emergency call light in the bathroom for room [ROOM NUMBER] did not work. Resident #1 stated he used the bathroom himself regularly and had not had to use the call light. He denied falling. Resident #2 stated the call lights have not been working for about 3 weeks now. Resident #2 stated he used the bathroom himself and denied any falls. Resident #2 stated, anything can happen like falls, just like murphy's law: anything that can go wrong will go wrong. During an observation and interview on 11/10/2023 beginning at 8:45 AM in room [ROOM NUMBER], the bathroom call light did not work. Resident #4 stated she liked to use the shower and would prefer the call light work as well. She stated she still had not been given a bell. There was no bell within her reach or anywhere in the room. During an observation and interview on 11/10/2023 at 8:55 AM, Resident #5 was sitting in her wheelchair next to her bed. There was a handheld bell within her reach. She also had the call light box in her hand. Resident #5 stated she was given the bell yesterday (11/09/2023). She stated prior to the bell the call light would never work. She stated she would press the buttons, and no one would come, and she would have to ask Resident #4 to call out for help. During an interview on 11/10/2023 at 9:00 AM, CNA F stated she had a list of rooms with call lights not working. CNA stated she received the list yesterday (11/09/2023) and that usually the nurses would tell her verbally which rooms had call light issues but yesterday was different and she was given a list. During an interview on 11/10/2023 at 9:15 AM, the DON stated the call light system had been a problem since the lighting struck in September 2023. The DON state she was under the impression all the call lights were working d/t it was discussed in one of the morning meetings after the Service Company came out and did their inspection. The DON did not recall the exact dates. The DON stated she learned that some of the call lights were not working last week then the Service Company came and during a meeting, they were told everything was functioning as expected. The DON stated the contingency plan was put in place after the lightning strike and included having bells for the residents. The staff had been in-serviced to do frequent rounds. The DON stated she heard about one call light not working yesterday. She stated the staff were told not to leave residents alone in the restrooms and to give residents bells to use in the restrooms. She stated the residents were educated and reminded to take the bells with them while in the restroom. The DON stated the resident's needs were being met by anticipating their needs and the ones with the call lights out were in the long-term care side. She stated the nursing staff establish a routine with the residents, were able to anticipate their needs and the nurses assessed and made frequent rounds. She stated the managers are out on the floor frequently for extra help. She stated, there are enough staff, and we like to keep the same aides assigned to residents so there is continuation of care. The DON stated the Administrator oversees Maintenance. During a telephone interview and Record Review on 11/10/2023 at 9:30 AM, the Service Company Representative stated the electrical system was red tagged on 9/11/2023 after the lighting strike and the work order was for troubleshooting the damage caused by lightning. The Representative stated the repair was made to the main board to ensure the nursing call system was receiving power supply. The Representative was asked about the note on the invoice dated 09/26/2023, the representative stated it meant that the main board power supply was replaced and was receiving power. The Representative stated the technician would not have tested each individual room and that if they did test it would have been included in the notes. The Representative stated it was entirely possible they would not know whether each call light was functioning unless testing was done where the power was not going through and unfortunately, with lighting strikes it was not unusual to find issues later. During an interview on 11/10/2023 at 10:25 AM, CNA G stated that she had a list of which rooms had call lights that did not work and that was why she rounds frequently. CNA G stated the residents have bells to use and the risk of not having call system would be resident falls. During an interview on 11/10/2023 at 10:30 AM, LVN H stated if the call light system did not work the resident had bells and she would do frequent room checks. LVN H was asked what the risks would be to a resident if there was no call system in place, LVN H stated the residents had bells and she would do frequent room checks. During an interview on 11/10/2023 at 10:35 AM, the Administrator stated if the residents did not have a working call system, they would not be able to call the staff and their needs would not be met and that was why after the lightning strike the residents were given hand bells. During an interview on 11/10/2023 at 2:20 PM, the DON stated with some call lights not working she monitored the residents by rounding and conducting resident interviews. The DON stated she was not aware of any accidents related to the call light system malfunctioning. She stated she conducted daily rounds throughout the day and that the managers do the same. The DON stated she will attend meal service to monitor residents in the dining room and all the managers and department heads will rotate monitoring duties during meal service in the dining room as well as meals in the halls. She stated they also have Guardian Angel rounds who monitor residents. During an observation and interview on 11/10/2023 beginning at 3:20 PM in room [ROOM NUMBER], the call light in the room and in the resident bathroom did not work. Resident #7 had a handheld bell and stated she used once, and staff did come. During an observation and interview on 11/10/2023 beginning at 3:30 PM, observation of the door to room [ROOM NUMBER] was closed. CNA J stated the call light should work. In observation CNA J pressed the call light button at Resident #8's bedside and it did not work. The call light in the bathroom did not work. CNA J stated Resident #8 liked to have his door closed d/t residents yelling and this was why she would check on him every 30 minutes to ensure he did not need anything. Resident #8 had a handheld bell within reach, he was lying on his back in bed watching TV. During an observation on 11/10/2023 at 3:35 PM, the Resident in room [ROOM NUMBER] bed A was non-interviewable and the handheld bell was not in reach of the resident. The resident at the window bed was asleep. There were no handbells visible around the resident. Record review of the list of residents who could not use a call system included the resident in room [ROOM NUMBER] bed A. During an interview on 11/10/2023 at 4:10 PM the DON stated she started the list of rooms with call light malfunctioning yesterday 11/09/2023. She stated prior to that the CNAs were given a verbal report by the nurses on which rooms had call lights that were not working. She stated at that time there were not many rooms with malfunctioning call lights. She did not say which rooms had malfunctioning call lights prior to 11/09/2023. During an observation and interview on 11/10/2023 beginning at 4:15 PM in room [ROOM NUMBER], the call light did not work. Resident #9 had a handheld bell that was not within reach. During an observation and interview on 11/10/2023 beginning at 4:20 PM Resident #3 stated they took her handheld bell away. She pressed the call light, and it was not working. The lighting fixture outside the door was hanging off the wall. The technicians were observed in the building doing their inspection. There was no handbell within reach of the resident. During an observation and interview on 11/10/2023 beginning at 4:25PM, Resident #2 had a handheld bell. Resident #10 did not have the handheld bell within reach. Resident #11 stated the hand bell was useless and was not the answer to the problem. Resident #12 stated she did not know anything about the bell, but she had one at the nightstand. Resident #13 stated that she had to bang the handle of the bell on the overbed table for staff to answer her call. She demonstrated banging the handle on the table hard and loudly. During an observation and interview on 11/10/2023 at 4:30 PM, Resident #5 was asleep in bed and the handheld bell was on the nightstand and not in her reach. Resident #4 stated she could see the bell and would not be able to reach it for Resident #5 and she states she still did not have a bell of her own. During an interview on 11/10/2023 at 4:35 PM, the Administrator stated the Service Company would be giving her a quote to repair the call system but could not fix it today. The Administrator stated the Fire Marshall and Service Company were at the facility on 11/06/2023 and that the Fire Marshall notified her that the system was working. During an interview on 11/10/2023 at 6:15 PM the Administrator stated all residents should have handheld bells and did not know why some did not have them. The Administrator stated there were no monitoring logs for this necessarily and there were no logs regarding which staff members handed out the bells and to which residents. The Administrator stated the bells should be in reach so the residents can notify staff when they need assistance. She stated she expected the call lights to be checked every month by Maintenance and did not know the reason why the checks were not completed in October 2023. During an interview on 11/13/2023 at 10:00 AM, LVN E stated to his knowledge the contingency plan was in effect until further notice. He stated without a functioning call system a lot of things could happen to the residents. He stated their care would not be rendered if they need assistance. He stated it would depend on the level of care, for example if they needed peri care and they did not get the assistance d/t the call lights not functioning then they may develop a rash. During an interview and record review on11/13/2023 beginning at 1:15 PM the Maintenance Director was asked about the workorder report generated 11/10/203 for closed dates of 09/26/2023 to 11/08/2023. He stated the workorder #1382 opened 10/03/2023 at 7:37 PM and for call light broken in 200 Hall, was not specific and he left by the closed date and time of 10/12/2023 at 6:49PM. He stated there was no specific room listed for workorder #1396 for call light blinking red in 100 Hall opened on 10/09/2023 at 6:19 PM and closed on 10/25/2023 at 1:05PM. He did not say anything when asked if he followed up on the two workorders. Further review revealed no room numbers were associated with each call light malfunction. During an interview on 11/14/2023 at 11:45 AM, the Administrator confirmed that lightning struck the building on Saturday 09/09/2023 and the Service Company came to the facility on the same day. Record review of the facility reported incident reported on 09/09/2023 revealed the facility was struck by lightning in the early morning hours of 09/09/2023 which attributed to the alarm system and call light system malfunctioning. The Maintenance Director attempted to reset the system with the aid of the Service Company. This was unsuccessful and therefore the fire marshal was contacted. On 09/09/2023 the staff were in-serviced on elopement of high-risk residents, in-serviced for answering call light frequently, frequent checks of the residents, staff to provide residents with physical bells and staff to answer ringing of bells immediately. Record review of the Service Company invoice for nurse call repair dated 09/11/2023 indicated a quote to replace the main control board/power supply and that the damage to the field device was not determined until the main was replaced. Record review of the Service Company invoice for the fire alarm dated 09/14/2023 indicated a quote for the fire alarm and that damage to other devices was not determined until the mainboard could be replaced. Record review of the Service Company invoice dated 9/26/2023 read in part: .Notes: Replaced main board of power supply. Tested and working. Cleared red tag . Record review of the facility Monthly Nurse Call Checks log sheets revealed on 06/14/2023 100 Hall rooms were marked as checked and passed. On 07/20/2023 200 Hall rooms were marked as checked and passed. On 08/15/2023 300 Hall rooms were marked and checked as passed. Further review of the Monthly Nurse Call Checks log sheets revealed there were no Monthly Nurse Call Checks completed for September 2023 and October 2023. Record review of the Service Company invoice dated 11/10/2023 read in part: .service completed: Check nurse call issues .Notes: Service call to check nurse call system. We did a complete audit of the system. We found multiple issues on each hall with devices after facility took a lightning strike. Rooms with issues were 111, 113, 115, 117, 119, 123, 125, 118, 114, 112, 110, 106, 104, 102, 201, 203, 205, 207, 209, 211, 213, 215, 217, 219, 218, 210, 208, 206, 202, 303, 309, 311, 313, 315, 317, 319, and 314. Most bed stations in these rooms will need to be replaced. 2 techs were on site for work. Record review of the facility nursing policy and procedure for call lights, responding to, revised on May 5, 2023, read in part: Policy: the staff will respond to call lights or other requests for assistance to meet patient's/resident's needs. Procedures: 1. Respond to call lights and requests for assista[TRUNCATED]