**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure a resident's environment remained as free of accidents and hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for transfers in that: - CNA A failed to provide incontinence care with another staff member when Resident #1 required assistance of 2 staff, which resulted in the resident rolling off the bed on 8/19/24, sustaining a right femur fracture, and requiring surgery. An Immediate Jeopardy (IJ) was identified on 9/30/24. The IJ template was provided to the facility on 9/30/24 at 2:46p.m. While the IJ was removed on 10/1/24 at 2:50p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falling out of bed, injuries, and hospitalization. Findings included: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of aftercare following joint replacement surgery, cognitive communication deficit, muscle weakness, vascular dementia, osteoporosis, displaced fracture of lower end of right femur, right artificial knee joint, difficulty in walking, type 2 diabetes, and Alzheimer's disease. Record review of Resident #1's Annual MDS assessment dated [DATE] indicated a BIMS was unable to be performed due to her medical conditions. The resident was severely impaired with cognitive skills for daily decision making and never/rarely made decisions. She was dependent (staff does all the work and resident does none of the work. Or resident requires 2 or more staff members) with all ADLs. The resident was always incontinent of bowel and bladder. The MDS indicated she had a hip and knee replacement. The MDS did not have Resident #1's fall on it. Record review of Resident #1's care plan dated 9/13/24 revealed a Focus: The resident is at risk for falls r/t unaware of safety needs with an actual fall (Initiated: 2/23/21, Revised: 9/17/24). Goal: The resident will be free of falls through the review date. The resident will not sustain serious injury through the review date (Initiated: 2/23/21, Revised: 9/15/24, Target: 12/13/24). Interventions: Resident with actual fall during care. Resident rolled and was guided to the floor mat by CNA A. Resident sent to the hospital (Initiated: 8/19/24). Focus: The resident had a fracture after a fall (Initiated: 7/16/21, Revised: 9/17/24). Goal: Resident's surgical incision will heal without s/sx of infection or breakdown by review date (Initiated: 9/17/24, Revised: 9/17/24, Target: 12/13/24). Interventions: Change surgical incision dressing as per order and PRN (Initiated: 9/17/24). Focus: Resident has an ADL self-care performance deficit. Goal: Resident will demonstrate the appropriate use of adaptive devices to increase ability in bed mobility through the review date (Initiated: 12/22/23, Revised: 9/15/24, Target: 12/13/24). Interventions: Bed Mobility: requires staff x2 for assistance (Initiated: 12/22/21). Record review of Resident #1' s undated [NAME] (information about how to care for the resident in the EMR), indicated she required 2 staff assistance for bed mobility. Record review of Resident #1's nursing note dated 8/19/24 at 6:55am, revealed the resident rolled off the bed and on to the floor while CNA A performed bed side care. Record review of Resident #1's fall-risk assessment dated [DATE] at 6:57am, indicated she was a high fall risk. Record review of Resident #1's nursing note dated 8/19/24 at 9:04am, indicated there was a new order for an x-ray for her right knee and right leg r/t pain and the fall. Record review of Resident #1's fall nurses note dated 8/19/24 at 10:46pm, indicated she had bruises to her BLE that were blue/purple. Record review of Resident #1's SBAR dated 8/19/24 at 10:56pm, indicated she had a fracture of the distal shaft (part of her femur by her knee) of her right femur and MD O ordered her to be sent to the ER. Record review of Resident #1's hospital records dated 8/20/24 at 1:03pm, indicated she had a comminuted (broken in 3 or more places) right femoral (thigh bone) fracture extending along the medial lateral (inside and outside) margins of the femoral component (part of the thigh bone that goes into the knee) of the knee arthroplasty (knee replacement). Record review of Resident #1's hospital records dated 8/21/24 at 11:51am, indicated she would need surgery for her right femur fracture, along with revision of her right knee arthroplasty (knee replacement). Record review of Resident #1's hospital records dated 8/25/24 at 10:28am, indicated the resident had a right open reduction internal fixation (repairing fractured bone using plates, screws or rods to stabilize the bone) of her femur on 8/22/24. During an interview on 9/29/24 at 12:26pm, Resident #1's family member said she had fallen out of bed twice in the last month and 10 times in the last year. He said it always happened early in the morning or late at night. He said Resident #1 was non-verbal and bedbound and the last time she fell was when a staff member was changing her and she rolled out of bed onto the floor. During an interview on 9/29/24 at 2:18pm, LVN B said he observed Resident #1 on her back on the floor, next to her bed, on 8/19/24. He said there was 1 CNA who had provided care and he thought the resident was a 1-person assist. During an interview and observation on 9/29/24 at 3:25pm, Resident #1 was laying on her back in bed. The bed was in the lowest position. Resident #1 said she was not having any pain at that time. During an interview on 9/29/24 at 3:35pm, CNA C said the way she knew if a resident was a 2-person assist, was based on the need of the resident, the weight, and the experience of the CNA. She said if a resident had to be a 2-person assist it would be listed in the POC/[NAME]. She was not sure if Resident #1 was a 2-person assist. During an interview on 9/29/24 at 3:40pm, CNA D said if a resident was a fall risk and/or a 2-person assist it would be noted in their POC/[NAME]. She said Resident #1 was a 2-person assist and she would never change her without another person because the resident could fall. During an interview on 9/29/24 at 3:48pm, CNA E said if a resident is a fall risk and their mobility status, would be on their [NAME]. She said if a resident was a 2-person assist and there were not 2 CNAs, then a nurse or some other staff member could assist. She said if only 1 person assists a resident when they need 2 people, they could fall. During an interview on 10/2/24 at 3:15pm, CNA A said Resident #1 rolled off the bed when she turned her away from her during incontinence care. She said at the time, she thought the resident was a 1-person assist and did not know the resident was a 2-person assist. She said she knew to look at the [NAME] for mobility and transfer information, but she never thought to look, and it was a mistake. Record review of the facility's policy titled Safe Patient Handling dated 12/30/05 indicated: The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safe transfer, repositioning and resident movement. Nurses will identify residents in need of transfer, repositioning, or movement assistance. Nurses will assess the risks associated with lifting, transferring, repositioning or movement assistance. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling. Resident will be evaluated on admission and as needed for alternative means of lifting, transferring, repositioning and other movement to minimize risk of injury. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury. Facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. Nursing will request therapy disciplines to evaluate resident ability to assist and amount of assistance needed with lifting, repositioning, transferring or mobility. An Immediate Jeopardy (IJ) was identified on 9/30/24. The IJ template was provided to the facility on 9/30/24 at 2:46pm. The Plan of Removal was accepted on 9/30/24 at 6:09pm. The plan of removal reflected the following: Interventions: A head-to-toe assessment on resident #1 was completed as of 9/30/24. No additional injuries or complaints of pain were noted. Bilateral grab bars were installed on the bed for resident #1 to assist with turning and repositioning on 9/30/24. As of 9/30/24, The Administrator and DON was 1:1 in-serviced by the Regional Compliance Nurse on 9/30/24 on the topics below. Then CNA A was in-serviced 1:1 by the DON on the following topics below: Completion date 9/30/24. o Following the [NAME] in [EMR system] for required assistance with bed mobility. How t o locate the [NAME] and determine the staff needed for bed mobility and other ADLS. o Abuse and Neglect (failure to provide the proper number of staff for bed mobility could result in neglect). o Fall Prevention Policy This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor or if CNA must assist a resident to the floor. If the charge nurse is not available, staff will report to the DON immediately. o Safe Handling- the resident will be positioned in the center of bed prior to be turned for care. The other staff member will be positioned on the other side of the bed to prevent the resident from rolling off the bed. o Notification of change in condition- if a resident reports pain or suspected injury, the charge nurse, DON, and/or Physician will be notified. As of 9/30/24 head to toe skin assessments were initiated on all residents in the facility by the DON/ADON/Tx Nurse for any injuries and/or fractures. No additional issues were found. Completion date will be 10/1/24. On 9/30/24, all residents in the facility were assessed and evaluated for assistance with bed mobility by the DON/ADON and Director of Rehab. On 9/30/24, all resident care plans were reviewed for accuracy of assistance needed for bed mobility by Regional Compliance Nurse, DON, and ADON. No issues were identified. The medical director was notified of the immediate jeopardy on 9/30/24 by the Administrator. Ad hoc QAPI was held with the Medical Director and facility interdisciplinary team on 9/30/24 to discuss the immediate jeopardy and subsequent plan of removal. In-services: The DON and ADON then initiated in-servicing all nursing staff on the following topics below as of 9/30/24. All staff not present will not be allowed to assume their duties until in-serviced.?All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to start of their assignment. o Following the [NAME] in Point Click Care for required assistance with bed mobility. How to locate the [NAME] and determine the staff needed for bed mobility and other ADLS. o Abuse and Neglect (failure to provide the proper number of staff for ADLs could result in neglect). o Fall Prevention Policy This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor or if CNA must assist a resident to the floor. If the charge nurse is not available, staff will report to the DON immediately. o Safe Handling- the resident will be positioned in the center of bed prior to be turned. The other staff member will be positioned on the other side of the bed to prevent the resident from rolling off the bed. o Notification of change in condition- if a resident reports pain or suspected injury, the charge nurse, DON, and/or Physician will be notified. On 10/1/24 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed: Record review of Resident #1's skin assessment performed by the DON on 9/30/24 at 3:18pm, indicated bruising was found on the R hand, L hand, and R 1st and 2nd toe. Resident #1 had a healed incision to her L and R knee, a rash under both breasts, and an abrasion to the L and R thigh. Record review of Resident #1's bed rail assessment performed by the DON on 9/30/24 at 4:10pm, indicated bilateral 1/3 rails would be used for turning side to side and holding herself to one side. Record review of Resident #1's bed rail consent from the [family member] on 9/30/24 at 4:11pm, indicated it was for bilateral 1/3 partial rails. Record review of in-services dated 9/30/24 given to the ADM by the Regional Compliance Nurse, reflected Notification of Fall/Injury to Regional Compliance Nurse: To ensure she reaches out to the Compliance Nurse to go over falls/injuries to ensure policies/procedures are being followed accurately and timely, Following the [NAME] in [EMR system] for Required Assistance with Bed Mobility, How to Locate the [NAME] and Determine Staff Needed for Bed Mobility and Other ADLs, ANE, Fall Prevention Policy, Safe Handling, and Notification of Change in Condition. Record review of in-services dated 9/30/24 given to the DON by the Regional Compliance Nurse, reflected Notification of Fall/Injury to Regional Compliance Nurse: To ensure she reaches out to the Compliance Nurse to go over falls/injuries to ensure policies/procedures are being followed accurately and timely, Following the [NAME] in [EMR] for Required Assistance with Bed Mobility, How to Locate the [NAME] and Determine Staff Needed for Bed Mobility and Other ADLs, ANE, Fall Prevention Policy, Safe Handling, and Notification of Change in Condition. Record review of in-services dated 9/30/24 given to CNA A by the DON reflected, Following the [NAME], ANE, Fall Prevention Policy, Safe Handling, and Notification of Change. Record review of head-to-toe skin assessments dated 9/30/24 performed by the DON/ADON/Treatment Nurse, reflected all 87 resident assessments were completed on 10/1/24. 2 residents were found with new skin issues. 1 resident had new skin tears to Bil knees and R shin. The other resident had new rashes to her lower back and the back of her Bil knees. Record review of assistance with bed mobility dated 9/30/24 assessed by the DON/ADON and Director of Rehab, reflected no new residents were found with mobility concerns, and no changes needed to occur with the current mobility of residents. Record review of care plans dated 9/30/24 assessed by the Regional Compliance Nurse, DON, and ADON, reflected no issues found with any care plans. Record review revealed the Medical Director was notified of the IJ on 9/30/24 by the ADM. Record review of the Ad Hoc QAPI meeting dated 9/30/24 reflected the Medical Director, ADM, DON, ADON, SW, Dietary Manager, Activities Director, Maintenance Supervisor, Director of Rehab, and all other appropriate members were in attendance. Record review of in-services dated 9/30/24 to all nursing staff, reflected the [NAME], ANE, Fall Prevention, Safe Handling, and Notification of Change in Condition. As of 9:30am on 10/1/24 100% of the nursing staff had completed in-services either in person or over the phone. During an interview on 10/1/24 at 11:39am with the ADM, she said she received in-services on ANE, Reporting, [NAME], Fall Prevention, Safe Handling, and COC. She received in-services on what COC means. She received in-services on ANE and the different types of abuse which were: physical, mental, sexual, and misappropriation. She said if she were to see any ANE she investigated, suspended the staff member, and reported to her superiors. She said the [NAME] was the resident's plan of Care and had their mobility, assistance, skin issues, and diets on it. The ADM said she was in-serviced on falls and interventions like, fall mats and non-slip footwear. Safe handling was also in-serviced which was 2 person transfers, pulling the resident towards yourself when changing. COC was vomiting, coffee ground emesis, blood in the stool, or change in mobility. If the ADM were to see a COC, she would notify the DON. During an interview on 10/1/24 at 11:32am with the DON she said she received in-services on mechanical lift transfers, and gait belt transfers, ANE and the different types like, physical, mental, misappropriation, neglect, and sexual. She said if she were to see any ANE she would report to the Abuse Coordinator (ADM). She received in-services on how to use the [NAME] and what was on it like, mobility, fall prevention, and ADLs. She also was in-serviced on fall prevention and who to notify and Safe Patient Handling, which was having 1 person on each side of the bed and centering the resident in the bed. COC in-services were also given which could be pain, injury, bruises, or anything changed from baseline. If there was a COC staff were to notify the Charge Nurse or herself. During an interview on 10/1/24 at12:42pm with CNA A she said she received in-services on notification of changes, the [NAME], mechanical lifts, ANE, Fall Prevention, and Safe Handling. She said safe handling was positioning the resident in the center of the bed and having 1 person on each side of the bed when changing a resident. She said the [NAME] had toileting, and information you need to take care of the resident like, transferring. She said the different types of ANE were physical, mental, and sexual. She said she would report to the ADM (Abuse Coordinator). She said if a resident was falling and was guided to the floor, it was still a fall. CNA A said she would report to a fall to the Charge Nurse, and if she was not available then the DON. During an interview on 10/1/24 at 10:02am with CNA F she said she received in-services on mechanical lifts, who to call when there was a fall, following the [NAME], abuse/neglect, safety handling, and fall prevention. She said the different types of ANE were physical, mental, sexual, and misappropriation. If she were to witness any she would report to the DON/ADM (Abuse Coordinator). She said safe handling was always having 2 people to assist the resident if they required it and having the resident in the center of the bed during care. She said she would report a fall/COC to the Charge Nurse/DON. CNA F said the [NAME] had the resident's diet, how many staff members it took to transfer/take care of the resident, and any information needed to take care of a resident. During an interview on 10/1/24 at 10:10am with CNA G she said she had in-services on fall prevention, transfers, ANE, 2-person transfers, positioning, notification of change, safe handling, and the [NAME]. She said the [NAME] had information on how to transfer residents or if they were a 2-person assist, their mobility, how to take care of them, and their ADLs. She said the different types of ANE were verbal, physical, mental, misappropriation, and isolation. She would report to the ADM (Abuse Coordinator) if she ever saw any. CNA G said she would report a fall to the Charge Nurse immediately or the DON. She said safe handling was ensuring the resident was positioned properly in bed, ensuring the resident was centered in bed, pulling the resident towards you before turning, and making sure there was a second person to help. If she noticed a COC, she would notify the Charge Nurse. During an interview on 10/1/24 at 10:22am with CNA H she said she received in-services on gait belts, transferring, mechanical lifts, fall prevention, COC, who to report to, [NAME], ANE, and safe handling. She said the [NAME] had information about if the resident required 2 person transfers, their mobility, diet, and how to take care of the resident. She said the different types of ANE were physical, verbal, sexual, seclusion, and misappropriation. If she were ever to see any ANE she would report to the ADM (Abuse Coordinator). She said safe handling was using 2-persons if needed and positioning the resident correctly in bed. If she saw a COC, she would notify the Charge Nurse or the DON. If she found a resident who had fallen, she would not move the resident, and get the nurse/DON. During an interview on 10/1/24 at 10:30am CNA I said she had in-services on the [NAME], transfers, ANE, reporting falls to the Abuse Coordinator, and safe handling. She said safe handling was positioning the resident in the center of the bed when providing care, pulling them towards you, and having 2 people assist. The [NAME]: had information on how many people it took to transfer, how they ate, their mobility, toileting, and ADLs. She said the different types of ANE were physical, mental, exploitation, and neglect. She said she would report to the nurse, ADON, and ADM (Abuse Coordinator) if she were ever to see any ANE. If she saw a fall she would get the nurse, would not move the resident, and would get the DON if the Charge Nurse was not available. She said a COC was something different on the skin, pain, seeing something that was different from baseline, or not eating. She would notify the nurse/DON. During an interview on 10/1/24 at 11:00am CNA J said she received in-services on transfers, mechanical lifts, gait belts, ANE, turning/positioning, 2-person assist, COC, and the [NAME]. She said the [NAME] had information about how many people were needed for turning/mobility, and ADLs. She said examples of ANE were physical, mental, verbal, sexual, neglect, and misappropriation. If she were to see ANE she would inform the Charge Nurse/ADM (Abuse Coordinator). If she were to witness a fall, she would notify the nurse and would not move the resident because they could have broken bones. She said a guided fall was still a fall. She said safe handling was putting the resident in the middle of the bed, having 2 people, making sure there was enough room to turn the resident, and always using 2 people with mechanical lifts. She said if she noticed a COC, she would notify the Charge Nurse/DON. A COC could be redness, bruising, skin tear, rash, bed sore, or a change in mood. During an interview on 10/1/24 at 11:04am Med Aide K said she had in-services on mechanical lifts, transfers, 2-person assist, safe handling, ANE, the [NAME], and COC. She said safe handling was having 2 people assisting the resident, having the resident in the center of the bed, and having the resident face you when turning them. She said the different types of ANE were physical, verbal, and neglect. If she saw any ANE she would notify the Abuse Coordinator (ADM). The [NAME] had information on it like the resident's mobility, their amount of assistance needed, and ADLs. She said a COC could be pain or not urinating and she would notify the Charge Nurse or the DON. During an interview on 10/1/24 at 11:17am CNA L said she had in-services on fall prevention, transferring, person assist, the [NAME], ANE, and safe handling. She said the [NAME] had information about the resident's transferring assistance, mobility, and ADLs. She said examples of ANE were physical, mental, verbal, and sexual. If she were to see ANE she would report to the Charge Nurse, the DON, and the Abuse Coordinator (ADM). She said if she had a resident who had fallen, she would notify the nurse and would not move the resident. If the nurse was not available, she would notify the DON. She said safe handling was taking a second person or nurse to change the resident and pulling the resident toward you. A COC could be skin tears, bruising, or anything out of the normal and she would report it to the Charge Nurse and the DON. During an observation on 10/1/24 at 1:46pm Resident #1 was asleep on her back in bed. The bed was in the lowest position and there were bil side rails up on the bed. During an interview on 10/1/24 at 2:00pm LVN B said he had in-services on ANE, transferring residents, mechanical lifts, 1-2 person assists, COC, the [NAME], fall prevention, and safe handling. He said the different types of ANE were physical, verbal, mental, and misappropriation. He said he would report ANE to the Abuse Coordinator (ADM). He said the [NAME] was a care plan for each resident, and had transferring, and ADLs on it. He said safe handling was having 1 person on each side of the bed during resident care, positioning yourself and the resident safely, and turning the resident towards yourself if alone. A COC was any change from baseline like, confusion, or agitation. He would notify the MD and perform an SBAR. If a resident were to fall, he would assess the resident on the spot, get vitals, and notify the MD. He said he would start neuro checks if the fall was unwitnessed and continue even when the resident comes back from the hospital. During an interview on 10/1/24 at 2:14pm LVN M said she received in-services on transfers with Hoyer lifts and gait belts, ANE, safe handling, the [NAME], COC, Falls, and ANE. If a resident had a COC, she would notify the DON and the CNAs notify her. If a resident had a fall, she would notify the DON and the ADM. She said examples of ANE were physical, emotional, misappropriation, mental, sexual, neglect and she would report it to the DON and ADM (Abuse Coordinator). She said the [NAME] had the resident's transfer status, mobility, and ADLs. She said safe handling was having 1 person on each side of the bed and rolling the resident toward you. During an interview and observation on 10/1/24 at 2:32pm CNA N and CNA F were observed performing incontinence care on a resident who was a 2 person assist. The resident was centered in the bed. CNA F pulled the resident toward her and then turned her toward CNA N. When the resident was clean, the resident was pulled toward CNA N and turned toward CNA F. After the resident was finished, she was centered back in the bed. The CNAs explained the process during the procedure and the resident remained safe the whole time. An Immediate Jeopardy (IJ) was identified on 9/30/24. The IJ template was provided to the facility on 9/30/24 at 2:46pm. While the Regional Nurse Consultant was notified the IJ was removed on 10/1/24 at 2:50pm, the facility remained out of compliance at a severity of no actual harm with the potential for minimal harm, that is not immediate jeopardy with a scope of isolated, 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 ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent elopement for two of seven residents (Resident #4 and Resident #5) reviewed for accident hazards and supervision. -The facility failed to ensure Resident #4 had adequate supervision on 4/5/2024 and 4/30/2024 which allowed her to elope from the facility's memory care unit. -The facility failed to ensure Resident #5 had adequate supervision on 4/30/2024 which allowed her to elope from the facility's memory care unit at a different time from Resident #4. -The facility failed to ensure the memory care unit's secured doors remained secured on 4/5/2024 and 4/30/2024 allowing two residents to elope. The noncompliance was identified as PNC and the Administrator was given the I.J. Templae on 8/9/24 at 2:15 p.m. The IJ began on 4/5/2024 and ended on 4/30/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious injury or harm. Findings include: Resident #4 Record review of Resident #4's face sheet revealed an [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included lack of coordination, dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), malnutrition (a condition that occurs when a person's intake of energy and nutrients is deficient, excessive, or imbalanced), anxiety disorder (mental health conditions that cause excessive fear, worry, and other feelings of dread and uneasiness), TIA (medical emergency that occurs when blood flow to the brain is temporarily disrupted, causing a lack of oxygen to the brain), difficulty walking, restlessness and agitation, and adjustment disorder (condition in which a person has an unhealthy or excessive emotional or behavioral reaction to a stressful event or life change within three months of it happening). Record review of Resident #4's admission MDS dated [DATE] with an ARD of 4/14/2024 revealed a BIMS score of 8 indicating significant cognitive impairment. The MDS documented she had no potential indicators of psychosis, behaviors affecting others, or rejection of care. Per the MDS, Resident #4 had wandering behaviors daily during the review period. The MDS revealed she had an impairment of one lower extremity, and she used a walker for mobility. The MDS documented she required supervision or assistance with all ADL's except eating. Per the MDS, Resident #4 received OT services. Record review of Resident #4's care plan dated 4/18/2024 revealed a focus on her admission to the secure unit due to her dementia diagnosis and elopement risk with interventions including monitoring for possible off unit activities, monitoring for signs of depression, and monitoring and reporting any changes of condition. The care plan documented a focus on her risk of wandering with interventions including distraction from wandering, monitoring and identifying a pattern of wandering, remaining with her when she was exit-seeking, providing her with structured activities, and ensuring she remained on the secure unit. The care plan included a focus on her previous attempts to exit the facility with interventions including assessing and reporting factors leading to her elopement, close supervision, providing structured activities, and remaining with her if she was exit-seeking. Per the care plan, she was found outside the facility and returned with no injuries. Record review of Resident #4's nurse's note dated 4/5/2024 revealed she had been found outside the facility on the street leading away from the facility at approximately 7:45 PM. The note documented she was provided with food and water, and she was assessed. Per the note, Resident #4 said she was looking for her family member but was unable to find her. Record review of the facility's Provider Investigation Report (PIR) dated 4/12/2024 for Intake ID 495508 revealed Resident #4 had eloped from the facility shortly after 6:00 PM on 4/5/2024. The PIR documented the nurse on duty had last had contact with Resident at approximately 6:00 PM on 4/5/2024. Per the PIR, at approximately 7:45 PM on 4/5/2024 a staff member from an adjacent business called the facility and reported Resident #4 had been found walking on the street near the facility, walking towards a major thoroughfare. The PIR revealed the staff member from the adjacent business was able to coax Resident #4 into the staff member's car and bring her back to the facility. The report documented the facility had an outside vendor and staff ensure all doors were working properly after the incident. Interview on 8/9/2024 at 2:14 PM with the Admin, who said her expectations for a resident elopement were that staff would complete an internal and external search of the facility and call a code orange. The Admin said she expected that staff would search further from the facility to the major thoroughfare approximately a half mile away. The Admin said she expected that when staff heard a door alarm sound the staff would immediately go to the door, visually assess the outdoor area near the door, ensure no one exited the facility, inform the charge nurse, and the charge nurse would complete a headcount. The Admin said during a power outage, all staff were required to go to a specific door until the power returned or the backup generator provided power to the doors, and they were manually reset. The Admin said the plastic covers were installed over the emergency door release buttons near the two nurses' station after the incidents in April, the emergency door release button cover had been installed on the emergency door release in the memory care unit prior to her onboarding, the facility had one reset button for all the doors near the nurse's station on the skilled nursing side of the building and would be installing another one near the nurses' station on the long term care side so staff could reset from each side of the facility. Record review of Resident #4's nurse's note dated 4/30/2024 revealed that the staff was unable to find her on the hall or other halls at approximately 8:46 PM. The note documented the DON at the time was notified that Resident #4 was missing. Record review of Resident #4's behavior note dated 5/20/2024 revealed she was exit-seeking. The note documented she said she wanted to leave, and the facility was holding her against her will. Per the note, Resident #4 picked up a trash can, hit the window with the can, pulled a staff member's hair, and punched a staff member. Record review of Resident #4's nursing note dated 7/19/2024 revealed she was pounding on the door in the secure unit attempting to leave. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was an elopement risk. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was an elopement risk. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was an elopement risk. Observation on 7/5/2024 at 2:35 PM revealed Resident #4 was in the activity room of the memory care unit engaged with other residents. Observation on 8/9/2024 at 9:54 AM revealed Resident #4 was in her bed sleeping. Resident #4 appeared dressed and appropriately groomed. Resident #5 Record review of Resident #5's face sheet dated 7/5/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included encephalopathy (any disease, disorder, or damage that affects the structure or function of the brain), epilepsy (chronic neurological disorder of the brain that causes people to have recurrent, unprovoked seizures more than twenty-four hours apart), difficulty walking, dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), brief psychotic disorder (psychotic condition that begins suddenly and lasts for at least one day but less than one month), generalized anxiety disorder (mental health condition that causes excessive, persistent, and unrealistic worry about everyday events and situations), adjustment disorder (condition that occurs when an individual has an emotional or behavioral reaction to a stressful event or life change that is considered unhealthy or excessive), and kidney failure (occurs when the kidneys are unable to function properly and remove waste and extra water from the blood, or maintain the body's chemical balance). Record review of Resident #5's quarterly MDS dated [DATE] with an ARD of 4/22/2024 revealed no BIMS was completed as she was unable to complete the interview. The MDS documented she had inattention and disorganized thinking. Per the MDS, Resident #5 had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering behaviors. The MDS revealed she had no impairments of her upper or lower extremities, and she used a walker for mobility. The MDS documented she required supervision or assistance with all ADL's except eating. The MDS revealed she received OT services. Record review of Resident #5's care plan dated 4/1/2024 revealed a focus on her risk of wandering with interventions including a fall risk assessment, distracting her form wandering, identifying a pattern of wandering, remaining with her when she was exit-seeking, and providing her with structured activities. The care plan documented a focus on her elopement risk with interventions including ensuring she resided on the secure unit, assessing for potential elopement causes, providing structured activities, and distracting her. Per the care plan she was found out of the secured unit and returned on an unknown date. Record review of Resident #5's nurse's note dated 4/30/2024 at 9:04 PM revealed a CNA could not locate her on the secure unit. The note documented she was not found on the secure or other units. Per the note, the DON at the time was notified Resident #5 could not be located. Record review of the facility's Provider Investigation Report (PIR) dated 5/9/2024 for Intake ID 501268 revealed Resident #4 and Resident #5 had eloped from the facility on 4/30/2024 sometime before the dinner service. The PIR documented a CNA had searched the memory care unit for the residents and was unable to locate them prior to dinner service. Per the PIR, the CNA informed the nurse the residents were missing. The PIR revealed that at 6:38 PM the residents were located, returned to the facility, assessed, and no injuries were identified. The PIR revealed the facility placed plastic covers over the door release buttons throughout the facility and no further elopements had occurred after that time. Interview on 8/9/2024 at 2:14 PM with the Admin, who said her expectations for a resident elopement were that staff would complete an internal and external search of the facility and call a code orange. The Admin said she expected that staff would search further from the facility to the major thoroughfare approximately a half mile away. The Admin said she expected that when staff heard a door alarm sound the staff would immediately go to the door, visually assess the outdoor area near the door, ensure no one exited the facility, inform the charge nurse, and the charge nurse would complete a headcount. The Admin said during a power outage, all staff were required to go to a specific door until the power returned or the backup generator provided power to the doors, and they were manually reset. The Admin said the plastic covers were installed over the emergency door release buttons near the two nurses' station after the incidents in April, the emergency door release button cover had been installed on the emergency door release in the memory care unit prior to her onboarding, the facility had one reset button for all the doors near the nurse's station on the skilled nursing side of the building and would be installing another one near the nurses' station on the long term care side so staff could reset from each side of the facility. Record review of Resident #5's elopement risk assessment dated [DATE] revealed she was an elopement risk. Record review of Resident #5's elopement risk assessment dated [DATE] revealed she was an elopement risk. Observation on 7/5/2024 at 2:36 PM revealed Resident #5 was in the activity room with other residents and engaged. Observation on 8/9/2024 revealed Resident #5 was walking in the hall. Resident #5 appeared dressed and appropriately groomed. Observation on 7/5/2024 at 12:49 PM revealed a doorbell had to be pressed to enter the facility. The door was locked and there was keypad near the door to open it. A sign was on the door with a telephone number to call if no one answered the door. Observation on 7/5/2024 at 1:19 PM revealed the exterior doors on the 300 and 600 halls were locked and unable to be opened without using the push bar. The doors had a keypad near them to allow exit. Both doors had a sign that said an alarm would sound if they were opened without the code. Observation on 7/5/2024 at 1:24 revealed the door to the interior courtyard was unlocked and able to be opened. The courtyard was surrounded on all sides by the facility. There were three exits to the courtyard from the facility, but no exit to the exterior of the facility. Video cameras were observed on the courtyard. There was no manner to exit the courtyard to the exterior of the facility. Observation on 7/5/2024 at 1:26 PM revealed the memory care unit was secured with a keypad to enter and exit. On the memory care unit were two CNA's, a nurse, and a hospitality aid. There was an emergency exit at the end of the memory care unit hall, but the door was locked and unable to be opened. The door had a push bar and an alarm if opened. Interview on 7/5/2024 at 2:02 PM with the DON, who said the facility did not have a policy specific to rounding. The DON said the facility's elopement risk residents were on the secure unit. Interview on 7/5/2024 at 4:08 PM with CNA A, who said she had been employed for three years. CNA A said her primary duties as a CNA were to ensure the residents were groomed, showered, and provided with incontinence care, making the beds, and supervising the residents. CNA A said she completed her rounds hourly most times, but at least every two hours. CNA A said there was no specific policy related to rounds, but the expected practice was to complete rounds at least every two hours. CNA A said when she completed rounds, she checked the residents to determine if they required incontinence care, looked to make sure no residents had fallen, and made sure all the residents were on the hall. CNA A said the staff were required to complete a headcount every fifteen minutes on the secure unit. CNA A said after completing the head count, the staff had to sign that it was completed. CNA A said the DON kept the documentation for the headcounts. CNA A said the facility had completed the headcounts since she had been employed. CNA A said she was not present when Resident #4 eloped on 4/5/2024, when Resident #4 and Resident #5 eloped on 4/30/2024. CNA A said the residents may have eloped through the door from the memory care unit to the rest of the facility if it was not closed completely, but she did not know for sure as she was not at the facility for any of those elopements. CNA A said if a resident eloped the staff were trained to inform the nurse immediately and then begin searching for the resident. CNA A said she did not recall the most recent date the facility provided in-service training related to elopement risk of residents. CNA A the staff were to redirect or distract Resident #4 and Resident #5 if they were near the door to the memory care unit. CNA A said she did not know of any other elopements between 4/1/2024 and 7/5/2024. CNA A said she was required to provide written statements for incidents at the facility including elopements, falls, and other injuries. CNA A said she had never been asked to provide a false statement for any incident by the facility. CNA A said the facility was well prepared to mitigate elopement behaviors on the memory care unit as the door was locked and there were three staff for the unit. CNA A said there were two CNA's and one hospitality staff assigned to the unit daily. Interview on 7/5/2024 at 4:22 PM with RN B, who said that was her first shift on the memory care unit and she had been employed by the facility for one week. RN B said CNA's were expected to complete rounds at least every two hours, and more often when needed. RN B said the CNA's were expected to ensure the residents did not require incontinence care, were present, and not walking into other residents' rooms. RN B said the CNA's were expected to be out on the floor with the residents as often as was possible. RN B said if a resident was identified as missing, the staff were to look through the hall, in the resident rooms, the closets, and the restrooms. RN B said if the resident could not be located on the hall, the staff throughout the facility would begin searching for the resident, staff would begin searching the grounds of the facility, the DON and law enforcement would be notified, and staff would begin searching the areas near the facility both on foot and in cars. RN B said since she had been at the facility there had not been any elopements she was aware of. RN B said nurses also completed their rounds every two hours and ensured all residents were accounted for. Interview on 7/5/2024 at 4:40 PM with RN C, who said she had worked at the facility for six years. RN C said her primary duties included acting as the charge nurse, ensuring all residents were rounded on, ensuring the CNA's knew the plan of care for the residents, charting, administering medications, providing G-tube care and medications, providing the injected medications to all residents, and ensuring all residents at the facility were safe and properly cared for. RN C said the CNA's were expected to round every two hours. RN C said during the CNA rounds, they were expected to ensure the resident's safety, determine if any residents required incontinence care, ensured all residents had water near them, and ensured the residents were accounted for. RN C said if a resident was determined to be missing, CNA's were expected to notify the nurse and the staff would check the hall. RN C said if the resident was not located on the hall, all the staff would look for the resident on all the halls and the grounds of the facility. RN C said because of the alarms on all the doors of the facility, residents should not be able to elope out of the facility, but they may follow a family out when the family left. RN C said the door alarms had not worked in the past. RN C said when the door alarms did not work the staff would conduct fifteen-minute rounds to ensure all residents were accounted for and log the rounds. RN C said the most recent time the doors were not working was after the inclement weather that interrupted electricity in Houston. Interview on 7/5/2024 at 5:11 PM with the DON, who said she had been employed since 6/17/2024, had been employed prior to that time as well, but not been employed by the facility during the month of April 2024. The DON said the steps taken to ensure residents are unable to elope included securing the doors, reinforcing the lock on the gate of the memory care unit's exterior area, and updating the locks on the doors to not disengage with power outages. The DON said there had been no elopements at the facility since her return on 6/17/2024. The DON said Resident #4 and Resident #5 may have exited by following a visitor out of the memory care unit, but she was unsure how those elopements occurred. The DON said the codes to enter the building and the memory care unit have been recently updated to ensure visitors do not know the codes and cannot accidentally allow residents to leave. The DON said she expected CNA's and nurses to round at least every two hours. The DON said she was unsure if staff in the memory care unit completed headcounts every fifteen minutes. The DON said the facility had taken steps to ensure elopements did not occur including monitoring the doors, monitoring when visitors entered and exited the memory care unit, and redirecting residents away from the doors at all times. The DON said some of the memory care unit residents ate in the dining hall with other residents, but at least one CNA and one hospitality aide monitored them when they were not in the memory care unit. Interview on 7/5/2024 at 5:45 PM with the Admin, who said her primary duties were to manage the overall operation of the facility. The Admin said on 4/5/2024 Resident #4 went to the business in the building behind the facility. The Admin said the secretary for the other business called the facility and a nurse brought Resident #4 back to the facility. The Admin said she was unsure how Resident #4 got out of the facility, but she believed it was by staff or a resident accidentally pressing an emergency door release button on the wall throughout the facility which released all the doors allowing her to elope. The Admin said when one of the emergency release buttons is pressed all the doors in the facility are released. The Admin said Resident #4 was found in the roundabout leading from the facility to a major thoroughfare and by a hospital parking lot. The Admin said Resident #4 often wants to go home but she cannot due to her diagnoses and needs. The Admin said Resident #4 must have been walking quickly to be found at the roundabout. The Admin said she was unsure how long Resident #4 was out of the facility on 4/5/2024. The Admin said 4/5/2024 was Resident #4's first day at the facility. The Admin said after the incident, all residents were assessed for an elopement risk, and Resident #4 was provided with increased supervision. The Admin said on 4/30/2024 Resident #4 and Resident #5 were able to elope from the facility. The Admin said she was unsure how the residents were able to exit through the backdoor of the memory care unit and through the normally locked gate. The Admin said the gate could not be unlocked by a resident. The Admin said the gate may have been unlocked by the lawncare agency contracted with the facility. The Admin said since the incidents on 4/5/2024 and 4/30/2024 the facility had the alarm contractor review the facility's needs and risks. The Admin said the release buttons had a protective cover placed over them to ensure no accidental releases occurred. The Admin said the facility was also installing a reset button to automatically relock any doors opened with the emergency release buttons. The Admin said if the power goes out in the facility the doors automatically release and have to be reset. The Admin said the staff have been provided training to ensure that any time the electricity was to go out the staff immediately check and reset the doors. The Admin said the facility was monitoring the doors weekly to ensure there were no further incidents. The Admin said the facility had also added a third staff to the memory care unit which now consisted of two CNA's, a hospitality aide, and a nurse. The Admin said there had been no other concerns in the memory care unit since that time. Interview on 8/8/2024 at 11:09 AM with the Maintenance Director, who said he had been employed for four years. The Maintenance Director said his primary duties included overall facility maintenance of any needs and repairs for the facility. The Maintenance Director said the residents had eloped on 4/5/2024 and 4/30/2024 by following staff and/or visitors out of the memory care unit. The Maintenance Director said on 4/05/2024 Resident #4 eloped from the facility through the back door of the memory care unit. The Maintenance Director said the back door may not have been secured when Resident #4 eloped on 4/5/2024 because when the facility's power surges or goes out the doors disengage. The Maintenance Director said when that occurred staff had to reset the doors. The Maintenance Director said when the facility's generator was engaged due to lack of power the doors disengage and the staff have to reset the system. The Maintenance Director said the facility had the same system currently, but staff were provided with an in-service training related to resetting and checking all exit doors in the event of a power outage or surge. The Maintenance Director said the cover over the emergency door release button had been in place in the memory care unit since it was converted from long term care to memory care multiple years ago. The Maintenance Director said the covers over the other two emergency door release buttons were installed in May of 2024. The Maintenance Director said the emergency door release button could have been the cause of the elopements if someone had accidentally pressed the button. The Maintenance Director said he assisted in presenting the in-service trainings. The Maintenance Director said to his knowledge all staff have received the training. The Maintenance Director said he did not know how long the residents were outside the facility on 4/5/2024 or 4/30/2024. The Maintenance Director said he had made adjustments to the doors to increase the speed at which they close and relock if the release bar is pressed. The Maintenance Director said there had been no more elopements since the door adjustments and cover over the emergency door release buttons were installed. Interview on 8/8/2024 at 1:11 PM with LVN D, she said she had been employed since April 2024 and worked primarily on the memory care unit. LVN D said she was not in the building when Residents #4 and #5 eloped on 4/30/2024. LVN D said she was informed that two residents were able to elope. LVN D said since that time the facility had routine meetings and in-service related to resident supervision and elopements. LVN D said the facility had conducted rounds every fifteen minutes on the secure unit until 8/5/2024. LVN D said the staff in the memory care unit completed two security checks on the front and back doors of the unit each shift. LVN D said the staff were alert for any alarm sounds indicating a door on the memory care unit had become unlocked. LVN D said all the facility's staff were trained where to go if the power went out during a shift. LVN D said she was trained that if power went out the facility's doors became unlocked. LVN D said the staff were trained to go to the doors and secure them to ensure residents did not exit, and nurses would conduct a head count to ensure no residents were unaccounted for, and additional staff would monitor the outdoor area of the facility to ensure no residents had left when the power was out. LVN D said since 4/30/2024 no residents had eloped, and the facility was secure at all times. LVN D said during in-service trainings related to elopement, he was trained that if the power went out or there was a power surge at the facility staff were immediately to go to the doors, nurses were expected to complete a headcount, and staff that reached the doors first were to complete visual inspection of the area around the door to ensure no residents had eloped prior to the staff reaching the doors. LVN D said the staff had to demonstrate their understanding of the information to the DON. LVN D said the doors had an alarm which would chirp if the doors became unlocked. LVN D said if the staff heard a door alarm sound or chirp, the staff were to go to the door immediately, complete a visual assessment of the area around the door to ensure no residents had eloped, and reset the alarm. LVN D said the staff were also expected to attempt to identify any residents or visitors who may have caused the alarm to sound so they could be reeducated on the door alarms. Interview on 8/9/2024 at 1:20 PM with CNA E, who said she had been employed for one year. CNA E said her primary duties included assisting residents with ADL's and everyday care. CNA E said she typically work on all halls, and did not have a specific hall she was assigned to. CNA E said would assist in the memory care unit, but it was not her typical assignment. CNA E said when she worked in the memory care unit she was expected to supervise the residents and ensure they did not get out of the secured doors from the unit. CNA E said she had recently received in-service training related to resident abuse, neglect, and exploitation, and resident elopements. CNA E said during the resident elopement in-service training she was informed that if a door alarm sounded in the facility, all CNA staff went to a door and stood by it until the all clear was called and the system was reset. CNA E said she was also informed that if the power went out at the facility the doors unlocked. CNA E said during the in-service training she was instructed that if there was a power outage at the facility the CNA's were to go to all the doors and gates of the facility until the all clear was sounded and the door locks were reset with the return of power or the backup generator and someone pressed the reset button. CNA E said the nurses completed a headcount while the CNA's remained by the doors. CNA E said if a specific door alarm sounded staff went to that door, went outside the door and conducted a visual assessment of the area around the door to ensure there were no residents outside . CNA E said she was not present when Residents #4 and #5 had eloped in April of 2024, but she was informed it occurred. CNA E said since the residents were able to elope in April of 2024, the facility had installed plastic covers over the emergency door release buttons near the two nurses' stations. CNA E said there had been a cover over the emergency release button in the memory care unit since she had been employed. Interview on 8/9/2024 at 1:27 PM with LVN F, who said she had been employed for seven years. LVN F said her primary duties included medication administration, monitoring the residents, g-tube care, monitoring residents for any changes of condition, and making notifications of resident needs to the physicians and families. LVN F said she primarily worked on the 200-Hall and 300-Hall. LVN F said she had recent in-service training related to resident abuse, neglect, and exploitation, rounding, and resident elopements. LVN F said during the elopement in-service trainings she was instructed that if a resident was determined to be missing staff were to visually observe all residents, conduct head counts, and check the perimeter of the facility for the resident. LVN F said she was also informed that if the facility lost power for any reason the doors unlocked. LVN F said during the in-service training staff were informed that the CNA's were each assigned to a specific door to ensure no residents could elope. LVN F said another staff was assigned to press the reset button to reset the doors when the power was restored or if the backup generator was providing power. LVN F said she was trained that if the facility's power flickered staff must check each door and ensure no residents had eloped. LVN F said the staff were to complete a visual assessment outside the door to ensure there were no residents outside. LVN F said if staff heard a door alarm sound, the staff were instructed to assess the exterior near the door, complete a headcount, and monitor the door until it was reset. LVN F said if staff could not locate a resident the staff called a code orange. LVN F said the nurses completed a head count, the CNA's searched each room, restroom, closet, shower room, or other area accessible to residents, and additional staff searched the exterior of the facility to a perimeter of approximately one mile. Interview on 8/9/2024 at 1:36 PM with CNA G, who said she had been employed for one year. CNA G said her primary included ensuring residents were cared for, answer call lights, and conducting resident care rounds every two hours. CNA G said her role was to meet the residents' needs and keep them safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately consult with resident physician and notify the resident representative when there was a significant change in the resident's physical or mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 17 residents (CR#1) reviewed for notification of change. The facility failed to notify CR#1's physician when she had an unwitnessed fall sustaining an injury and bleeding from her head. The facility failed to notify CR#1's representative party (RP) when CR#1 had an unwitnessed fall sustaining an injury and bleeding from her head. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures place residents at risk of delayed treatment causing additional injury, pain, and death. Findings include: Record review of CR#1's face sheet dated [DATE] revealed that she was a [AGE] year-old female that was originally admitted to facility on [DATE]. She had the diagnoses of Alzheimer's Disease, Cellulitis of lower left limb, repeated falls, hypertension, Major Depressive disorder, anxiety disorder, and insomnia. Record review of CR#1's Quarterly MDS assessment, dated [DATE] revealed CR#1 could not complete BIMS due to cognitive impairment. MDS completed by staff, which indicated CR#1 had memory problems and was severely impaired cognitively. CR#1 did exhibit behavioral symptoms of wandering and required supervision and two-person physical assist for ADLs. Record review of CR#1 MDS also revealed that code for four was used to signify a significant change in status when CR#1 had a fall. Record review of CR #1's care plan dated [DATE] indicated she had impaired communication, evidenced by: slurred speech, rarely/never understood. Interventions include administer medications as ordered, engage the resident in simple structured activities that avoid overly demanding tasks. CR#1 was also care planned for falls. Interventions to prevent falls was for CR#1 to wear appropriate footwear, helmet and walk on even flooring. Record review of CR#1's nurses note dated [DATE] written by RN A read in part, Resident was found by CNA at 4:47am to have sustained a small gash or laceration to her right upper brow. She was awake and alert. Wound was cleaned and dressed, resident medicated for pain and continued anxiety. BP 128/82, HR 106. Resident is resting quietly in bed now. Record review of CR#1's hospital record dated [DATE] revealed that CR#1 was examined in the emergency room and was found to have crepitus (friction between bone and cartilage or fractured bone) in the left face and neck and arms, chest and abdomen. The patient had left pneumothorax (air leaks into space between lungs and chest wall- caused by blunt or penetrating chest injury or lung disease), pneumomediastinum (air is present in the mediastinum-caused by trauma) left sided pneumoperitoneum (air or gas in abdominal cavity), subcutaneous emphysema rib fracture (emphysema caused by injury). In recored review of CR#1 nurses note dated [DATE] revealed that CR# 1 was sent to the hospital because of swelling to her face and neck. The facility nursing staff did notify all pertinent parties and they were given orders to give CR#1 Benadryl and to send CR#1 to the Hospital for further evaluation. In an interview on [DATE] at 5:05pm with CR #1's responsible party, she said she was not notified the CR#1 had an injury on [DATE]. The RP indicated she was not made aware of the incident until [DATE]. In an interview on [DATE] at 8:25am with CNA A, she said that CR#1 was in her room on the fall mat bleeding from her head. CNA A said that RN A was notified, and RN A assessed and cleaned CR#1's laceration and CR#1 was put back in bed. In an interview on [DATE] at 6:01pm RN A said she was notified by staff that CR#1 was in her room on the floor. RN A said she went into CR#1's room, and she noticed that CR#1 had an injury to her right upper eyebrow. RN A said that she cleaned and dressed the injury. RN A said that she administered 0.5ml of morphine to CR#1 for pain. RN A said that she took CR#1's vital signs and performed neuro checks on CR#1. RN A said that she sent a text message to the facility phone informing administration of CR#1's fall. She said that she did not know that she had to call the DON, RP, and the NP. Record review of CR#1's clinical file on [DATE] revealed that neuro checks had not been conducted on CR#1. Also, during this review it revealed that RN A did not notify the facility's DON, Administrator, NP, nor did she notify CR#1's RP. Neuro checks should have been conducted after the resident had fallen and the checks should have been done every 15min to 30min or as necessary until the resident was sent out to the hospital. In an interview on [DATE] at 6:32pm with DON she said she was not aware of CR#1 had an injury on [DATE]. The DON said that she did not receive a call from RN A on [DATE] that an injury had occurred involving CR#1. The DON said that RN A did not follow facility policy of notifying pertinent parties of injuries involving residents. The DON said that RN A should have called the DON, Administrator, NP, and the RP. The DON said the nurses are to report any issues that occurred over their shift or the previous shift during the morning meeting. She said without notifying the pertinent parties, it did not give them the chance to intervene or assist with the residents' care. Record review the facility policy titled Notifying the Physician of Change in status dated [DATE], states that the Nursing staff should call the DON, Administrator, NP, and the RP when there is a change in condition regarding a resident. And if the Physician does not return the call within a reasonable time the Nurse should call the Physician a second time. If still there is no response from the Physician, the nurse must contact the Medical Director and if it is and emergency the Nurse should call an ambulance service. The Nurse then must document this in the resident clinical records and the Nurse reports any issues that occurred over their shift to the oncoming shift. In an interview on [DATE] at 9:56am with the facility's NP she said she was not notified that CR#1 had an injury to her head on [DATE]. She said that if she had been notified, she would have given RN A an order to perform neuro checks and to have CR#1 transported to the hospital for further evaluation. Record review of the facility's policy regarding to Change in Status date 03/2011 read in part, The facility utilizes the INTERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident's condition requires immediate notification of the physician or non-immediate/Report on the Next Workday notification of the physician. Record review of CR#1 progress note dated [DATE] after another fall regarding CR#1revealed that the facility's Medical Director noted that he explained to CR#1 Power of Attorney, that if CR#1 continues to have multiple falls at this rate, she will likely suffer a significant trauma and death. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. The Plan of Removal was accepted on [DATE]. Record review of In-Service training attendance roster dated [DATE] revealed that RN A was in serviced on the following Abuse Neglect, Incident Reporting, Change in Condition, Event Notification, 72-hour report, How to notify Director of Nursing, Doctor, Responsible party, and Neuro Checks. Immediate Actions: o o As of [DATE] resident CR#1 was transferred to the hospital for evaluation. o o RN-A was provided 1 on 1 education by Assistant Director of Nursing (ADON) on [DATE] and again by the DON on [DATE] regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: o o Abuse & Neglect policy was reviewed and in-serviced on [DATE], the Compliance Nurse provided in-service with DON and ADON. DON/ADON will in-service Charge Nurses to ensure compliance for this policy and procedure. Will be in-serviced as needed thereafter. o o Compliance Nurse in-serviced DON and ADON's on Event note completion and Neuro check policy [DATE]. DON/ADON in-serviced Charge Nurses on neuro checks(neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. In-services will be completed for the next 3 months, then as needed thereafter. o o Notifying Physician on change in status policy that includes falls with head injury or other serious o injury was reviewed & in-serviced on [DATE], the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-serviced Charge Nurses to ensure .compliance for this policy & procedure. In-services will be completed for the next 3 months, then as needed thereafter. The Regional Compliance Nurse visited the facility [DATE] to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator also received in-service training on these topics on [DATE]. Audits completed: Event (incident) notes for the last 3 months were audited to ensure neuro checks were initiated and completed per policy. Progress notes were audited using Realtime software to ensure all events (incidents) resulting in a gash or laceration had the appropriate follow-up/treatment. o Notifying oncoming Nurse on change on any resident injury or changes that include falls or injury during change of shift report process reviewed, the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedures In-services will be completed for the next 3 months, then as needed thereafter. o Nurses were in-serviced on notifying the DON of any falls resulting in injury or any other serious injury immediately by the DON/ADON on [DATE]. o All nurses not in-serviced on [DATE] will be in-serviced prior to their next shift. o The Medical Director was notified by the Administrator on [DATE] at 12:46pm on the immediate jeopardy citation. o An AD HOC QAPI meeting was held on [DATE] by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: o The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 5 days per week (Monday through Friday) to ensure physician/NP were notified. Monitoring began [DATE] and will continue x 4 weeks and weekly thereafter. o The DON and/or designee will monitor fall events 5 days a week (Monday through Friday) to ensure neuro checks and assessments were initiated for all falls. Monitoring began [DATE] and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. o Falls will be reviewed in the morning meeting for proper documentation/assessment and follow up. This plan will be reviewed monthly at QAPI for the next three months. The Immediate Jeopardy for Villa Toscana at Cypress Woods was lowered on [DATE] at 2:02pm. Monitoring of the facility's POR Record review of the facilities in services dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that four nurses RN-B, LVN-A, LVN-B ,LVN-C, three CNA , CNA- B, CNA-C, CNA-D and the Physical therapy department were in serviced on the 2p-10p shift. In an interview with the DON and ADON on [DATE] revealed that they had conducted and revived In-Services on the information listed below: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facility's in services dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that two nurses, two CNA and the house keeping department were in serviced on the 6a-2p shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facility's in services dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that two nurses, two CNA and the house keeping department were in serviced on the 10p-6a shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report The facility was notified that the IJ was lowered on [DATE] at 2:02pm, however, the facility remaiend out of compliance at a scote of isolated and a severity level of actual harm that is not immediate jeopardy due to the facilities needing to evaluate teh effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (CR #1) reviewed for quality of care. The facility failed to notify CR#1's physician when she had an unwitnessed fall sustaining an injury and bleeding from her head. The facility failed to complete neuro checks, monitor, and send CR#1 to hospital for treatment after CR#1 had an unwitnessed fall sustaining an injury and bleeding from her head. An Immediate Jeopardy (IJ) was identified on 08/25/2022 at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on 08/29/2022, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of further injury, pain and delayed medical treatment. Findings include: Record review of CR#1 face sheet on 08/09/23 at 10:30am revealed that she was a [AGE] year-old white female that was originally admitted to facility on 07/16/21. She has the diagnoses of Alzheimer, Cellulitis of lower left limb, repeated falls, hypertension, Major Depressive disorder, anxiety disorder, and insomnia. Record review of CR#1's Quarterly MDS, dated [DATE] revealed CR#1 could not complete BIMS due to cognitive impairment. MDS completed by staff, which indicated CR#1 had memory problems and was severely impaired cognitively. CR#1 did exhibit behavioral symptoms of wandering and required supervision and two-person physical assist for ADLs. Record review of CR #1's care plan dated 05/19/23 indicated she had impaired communication, evidenced by: slurred speech, rarely/never understood. Interventions include administer medications as ordered, engage the resident in simple structured activities that avoid overly demanding tasks. Record review of CR#1's hospital record dated 08/03/23 revealed that CR#1 was examined in the emergency room and was found to have crepitus (friction between bone and cartilage or fractured bone) in the left face and neck and arms, chest and abdomen. The patient had left pneumothorax (air leaks into space between lungs and chest wall- caused by blunt or penetrating chest injury or lung disease), pneumomediastinum (air is present in the mediastinum-caused by trauma) left sided pneumoperitoneum (air or gas in abdominal cavity), subcutaneous emphysema rib fracture (emphysema caused by injury). In record review of CR#1 nurses note dated 08/03/23 revealed that CR# 1 was sent to the hospital because of swelling to her face and neck. The facility nursing staff did notify all pertinent parties and they were given orders to give CR#1 Benadryl and to send CR#1 to the Hospital for further evaluation. In an interview on 08/09/23 at 8:25am with CNA A, she said that CR#1 was in her room on the fall mat bleeding from her head. CNA A said that RN A was notified, and RN A assessed and cleaned CR#1 laceration and CR#1 was put back in bed. In an interview with RN-A on 08/08/23 at 5:53pm she stated that facility staff notified her that CR#1 was in her room on the floor bleeding from her head. RN-A said that she took CR#1 vitals and she cleaned and dressed the injury. She gave CR#1 medication for pain and CR#1 was placed back in bed. RN-A said that she sent a text message to the facility phone regarding the incident. RN-A stated that she did not notify the facility NP. When RN-A was asked why she didn't notify the NP she said that she sent a message to the facility phone. She said she did not have the number for the DON, nor the NP. RN-A was asked why she didn't perform neuro checks on CR#1 and she stated that she did do neuro checks but she did not know how to save it in the system. Record review of CR#1's nurses note dated 08/01/20223 written by RN A read in part, Resident was found by CNA's to have sustained a small gash or laceration to her right upper brow. She was awake and alert. Wound was cleaned and dressed, resident medicated for pain and continued anxiety. BP 128/82, HR 106. Resident is resting quietly in bed now. In an interview on 8/08/23 at 6:01pm RN A said she was notified by staff that CR#1 was in her room on the floor. RN A said she went into CR#1's room, and she noticed that CR#1 had an injury to her right upper eyebrow. RN A said that she cleaned and dressed the injury. RN A said that she administered 0.5ml of morphine to CR#1 for pain. RN A said that she took CR#1 vital signs and performed neuro checks on CR#1. However, upon record review of RN A nurses' notes it revealed that no neuro checks had been conducted on CR#1. Also, during this review of RN, A nurses' notes it revealed that RN A did not notify the facilities' DON, Administrator, NP, nor did she notify CR#1's RP. In an interview on 08/08/22 at 6:32pm with DON she said she was not aware of CR#1 had an injury on 08/01/23. The DON said that she did not receive a call from RN A on 08/01/23 that an injury had occurred involving CR#1. The DON said that RN A did not follow facility policy of notify pertinent parties of injuries involving residents. The DON said that RN A should have called the DON, Administrator, NP, and the RP. The DON said the nurses are to report any issues that occurred over their shift or the previous shift during the morning meeting. She said without notifying the pertinent parties, it doesn't give them the chance to intervene or assist with the residents' care. DON stated that by RNA not contacting the NP and getting an order to send CR#1 at greater risk of harm. DON also stated that she could not confirm that RN A conducted neuro checks. In an interview on 08/09/23 at 9:56am with the facilities NP she said she was not notified that CR#1 had an injury to her head on 08/01/23. She said that if she had been notified, she would have given RN A an order to perform neuro checks and to have CR#1 transported to the hospital for further evaluation. NP stated that by not informing medical staff of the head injury could put the resident a risk for serious injury. Record review of the facilities policy regarding to Change in Status date 03/2011 read in part, The facility utilizes the INTERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident's condition requires immediate notification of the physician or non-immediate/Report on the Next Workday notification of the physician. Record review of CR#1 progress note on 08/26/23 at 11:30am dated 05/25/23 revealed that the facilities Medical Director noted that he explained to CR#1 Power of Attorney, if CR#1 continues at this rate, she will likely suffer a significant trauma and death. In an interview on 08/26/23 at 11:45am with the DON she was asked if she knew that the Medical Director had informed CR#1 Power of Attorney that if CR#1 continues at this rate, she will likely suffer a significant trauma and death. The DON said that she was aware of the conversation, because she and the Medical Director felt that hospice was the best course of action for CR#1. An Immediate Jeopardy (IJ) was identified on 08/25/2022 at 2:00 p.m. The IJ template was provided to the facility at that time. While the IJ was removed on 08/29/2022, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. The Plan of Removal was accepted on 08/27/23. Immediate Actions: o o As of 8/2/23 resident CR#1 was transferred to the hospital for evaluation. o o RN-A was provided 1 on 1 education by Assistant Director of Nursing (ADON) on 8/8/23 and again by the DON on 8/26/23 regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: o o Abuse & Neglect policy was reviewed and in-serviced on 8/25/23, the Compliance Nurse provided in-service with DON and ADON. DON/ADON will in-service Charge Nurses to ensure compliance for this policy and procedure. Will be in-serviced as needed thereafter. o o Compliance Nurse in-serviced DON and ADON's on Event note completion and Neuro check policy 8/25/23. DON/ADON in-serviced Charge Nurses on neuro checks(neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. In-services will be completed for the next 3 months, then as needed thereafter. o o Notifying Physician on change in status policy that includes falls with head injury or other serious o injury was reviewed & in-serviced on 8/25/23, the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-serviced Charge Nurses to ensure .compliance for this policy & procedure. In-services will be completed for the next 3 months, then as needed thereafter. The Regional Compliance Nurse visited the facility 8/25/23 to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator also received in-service training on these topics on 8/25/23. Audits completed: Event (incident) notes for the last 3 months were audited to ensure neuro checks were initiated and completed per policy. Progress notes were audited using Realtime software to ensure all events (incidents) resulting in a gash or laceration had the appropriate follow-up/treatment. o Notifying oncoming Nurse on change on any resident injury or changes that include falls or injury during change of shift report process reviewed, the Compliance Nurse in-serviced DON and ADON. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedures In-services will be completed for the next 3 months, then as needed thereafter. o Nurses were in-serviced on notifying the DON of any falls resulting in injury or any other serious injury immediately by the DON/ADON on 8/25/23. o All nurses not in-serviced on 8/25/23 will be in-serviced prior to their next shift. o The Medical Director was notified by the Administrator on 8/25/23 at 12:46pm on the immediate jeopardy citation. o An AD HOC QAPI meeting was held on 8/25/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: o The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 5 days per week (Monday through Friday) to ensure physician/NP were notified. Monitoring began 8/25/23 and will continue x 4 weeks and weekly thereafter. o The DON and/or designee will monitor fall events 5 days a week (Monday through Friday) to ensure neuro checks and assessments were initiated for all falls. Monitoring began 8/25/23 and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. o Falls will be reviewed in the morning meeting for proper documentation/assessment and follow up. This plan will be reviewed monthly at QAPI for the next three months. Monitoring of the facilities POR Record review of the facilities in services on 08/27/23 at 3:10pm revealed that four nurses, three CNA and the Physical therapy department were in serviced on the 2p-10p shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facilities in services on 08/28/23 at 11:00am revealed that two nurses, two CNA and the house keeping department were in serviced on the 6a-2p shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report Record review of the facilities in services on 08/29/23 at 9:00am revealed that two nurses, two CNA and the house keeping department were in serviced on the 10p-6a shift. The in service was on: 1. How to notify the Director of Nursing, Medical Director, Administrator, and responsible party of falls. 2. Neuro Checks 3. Shift Reports 4. Abuse and Neglect 5. Event Reporting 6. 72-hour report The facility was notified that the IJ was lowered on 08/29/23 at 2:02pm, however, the facility remaiend out of compliance at a scote of isolated and a severity level of actual harm that is not immediate jeopardy due to the facilities needing to evaluate teh effectiveness of the corrective systems.