**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 15 residents (Resident#74) reviewed for accident hazards and supervision. Resident #74 eloped at night and crossed a busy 5-lane road before she was found at a bus stop by an off-duty CNA. This failure resulted in the identification of an IJ (Immediate Jeopardy) on 09/10/25. While the immediacy was removed on 09/12/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal This failure could place residents at risk for elopement, significant injury, and serious impairment or death.The Findings included:Observation on 9/9/25 from 8:50 AM to 10:15 AM of facility reflected: the inside door to the front lobby had a charm and keypad; the charm sounded when the door was opened. The door had an old wandering alert system not working and an electronic magnetic lock not working. The front door of the facility had no charm and/or keypad system or 15 second delay system; the front door was locked by a dead bolt. Receptionist desk was adjacent to the front door. Receptionist was present at the receptionist desk. Further observation of the path Resident #1 took during the elopement incident reflected the bus stop was about 150 feet from the facility. The bus stop was off the facility's ground and a 5-lane highway with busy traffic was adjacent to the bus stop. The resident had to cross the 5-lane road to get to the bus stop. Record review of Resident #74's face sheet, dated 9/10/25, reflected a 75 -year-old female who was admitted to the facility on [DATE] for respite care and discharged [DATE]. Resident #74 had diagnoses which included: HTN (hypertension), dementia (brain disorder resulting in decline in cognition), Alzheimer's disease (progressive disease that destroys memory), and breast cancer. The RP was listed as a family member. Record review of Resident's MDS, dated [DATE] in progress, reflected the resident's BIMS score was zero indicative of severe impairment in cognition. Resident was ambulatory. Record review of facility's incident report dated 9/6/25 titled Elopement Attempt Report, Resident #74, reflected: the timeline of elopement, namely between 8:59 PM and 10:08 PM. Further, the interview the Administrator had with the resident at 9/7/25 at 9:45 AM, the resident communicated to the Administrator she looked for an opportunity to elope and did not want to remain in the facility and wanted to visit her sister. The resident stated her work was done and she did not need to occupy a bed of another patient. Record review of Resident #74's Ambulation Assessment, dated 9/3/25, reflected resident was ambulatory. Record review of Care Plan dated 9/3/25 (baseline) read: .Assess for risk of elopement.Frequent rounding of resident. Record review of Resident #74 elopement score, dated 9/3/25 was 7 (moderate risk) [3-7score equaled moderate risk for elopement] Record review of Resident #74's Nurse Note, dated 9/6/25, at 8:58 PM authored by RN E reflected resident was seen wandering throughout the facility. Record revies of Resident #74's Nurse Note dated 9/6/25 at 10:33 PM authored by RN E read, .CNA [D] reports to this nurse [RN E], resident noted at bus stop across the street from facility. Brought resident back in with him. Resident confused; states she is trying to find her sister. Resident denies being hurt or any pain. Respiration even. Skin warm and dry. Skin assessment clear, no issues. [vitals]116/74 [blood pressure]62 [pulse] 18 [respiration] 97.8 [temperature] 96% [O2]Room Air Assisted to room and into bed. No acute distress noted. Call placed and message left for RP. Record review of facility's Elopement Binder, undated, found at the receptionist's desk reflected the presence of 15 face sheets with photographs. Resident #74 's face sheet and photo were in the binder. Record review of receptionist's written statement undated reflected she left the receptionist station around 9:40 PM to purchase dinner at a nearby restaurant. Receptionist stated she did not turn on the foyer alarm at 8:00 PM and she could not recall setting the alarm at 10:00 PM. During an interview on 9/9/25 at 10:10 AM the Maintenance Director, who accompanied the survey on Resident #74's route of elopement, stated he could not explain why the inside door charm was not heard and the keypad not set after 8:00 PM. The Maintenance Director stated the facility did not have a patient alert system. The Maintenance Director stated the distance to the bus stop was about 150 feet from the facility. The Maintenance Director stated it was a negative incident for a resident to wander to the bus stop because of the dangers of traffic, accidents and hazards, and stray dogs. The Maintenance Director stated the last time he checked the door alarm system was 8/25/25 and there were no concerns and he checked the alarm system weekly. During an interview on 9/9/25 at 11:05 AM, the DON stated Resident #74 was discharged on 9/8/25 around 5 PM because she needed to be in an environment that she was more comfortable in, and her family returned to town yesterday (9/8/25). The DON stated the resident was scheduled for respite care for 8 days at the time of admissions (9/3/25). The DON stated the resident's primary diagnoses included dementia, breast cancer, HTN, and pain; and the resident's BIMs was a zero (severe impairment). The DON stated Resident #74' elopement assessment on 9/3/25 scored was 07 indicative of at risk for elopement. The DON stated RN E documented that the resident was confused on 9/6/25 [date of elopement] and wandering throughout the facility and easily redirected. The DON stated that in RN E's statement she visibly saw the resident around 9:50 PM and the resident was following CNAs down the hall. The DON stated the last time Resident #74 was seen was at 10:08 PM by CNA D at the bus stop and brought back to the facility. The DON stated that Resident #74 communicated to CNA D she wanted to go home. DON stated the resident was assessed by RN E and the resident did not exhibit any adverse physical or psychosocial harm. The DON stated the RP, and the MD were notified. The DON stated a receptionist [Receptionist F] was not present between 9:50 PM and 10:08 PM (an 18-minute gap). The DON repeated there was no receptionist present at the timeframe of elopement. The DON stated she assumed the exit foyer door charm rang but not heard by any staff and the keypad was not set. The DON stated after the facility's investigation, it was determined the keypad was not set. The DON stated she was notified of the elopement on 9/8/25 around 10:10 PM. The DON stated it was not safe for Resident #74 to be outside the facility because she could be struck by a car or gotten lost. During an interview on 9/9/25 at 11:53 AM, CNA D stated he was off on 9/6/25 and passed the facility and, I glanced at the facility and saw the resident at the bus stop. CNA D stated he recognized the resident based on the fact he had seen the resident in the facility. CNA D stated he stopped, and the resident told him she wanted to go home; and she forgot where she was. CNA D stated the bus stop was across the street from the facility. CNA D stated he did not know how the resident crossed the street. CNA D stated the resident could have been harmed or struck by a car or a lot of things. CNA D stated he knew the resident had a diagnose of dementia. CNA D stated he had no explanation how the resident eloped. During a telephone interview on 9/9/25 at 1:35 PM, the RP stated she was called when the resident eloped. The RP described the resident as a person with dementia who was ambulatory and exit seeking. The RP stated she was concerned that the resident was able to elope without the facility noticing her absence and her crossing a busy road. The RP stated that the resident told her she left the facility during shift change. The RP stated the resident was safe in her home after being discharged from the facility on 9/8/25. During a telephone interview on 9/9/25 at 2:00 PM, RN E stated she physically saw Resident #74 following staff (CNAs and CMAs) asking them where her sister was. RN E stated the resident was a wanderer throughout the facility. RN E stated the resident eloped during night shift change (10:00 PM). RN E stated the door leading to the front door required the setting of the keypad at 8:00 PM when the receptionist ended her workday. RN E stated, staff forgot to set the keypad which was the root-cause of the resident eloping. RN E stated she assessed the resident when she returned to the facility and there was no physical or psychosocial harm. RN E stated the resident could have been hit by a car crossing the road near the facility. During a telephone interview on 2/9/25 at 2:15 PM, the MD stated the facility should have followed elopement protocols involving Resident #74. The MD stated the key to Resident #74's elopement should have been prevention. During a telephone interview on 9/10/25 at 10:53 AM RN H stated she saw Resident #74 wandering throughout the facility on 9/6/25 and she knew the resident had a diagnosis of dementia. RN H stated she was not called at 8:00 PM by the receptionist [Receptionist F] to set the foyer key lock alarm. RN H stated she was called by the receptionist [F] at 10:00 PM to set the alarm but she was too busy and did not set the alarm. RN H stated she was aware of the need to set the keypad alarm as per elopement protocol. RN H stated at shift change she was not present at the foyer location to hear the charm sounding. RC H stated she could not give an explanation how the resident eloped and why the resident was not monitored as a wanderer at risk for elopement by other nursing staff. During an interview on 9/9/25 at 3:04 PM, the Administrator stated Resident #74 was admitted for 5-7 days for respite care. The Administrator stated the timeline based on the self-report was the resident was admitted on [DATE] and was last seen on 9/6/25 at 9:50 PM by RN E; shift change occurred at 10:00 PM; and the resident was found across the street at a bus stop at 10:08 PM by CNA D who was not on duty. The Administrator stated the keypad had not been set at 8:00 PM by the RN H as requested by the receptionist [Receptionist F]. The Administrator stated RN H confirmed the keypad had not been set on 9/6/25 at 8:00 PM per protocol. The administrator stated the facility had a protocol for elopement and he did not explain why the protocol was not followed by the receptionist [F] and verified by the RN [H]. The Administrator stated the What apps [computer-based application for tracking setting of alarms] did not show that the keypad was armed/set on 9/6/25 at 8:00PM. The Administrator stated he assumed the keypad would be set at 8:00 PM. During an interview on 9/10/25 at 9:11 AM, the ADON stated based on nursing practice after a shift change at 10:00 PM the on-coming nursing staff would check on the resident population or at a minimum by midnight. The ADON stated that she could not give an explanation why the headcount of Resident #74 after shift change (average time was 15-20 minutes) was not done or documented by exception. During a telephone interview on 9/10/25 at 10:00 AM, Receptionist F stated she did not arm the foyer door at 8:00 PM on 9/6/25 because I got busy. The receptionist stated protocol called for the arming of the foyer door at 8:00 PM and verified by another staff member. The receptionist stated her shift was from 8 AM to 10:00 PM and she left duty on 9/6/25 at 10:01 PM. The receptionist stated she did not see Resident #74 throughout the day and there was an elopement binder at the receptionist desk which contained the face sheet and photo of Resident #74. The receptionist stated that RN H did not arm the foyer door at 8:00 PM. Record review of facility's investigation binder dated 9/6/25 reflected:---HHS self-report dated 9/6/25 with a finding of confirmed.---Written statement by CNA D dated 9/6/25 which documented while he was off-duty found Resident #74 across the facility at a bus stop.---Written statement by RN E dated 9/6/25 which documented she last saw Resident #74 in the facility on 9/6/25 at 9:50 PM.---The Facility's root -cause analysis which identified the root cause as the foyer alarm not being set and the receptionist not being at the front door receptionist desk.----The Disciplinary form entitled coaching given to the Receptionist F for not setting the alarm and giving false information.---The Sign-in sheet for the Ad-hoc QAPI meeting on 9/7/25 which addressed the root-cause analysis of Resident #74's elopement.---The In-service sign in sheets on elopement dated 9/7/25 given to 18 staff members [total paid staff was 89].----Resident #74's 15-minute monitoring sheet started 9/6/25 and ended 9/8/25.---Resident #74's one-on-one monitoring sheet initiated on 9/7/25 and ended 9/8/25. Record review of facility's Maintenance Log, undated, reflected the alarm system to the door leading to the front lobby was checked on 8/25/25. Record review of Receptionist F's Employee Coaching dated 9/7/25 reflected she provided inaccurate information to the Administrator that the foyer door was locked and keyed at 8:00 PM on 9/6/25. Receptionist was in-serviced on elopement policy, accurate reporting, and expectations. Record review of RN E's written statement dated 9/6/25 reflected she saw Resident #74 wandering the facility at 9:50 PM following a CNA. The next time RN E saw the resident was at 10:08 PM when she was returned to the facility by a CNA D. Record review of RN H's written statement date 9/7/25 reflected the RN H did not set the alarm (9/6/25 at 8:00 PM) when it was due to be set. Record review of facility's Alarm Check form, undated, read: .First door alarm to be turned on no later than 8:00 PM. Door will be checked every 2 hours to ensure it is functional. Record review of facility's Emergency Procedure-Missing Resident, dated August 2028, read: .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Record review of the facility's Wandering and Elopement policy, dated March 2029 read: .If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This was determined to be an immediate jeopardy (IJ) on 09/10/25 at 4:25 PM. The Administrator was notified. The Administrator was provided with the template on 09/10/25 at 4:25 PM.The following Plan of Removal submitted by the facility was accepted on 09/11/25 at 10:32 AM. It was documented as follows: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes.On September 10, 2025, an investigation was initiated at [Nursing Facility] At approximately 4:41 pm on September 10, 2025, a surveyor provided written notification that Texas Health and Human Services had determined the conditions at [ Nursing Facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas:F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy.On September 6, 2025, at approximately 10:08pm resident #74, who was admitted on [DATE], for a short-term respite stay, was identified as having eloped from facility and returned safely at 10:10pm by a C.N.A. who was not on shift. Action: Resident #74 was immediately assessed by charge nurse on duty, RN [E] and found to be free of adverse effects related to elopement. Resident was placed on 15-minute checks while sleeping throughout the night, and on 1:1 care at 7:25am and remained on 1:1 supervision until safely discharging home with family on September 8, 2025, at 5:00pm. On September 10, 2025, at approximately 5:00 pm the following actions were taken:Action: Facility Administrator and Director of Nursing were educated by Regional Clinical Nurse and Area President on Abuse and Neglect, Wandering and Elopement, Emergency Procedure for Missing Persons, Elopement/Missing Person Protocol The sole responsibility was on the receptionist [Receptionist F] who didn't comply. The receptionist was coached (and placed on notice) by the Administrator and Director of Nursing (DON). She was also re-educated on the protocol. The RN [H] was re-educated on the protocol by the DON. Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Regional Clinical Nurse/Area President Action: Education initiated Abuse and Neglect, Residents Rights, Wandering and Elopement, Emergency Procedure for Missing Persons, Elopement/Missing Person Protocol, Process to secure front door. The Staff was in-serviced on resetting door code/keypad. The staff were also educated on the receptionist duty hours of 8:00 am to 10:00 pm by the DON, Administrator, Director of Nursing or Department Manager or designee. The staff has been in-serviced by the DON, Administrator, Director of Nursing or Department Manager or designee that the doors are locked at 8:00 pm. Education will be completed for all staff, including PRN employees or agency (if applicable). The facility does not utilize agency staff. New hires will be educated in orientation.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Director of Nursing/designee Action: Administrator validated that exit doors are functioning as designed and intended. Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Administrator/Designee IDENTIFICATION OF OTHERS AFFECTED:All residents have the potential to be affected.Action: An audit was completed on Elopement and Wandering Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES:Action: In-service and education on Abuse and Neglect, Resident Rights, Wandering and Elopement, Emergency Procedure for Missing Persons, Elopement/Missing Person Protocol, and the process to secure front door.Start Date: 9/10/2025.Completion Date: 9/10/2025 and ongoing for all new hiresResponsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 9/10/2025.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Administrator/Designee Action: A secondary alarm was installed on exterior front door. The secondary alarm will be secured at 8pm daily and validated by receptionist and a nurse employee. Once alarm has been secured, employees will send a secure message to department heads to confirm completion. A quote for exterior doors with magnetic lock and keypad release was obtained, reviewed, and submitted to corporate office for scheduling of installation.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible Party: Maintenance Director/Administrator or designee Tracking and Monitoring Director of Nursing/Designee will review residents with at risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 9/10/2025 Administrator/designee will complete random audit every shift for 7 days, beginning 9/11/205, for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week. Administrator/designee will complete audit of exits for proper functioning of doors, and alarms for proper functioning every shift for 7 days, beginning 9/10/2023 then will monitor random shifts, 5 times a week. The receptionist is on duty 7 days a week from 8:00 am to 10:00 pm including weekends Tracking and Monitoring will be reviewed with Quality Assurance Committee monthly, for three months and as needed thereafter. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review. Administrator Validation of the POR. Key Observations: Observation on 9/11/25 from 4:45 PM-4:50 PM reflected no door posed an elopement risk. The doors sounded with an alarm which allowed staff to respond in the event a resident attempted an elopement. Further observation reflected the foyer door where Resident #74 used to elope was armed and the keypad was operational. The front door to the facility had been modified with an alarm. Observation on 9/11/25 at 4:55 PM of facility's Elopement Risk binder contained 24 residents face sheets and photo. Also, the binder contained the elopement risk tool and the elopement protocol. Observation on 9/11/25 at 4:56 PM reflected the presence and functioning of a secondary alarm on the exterior front door. Also sign present for visitors was a posting on the foyer exit door that read: Attention. Please be observant. Do not allow residents to follow you out. Key Interviews:During a telephone interview on 9/9/25 at 1:35 PM, RP stated she was called when the resident eloped. The RP confirmed that the resident was at her home. During a joint interview on 9/11/25 at 4:20 PM with the Administrator and DON, the Administrator stated the highlight of the training on ANE was to utilize the elopement protocol to ensure safety and for staff/residents/visitors to report any allegation of ANE. The Administrator stated the highlight of the Wandering Inservice was not to make assumptions that staff followed elopement protocols. The DON stated the point stressed on Emergency Procedures was to know the whereabout of residents throughout the day. The DON stated the highlight of the Elopement/Missing Person Protocol was to thoroughly check the elopement risk score and put prevention measures in place. The Administrator stated: The sole responsibility was on the receptionist who did not comply. The receptionist was coached (and placed on notice) by the Administrator and Director of Nursing (DON). She was also re-educated on the protocol. During an interview on 9/11/25 at 4:35 PM, the DON stated the facility had 3 shifts (6:00 AM-2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00AM; and same shifts on weekends. During an interview on 9/11/25 at 4:37 PM, the Administrator stated he checked the exit doors every starting on 9/10/25 and would continue for 7 days and then for 5 days and then there would be a QAPI review. During an interview on 9/11/25 at 5:11 PM, CMA J(Medical Records, CMA) stated she attended the QAPI meeting on 9/10/25 and the highlight of the meeting was discussion of measures to prevent elopement and review of the elopement protocol. During an interview on 9/11/25 at 5:19 PM, CMA J stated when assigned the duty of receptionist would call a nurse to set the keypad at the foyer door at 8 PM, and wait until it was set, and test that the alarm triggered. Once the alarm was set the receptionist would send a message to department heads that the alarm was set at 8:00 PM. During an interview on 9/11/25 at 5:34 PM, the DON stated the facility had one new admission on [DATE] and the resident (Resident #1) scored a zero on elopement screen. [Record review of resident #1's elopement score on 9/11/25 reflected a score of zero.] During an interview on 9/11/25 at 5:44 PM stated the next QAPI meeting was scheduled for 9/29/25. In-service: During an interview on 9/11/25 at 6:00 PM, Receptionist L stated the highlights of his training included: ANE was to report immediately, for elopement to check on residents that wandered and check the elopement risk book if not certain, and to search for any missing residents. Also, Receptionist L stated to check on the setting of the alarm at 8:00 PM and if he had to take a break have another staff cover the reception desk. During an interview on 9/11/25 at 6:10 PM, RN M stated Abuse/Neglect/Exploitation [ANE [highlight was to report immediately. The main point on elopement to monitor wanders and start an immediate search when a resident; to check on residents every shift change and every 2 hours. The RN stated that the alarm had to be set at 8:00 PM and check the alarms every 2 hours. During an interview on 9/11/25 at 6:15 PM, CNA N stated ANE highlight was to report allegations of abuse to the Administrator who was the Abuse Coordinator. Regarding rights was to respect the resident rights. As for elopement to monitor, check on the whereabouts of residents, and listen for the door opening a closing. The CNA stated that at 8:00 PM to check that the exit door keypad was set. Likewise, when she arrived on duty to ensure assigned are in the facility. During an interview on 9/12/25 at 2:05 PM, LVN I stated she attended in-services, and the major highlights were report ANE to the Abuse Coordinator, respect resident rights, and to headcount the caseload. LVN stated that nursing staff needed to follow elopement and missing person protocols. During an interview on 9/12/25 at 2:09 PM, CMA O stated he attended in-services and the highlights were report ANE, respect resident rights, and ensure the doors were secured at 8:00 PM. The CNA stated that staff need to monitor wanderers and at shift change do a head count of the residents. The CNA commented that he had to participate in searching in the event a resident went missing. During an interview on 9/12/25 at 2:15 PM, CNA P stated she attended in-services and recalled the points made were to report ANE to the Abuse Coordinator, the Administrator, and to be alert for residents that were wanderers and exit seekers. She also was to check that doors were armed and secured at 8:00 PM and participate in the search of any missing resident. Night Shift (10 PM-6 AM) During a telephone interview on 9/11/25 at 10:05 PM, LVN Q stated: the highlight of the in-service on ANE was to report any suspicion of abuse to the Abuse Coordinator. As for Rights, LVN Q stated to respect the resident's right to participate in treatment. LVN Q stated the high point on the elopement training was to check on residents and to ensure the door key lock was properly set. During a telephone interview on 9/11/25 at 10:10 PM, LVN R stated the highlights of the in-services were report abuse, respect resident rights, know the whereabouts of residents, and properly set the door key lock at 8:00 PM. During a telephone interview on 9/11/25 at 10:15 PM, LVN S stated she attended in-service training and some of the highlights were: the abuse coordinator was the Administrator, respect resident rights, and check on residents during shift change and regularly throughout the shift. LVN added that a code had to be called when a resident was missing and to follow the elopement and missing person protocols. Day Shift (6:00 AM-2:00 PM) During an interview on 9/12/25 at 8:35 AM, LN A stated the highlights of her in-service trainings were report ANE to the abuse coordinator, respect resident rights to participate in care, and for elopement to search and know the whereabouts of residents; and set the alarm at night and check often that the alarm is set. During an interview on 9/12/25 at 8:47 AM, LVN T stated the key points of the in-services were: to report immediately any allegations of ANE; and to respect the resident rights make decisions on care. LVN stated that staff needed to know the whereabouts of residents and to immediately search for any missing resident per protocol. LVN stated to set alarm at night and to document the setting of the alarm. During an interview on 9/12/25 at 8:54 AM, RT [respiratory therapist] U stated the key points made in the in-services were to report ANE in a timely manner, and respect resident right around treatment and care. RT stated the highlight of the elopement in-service was to follow protocols and ensue the alarm was set. The RT U stated, to also know the whereabouts of residents. During an interview on 9/12/25 at 1:50 PM, Housekeeping V, stated she learned from her training to report any suspicion of ANE to nurse management. She added that as a housekeeper she was to monitor any resident exit seeking and to inform nurse management. Also, she was to participate in any search of missing residents. During an interview on 9/12/225 at 1:53 PM, Rehab Director W, stated he attended in-services, and the main points made were: follow elopement and missing person protocols; and report ANE to the Abuse Coordinator, the Administrator. During an interview on 9/12/25 at 1:55 PM, CNA X stated she attended in-services, and she recalled report ANE, check on doors and whereabouts of residents. Also, the CNA stated she was to check doors and ensure resident safety. During an interview on 9/12/25 at 1:58 PM, CNA Y stated she attended in-services and what stood out was to report ANE to the Administrator. As for elopement and missing persons she was to monitor wanders and know the whereabouts of her caseload. Weekend Coverage During an interview on 9/12/25 at 8:40 AM, CMA Z stated that he worked on weekends and had received in-service training. CMA stated he remembered from the training ANE to report immediately to the Abuse Coordinator, respect resident rights. As for elopement the CMA stated the highlights were: monitor residents always especially shift change and ensure that the alarm is set at 8 PM to 6 AM. CMA stated if a resident was missing to follow missing person protocol. During an interview on 9/12/25 at 9:05 AM, CMA J (Medical Records and Receptionist) stated she works as weekends. She stated that training was initiated after the incident of elopement of 9/6/25. She remembered from the training to report immediately to the Administrator any allegation of ANE. She commented that resident rights needed to be respected. Regarding elopement, she stated: to monitor movement of the exit door and check the elopement binder. Moreover, she stated the alarm was set at 8:00 PM and the receptionist evaluated the alarm system and then sent a notice to management on the What Apps that the alarm was set and secured. PRN Staff During telephone interview on 9/12/25 at 1:30 PM, Receptionist AA, stated the highlights of the in-services were: report abuse, respect resident rights, and for elopement check on the exit door and check the alarm was set. Receptionist stated that a elopement binder was at the receptionist desk and her training called for search for missing residents and reporting to management. During a telephone interview on 9/12/25 at 1:35 PM, LVN Q stated the key points of her in-services were: to report ANE and follow protocols on elopement and missing persons. LVN stated the training stressed to headcount residents during shift change and throughout the day. During a telephone interview on 9/12/25 at 1:38 PM, CNA BB stated, the in-services stressed to report ANE and respect resident rights. Also, the CNA stated she needed to headcount her residents and monitor the movement of wanders. The CNA stated she needed to ensure doors were armed and locked at 8:00 PM. In the event a resident went missing she was to follow the missing person checklist. During a telephone interview on 9/12/25 at 1:43 PM, CNA CC stated she attended in-services and remembered to report any allegations of ANE to the Abuse Coordinator, the Administrator. She stated that as a CNA she needed to headcount her caseload and check on the arming of doors after 8:00 PM. If a resident went missing, she would participate in the search of the resident. During an interview on 9/12/25 at 10:57 AM, the Administrator stated the 1:1 [for Resident #74] started on 9/7/25 at 7:00 AM by staff member CMA J and continued by CMA K and thereafter continued on a 24-hour basis until resident's discharge on [DATE] at 5:00 PM. Key Record Reviews: Record review of receptionist timecards [receptionist F, G and J] from 9/6/25 to 9/11/25 reflected a schedule of hours from 8:00 AM to 10:00 PM. Record revies of Resident #74's Nurse Note dated 9/6/25 at 10:33 PM authored by RN E read: .CNA [D] reports to this nurse [RN E], resident noted at bus stop across

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for one (Resident #1, of five residents reviewed for baseline care plans, in that: The facility failed to implement Resident #1's baseline care plan and failed to include Resident #1's current urinary tract infection and antibiotic use in the baseline care plan resulting in Resident #1's hospitilization with a diagnosis of sepsis. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life, infection, and hospitalization. An IJ was identified on 04/29/25. The IJ template was provided to the facility on [DATE] at 9:37 pm. While the IJ was removed on 05/02/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings Included: Review of Resident #1's face sheet reflected a [AGE] year old man who was admitted to the facility on [DATE] and discharged from the facility on 03/12/25 with diagnoses of Hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis refers to partial weakness on one side) following cerebral infarction (a condition where a blood clot or blockage in a blood vessel prevents oxygen and blood from reaching a part of the brain, causing brain tissue to die), and Wernicke's encephalopathy (a serious, acute neurological emergency cause by a deficiency of thiamine (vitamin B1) most often due to chronic alcohol use). Review of Resident #1's care plan reflected a focus dated 03/10/25 of impaired communication due to: and intervention dated 03/10/25 of use simple and direct communication to promote understanding. Care plan focus dated 03/10/25 of alteration in elimination of bowel and bladder with a goal dated 03/10/25 of will be free from signs and symptoms of incontinence through next review date and interventions dated 03/10/25 of if catheter in place, secure per protocol, cath q shift per protocol, monitor for drainage, out, s/s of UTI: changes in color, odor, or consistency of urine, dysuria (painful or burning urination) frequency, fever, pain and provide assistance to toilet as needed. Review of Resident #1's MDS, dated [DATE], did not reflect he had an indwelling catheter. Review of Resident #1's MDS BIMS dated 03/11/25 reflected a score of three suggesting severe cognitive impairment. Review of Resident #1's rehabilitation hospital discharge records dated 03/20/25 reflected Resident #1 was discharged with a foley catheter (a thin flexible tube inserted into the bladder to drain urine) with instructions, The most important thing you want to do is prevent infection. Discharge records reflected cognitive status A&O X2 (a person is alert and aware of their person and place), other comments reflected, confused. Review of Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected wound care indwelling catheter (including suprapubic catheter (a medical device, a tube inserted into the bladder through a small incision in the lower abdomen, used to drain urine) and nephrostomy tube (a thin, flexible catheter inserted through the back into the kidney to drain urine when normal urine flow is blocked) and summary of head to toe assessment findings included a description of any progress toward goals or decline note reflected confusion noted. Review of Resident #1's orders did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Review of Resident #1's progress notes reflected 3 (three) notes referencing Resident #1 foley catheter 1. Skin/wound progress note dated 03/11/25 foley catheter in place 2. Skin/wound progress note dated 03/12/25 foley catheter 3. Note physician history and physical dated 03/12/25 foley catheter in place Review of Resident #1's EMR reflected no nurses' notes regarding skilled nurse assessments or urine output measurements for Resident #1's foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:21 pm, late entry, reflected Resident #1 continued with antibiotics for UTI. Review of Resident #1 Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:49 pm, late entry, reflected confusion noted. Review of admission & Baseline care plan/summary dated 03/10/25 signed by LVN B reflected GI/Bowel abdomen soft, non-tender, non-distended, urine normal color/consistency, catheter/nephrostomy tube indwelling catheter/suprapubic/nephrostomy, bowel and bladder care plan focus alteration of elimination of bowel and bladder, goal will be free from s/s of UTI or complications related to incontinence through next review dated, interventions call light within reach and remind to use call light as needed, intervention if catheter in place, secure per protocol, cath care q shift per protocol, monitor for drainage, output, s/s of infection and follow up with physician as needed, monitor and report s/s of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever pain. Comments: Resident #1 continues with antibiotics for UTI, confusion noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LPN C reflected behavior problems verbal, other behaviors (socially inappropriate), rejects evaluation or cares, indwelling catheter, summary of Head-to-Toe Assessment/Findings including a description of any progress toward goals or decline noted - confusion noted. Review of Resident #1's Elopement Risk Assessment Tool dated 03/11/25, unsigned by staff, reflected Resident #1 had a diagnosis of Dementia, OBS (a condition characterized by cognitive impairment and behavioral changes caused by underlying brain damage), Alzheimer's, Intellectual/Developmental Disability, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia, Resident #1 cognitively impaired with poor decision making skills (example disorientation, cognitive deficits, disorganized thinking). Review of Resident #1's Trauma Abbreviated PCL-C dated 03/11/25 signed by LPN C reflected, unable to obtain answers from resident due to impaired cognition/communication and representative is unable to answer. Review of Resident #1's Infection Surveillance Form dated 03/11/25, unsigned, reflected, confusion note. Review of Resident #1's Skin/Wound Progress Noted note dated 03/11/25 by LVN A wound care nurse, reflected Resident, Pt. arrived at facility with . Foley Catheter in place ., MD, DON and RP at bedside. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected, resident was alert and oriented X1. Resident was not able to voice needs. MD notified of admission, orders verified, admission assessment completed, call button within reach will continue to monitor, resident came into facility with peg tube. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 at 5:43 am reflected redirected resident multiple times this shift, observed attempting to get out of bed, re-educated resident to call light, assigned CNA instructed to monitor resident frequently throughout shift, every effort made in making resident as comfortable as possible, as needed Tylenol administered as ordered for nonverbal indicator of discomfort, will monitor through the remainder of this shift Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected witnessed fall resident observed crawling out of bed onto floor by floor mat, he stated he wanted to stand up. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 late entry reflected resident had behaviors; resident had restlessness and anxiety noted Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected confusion noted stable no new concerns. Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected resident on antibiotic for UTI for 5 days, call light was in reach, staff continued to monitor resident. Review of Resident #1's Skin and Wound Nurses Note (identity of nurse unknown) dated 03/12/25 reflected GU: urinary incontinence, foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 at 1:40 pm reflected resident found on floor by physical therapy, resident confused and unable to express what happened, nurse conducted physical assessment, neurological checks, resident complained of generalized pain and was confused, but normal for baseline, continued to monitor. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected DON and CNA made nurse aware that resident was on the floor, resident was complaining of pain to left wrist 3/10 (0 = no pain, and 10 = worst imaginable pain). Nurse assessed resident, resident was able to move right upper extremity, x-ray ordered to the left hand, pain medication given and was not effective, nurse monitored and updated provider with any changes. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected resident was sent out to hospital for pain to left wrist, resident showing signs of restlessness and anxiety, medications were in place, resident was a fall risk, resident continued with antibiotics for UTI, no new concerns. Review of IDT Event Review progress note dated 03/12/25 witnessed fall from bed, no injuries noted, root cause analysis for event new admission, anxiety, impulsivity, diagnosis of UTI, dementia, difficulty expressing self, hepatic encephalopathy (a neuropsychiatric syndrome caused by impaired brain function due to liver disease, specifically when the liver fails to remove toxins from the blood), CVA (Cerebrovascular Accident), call light in reach, psych evaluation and treatment anxiety and restlessness. Review of Resident #1's Pain assessment - Post Incident dated 03/12/25 signed by LVN B reflected pain behavior - resistiveness to cares, restlessness, repetitive verbalizations or movements, verbal expression of distress/crying, sad, pained, worried facial expressions. Resident's current level of pain on a numeric scale of 1-10 (0 = no pain, and 10 = worst imaginable pain) 3. Review of Resident #1's Anxiolytic (medications, also called anti-anxiety agents, used to treat or prevent anxiety) Medication Informed Consent dated 03/12/25 signed by LVN B reflected anxiolytic medication & indication for use Xanax (treats anxiety) anxiety, potential contributing factors previously addressed - pain and infection or other change in condition, target behavior symptoms Resident #1 was showing [NAME] of anxiety and restlessness and came moving to the edge of bed and rolling off the bed. Review of Resident #1's Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected, the change in condition, symptoms, or signs LVN B was calling about is/are: Falls, pain (uncontrolled), Behavioral symptoms (e.g. agitation, psychosis) started on: 03/12/25 Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected: Since the change in condition occurred have the symptoms or signs gotten worse - medication given was not effective This condition, symptom or sign had occurred before: No. Other relevant information: Resident has had a past history of left wrist pain with no fractures noted. Summarize your observations, evaluation, and recommendations: Left wrist with pain noted. Pain scale is 5/10 (0 = no pain, and 10 = worst imaginable pain). No swelling. X-ray administered. Resident sent to the hospital per family request. Describe mental status of changes (compared to baseline; check all that you observe: increased confusion (e.g. disorientation), abrupt significant change in cognitive function form usual, with or without altered level of consciousness. Functional status evaluation: describe functions status changes - fall. Recommendation of primary clinician - send to the hospital, testing x-ray, interventions - new or change in medications Behavioral status evaluation - describe behavioral changes: resident is having signs and symptoms of anxiety and restlessness and symptoms or signs of pain. Is an abdominal/GI assessment relevant to the change in condition being reported - not clinically applicable to the change in condition being reported (distended abdomen box not checked) Genitourinary (refers to the urinary and genital organs, also known as the urogenital system. It encompasses both the reproductive organs and the urinary tract) Status Evaluation: not clinically applicable to the change in condition being reported. Pain Status Evaluation - is pain assessment relevant to the change in condition been reported: yes Does the resident/patient have pain: yes Is the resident/patient cognitively able to rate their pain scale: - No Negative vocalization: troubled - repeated trouble calling out, loud moaning or groaning, crying, facial expression - sad/frightened/frown Body language: tense, distressed pacing, fidgeting, Consolability: distracted or reassured by voice or touch Is the pain: acute Pain location: not applicable/not assessed Specify exact location of pain: left hand (palm) complaining of left hand with pain scale of 5/10 (0 = no pain, and 10 = worst imaginable pain) Tylenol given X-ray results: -no fracture noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected evidenced of an acute change in mental status from the resident's baseline behavioral problems of verbal behavior (screaming, cursing, etc.), other behaviors (social inappropriate), and rejects evaluation or cares, indwelling catheter, [Resident #1] was sent out to [hospital] for pain to left wrist, falls . Resident showing signs of restlessness and anxiety. Medications are in place. Resident is a fall risk. Resident continues with abt's for UTI. Review of Resident #1's Skilled Nursing Facility Records to Hospital Transfer Form dated 03/12/25 reflected ADLs totally dependent, bladder function incontinent, last know bowel movement 03/12/25, urinary catheter in place left blank. Unusual mental status/cognition function before the change in condition - alert, disoriented but cannot follow simple instructions. Medications on antibiotics - Cephalexin oral capsule 500 MG for UTI treatment duration 03/16/25, treatment started 03/11/25. Devices - bladder (Foley) catheter - left blank. Risk alerts agitation with risk to harm self or others and high fall risk. Resident was showing signs and symptoms of anxiety and restlessness. Redirection given. Review of Resident #1 hospital history of present illness records dated 03/13/25 reflected male with history of CVA with outlet obstruction chronic foley (a persistent blockage in the urinary tract, preventing the bladder from emptying properly) presented to the ER with recurrent falls. Resident #1 had been complaining of left sided hip pain, left wrist pain, back pain, lower back pain, left lower quadrant pain, and left femur pain. Review of Resident #1's hospital X-ray of chest, abdomen and pelvis dated 03/13/25 reflected foley catheter was present within the urinary bladder. The bladder remained distended and recommended correlation for catheter dysfunction (mechanical issues like kinking, catheter malposition, or thrombotic complications such as intracatheter thrombosis and fibrin sheath formation). Review of Resident #1's hospital records dated 03/13/25 reflected Resident #1's general appearance, chronically ill appearing, confused . Review of Resident #1's hospital Diagnosis Assessment Plan dated 03/13/25 reflected UTI/Sepsis, change foley catheter - done in the ER. Interview on 04/29/25 with a family member by phone at 1:59 pm revealed Resident #1 had a foley catheter and the hospital told her it was placed wrong, pulled, or neglected and Resident #1 got sepsis. Interview on 04/30/25 with LVN B at 2:20 pm revealed she looked at care plans and care plans were the blueprint of the residents' care including what the resident needed, residents' goals, and how to take care of the resident. She said the negative effects of not following the catheter care plan were the resident could get a UTI or become septic if catheter care was not properly care planned and followed through for the resident. Interview on 04/30/25 with LVN F at 1:44 pm revealed everything about a resident should be care planned and of course the catheter care should be care planned. She revealed the negative effects of not having a resident centered care plan in place was that you don't have a plan in place to care for the resident and if you don't carry out catheter care planning, it means that the needs of the resident were not being meet. She said that all the nurses, not just the admitting nurse, were responsible to make that it was made known that Resident #1 had a foley catheter and to make sure it was care planned and the residents' catheter care needs were meet. Interview on 04/30/25 with the Administrator at 12:24 pm revealed the nurse who admits the resident into the facility can open the care plan. There was a care plan for the resident, but it was not specific to the information from the hospital discharge information. Resident #1 had a UTI, and he was on an antibiotic and that was not included in his care plan. The negative effect of not having a care plan that addressed the individual resident needs was that it was not resident centered and there was the opportunity for error in for the care or service to be provided to that resident. The Administrator said a care plan provided body of knowledge to be able to carry out the services or elements of the needs of the resident and was the template that allowed you and your staff meet the welfare of the resident. The administrator said the care plan was the responsibility admitting nurse because Resident #1 was at the facility less than 72 hour and the admitting nurse should have done the admitting orders for the foley catheter care. The negative effects of not having the order entered was the failure of not having Resident #1's needs meet. He stated if you don't take care of a catheter a resident could get an infection. He said he was not a nurse, but he did not feel like catheter care was carried out for this resident. Interview on 04/30/25 with the DON at 8:47 am revealed a care plan contained all the residents' information gathering in one central area for anything that is important to the residents' care, and it should be resident specific. She revealed the catheter care plan should be specific to the catheter size and include the reason the catheter was present, and the reason would be different from resident to resident. The care plan should include everything that should be included in a catheter order including monitoring urine output. She said the IDT team was responsible for the care plan, but it was a whole facility approach. She said the nurse who signed the baseline care plan should make sure that that all the information was in the care plan. She stated this was the responsibility of the previous DON. The current DON said the negative effect of not having a person-centered care plan was that you don't really know how to care for the resident, and everyone was different, so their care was different. She said she thought the care plan had everything that it needed to have for the care of Resident #1's catheter needs but based on the progress notes there was no indication that they carried out catheter care. She said she hoped that they carried out Resident #1's catheter care plan but the documentation was poor. She stated she subscribed to the idea that if care was not charted it did not happen. Review of facility Care Plans, Comprehensive Person-Centered dated 2022 reflected: Policy statement Measurable objectives and at timetables to meet the residence physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person centered plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The ADM was notified on 04/29/25 at 9:37 pm that an IJ had been identified and an IJ template was provided. An amended IJ template was provided on 04/30/25 at (I have to find the time). The following POR was approved on 04/30/25 at 4:36 pm: The POR included the following: CARE PLAN TAG F656 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On April 29, 2025, an investigation was initiated at the Rehabilitation and Care Center. At approximately 9:37 p.m. on April 29, 2025, a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at Rehabilitation and Care Center constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F656 - The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to write a care plan for Resident #1's catheter care. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Resident #1 no longer resides at facility On April 29, 2025, at approximately 10:00pm the following actions were taken; Action: Director of nursing/Designee validated all residents with urinary catheters have comprehensive care plans with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in place for each identified resident. All identified residents with urinary catheters were validated to have comprehensive, person-centered care plans to incorporate care of catheter and identified risk factors associated with catheters. The DON was trained by Corporate Clinical Support. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing/Designee Action: Ad Hoc QAPI with Administrator, Director of Nursing, and Medical Director was conducted to review citations and Plan of Correction for removal Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Administrator and Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with urinary catheters have the potential to be affected. Action: Director of Nursing/designee completed a sweep of all residents to identify any resident with urinary catheter, and to validate residents with catheters have comprehensive plans of care in place addressing the following: Catheter care, monitoring and identification of signs and symptoms of infection, pain, monitoring of output urine, monitoring for appropriate drainage, and for signs of change of condition. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: Director of Nursing/Designee completed education with all licensed nursing staff on the requirement and facility policy to ensure completion of comprehensive plan of care with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in place for each resident. Education included the need to ensure all residents with urinary catheters have comprehensive, person-centered care plans to incorporate care of catheters and identified risk factors associated with catheters. Start Date: 4/29/2025 Completion Date: Ongoing until all licensed staff have received education prior to their next scheduled shift. Responsible Party: Director of nursing/designee Action: Director of Nursing/designee will review all residents with foley catheters upon admission. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission and identification of resident admitted with a foley catheter. All residents with foley catheters will be added to facilities daily internal tracking tool and reviewed daily, Monday through Friday, by interdisciplinary team for compliance with facility policy and procedure related to foley catheter care and care planning requirements. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible Party: Director of Nursing/Designee Tracking and Monitoring Director of nursing/designee will monitor all resident with new orders for catheters, or newly admitted with catheters, daily Monday through Friday, x 4 weeks, then weekly x 4 weeks, to include review of any new admissions from weekend on Mondays, to validate all residents with urinary catheters have comprehensive care plan with measurable objectives and timetables to ensure they have comprehensive, person-centered care plan to incorporate care of catheter and identified risk factors associated with catheter, including s/s of infection, cares of catheter, output, pain, drainage, and change in condition. Results will be supplied to the Quality Assurance Committee. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review Monitoring: Review on 05/01/25 of nurses note that Resident #1 was discharged to the hospital, review of skilled nursing facility to hospital form transferring Resident #1 to the hospital. A review of PCC reflected Resident #1 was discharged from the facility to the hospital on [DATE] and he is no longer a resident at the facility. Record review on 05/01/25 of statement from the DON that she performed a sweep of all residents by pulling the order listing report to identify any resident with a urinary catheter, and to validate residents with catheters have comprehensive plans of care in place to address catheter monitoring and care, monitoring and identifying signs and symptoms of infections, pain, monitoring output of urine, monitoring for appropriate drainage and for signs of change in condition. Review on 05/01/25 of the care plans for the three (3) residents in the facility with urinary catheters reflected comprehensive, person-centered care plans that incorporated the care of catheters and identified risk factors associated with catheters. Record review of statement on 05/01/25 from DON that as of 04/29/25 the facility had no new admissions of residents with foley catheters. Interview on 05/01/25 with the CNO at 4:08 pm revealed she in-serviced the DON on comprehensive care plans and discussed the importance of comprehensive care plans specific to catheters that on admission residents who have urinary catheters have comprehensive care plan with measurable objectives and timetables to ensure they have comprehensive, person-centered care plan to incorporate care of catheter and identified risk factors associated with catheter, including s/s of infection, cares of catheter, output, pain, drainage, and change in condition. Interview on 05/01/25 with the DON at 1:47 pm revealed she reviewed the facility care plan policy with the CNO and was in-serviced to make sure resident care plans are accurate and resident care plans will be audited. She was further in-serviced by the CNO regarding comprehensive care plans specific to catheters that on admission residents who have urinary catheters have comprehensive care plan with measurable objectives and timetables to ensure they have comprehensive, person-centered care plan to incorporate care of catheter and identified risk factors associated with catheter, including s/s of infection, cares of catheter, output, pain, drainage, and change in condition. Record review on 05/01/25 of Ad Hoc QAPI with Administrator, Director of Nursing, and Medical Director dated 04/29/25. Record review completed on 05/01/25 of log used to complete training for staff, indicated who was trained over the phone or in person. 100 percent of the nursing staff was in-serviced, this included PRN staff. During interviews on 05/01/25 from 10:15 am - 2:29 pm 2 RNs, 1 LPN, and 9 LVNs from different shifts all stated they were in-serviced before working their shift on the requirements and facility policy to ensure completion of comprehensive plan of care with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in place for each resident. The in-service included the need to ensure all residents with urinary catheters have comprehensive, person-centered care plans to incorporate care of catheters and identified risk factors associated with catheters. While the IJ was removed on 05/02/25 at 12:11 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents with indwelling catheters received appropriate treatment and services for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to manage Resident #1's foley catheter by not having orders for catheter care, monitoring for signs/symptoms of infection, or monitoring the input/output, subsequently leading to hospitalization on 03/12/25 and a diagnosis of sepsis. These failures could place Residents with indwelling urinary catheters at risk of discomfort, infections, and a decreased quality of life, and hospitalization. An IJ was identified on 04/29/25. The IJ template was provided to the facility on [DATE] at 9:37 pm. While the IJ was removed on 05/02/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings Included: Review of Resident #1's face sheet reflected a [AGE] year old man who was admitted to the facility on [DATE] and discharged from the facility on 03/12/25 with diagnoses of Hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis refers to partial weakness on one side) following cerebral infarction (a condition where a blood clot or blockage in a blood vessel prevents oxygen and blood from reaching a part of the brain, causing brain tissue to die), and Wernicke's encephalopathy (a serious, acute neurological emergency cause by a deficiency of thiamine (vitamin B1) most often due to chronic alcohol use). Review of Resident #1's care plan reflected a focus dated 03/10/25 of impaired communication due to: and intervention dated 03/10/25 of use simple and direct communication to promote understanding. Care plan focus dated 03/10/25 of alteration in elimination of bowel and bladder with a goal dated 03/10/25 of will be free from signs and symptoms of incontinence through next review date and interventions dated 03/10/25 of if catheter in place, secure per protocol, cath q shift per protocol, monitor for drainage, out, s/s of UTI: changes in color, odor, or consistency of urine, dysuria (painful or burning urination) frequency, fever, pain and provide assistance to toilet as needed. Review of Resident #1's MDS, dated [DATE], did not reflect he had an indwelling catheter. Review of Resident #1's MDS BIMS dated 03/11/25 reflected a score of three suggesting severe cognitive impairment. Review of Resident #1's rehabilitation hospital discharge records dated 03/20/25 reflected Resident #1 was discharged with a foley catheter (a thin flexible tube inserted into the bladder to drain urine) with instructions, The most important thing you want to do is prevent infection. Discharge records reflected cognitive status A&O X2 (a person is alert and aware of their person and place), other comments reflected, confused. Review of Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected wound care indwelling catheter (including suprapubic catheter (a medical device, a tube inserted into the bladder through a small incision in the lower abdomen, used to drain urine) and nephrostomy tube (a thin, flexible catheter inserted through the back into the kidney to drain urine when normal urine flow is blocked) and summary of head to toe assessment findings included a description of any progress toward goals or decline note reflected confusion noted. Review of Resident #1's orders did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Review of Resident #1's progress notes reflected 3 (three) notes referencing Resident #1 foley catheter 1. Skin/wound progress note dated 03/11/25 foley catheter in place 2. Skin/wound progress note dated 03/12/25 foley catheter 3. Note physician history and physical dated 03/12/25 foley catheter in place Review of Resident #1's EMR reflected no nurses' notes regarding skilled nurse assessments or urine output measurements for Resident #1's foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:21 pm, late entry, reflected Resident #1 continued with antibiotics for UTI. Review of Resident #1 Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:49 pm, late entry, reflected confusion noted. Review of admission & Baseline care plan/summary dated 03/10/25 signed by LVN B reflected GI/Bowel abdomen soft, non-tender, non-distended, urine normal color/consistency, catheter/nephrostomy tube indwelling catheter/suprapubic/nephrostomy, bowel and bladder care plan focus alteration of elimination of bowel and bladder, goal will be free from s/s of UTI or complications related to incontinence through next review dated, interventions call light within reach and remind to use call light as needed, intervention if catheter in place, secure per protocol, cath care q shift per protocol, monitor for drainage, output, s/s of infection and follow up with physician as needed, monitor and report s/s of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever pain. Comments: Resident #1 continues with antibiotics for UTI, confusion noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LPN C reflected behavior problems verbal, other behaviors (socially inappropriate), rejects evaluation or cares, indwelling catheter, summary of Head-to-Toe Assessment/Findings including a description of any progress toward goals or decline noted - confusion noted. Review of Resident #1's Elopement Risk Assessment Tool dated 03/11/25, unsigned by staff, reflected Resident #1 had a diagnosis of Dementia, OBS (a condition characterized by cognitive impairment and behavioral changes caused by underlying brain damage), Alzheimer's, Intellectual/Developmental Disability, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia, Resident #1 cognitively impaired with poor decision making skills (example disorientation, cognitive deficits, disorganized thinking). Review of Resident #1's Trauma Abbreviated PCL-C dated 03/11/25 signed by LPN C reflected, unable to obtain answers from resident due to impaired cognition/communication and representative is unable to answer. Review of Resident #1's Infection Surveillance Form dated 03/11/25, unsigned, reflected, confusion note. Review of Resident #1's Skin/Wound Progress Noted note dated 03/11/25 by LVN A wound care nurse, reflected Resident, Pt. arrived at facility with . Foley Catheter in place ., MD, DON and RP at bedside. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected, resident was alert and oriented X1. Resident was not able to voice needs. MD notified of admission, orders verified, admission assessment completed, call button within reach will continue to monitor, resident came into facility with peg tube. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 at 5:43 am reflected redirected resident multiple times this shift, observed attempting to get out of bed, re-educated resident to call light, assigned CNA instructed to monitor resident frequently throughout shift, every effort made in making resident as comfortable as possible, as needed Tylenol administered as ordered for nonverbal indicator of discomfort, will monitor through the remainder of this shift Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected witnessed fall resident observed crawling out of bed onto floor by floor mat, he stated he wanted to stand up Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 late entry reflected resident had behaviors; resident had restlessness and anxiety noted. Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected confusion noted stable no new concerns. Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected resident on antibiotic for UTI for 5 days, call light was in reach, staff continued to monitor resident. Review of Resident #1's Skin and Wound Nurses Note (identity of nurse unknown) dated 03/12/25 reflected GU: urinary incontinence, foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 at 1:40 pm reflected resident found on floor by physical therapy, resident confused and unable to express what happened, nurse conducted physical assessment, neurological checks, resident complained of generalized pain and was confused, but normal for baseline, continued to monitor. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected DON and CNA made nurse aware that resident was on the floor, resident was complaining of pain to left wrist 3/10 (0 = no pain, and 10 = worst imaginable pain). Nurse assessed resident, resident was able to move right upper extremity, x-ray ordered to the left hand, pain medication given and was not effective, nurse monitored and updated provider with any changes. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected resident was sent out to hospital for pain to left wrist, resident showing signs of restlessness and anxiety, medications were in place, resident was a fall risk, resident continued with antibiotics for UTI, no new concerns. Review of IDT Event Review progress note dated 03/12/25 witnessed fall from bed, no injuries noted, root cause analysis for event new admission, anxiety, impulsivity, diagnosis of UTI, dementia, difficulty expressing self, hepatic encephalopathy (a neuropsychiatric syndrome caused by impaired brain function due to liver disease, specifically when the liver fails to remove toxins from the blood), CVA (Cerebrovascular Accident), call light in reach, psych evaluation and treatment anxiety and restlessness. Review of Resident #1's Pain assessment - Post Incident dated 03/12/25 signed by LVN B reflected pain behavior - resistiveness to cares, restlessness, repetitive verbalizations or movements, verbal expression of distress/crying, sad, pained, worried facial expressions. Resident's current level of pain on a numeric scale of 1-10 (0 = no pain, and 10 = worst imaginable pain) 3. Review of Resident #1's Anxiolytic (medications, also called anti-anxiety agents, used to treat or prevent anxiety) Medication Informed Consent dated 03/12/25 signed by LVN B reflected anxiolytic medication & indication for use Xanax (treats anxiety) anxiety, potential contributing factors previously addressed - pain and infection or other change in condition, target behavior symptoms Resident #1 was showing [NAME] of anxiety and restlessness and came moving to the edge of bed and rolling off the bed. Review of Resident #1's Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected, the change in condition, symptoms, or signs LVN B was calling about is/are: Falls, pain (uncontrolled), Behavioral symptoms (e.g. agitation, psychosis) started on: 03/12/25 Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected: Since the change in condition occurred have the symptoms or signs gotten worse - medication given was not effective This condition, symptom or sign had occurred before: No. Other relevant information: Resident has had a past history of left wrist pain with no fractures noted. Summarize your observations, evaluation, and recommendations: Left wrist with pain noted. Pain scale is 5/10 (0 = no pain, and 10 = worst imaginable pain). No swelling. X-ray administered. Resident sent to the hospital per family request. Describe mental status of changes (compared to baseline; check all that you observe: increased confusion (e.g. disorientation), abrupt significant change in cognitive function form usual, with or without altered level of consciousness. Functional status evaluation: describe functions status changes - fall. Recommendation of primary clinician - send to the hospital, testing x-ray, interventions - new or change in medications Behavioral status evaluation - describe behavioral changes: resident is having signs and symptoms of anxiety and restlessness and symptoms or signs of pain. Is an abdominal/GI assessment relevant to the change in condition being reported - not clinically applicable to the change in condition being reported (distended abdomen box not checked) Genitourinary (refers to the urinary and genital organs, also known as the urogenital system. It encompasses both the reproductive organs and the urinary tract) Status Evaluation: not clinically applicable to the change in condition being reported. Pain Status Evaluation - is pain assessment relevant to the change in condition been reported: yes Does the resident/patient have pain: yes Is the resident/patient cognitively able to rate their pain scale: No Negative vocalization: troubled - repeated trouble calling out, loud moaning or groaning, crying, facial expression - sad/frightened/frown Body language: tense, distressed pacing, fidgeting, Consolability: distracted or reassured by voice or touch Is the pain: acute Pain location: not applicable/not assessed Specify exact location of pain: left hand (palm) complaining of left hand with pain scale of 5/10 (0 = no pain, and 10 = worst imaginable pain) Tylenol given X-ray results: -no fracture noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected evidenced of an acute change in mental status from the resident's baseline behavioral problems of verbal behavior (screaming, cursing, etc.), other behaviors (social inappropriate), and rejects evaluation or cares, indwelling catheter, [Resident #1] was sent out to [hospital] for pain to left wrist, falls . Resident showing signs of restlessness and anxiety. Medications are in place. Resident is a fall risk. Resident continues with abt's for UTI. Review of Resident #1's Skilled Nursing Facility Records to Hospital Transfer Form dated 03/12/25 reflected ADLs totally dependent, bladder function incontinent, last know bowel movement 03/12/25, urinary catheter in place left blank. Unusual mental status/cognition function before the change in condition - alert, disoriented but cannot follow simple instructions. Medications on antibiotics - Cephalexin oral capsule 500 MG for UTI treatment duration 03/16/25, treatment started 03/11/25. Devices - bladder (Foley) catheter - left blank. Risk alerts agitation with risk to harm self or others and high fall risk. Resident was showing signs and symptoms of anxiety and restlessness. Redirection given. Review of Resident #1 hospital history of present illness records dated 03/13/25 reflected male with history of CVA with outlet obstruction chronic foley (a persistent blockage in the urinary tract, preventing the bladder from emptying properly) presented to the ER with recurrent falls. Resident #1 had been complaining of left sided hip pain, left wrist pain, back pain, lower back pain, left lower quadrant pain, and left femur pain. Review of Resident #1's hospital X-ray of chest, abdomen and pelvis dated 03/13/25 reflected foley catheter was present within the urinary bladder. The bladder remained distended and recommended correlation for catheter dysfunction (mechanical issues like kinking, catheter malposition, or thrombotic complications such as intracatheter thrombosis and fibrin sheath formation). Review of Resident #1's hospital records dated 03/13/25 reflected Resident #1's general appearance, chronically ill appearing, confused . Review of Resident #1's hospital Diagnosis Assessment Plan dated 03/13/25 reflected UTI/Sepsis, change foley catheter - done in the ER. Interview on 04/29/25 with a family member by phone at 1:59 pm revealed Resident #1 had a foley catheter and the hospital told her it was placed wrong, pulled, or neglected and Resident #1 got sepsis. Interview on 04/29/25 with CNA D by phone at 2:33 revealed he had worked at the facility for about a year. CNA D said he was responsible for emptying out the urine in catheters and measuring the amount of urine and telling the nurse the amount, but he said he did not remember Resident #1 except that his name was familiar. He said if the urine was not emptied from the catheter bag, it could go back into the bladder and cause an infection. Interview on 04/29/25 with CNA E at 2:25 pm revealed she worked at facility during the time frame Resident #1 was at the facility but could not recall helping Resident #1, but she did provide foley catheter care to residents. She said if a resident had a foley catheter, CNAs needed to check the bag to see if it needs to be emptied of urine and then do the peri care (cleaning the genitals and anal area to promote hygiene and prevent infections). She said if the catheter bag was full of urine, it hurt the resident. She said she emptied catheter bags of the urine, measured the amount of urine, then told the amount to the nurse. Interview on 04/29/25 with LVN B at 6:38 pm revealed she vaguely remembered the resident, but she did not remember him having a catheter. She said nurses were supposed to look at the catheters and chart when they had looked at it and what they saw. She said nurses looked at the residents' catheters to confirm that there was no trauma to the cite, that the color and consistency of the urine was not abnormal, that the output was measured, and there was no blood in the urine. LVN B said this information would have been charted by the nurse. She said if the urine was not emptied from the catheter bag, it could go back into the bladder and cause the bladder to become distended, and the person could get sick, develop sepsis, and possibly die. She did not remember Resident #1 being confused, she said this would have concerned her. She revealed she did not remember him, she said it was a crazy time and it was like a blur because the facility was changing ownership, and they were in-between 2 (two) nurse managers. Interview on 04/30/25 with LVN B at 2:20 pm revealed when Resident #1 was at the facility, either the ADON or the DON were putting in the orders in for catheter care. She said she would have taken report from the hospital, and she would do baseline admission and care plan admission assessment. She said the ADON and DON should have looked at the assessments and they were not looking at the assessments. She said catheter care required more immediacy. LVN B said she did not remember the names of any CNAs who would have helped Resident #1 with his catheter care. She said if there was not an order entered for catheter care, the EMR did not prompt for the catheter care needs for a resident who had a catheter. She said if you visually saw a resident had a catheter, and there were no orders for catheter care, you could manually enter the catheter care order into the EMR system to prompt the necessary care. LVN B did not know what happened to cause the catheter care order to be missed and it was a problem that the order was not placed because treatment was missed. Interview on 04/29/25 with LVN A by phone at 7:05 pm revealed she no longer worked at the facility, and she did not remember working with Resident #1. She revealed she was the wound care nurse, and the floor nurses did the catheters. Surveyor told LVN A there was a wound care progress note dated 03/11/25 with her name that discussed Resident #1's skin care and the note did not reflect that Resident #1's bladder was distended. LVN A revealed if Resident #1's bladder was distended, she would have reported it to the floor nurse and the floor nurse would have reported it to the MD. She said there were procedures to follow when a resident had a foley catheter. She said a residents' catheter needed to be checked and monitored to make sure everything was in place. She revealed if the foley catheter was not monitored, absolutely things could go wrong with the resident, a resident could go septic. She said it was the responsibility of the floor nurse to check the foley catheter every shift and monitor the output. She said if the monitoring was not charted, then the foley catheter was not monitored. Interview on 04/29/25 with LVN F at 1:44 pm revealed she remembered Resident #1 but did not remember if he had a catheter. She said she remembered him because he had a lot of falls. She said she did not remember anyone providing catheter care to him. She said she felt like he fell because he was restless, did not want to be at the facility, and he seemed confused. She said if she saw a resident who had a catheter, but did not have catheter orders, she would prompt them to be entered in the system so catheter care would be populated as a resident care task. LVN F said the lack of catheter care could have caused and infection and caused a distended bladder. She said that Resident #1 could have been restless because of the discomfort from the infection caused by the lack of catheter care. She said the admission nurse was responsible for entering the catheter orders. She said the negative effects of not providing catheter care were infection, sepsis, and possibly death. She said all nurses needed to check on the residents even if they were not the admitting nurse and confirm that the necessary catheter orders were in place. Interview on 04/30/25 with the previous DON by phone at 11:11 am revealed she recalled Resident #1, and she was aware that he had a catheter, but she did not assist with catheter care. She said the CNAs would have provided catheter care but she did not see anyone provide catheter care but that did not mean it had not been provided. She said if catheter care was done, it was in the nursing notes. She said usually there was an ordered entered for catheter care. She said the nurse who did Resident #1's assessment could have created his order for catheter care and the ADON and DON would have followed up. She said it was part of the nurses skilled notes to document a residents' catheter care. Interview on 04/30/25 with the Administrator at 12:24 pm revealed the nurse who admitted Resident #1 was at the facility less than 72 hour and the admitting nurse should have done the admitting orders for the foley catheter care. The negative effects of not having the order entered was the failure of not having Resident #1's needs meet. He stated if you don't take care of a catheter the resident could get an infection. He said he was not a nurse, but he did not feel like catheter care was carried out for this resident. Interview on 04/30/25 with the DON at 8:47 am reflected she began working at the facility on 04/10/25. The DON stated Resident #1 should have had standard foley catheter orders in place for measuring urine output, looking for s/s of infection, securing the catheter bag so the catheter bag was below the resident's bladder, Enhanced Barrier Protection (infection control measures that expand standard precautions by incorporating the use of gowns and gloves during high-contact resident care activities), and orders to change the bag once a month. She said all of these measures should have been in the nursing orders. She said the admitting nurse should have entered the orders. The DON said the negative effects of not entering the orders at admission was that if orders were not in place, necessary resident care would get missed. The DON said it was important to assess the catheter to confirm there was no obstruction or urinary retention and make sure catheter was flowing. She said if the catheter was not flowing well and emptied property it could cause bladder distention and pain. She said it was the responsibility of the nursing management team to double check and make sure orders were correctly entered. She said that it is important to trust but verify that orders were not missed and that Resident #1 did not have a catheter because there were no catheter ordered entered. She said the negative effect of not checking if a resident has a catheter and the resident did have a catheter was missing the s/s of infection. Interview on 04/29/25 with the MD by phone at 5:33 pm revealed if a resident was admitted to the facility with a catheter, the resident would have pre-set orders from the facility to address the necessary catheter care to prevent infection. She said that Resident #1's output should have been monitored, that was basic nursing 101 (refers to the introductory or fundamental level of a subject). She said if there was a change in condition related to the catheter care, she would have been notified, but if they are not monitoring the catheter and there were no skilled nursing notes regarding checking the catheter and notes documenting the urine output, it would be hard to notify of a change of condition of something that was not monitored. She said the facility was changing ownership at that time and staff both quit and walked out and documentation was not very good. Review of facility Catheter Care, Urinary dated 2018 reflected Input/Output - observe the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly, report it to the physical or supervisor. Maintain as accurate record of the resident's daily output, per facility policy and procedure. Check the resident to be sure he or she is not lying on the catheter and to keep the catheter and be free of kinks. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage back from flowing back into the urinary bladder. Documentation - The following information may be recorded in the resident's medical record: 1. The date and time that catheter care was given 2. The name and title of the individual(s) giving the catheter care. 3. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain 4. Any problems or complaints made by the resident related to the procedure 5. If the resident refused the procedure, the reason(s) why and the intervention taken 6. The signature and title of the person recording the date 7. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Reporting other information in accordance with facility policy and professional standards of practice. The ADM was notified on 04/29/25 at 9:37 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/30/25 at 4:36 pm: The POR included the following: FOLEY CATHETER TAG F690 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On April 29, 2025, an investigation was initiated at the Rehabilitation and Care Center, At approximately 9:37 p.m. on April 29, 2025, a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at Rehabilitation and Care Center constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F690 - The facility must ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to manage Resident #1's foley catheter by not having orders for catheter care, monitoring for signs/symptoms of infection, or monitoring the input/output, subsequently leading to hospitalization and being diagnosed with sepsis. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Resident #1 no longer resides at facility On April 29, 2025, at approximately 10:00pm the following actions were taken; Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing Action: All nursing staff were immediately educated on foley catheter care. Education entailed: Appropriate catheter care and documentation of caring out orders on changes of condition, admission or propose of catheter use. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission or change of condition and identification of resident admitted with a foley catheter. The staff will retain if a discrepancy is discovered during review or audit. The current nursing staff has been in-service. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing Action: Ad Hoc QAPI with Administrator, Director of Nursing, and Medical Director was conducted to review citations and Plan of Correction for removal Record review on 05/01/25 Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Administrator and Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents requiring assistance with incontinent care related to the use of a foley catheter have the potential to be affected. SYSTEMIC CHANGES AND/OR MEASURES: Action: Orders for all residents with foley catheters will be reviewed upon admission. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission and identification of resident admitted with a foley catheter. All residents with foley catheters will be added to facility's daily internal tracking tool and reviewed daily, Monday through Friday, by interdisciplinary team for compliance with facility policy and procedure related to foley catheter care. This process will be ongoing. Start Date: 4/29/2025 Completion Date: 4/29/25 Responsible Party: Director of Nursing, Assistant Director of Nursing and/or designee Action: Director of nursing/designee completed education with all nursing staff, including PRN employees and agency staff on care and competencies for urinary catheters. Education included review of facility policy on catheter cares, requirement to maintain an accurate record of resident's daily output, monitoring for problems such as drainage, s/s of infection, dysuria, redness, crusting, pain, distention and for any change in condition. Start Date: 4/29/2025 Completion Date: 4/29/25. All new employees will receive education upon hire and prior to start of their shift. Education entailed: Appropriate catheter care and documentation of caring out orders on changes of condition, admission or propose of catheter use. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission or change of condition and identification of resident admitted with a foley catheter. The staff will retain if a discrepancy is discovered during review or audit. The current nursing staff has been in-service. Responsible Party: Director of Nursing, Assistant Director of Nursing and/or designee Tracking and Monitoring The Director of Nursing will conduct a weekly audit, for four weeks, of all residents with orders for foley catheters to ensure compliance with facility policy and physician orders. Verification of findings will be documented and submitted to the administrator for tracking and trending. Results will be provided to the Quality Assurance Committee. Any trends or concerns were/will be

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. The facility failed to supervise Resident #1 who eloped from the facility on 06/19/2024 and was found approximately 50 feet away from the facility at an intersection. This noncompliance was identified as past non-compliance. The past non-compliance IJ began on 06/19/2024 and ended on 06/23/2024. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: A record review of Resident #1's admission record dated 08/02/2024 revealed Resident #1 was admitted on [DATE] with diagnoses which included hemiplegia (left sided semi paralysis), vascular dementia (brain damage caused by multiple strokes), and general anxiety disorder. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 09 out of a possible 15 which indicated moderate cognitive impairment. Resident was assessed as using a manual wheelchair and was assessed as, Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity . Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns A record review of Resident #1's care plan dated 08/02/2024 revealed Resident #1 was an elopement risk and had a history of elopement 06/19/2024 . monitor Resident #1 for indications of elopement seeking, cigarette seeking . redirect to next smoke break, offer activities television, music, magazines, snacks . is/has potential to be verbally aggressive to staff and other residents r/t mental/emotional illness . assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. assess resident's coping skills and support system . give the resident as many choices as possible about care and activities . provide positive feedback for good behavior . emphasize the positive aspects of compliance . psychiatric/psychogeriatric consult as indicated . when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later A record review of Resident #1's medical record from 09/01/2023 to 08/02/2024 revealed Resident #1 was assessed on 03/23/2024 as a low wander elopement risk and on 06/19/2024 had an elopement incident. A record review of Resident #1's nursing notes revealed LVN A documented on 06/19/2024 at 01:34 AM, Resident #1 was seen in the smoking courtyard at approximately 09:50 PM and by 10:45 PM could not be located. LVN A documented she initiated the facility's elopement procedure and began an all-facility search, notified the DON, the Administrator, and the local police department, accounted for all other residents, and expanded the search to outside of the facility. LVN A documented while on the telephone with the DON the local police department called the facility at 11:28 PM to report they were supervising Resident #1 nearby the facility. During an interview on 08/01/2024 at 04:58 PM the DON stated on 06/19/2024 at 09:50 PM Resident #1 was seen by LVN A in the facilities smoke break area hyper focused on receiving another cigarette. The DON stated he had already smoked his cigarette, the last allotted for the day, and staff redirected him to other activities to have the Resident continue with his activities of daily life and prepare for bed. The DON stated by 10:45 it was recognized by LVN A that Resident #1 was not in the facility. The DON stated she and LVN A initiated the facility's elopement protocol and assigned staff responsibilities to simultaneously account for all residents, search the entire facility, alert the local police department, alert the DON, the Administrator, and expand the search to the exterior of the facility. They organized a staff lead vehicle assisted search of the surrounding neighborhood when the local police department called the facility and stated they were supervising Resident #1 who was alongside of the road by the facility. The DON stated she and the Administrator met the police officers and assumed custody of Resident #1 at 11:58 PM on 06/19/2024. The DON stated Resident #1 was located across the street from the facility about a block down the road and described the location on an internet-based map. The DON stated Resident #1 was returned to the facility and assessed without any injuries. The DON stated Resident #1's physician ordered bilateral knee x-rays which resulted negative for injuries. The DON stated Resident #1 received enhanced monitoring from a 1 to 1 staff member every 15 minutes for 6 hours. The DON stated the Administrator initiated an investigation. A record review of an internet-based map accessed on 08/02/2024 as described by the DON revealed Resident #1 was located approximately 688 feet from the facility's front door. The Administrator was notified on 08/02/24 at 06:00 PM, a past non-compliance IJ situation had been identified due to the above failure. It was determined the failures placed Resident #1 in an IJ situation on 06/19/2024. The facility implemented the following interventions. During a joint interview on 08/02/2024 at 04:00 PM the Administrator and the DON stated the facility had 2 exit doors commonly utilized by staff to enter and exit the facility. The DON stated one door was the front door which was monitored by the facility's receptionist from 06:00 AM to 08:00 PM and the other door was the back door which was secured with an electromagnet and released by a numeric coded keypad. The DON stated the front door also had an electromagnet and was secured from the hours of 08:00 PM to 06:00 AM. The Administrator stated the front door was secured by the receptionist when she left for the day, and he would receive a daily message alerting him to the practice of securing the front door. The Administrator stated on 06/20/2024 immediately after Resident #1's elopement the facility initiated an investigation, reported the incident to the state agency, assessed Resident #1 and concluded he had no injuries, assessed peer residents for safety and revealed all were safe without injuries, interviewed all staff on duty, and interviewed residents who may have witnessed Resident #1. It was concluded Resident #1 may have eloped through the facility's front door either by exiting concurrently when a staff or visitor entered or exited the facility or Resident #1 may have covertly gained knowledge of the code. The Administrator stated the facility reviewed the elopement incident and developed and implemented quality improvement initiatives which included monitoring the secured front doors and back door every 2 hours from 08:00 PM to 06:00 AM, changing the door codes every month, and replacing the alarm batteries every month. The DON stated Resident #1's care plan was updated by the interdisciplinary team to include enhanced monitoring of Resident #1 especially when he was agitated and became focused on finding cigarettes. The Administrator stated all staff were in-serviced on Resident #1's care plan, ANE prevention, elopement prevention, reporting allegations of ANE, and/or elopement. The DON stated Resident #1 has been assessed an elopement risk and has been added to the elopement binder located at the receptionist desk. A record review of the facility's elopement binder located at the receptionist desk revealed Resident #1 was identified as a wander elopement risk, should be redirected per his care plan, and staff were to communicate with each other to redirect Resident and/or initiate the elopement protocol with attempts to re-direct Resident #1 to safety. During an interview on 08/02/2024 at 01:15 PM Receptionist E stated she was the receptionist from 06:00AM to 02:00 PM or sometimes from 08:00 PM to 06:00 PM. Receptionist E stated the front door was monitored from 06:00 AM to 08:00 PM and if she was not there, other staff (the BOM, the Administrator, etc.) would monitor the front door from 06:00 to 08:00 AM when she arrived or from 06:00 PM to 0:0 PM when she left. Receptionist E stated she had access to the facility elopement binder located at the desk and identified Resident #1 with specific interventions to re-direct Resident #1 away from the front door. A record review of the facility's daily front door and back door monitor logs revealed the doors had been checked every 2 hours from 08:00 PM to 06:00 PM since 06/21/2024. A record review of the facility's employee roster dated 08/01/2024 revealed 73 employees. A record review of the facility's in-service records dated 06/20/2024, 06/21/2024, and 06/23/2024 revealed 63 employees across all departments and work shifts had signed and documented they received the re-enforced trainings for elopement protocol and reporting, ANE prevention and reporting, and resident #1's care plan to include re-direction interventions when he was becoming agitated and cigarette seeking. During an interview on 08/01/2024 at 5:01 PM LVN A stated she had received the elopement protocol, Resident #1's care plan, and ANE prevention and reporting in-service sometime at the end of June 2024. LVN A stated she recalled the DON ensured everyone received the in-services. During an interview on 08/02/2024 at 01:45 PM LVN B stated she worked all shifts and usually worked the 06:00 AM to 02:00 PM shift. LVN B stated she recalled everyone received in-services regarding Resident #1's elopement in June 2024. LVN B stated she would and had redirected Resident #1 when he became fixated on receiving a cigarette and Resident #1 forgets he just had a smoke break. LVN B stated it was a group effort with staff coordinating and providing Resident #1 with alternatives such as an activity, he likes bingo. During an interview on 08/02/2024 at 02:10 PM LVN C stated she had just started and had received in-service training to include Resident #1's care plan and ANE and elopement prevention protocols. LVN C stated she usually worked the 02:00 PM to 06:00 PM shifts and has been assigned to ensure the front door has been secured after 08:00 PM and to check on Resident #1 often. During an interview on 07/31/2024 at 11:20 AM CNA D stated he has worked with Resident #1 and has received training to redirect Resident #1 when he becomes aggressive with cigarette seeking. CNA D stated he would offer the Resident with assistance with the toilet or offer clothing change. CNA D stated he usually does not work with Resident #1 but had provided care for the Resident occasionally. CNA D stated, if he's soiled, he lets me change him, and he forgets about the cigarette. A record review of the facility's in-service records dated 06/20 through 06/23/2024 revealed policies which included: Emergency Procedure - Missing Resident dated 2018, the policy statement resident elopement resulting in a missing resident is considered a facility emergency . residents at risk for wandering and for elopement will be monitored, and staff will take necessary precautions to ensure their safety . staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Emergency procedure missing Resident . announce president missing using facility code, note the time the resident was discovered missing, notify the Administrator, director of maintenance, director of nursing. Initiate a thorough search by staff members to locate the Resident. Instruct staff members to search the entire facility, grounds and neighboring street. Assign each staff member an area to search to avoid overlap. Look under bed, furniture, clothing closet, and behind doors . staff will report search results to the Administrator . if the search is unsuccessful, the administrator will contact the police to report the missing result Wandering and elopement policy . the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. As at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the residence safety. If an employee observes a resident leaving the premises, he or she should: attempt to prevent the resident from leaving in a non-threatening courteous manner, request assistance from other staff members in the immediate vicinity as needed, instructed another staff member to alert the charge nurse, director of nursing and or administrator of the residents' intent to leave the premises . if a resident is missing, initiate the elopement missing resident emergency procedure:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 residents (Resident #2 and #1), in that: 1. Resident #2 was able to exit the building without staff knowing on 3/15/2024; staff were unaware Resident #2 had wheeled himself to a bus stop on a city sidewalk and was gone until he was brought back by police; staff were unaware that Resident #2 had exit seeking behavior although it was in his admission paperwork. 2. Resident #1 was able to exit the building without staff knowing on 3/19/2024; staff were unaware Resident #1 had exited the building and her whereabouts are still unknown. This failure could place resident at risk of neglect resulting in elopements that could have resulted in serious injury, harm, impairment or death. An IJ was identified on 03/22/2024. The IJ template was provided to the facility on [DATE] at 05:50 PM. While the IJ was removed on 03/23/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facilities need to evaluate the effectiveness of their corrective actions. The findings were: 1.Record review of Resident #2 Administration Record dated 3/24/2024, revealed Resident #2 was a [AGE] year-old male originally admitted on [DATE] with diagnosis listed as: unspecified heart failure. Other active diagnosis included deaf, non-speaking; functional quadriplegia [completely immobile due to severe disability or frailty]; schizoaffective disorder bipolar type [mental health disorder marked by a combination of symptoms such as hallucinations or delusions, mood disorder symptoms such as depression or mania]. Further review a discharge date of 3/20/2024 to another nursing facility in the area. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was coded as highly impaired [absence of useful] hearing with unclear speech; ability to express ideas and wants was coded as usually understood; ability to understand others was coded as sometimes understands in Section B - Hearing, Speech, and Vision. In Section C - Cognitive Patterns, Resident #2 was coded as No for Should BIMS be Conducted due to resident is rarely/never understood; with Disorganized Thinking continuously present, does not fluctuate. In Section D - Mood, Resident #2 was coded as being short-tempered, easily annoyed, rarely felt lonely or isolated from those around you; In Section E - Behavior, Resident #2 was coded as none of the above for indicators of psychosis [hallucinations, delusions]. In Section GG - Functional Abilities, Resident #2 was coded as normally utilizing a wheelchair. Resident #2 was coded as substantial/maximal assistance [helper does more than half the effort] for wheel 50 feet with two turns, and wheel 150 feet with a manual wheelchair. Record review of Resident # 2's All-Inclusive admission with Baseline Care Plan, dated 11/09/2023, revealed the resident was at risk for wandering with a wandering risk score of 3. Under the subheading for vision, 4.) Residents' ability to see an adequate light and with glasses if used was coded as highly or severely impaired - sees only lights, colors, etcetera or no vision. Record review of referral documents from previous hospital admission, revealed under Emergency Department Medical Screen Exam on 11/03/2023 at 1:18, Resident #2 was deaf and communicates via sign language; does not want to go back to the group home .; wants to go into a nursing home. Reexamination on 11/03/2023 at 1:58 PM, presents to emergency department because he is unhappy with his living situation. At 11/03/2023 at 12:05 PM, documentation reveals, Informed that the patient [Resident #2] has been denied at multiple NH [nursing homes] because of behavioral issues he has had in the past. Under the History & Physical section dated 11/03/2023 at 3:28 PM, patient wanting a new placement and refusing to leave . Progress Note dated 11/05/2023 at 3:03 PM revealed, Resident #2 called 911 from group home .30 minutes after discharge from a hospital in [redacted] . upset due to circumstances. Record review of Behavior Note, dated 3/10/2024 at 5:57 AM, authored by LVN A revealed Resident #2, seen him going out the front door, wanting nurse to call 911. Record review of Behavior Note, dated 3/16/2024 at 2:03 AM, authored by LVN A revealed, Resident #2 found by police at bus stop, police was called by persons walking by for wellness check, policy finally got [Resident #2] to return to facility .EMS came, unable to take him since he is not critique [critical]. I had to station an aide at front door so resident wouldn't go back to bus stop. We need a inside lock on [front door] so this situation would not happen again. Record review of Internal Investigation Summary dated 3/16/2024, revealed Timeline of Event: 3/16/2024 at 12:48 AM Administrator received call from LVN A to inform the police have brought Resident #2 to the facility from the bus stop at the end of the parking lot on the city sidewalk. Resident #2 had wheeled himself to the bus stop without notifying a nurse or any other staff. Resident #2 told the police officer he wanted to go to the hospital. EMS was contacted at Resident #2's request; paramedics assessed the resident and declined to transfer to the hospital; resident declined head to toe assessment by DON at that time; resident uncooperative and upset; the next afternoon resident insisted that the doctor be called so he could be sent to the hospital; Attending physician was called and an order was obtained to transfer him to [Hospital]; Resident from [another major city] area originally where he had a habit of going to the hospital and then going to a different facility; Ended up in [this area] because he became hard to place in [another major city] area due to his behaviors; While inpatient at the hospital he requested another facility to be found and a social worker has been working to facilitate a transfer; Facility was willing to accept the resident back from the hospital; According to his mother, Resident #2 had past behaviors such as he will go to a hospital and not want to leave. Record review of handwritten statement dated 3/18/24, authored by LVN A revealed, statement, on 10-6 shift, while at the nurses' station north, vital check of Resident #2. Resident #2 was watching TV in the ding room between 10-11pm on 3/15/24. Record review of In-Servicing dated 3/16/24 included topics: Abuse and Neglect, and Resident Rights. The In-Servicing was signed by 18 staff. 2.Record review of Resident #1's admission Record, dated 3/22/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included: type 2 diabetes mellitus with foot ulcer secondary to resistance to multiple antibiotics, and cellulitis [an infection whereas bacteria enter through a break in the skin that causes selling, pain, redness, warmth to the affected area, and requires antibiotic treatment]. Record review of Resident #1's baseline care plan, dated 3/19/2024 at 6:49 PM, revealed Resident #1 had a wandering risk score of 1 indicative of low risk for wandering. Record review of referral documents from previous hospital admission, revealed under the heading Chief Complaint, dated 3/15/2024 at 5:05 PM, [Resident #1] occasionally telling nurses she wants to leave AMA. Under the heading Pre-Procedure Diagnosis, drug abuse (methamphetamine). Under the heading History of Present Illness, [Resident #1], is homeless and unable to take care of feet/obtaining medication. Under the heading, History - Adult longitudinal, Resident #1 had drug use: Meth/amphetamines, drug screen positive at admission. Record review of skilled nursing notes gated 3/19/2024 at 9:26 PM, authored by LVN C, Resident #1 arrived at the facility at 6:30 PM . Resident #1 Found in dining room at about 8:30 PM about to light a cigarette . Resident #1 Redirected to smoking courtyard. Resident #1 last seen by staff walking towards smoking courtyard at about 8:30 PM wearing clothing that she arrived in from the hospital [disposable paper scrubs]. during last medication round at 9:00 PM Resident #1 was not observed in her room and subsequently could not be found in the building. Missing resident protocols initiated. Record review of handwritten note entitled hospitals called, dated 3/20/2024 at 3:48 PM revealed 10 different local hospitals contact information indicating they had been contacted regarding Resident #1. Record review of [hospital] Patient Visit Information documents, dated 3/20/2024, revealed under the heading medication dose and instructions included medication dose and instructions, Resident #1 had a prescription for Bactrim, an antibiotic, to be taken twice a day for 14 days. Documents included information on Food Resources in the area. In an interview on 3/20/2024 at 5:05 PM, the DON stated, with the current census being low [49 at the time of interview], current staffing was very good. The DON stated the facility staffed 3 CNAs on the morning [6a-2p] and afternoon [2p-10p] shifts, and 2 CNAs on overnights. The DON stated the facility staffed 2 nurses on all shifts. The DON stated the ADON came in early, that she [the DON] stayed late, and the Treatment Nurse usually worked in the middle, an 8a-5p shift. The DON stated that there is a MA on each of the morning and afternoon shifts. The DON stated the medical records clerk and the ADM both have active CNA certifications and will jump in to work the floor when necessary. The DON stated the front desk receptionist position is usually 8a-5p, but there is flexibility for her to flex her shift as she needs to. In an interview on 3/20/2024 at 5:55 PM, the DON stated Resident #1 left no personal belongs behind when she eloped. The DON stated that Resident #1 was homeless and a drug addict. The DON stated Resident #2 had a known behavior in another major metropolitan area of requesting to go to the hospital, where he would refuse to return to his previous facility, and request alternative placement be found. The DON stated this was how he ended up in this area and ultimately in the facility. The DON stated Resident #2 was now difficult to place in that area. The DON stated that she wanted to give people a chance which is why she took these two residents despite their predilections for problematic behaviors. The DON stated the facility typically does not take residents that pace or have exit seeking elopement behaviors. In an interview on 3/20/2024 at 6:20 PM, MA F stated on 3/19/2024 at around 8:30 PM, he had been standing at the medication cart position just outside of a resident's room in the process of preparing that residents medications when he saw Resident #1 was at dining room table in the process of lighting a cigarette. He notified a staff member closer to Resident #1 to redirect Resident #1 to the smoking courtyard. He stated he saw Resident #1 walking towards that smoking courtyard. He stated that around 9:00 PM he was notified by his nurse, LVN B that Resident #1 was not in her room and was needed for medication administration. MA F stated the two of them, MA F and LVN B, went to look for the Resident #1 in the smoking courtyard. MA F stated upon not finding her there they initiated the facilities missing persons protocol and began a facility wide search. In an interview on 3/20/24 at 6:35 PM LVN B stated Resident #1 had arrived to the facility around 6:30 PM on 3/19/2024; and had dinner. Another staff member, MA F, notified him that Resident #1 was attempting to smoke in the dining room, so MA F redirected Resident #1 to smoke in the courtyard. Around 9:00 PM LVN B realized Resident #1 was not in her room, and LVN B needed to give her evening meds. LVN B went down to the smoking courtyard and did not find Resident #1 there. LVN B initiated an all staff search of the facility an exterior of the building. LVN B notified the DON and the ADM that Resident #1 had eloped. LVN B stated the local Police Department was notified, and a report was filed; Local Police declined to initiate a missing person report due to Resident #1's previous drug seeking behaviors and homelessness. LVN B stated he thought there were cameras in the parking lot but was not sure if they actually worked. In an interview on 3/20/24 at 6:55 PM, Resident # 3 stated he did not actually see the lady [Resident #1] leave. Resident #3 stated he had a brief conversation along the lines of hi how are you in the vestibule /waiting area and Resident #1 replied she was waiting for someone. Resident #3 stated he went about looking for a book to read and later noticed Resident #1 was gone and assumed she was picked up by whoever she had been waiting for. Resident # 3 stated Resident #1 had a small red bag and was wearing the paper hospital top and bottom. Resident #3 stated she did not seem upset and was calm when he saw her. Resident # 3 stated he thought it was around 8:30 PM or 9:00 PM yesterday [3/19/2024] when this occurred. In an interview on 3/20/24 at 7:00 PM, the ADM stated the facility did not have cameras. The ADM stated the doors do not alarm or chime upon opening. The ADM stated after hours the doors automatically lock behind you but can be opened from the inside. In an interview on 3/21/24 at 2:00 PM, Ombudsman stated she had not yet been informed of any elopement at this facility; Ombudsman A stated she did not have any concerns about this facility or elopements knowing the type of residents housed at this facility; Ombudsman A stated that since the new administrator and DON started at this facility, things have really turned around - patient morale and outlook has improved and things have really gotten better at this facility. Ombudsman A stated for the census this facility has a very good staffing ratio. In an interview on 3/21/2024 at 3:45 PM, the DON stated this facility does not normally admit residents with elopement/exit seeking behaviors; DON stated the recent in services included enhanced observations of behaviors that might lead to elopement/exit seeking behaviors such as expressions of dissatisfaction, increased aggression or agitation or statements to that effect. The DON stated this facility was not equipped for residents with significant behaviors for elopement or wandering. The DON stated those residents are diverted to one of their sister facilities that has a locked unit. In an interview on 3/21/2024 at 5:30 PM with Charge Nurse RN E at the local emergency room for [Hospital], stated Resident #1 presented to the emergency room on 3/20/2024 at 10:48 PM with anxiety and heel pain. Charge nurse RN E stated Resident # 1 was seen by [ER Physician]. Charge nurse RN E stated Resident #1 was not administered any medication while in the emergency room. Resident #1 was given paper prescriptions for medications to treat the infection and her regular maintenance medications. Resident #1 was also provided information on available food resources. Charge nurse RN E stated Resident #1 was alert and oriented times 4 [person, place, time, situation]. Resident #1 disposition was discharged home with medications. Charge nurse RN E stated while in the emergency room, Resident #1 did not reveal she was homeless or would have any difficulty obtaining the prescriptions. Charge nurse RN E stated while in the emergency room, Resident #1 did not reveal that she had eloped from the facility. In an interview and observation on 3/22/2024 at 2:15 PM with the ADM and the DON present, the ADM stated a new alarm system had been installed on the interior door to the vestibule area last night. The Administrator stated during the daytime hours a chime will sound anytime that door was opened. The Administrator further stated between the hours of 8:00 PM and 6:00 AM the nurses would enter a code that would switch the alarm from a chime to an alarm. The Administrator further stated after 8:00 PM, or when receptionist left for the day, an alarm would sound anytime that door was opened. The alarm required passcode be entered before the alarm would stop sounding. The Administrator stated the chime could be heard throughout the facility, even to the furthest points of resident occupied areas. and the alarm was louder and can be heard throughout the facility even to the furthest points of resident occupied areas. Record review of In-Service training report/attendance record dated 3/19/2024 included topics: Abuse Neglect, Resident Rights, Monitoring Signs of Possible Elopement Risk. It included 26 staff signatures. Record review of the facility's Wandering, And Elopement policy revised March 2019, revealed: if identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 2.) if an employee observes a resident leaving . attempt to prevent; Request assistance from other staff; Instruct another staff member to alert management 3.) if a resident is missing, initiate the elopement/missing resident emergency procedure: a determine if the resident is out on an unauthorized leave of absence; b.) if the resident was not on an unauthorized leave, initiate a search of the facility, grounds and immediate area surrounding the building; c.) if the resident is not in any of the searched areas notify the administrator, director of nursing, family/responsible party and law enforcement officials. Record review of In-Service training report dated 3/20/2024 on the topic of Alerts and Meaning; Contents or summary of training . Code green - missing residents. This training was conducted by the DON and included signatures of 22 staff members. The facility's Plan of Removal was accepted on 03/23/2024 at 7:51 A.M. and included: F600- Immediate Action Notify The Medical Director of the Immediate Jeopardy status. Resident # 1 and Resident #2 are no longer residing at the facility. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Alarm was installed on the dining room door to the front office, which contains the outside exit door. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. The alarm will remain turned on throughout the weekend. The alarm checks will be documented on a log included with the abatement plan. Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Upon admission, the Admissions Director and/ or designee will discuss facility rules with the resident and responsible party regarding signing in and out to go on pass. The charge nurse admitting the resident will further discuss the facility rules for exiting the facility and will assess the elopement risk of the new resident. If it is determined at any time post-admission that a resident is no longer safe and needs a secured unit, the resident will have 1:1 monitoring until safely discharged to an appropriate facility. Education will be provided on this process to the Department Managers, including the admission Director and Clinical Liaison, as well as the Charge Nurses and Nurse Managers. This training will be completed by the Administrator and the Director of Nurses by Sunday, 03/24/24, at noon. The DON and/ or designee will audit all new admissions and readmissions daily to ensure an elopement risk assessment has been completed and that the resident has been provided with orientation for the out-on-pass procedure. The Director of Nurses and/ or designee will complete and review elopement risk audits with each admission, readmission, and change of condition. Quarterly assessments and reviews will remain ongoing to ensure that an appropriate and personalized plan of care is in place for residents at risk and that compliance and standards are met. The administrator and director of nurses will provide the staff with training on Elopement Protocols by Sunday, 03/24/24, at noon. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a non-threatening, courteous manner. b. Request assistance from other staff member in the immediate vicinity as needed. c. Instruct another staff member to alert the charge nurse, Director of Nursing and/or Administrator of the resident's intent to leave the premises. If a resident is missing, initiate the elopement/missing resident emergency procedure: d. Determine if the resident is out on an unauthorized leave of absence. e. If the resident was not authorized to leave, initiate a search of the facility, grounds, and immediate areas surrounding the building. f. If the resident is not in the searched areas, notify the Administrator, the Director of Nursing, the family/responsible party, and law enforcement officials. When the resident returns to the facility, the director of nursing services or charge nurse shall: g. Notify staff and examine the resident for injuries. h. Notify the physician and medical director of the resident return and assessment findings. i. Notify the family/ responsible party. Verification included: Notify The Medical Director of the Immediate Jeopardy status. Verified via interview with Medical Director [Name of MD], on 3/23/24 at 1:12 PM, she was notified of the IJ at on 3/22/24 at 6:45 PM. Resident # 1 and Resident #2 are no longer residing at the facility. Verified, via interview with The DON on 3/23/24 at 1:24 P.M., that Resident # 1 was discharged from the facility on 3/20/24 at 107 P.M., and Resident # 2 was discharged from the facility on 3/19/24 at 10:00 P.M. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Verified, Elopement assessments completed on electronic medical records for 49 of 49 residents. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Verified, on 3/23/24 via Interview with DON, that none of the 49 current residents were identified as High Risk. Alarm was installed on the dining room door to the front office, which contains the outside exit door. Verified by surveyor on 3/23/24 at 10:45 a.m. upon entrance that dining room door to front office is present and functioning. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. Verified, via an interview with The Administrator on 3/23/24 at 120 p.m., that the alarm is turned on by the receptionist nightly at 8:00 P.M. Verified that the alarm is monitored during daytime hours by the receptionist. Verified, via logbook noted on south wing of [ name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. Verified, via log book signatures noted on south wing of [ Name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The alarm will remain turned on throughout the weekend. Verified, by surveyor on 3/23/24 at 10:45 a.m. upon entrance that alarm is on and functioning. The alarm checks will be documented on a log included with the abatement plan. Verified, via log book signatures noted on south wing of [ name of Nursing Home ] on 3/23/24 at 210 P.M . Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Verified, completed training for Door alarms was completed by 54/54 employees, noted with signatures acknowledging in-service. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. Verified, Inservice elopement/missing resident protocols staff signatures and interviews with the DON, ADON, and the Administrator revealed DON and ADON were trained step by step in elopement/missing resident protocols procedure on 03/22/23 to cover immediacy by the Administrator. DON and ADON were brought into the office, provided a copy of the procedure, and were able to verbalize understanding of the procedure. See the in-service sheets attached. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. Verified, in-service elopement/missing resident protocols was completed via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, and (2) 10 pm-0600 am LVN's. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. Verified via in-service elopement /missing resident protocols was completed for: (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. and (2) receptionists. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. Verified, via in-service signature, elopement /missing resident protocols was completed by The Clinical Liaison, Marketer, and Admissions Director. Verified via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. Verified, via record review of the in-service sheet Titled Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy reflected 54 staff members' signatures. 11 LVNs, 2 RNs, 12 CMA's, 11 Administrative personnel, 10 Therapists, 3 housekeepers, and 6 dietary staff. 24 out of 54 staff members interviewed (8 LVN, 2 RN, 6 Therapy, 3 Administrative, 5 dietary) verified Inservice. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. Verified via interview with the DON on 3/23/24 at 235 P.M. that no new licensed nurses have been hired since this IJ, and only one agency nurse has been used by the [ Name of Nursing home] since the IJ. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Verified via interview with Clinical Liaison and Admissions Director on 3/23/24 at 245 pm that they were in-serviced on referral paperwork that may need to be reviewed by the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 residents (Resident #2 and #1) reviewed for neglect., in that: 1. Resident #2 was able to exit the building without staff knowing on 3/15/2024; staff were unaware Resident #2 had wheeled himself to a bus stop on a city sidewalk and was gone until he was brought back by police; staff were unaware that Resident #2 had exit seeking behavior although it was in his admission paperwork. 2. Resident #1 was able to exit the building without staff knowing on 3/19/2024; staff were unaware Resident #1 had exited the building and her whereabouts are still unknown. This failure could place resident at risk of neglect resulting in elopements that could have resulted in serious injury, harm, impairment, or death. An IJ was identified on 03/22/2024. The IJ template was provided to the facility on [DATE] at 05:50 PM. While the IJ was removed on 03/23/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facilities need to evaluate the effectiveness of their corrective actions. The findings were: 1.Record review of Resident #2 Administration Record dated 3/24/2024, revealed Resident #2 was a [AGE] year-old male originally admitted on [DATE] with diagnosis listed as: unspecified heart failure. Other active diagnosis included deaf, non-speaking; functional quadriplegia [completely immobile due to severe disability or frailty]; schizoaffective disorder bipolar type [mental health disorder marked by a combination of symptoms such as hallucinations or delusions, mood disorder symptoms such as depression or mania]. Further review a discharge date of 3/20/2024 to another nursing facility in the area. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was coded as highly impaired [absence of useful] hearing with unclear speech; ability to express ideas and wants was coded as usually understood; ability to understand others was coded as sometimes understands in Section B - Hearing, Speech, and Vision. In Section C - Cognitive Patterns, Resident #2 was coded as No for Should BIMS be Conducted due to resident is rarely/never understood; with Disorganized Thinking continuously present, does not fluctuate. In Section D - Mood, Resident #2 was coded as being short-tempered, easily annoyed, rarely felt lonely or isolated from those around you; In Section E - Behavior, Resident #2 was coded as none of the above for indicators of psychosis [hallucinations, delusions]. In Section GG - Functional Abilities, Resident #2 was coded as normally utilizing a wheelchair. Resident #2 was coded as substantial/maximal assistance [helper does more than half the effort] for wheel 50 feet with two turns, and wheel 150 feet with a manual wheelchair. Record review of Resident # 2's All-Inclusive admission with Baseline Care Plan, dated 11/09/2023, revealed the resident was at risk for wandering with a wandering risk score of 3. Under the subheading for vision, 4.) Residents' ability to see an adequate light and with glasses if used was coded as highly or severely impaired - sees only lights, colors, etcetera or no vision. Record review of referral documents from previous hospital admission, revealed under Emergency Department Medical Screen Exam on 11/03/2023 at 1:18, Resident #2 was deaf and communicates via sign language; does not want to go back to the group home .; wants to go into a nursing home. Reexamination on 11/03/2023 at 1:58 PM, presents to emergency department because he is unhappy with his living situation. At 11/03/2023 at 12:05 PM, documentation reveals, Informed that the patient [Resident #2] has been denied at multiple NH [nursing homes] because of behavioral issues he has had in the past. Under the History & Physical section dated 11/03/2023 at 3:28 PM, patient wanting a new placement and refusing to leave . Progress Note dated 11/05/2023 at 3:03 PM revealed, Resident #2 called 911 from group home .30 minutes after discharge from a hospital in [redacted] . upset due to circumstances. Record review of Behavior Note, dated 3/10/2024 at 5:57 AM, authored by LVN A revealed Resident #2, seen him going out the front door, wanting nurse to call 911. Record review of Behavior Note, dated 3/16/2024 at 2:03 AM, authored by LVN A revealed, Resident #2 found by police at bus stop, police was called by persons walking by for wellness check, policy finally got [Resident #2] to return to facility .EMS came, unable to take him since he is not critique [critical]. I had to station an aide at front door so resident wouldn't go back to bus stop. We need a inside lock on [front door] so this situation would not happen again. Record review of Internal Investigation Summary dated 3/16/2024, revealed Timeline of Event: 3/16/2024 at 12:48 AM Administrator received call from LVN A to inform the police have brought Resident #2 to the facility from the bus stop at the end of the parking lot on the city sidewalk. Resident #2 had wheeled himself to the bus stop without notifying a nurse or any other staff. Resident #2 told the police officer he wanted to go to the hospital. EMS was contacted at Resident #2's request; paramedics assessed the resident and declined to transfer to the hospital; resident declined head to toe assessment by DON at that time; resident uncooperative and upset; the next afternoon resident insisted that the doctor be called so he could be sent to the hospital; Attending physician was called and an order was obtained to transfer him to [Hospital]; Resident from [another major city] area originally where he had a habit of going to the hospital and then going to a different facility; Ended up in [this area] because he became hard to place in [another major city] area due to his behaviors; While inpatient at the hospital he requested another facility to be found and a social worker has been working to facilitate a transfer; Facility was willing to accept the resident back from the hospital; According to his mother, Resident #2 had past behaviors such as he will go to a hospital and not want to leave. Record review of handwritten statement dated 3/18/24, authored by LVN A revealed, statement, on 10-6 shift, while at the nurses' station north, vital check of Resident #2. Resident #2 was watching TV in the ding room between 10-11pm on 3/15/24. Record review of In-Servicing dated 3/16/24 included topics: Abuse and Neglect, and Resident Rights. The In-Servicing was signed by 18 staff. 2.Record review of Resident #1's admission Record, dated 3/22/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included: type 2 diabetes mellitus with foot ulcer secondary to resistance to multiple antibiotics, and cellulitis [an infection whereas bacteria enter through a break in the skin that causes selling, pain, redness, warmth to the affected area, and requires antibiotic treatment]. Record review of Resident #1's baseline care plan, dated 3/19/2024 at 6:49 PM, revealed Resident #1 had a wandering risk score of 1 indicative of low risk for wandering. Record review of referral documents from previous hospital admission, revealed under the heading Chief Complaint, dated 3/15/2024 at 5:05 PM, [Resident #1] occasionally telling nurses she wants to leave AMA. Under the heading Pre-Procedure Diagnosis, drug abuse (methamphetamine). Under the heading History of Present Illness, [Resident #1], is homeless and unable to take care of feet/obtaining medication. Under the heading, History - Adult longitudinal, Resident #1 had drug use: Meth/amphetamines, drug screen positive at admission. Record review of skilled nursing notes gated 3/19/2024 at 9:26 PM, authored by LVN C, Resident #1 arrived at the facility at 6:30 PM . Resident #1 Found in dining room at about 8:30 PM about to light a cigarette . Resident #1 Redirected to smoking courtyard. Resident #1 last seen by staff walking towards smoking courtyard at about 8:30 PM wearing clothing that she arrived in from the hospital [disposable paper scrubs]. during last medication round at 9:00 PM Resident #1 was not observed in her room and subsequently could not be found in the building. Missing resident protocols initiated. Record review of handwritten note entitled hospitals called, dated 3/20/2024 at 3:48 PM revealed 10 different local hospitals contact information indicating they had been contacted regarding Resident #1. Record review of [hospital] Patient Visit Information documents, dated 3/20/2024, revealed under the heading medication dose and instructions included medication dose and instructions, Resident #1 had a prescription for Bactrim, an antibiotic, to be taken twice a day for 14 days. Documents included information on Food Resources in the area. In an interview on 3/20/2024 at 5:05 PM, the DON stated, with the current census being low [49 at the time of interview], current staffing was very good. The DON stated the facility staffed 3 CNAs on the morning [6a-2p] and afternoon [2p-10p] shifts, and 2 CNAs on overnights. The DON stated the facility staffed 2 nurses on all shifts. The DON stated the ADON came in early, that she [the DON] stayed late, and the Treatment Nurse usually worked in the middle, an 8a-5p shift. The DON stated that there is a MA on each of the morning and afternoon shifts. The DON stated the medical records clerk and the ADM both have active CNA certifications and will jump in to work the floor when necessary. The DON stated the front desk receptionist position is usually 8a-5p, but there is flexibility for her to flex her shift as she needs to. In an interview on 3/20/2024 at 5:55 PM, the DON stated Resident #1 left no personal belongs behind when she eloped. The DON stated that Resident #1 was homeless and a drug addict. The DON stated Resident #2 had a known behavior in another major metropolitan area of requesting to go to the hospital, where he would refuse to return to his previous facility, and request alternative placement be found. The DON stated this was how he ended up in this area and ultimately in the facility. The DON stated Resident #2 was now difficult to place in that area. The DON stated that she wanted to give people a chance which is why she took these two residents despite their predilections for problematic behaviors. The DON stated the facility typically does not take residents that pace or have exit seeking elopement behaviors. In an interview on 3/20/2024 at 6:20 PM, MA F stated on 3/19/2024 at around 8:30 PM, he had been standing at the medication cart position just outside of a resident's room in the process of preparing that residents medications when he saw Resident #1 was at dining room table in the process of lighting a cigarette. He notified a staff member closer to Resident #1 to redirect Resident #1 to the smoking courtyard. He stated he saw Resident #1 walking towards that smoking courtyard. He stated that around 9:00 PM he was notified by his nurse, LVN B that Resident #1 was not in her room and was needed for medication administration. MA F stated the two of them, MA F and LVN B, went to look for the Resident #1 in the smoking courtyard. MA F stated upon not finding her there they initiated the facilities missing persons protocol and began a facility wide search. In an interview on 3/20/24 at 6:35 PM LVN B stated Resident #1 had arrived to the facility around 6:30 PM on 3/19/2024; and had dinner. Another staff member, MA F, notified him that Resident #1 was attempting to smoke in the dining room, so MA F redirected Resident #1 to smoke in the courtyard. Around 9:00 PM LVN B realized Resident #1 was not in her room, and LVN B needed to give her evening meds. LVN B went down to the smoking courtyard and did not find Resident #1 there. LVN B initiated an all staff search of the facility an exterior of the building. LVN B notified the DON and the ADM that Resident #1 had eloped. LVN B stated the local Police Department was notified, and a report was filed; Local Police declined to initiate a missing person report due to Resident #1's previous drug seeking behaviors and homelessness. LVN B stated he thought there were cameras in the parking lot but was not sure if they actually worked. In an interview on 3/20/24 at 6:55 PM, Resident # 3 stated he did not actually see the lady [Resident #1] leave. Resident #3 stated he had a brief conversation along the lines of hi how are you in the vestibule /waiting area and Resident #1 replied she was waiting for someone. Resident #3 stated he went about looking for a book to read and later noticed Resident #1 was gone and assumed she was picked up by whoever she had been waiting for. Resident # 3 stated Resident #1 had a small red bag and was wearing the paper hospital top and bottom. Resident #3 stated she did not seem upset and was calm when he saw her. Resident # 3 stated he thought it was around 8:30 PM or 9:00 PM yesterday [3/19/2024] when this occurred. In an interview on 3/20/24 at 7:00 PM, the ADM stated the facility did not have cameras. The ADM stated the doors do not alarm or chime upon opening. The ADM stated after hours the doors automatically lock behind you but can be opened from the inside. In an interview on 3/21/24 at 2:00 PM, Ombudsman stated she had not yet been informed of any elopement at this facility; Ombudsman A stated she did not have any concerns about this facility or elopements knowing the type of residents housed at this facility; Ombudsman A stated that since the new administrator and DON started at this facility, things have really turned around - patient morale and outlook has improved and things have really gotten better at this facility. Ombudsman A stated for the census this facility has a very good staffing ratio. In an interview on 3/21/2024 at 3:45 PM, the DON stated this facility does not normally admit residents with elopement/exit seeking behaviors; DON stated the recent in services included enhanced observations of behaviors that might lead to elopement/exit seeking behaviors such as expressions of dissatisfaction, increased aggression or agitation or statements to that effect. The DON stated this facility was not equipped for residents with significant behaviors for elopement or wandering. The DON stated those residents are diverted to one of their sister facilities that has a locked unit. In an interview on 3/21/2024 at 5:30 PM with Charge Nurse RN E at the local emergency room for [Hospital], stated Resident #1 presented to the emergency room on 3/20/2024 at 10:48 PM with anxiety and heel pain. Charge nurse RN E stated Resident # 1 was seen by [ER Physician]. Charge nurse RN E stated Resident #1 was not administered any medication while in the emergency room. Resident #1 was given paper prescriptions for medications to treat the infection and her regular maintenance medications. Resident #1 was also provided information on available food resources. Charge nurse RN E stated Resident #1 was alert and oriented times 4 [person, place, time, situation]. Resident #1 disposition was discharged home with medications. Charge nurse RN E stated while in the emergency room, Resident #1 did not reveal she was homeless or would have any difficulty obtaining the prescriptions. Charge nurse RN E stated while in the emergency room, Resident #1 did not reveal that she had eloped from the facility. In an interview and observation on 3/22/2024 at 2:15 PM with the ADM and the DON present, the ADM stated a new alarm system had been installed on the interior door to the vestibule area last night. The Administrator stated during the daytime hours a chime will sound anytime that door was opened. The Administrator further stated between the hours of 8:00 PM and 6:00 AM the nurses would enter a code that would switch the alarm from a chime to an alarm. The Administrator further stated after 8:00 PM, or when receptionist left for the day, an alarm would sound anytime that door was opened. The alarm required passcode be entered before the alarm would stop sounding. The Administrator stated the chime could be heard throughout the facility, even to the furthest points of resident occupied areas. and the alarm was louder and can be heard throughout the facility even to the furthest points of resident occupied areas. Record review of In-Service training report/attendance record dated 3/19/2024 included topics: Abuse Neglect, Resident Rights, Monitoring Signs of Possible Elopement Risk. It included 26 staff signatures. Record review of the facility's Wandering, And Elopement policy revised March 2019, revealed: if identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 2.) if an employee observes a resident leaving . attempt to prevent; Request assistance from other staff; Instruct another staff member to alert management 3.) if a resident is missing, initiate the elopement/missing resident emergency procedure: a determine if the resident is out on an unauthorized leave of absence; b.) if the resident was not on an unauthorized leave, initiate a search of the facility, grounds and immediate area surrounding the building; c.) if the resident is not in any of the searched areas notify the administrator, director of nursing, family/responsible party and law enforcement officials. Record review of In-Service training report dated 3/20/2024 on the topic of Alerts and Meaning; Contents or summary of training . Code green - missing residents. This training was conducted by the DON and included signatures of 22 staff members. The facility's Plan of Removal was accepted on 03/23/2024 at 7:51 A.M. and included: F600- Immediate Action Notify The Medical Director of the Immediate Jeopardy status. Resident # 1 and Resident #2 are no longer residing at the facility. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Alarm was installed on the dining room door to the front office, which contains the outside exit door. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. The alarm will remain turned on throughout the weekend. The alarm checks will be documented on a log included with the abatement plan. Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Upon admission, the Admissions Director and/ or designee will discuss facility rules with the resident and responsible party regarding signing in and out to go on pass. The charge nurse admitting the resident will further discuss the facility rules for exiting the facility and will assess the elopement risk of the new resident. If it is determined at any time post-admission that a resident is no longer safe and needs a secured unit, the resident will have 1:1 monitoring until safely discharged to an appropriate facility. Education will be provided on this process to the Department Managers, including the admission Director and Clinical Liaison, as well as the Charge Nurses and Nurse Managers. This training will be completed by the Administrator and the Director of Nurses by Sunday, 03/24/24, at noon. The DON and/ or designee will audit all new admissions and readmissions daily to ensure an elopement risk assessment has been completed and that the resident has been provided with orientation for the out-on-pass procedure. The Director of Nurses and/ or designee will complete and review elopement risk audits with each admission, readmission, and change of condition. Quarterly assessments and reviews will remain ongoing to ensure that an appropriate and personalized plan of care is in place for residents at risk and that compliance and standards are met. The administrator and director of nurses will provide the staff with training on Elopement Protocols by Sunday, 03/24/24, at noon. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a non-threatening, courteous manner. b. Request assistance from other staff member in the immediate vicinity as needed. c. Instruct another staff member to alert the charge nurse, Director of Nursing and/or Administrator of the resident's intent to leave the premises. If a resident is missing, initiate the elopement/missing resident emergency procedure: d. Determine if the resident is out on an unauthorized leave of absence. e. If the resident was not authorized to leave, initiate a search of the facility, grounds, and immediate areas surrounding the building. f. If the resident is not in the searched areas, notify the Administrator, the Director of Nursing, the family/responsible party, and law enforcement officials. When the resident returns to the facility, the director of nursing services or charge nurse shall: g. Notify staff and examine the resident for injuries. h. Notify the physician and medical director of the resident return and assessment findings. i. Notify the family/ responsible party. Verification included: Notify The Medical Director of the Immediate Jeopardy status. Verified via interview with Medical Director [Name of MD], on 3/23/24 at 1:12 PM, she was notified of the IJ at on 3/22/24 at 6:45 PM. Resident # 1 and Resident #2 are no longer residing at the facility. Verified, via interview with The DON on 3/23/24 at 1:24 P.M., that Resident # 1 was discharged from the facility on 3/20/24 at 107 P.M., and Resident # 2 was discharged from the facility on 3/19/24 at 10:00 P.M. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Verified, Elopement assessments completed on electronic medical records for 49 of 49 residents. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Verified, on 3/23/24 via Interview with DON, that none of the 49 current residents were identified as High Risk. Alarm was installed on the dining room door to the front office, which contains the outside exit door. Verified by surveyor on 3/23/24 at 10:45 a.m. upon entrance that dining room door to front office is present and functioning. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. Verified, via an interview with The Administrator on 3/23/24 at 120 p.m., that the alarm is turned on by the receptionist nightly at 8:00 P.M. Verified that the alarm is monitored during daytime hours by the receptionist. Verified, via logbook noted on south wing of [ name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. Verified, via log book signatures noted on south wing of [ Name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The alarm will remain turned on throughout the weekend. Verified, by surveyor on 3/23/24 at 10:45 a.m. upon entrance that alarm is on and functioning. The alarm checks will be documented on a log included with the abatement plan. Verified, via log book signatures noted on south wing of [ name of Nursing Home ] on 3/23/24 at 210 P.M . Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Verified, completed training for Door alarms was completed by 54/54 employees, noted with signatures acknowledging in-service. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. Verified, Inservice elopement/missing resident protocols staff signatures and interviews with the DON, ADON, and the Administrator revealed DON and ADON were trained step by step in elopement/missing resident protocols procedure on 03/22/23 to cover immediacy by the Administrator. DON and ADON were brought into the office, provided a copy of the procedure, and were able to verbalize understanding of the procedure. See the in-service sheets attached. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. Verified, in-service elopement/missing resident protocols was completed via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, and (2) 10 pm-0600 am LVN's. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. Verified via in-service elopement /missing resident protocols was completed for: (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. and (2) receptionists. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. Verified, via in-service signature, elopement /missing resident protocols was completed by The Clinical Liaison, Marketer, and Admissions Director. Verified via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. Verified, via record review of the in-service sheet Titled Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy reflected 54 staff members' signatures. 11 LVNs, 2 RNs, 12 CMA's, 11 Administrative personnel, 10 Therapists, 3 housekeepers, and 6 dietary staff. 24 out of 54 staff members interviewed (8 LVN, 2 RN, 6 Therapy, 3 Administrative, 5 dietary) verified Inservice. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. Verified via interview with the DON on 3/23/24 at 235 P.M. that no new licensed nurses have been hired since this IJ, and only one agency nurse has been used by the [ Name of Nursing home] since the IJ. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Verified via interview with Clinical Liaison and Admissions Director on 3/23/24 at 245 pm that they were in-serviced on referral paperwork that may need

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a change in condition and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for physician notification, in that: Residents #1-#4 were administered blood pressure medications when their blood pressures were low and outside of the physician ordered parameters without physician notification prior to or after medication administration. This failure could result in decreased continuity of care, and a delay in needed treatment and services. An immediate jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:23 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm at a scope of pattern due to the facility's need to monitor the effectiveness of their plan of removal. The findings were: Closed record review of Resident #1's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (diffuse disease of the brain that alters brain function or structure caused by metabolic changes due to underlying health conditions), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #1 was discharged to the hospital on [DATE]. Closed record review of Resident #1's care plan revealed a focus for the diagnosis of hypertension initiated on [DATE] with the resident at risk for hypertension and hypotension episodes and a goal for Resident #1 to have no side effects of medications. Interventions included to assess reports of hypotension and hypertension episodes, check B/P as ordered and notify the doctor of abnormal results, observe for signs and symptoms and to provide medications as ordered. Closed record review of Resident #1's physician orders revealed an order with a start date of [DATE] for Losartan potassium 100mg tablet (medication used to lower blood pressure) to be given once daily for hypertension at 8:00 p.m. with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #1's EMAR for [DATE] revealed on [DATE] at 8:00 p.m. Losartan potassium 100mg tab was administered by LVN A with a B/P of 88/57, P-78. Closed record review of Resident #1's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Losartan potassium medication outside of the ordered parameters on [DATE]. Record review of Resident #2's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: cellulitis of right lower limb, essential primary hypertension, and legal blindness. Record review of Resident #2's care plan, revised [DATE], revealed a focus, [Resident #2] has [diagnosis] of Hypertension. Is at risk for Hypo-/hypertensive episodes, and interventions, Check B/P as ordered and notify MD of abnormal results and Provide medications as ordered. Record review of Resident #2's physician orders revealed an order with a start date of [DATE] for Metoprolol Tartrate Oral Tablet 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #2's EMAR for February 2024 revealed on [DATE] at 8:00 p.m., Metoprolol Tartrate Oral Tablet 25mg tablet was administered by LVN B with a B/P of 98/63, P-79. Record review of Resident #2's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Metoprolol Tartrate medication outside of the ordered parameters on [DATE]. Record review of Resident #3's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses including: unspecified dementia, essential primary hypertension, and heart failure. Record review of Resident #3's care plan, revised [DATE], revealed a focus, [Resident #3] has a [diagnosis] of Hyperlipidemia. Is at risk for complications related to [diagnosis] and adverse reaction to medications, and interventions, Provide medications as ordered. Further review revealed a focus, [Resident #3] is at risk for chest pains, irregular pulse and adverse reaction to medications due to [diagnosis] of Heart Failure, and interventions, Hold medications within parameters from MD and indicated (example: hold digoxin if pulse is below 60). Record review of Resident #3's physician orders revealed an order with a start date of [DATE] for Hydrochlorothiazide Tablet 25 mg. Give 1 tablet by mouth one time a day for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #3's EMAR for February 2024 revealed on [DATE] Hydrochlorothiazide was administered by LVN B with a B/P of 149/59, P-56. Record review of Resident #3's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Hydrochlorothiazide medication outside of the ordered parameters on [DATE]. Closed record review of Resident #4's face sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included ESRD (End Stage Renal Disease- medical condition in which the kidneys cease functioning on a permanent basis leading to the need for long-term dialysis or a kidney transplant to maintain life), hypertensive heart disease with heart failure (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation with the heart unable to pump enough blood to meet the body's needs for blood and oxygen), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #4 was discharged as expired on [DATE]. Closed record review of Resident #4's physician orders revealed an order with a start date of [DATE] and a DC date of [DATE] for Losartan potassium 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for [DATE] revealed losartan potassium 25mg was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of 103/58 P-77, and on [DATE] at 8:00 a.m. with a B/P of 104/37 P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed losartan potassium 25mg was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of 102/77 P-86, and on [DATE] at 8:00 a.m. by LVN B with a B/P of 102/54 P-113. Closed record review of Resident #4's physician orders revealed an order with a start date of [DATE] for carvedilol 25mg tablet by mouth twice daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for [DATE] revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of 103/58 P-77 and at 8:00 p.m. by LVN B with a B/P of 103/58 P-77. On [DATE] at 8:00 a.m. it was administered by LVN A with a B/P of 104/37 P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of 102/77 P-86 and at 8:00 p.m. by LVN B with a B/P of 102/77 P-86. On [DATE] at 8:00 p.m. by LVN B with a B/P of 101/47 P-68, on [DATE] at 8:00 p.m. by LVN B with a B/P of 101/47 P-70. On [DATE] at 8:00 a.m. by LVN B with a B/P of 102/54 P-113. Closed record review of Resident #4's EMAR for [DATE] revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 p.m. by LVN B with a B/P of 93/38 P-78 Closed record review of Resident #4's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure readings and or the administration of the Losartan potassium or Carvedilol medications outside of the ordered parameters. In an interview on [DATE] at 12:05 p.m., LVN A stated she takes her own vital signs and if she administered any medications outside of the ordered parameters then she had contacted the physician and documented in the resident progress notes or through the EMAR documentation. LVN A further stated she does not know what happened and does not copy vital signs. LVN A was unable to state where else the documentation of the physician being notified would be. In an interview on [DATE] at 5:17 p.m., LVN B stated that he personally measures and accurately records vital signs including blood pressure and pulse each time the physician orders call for vital signs and stated that he does not administer medications outside of the parameters noted in the physician orders. LVN B stated he always follows physician orders, including notifying the physician if and when a resident's vital signs were outside of parameters noted in the orders. When asked why he had not notified the physician on [DATE] when Resident #2 received medication outside of parameters, and on [DATE] when Resident #3 received medication outside of parameters, LVN B stated that he always notifies the physician when needed and stated he did not know why there was no documentation of his notification. In an interview with the DON [DATE] at 5:15 p.m., the DON confirmed that accurately measuring and recording vital signs as per physician order and notifying the physician of a change in the resident's condition and/or a need to alter the resident's treatment were integral to assisting the residents to maintain good health. In a telephone interview on [DATE] at 1:02 p.m. the MD stated he was not aware and could not recall being notified specifically with vital sign issues but was driving and did not have his patient records in front of him. The MD further stated patient safety was a priority for him and his group of physicians. In a telephone interview on [DATE] at 2:40 p.m. the MD stated the vital sign issues brought to his attention by surveyor were concerning. The MD stated he and other physicians in his group were in the facility often, and at times even 2 to 3 times a week and he had not recalled seeing blood pressure or vital sign issues on what was displayed to the physician. The MD further stated the vital sign issues could make clinical decision making more difficult. The facility's Plan of Removal was accepted on [DATE] at 5:10 p.m. and included: Date: [DATE] F 726 Immediate action: The Medical Director was notified of the Immediate Jeopardy status on [DATE] at 7:35 pm. Resident Vital Signs were taken when the issue was identified on [DATE]. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on [DATE]. The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on [DATE] once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. On [DATE], a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on [DATE]. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm [DATE]. All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of [DATE] @ 12:45pm. Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on [DATE] by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by [DATE] 11:59 pm. Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. POR Verification The Medical Director was notified of the Immediate Jeopardy status on [DATE] at 7:35 pm. - Confirmed via interview with the Medical Director [DATE] at 5:37 pm Resident Vital Signs were taken when the issue was identified on [DATE]. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on [DATE]. - Confirmed via interview with Medical Director [DATE] at 5:37 pm - Confirmed via record review of 15 resident clinical records The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on [DATE] once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. - Confirmed via interview with the DON [DATE] at 5:15 pm On [DATE], a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on [DATE]. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm [DATE]. - Confirmed via interview with the DON [DATE] at 5:15 pm - Confirmed via interview with the Medical Director [DATE] at 5:37 pm - Confirmed via record review of 15 resident clinical records All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of [DATE] at@ 12:45pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on [DATE] by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. - Confirmed via interview with DON [DATE] at 7:12 pm Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by [DATE] 11:59 pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. - Confirmed via interview with DON [DATE] at 7:12 pm Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. - Confirmed via interview with DON [DATE] at 7:12 pm The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. - Confirmed via interview with DON [DATE] at 7:12 pm During an interview with the DON on [DATE] at 5:15 p.m., the DON stated that only nurses and medication aides measured vital signs and administered at the facility and there were 2 medication aides and 12 nurses employed by the facility. The DON stated that 11 of the 14 staff members who administered medications had both of two in-service trainings and completed both of two skills checks. Skills checks required staff to demonstrate how to assess blood pressure using two techniques. The DON stated that the three staff members who did not yet receive training will be required to do so before their next shift. During an interview with LVN B on [DATE] at 5:17 p.m., LVN B stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN B further stated he had completed two demonstrative skills checks with the DON. During an interview with Medication Aide E on [DATE] at 5:22 p.m., Medication Aide E stated her work schedule was Monday through Friday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. Medication Aide E further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN A on [DATE] at 5:26 p.m., LVN A stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN A further stated she had completed two demonstrative skills checks with the DON. During an interview with RN F on [DATE] at 5:32 p.m., RN F stated her work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. RN F further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN G on [DATE] at 5:43 p.m., LVN G stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN G further stated he had completed two demonstrative skills checks with the DON. During an interview with LVN H on [DATE] at 5:50 p.m., LVN H stated her work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN H further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN I on [DATE] at 5:55 p.m., LVN I stated his work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN I further stated he had completed two demonstrative skills checks with the DON. During a telephone interview with LVN J on [DATE] at 6:04 p.m., LVN J stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN J further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN K on [DATE] at 6:16 p.m., LVN K stated her work schedule was Monday through Friday from 6:00 a.m. to 2:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN K further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN L on [DATE] at 6:24 p.m., LVN L stated her work schedule was Monday through Friday from 10:00 a.m. to 6:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LN L further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN M on [DATE] at 6:16 p.m., LVN M stated his work schedule was Monday through Friday from 10:00 p.m. to 6:00 a.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN M further stated he had completed two demonstrative skills checks with the DON. Record review of the facility in-service training, Checklist Vital Signs: Assessing Blood Pressure, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility in-service training, Blood Pressure Measurement (Digital) Skills Checklist, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility skills check, Vital Signs Parameters/Blood Pressure/Pulse, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility skills check, Vital Signs Parameters, dated [DATE], revealed it had been signed as completed by eleven staff members. The Administrator was informed the Immediate Jeopardy was lifted on [DATE] at 8:12 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. No facility policy regarding physician notification was received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for significant medication errors, in that: Residents #1, #2, #3, and #4 were administered medications to lower blood pressures when their blood pressures or Pulse was already low and outside the physician ordered parameters. An immediate jeopardy (IJ) was identified on 3/15/24. The IJ template was provided to the facility on 3/15/24 at 7:23 p.m. While the IJ was removed on 3/16/24, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm at a scope of pattern due to the facility's need to monitor the effectiveness of their plan of removal. This failure could result in critically low blood pressures, inadequate blood flow, and could result in dizziness, fainting, hospitalization, and death. The findings were: Closed record review of Resident #1's face sheet dated 3/13/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (diffuse disease of the brain that alters brain function or structure caused by metabolic changes due to underlying health conditions), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #1 was discharged to the hospital on [DATE]. Closed record review of Resident #1's care plan revealed a focus for the diagnosis of hypertension initiated on 11/6/23 with the resident at risk for hypertension and hypotension episodes and a goal for Resident #1 to have no side effects of medications. Interventions included to assess reports of hypotension and hypertension episodes, check B/P as ordered and notify the doctor of abnormal results, observe for signs and symptoms and to provide medications as ordered. Closed record review of Resident #1's physician orders revealed an order with a start date of 11/13/23 for Losartan potassium 100mg tablet medication used to lower blood pressure) to be given once daily for hypertension at 8:00 p.m. with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of less than 60 beats per minute. Closed record review of Resident #1's EMAR for November 2023 revealed on 11/18/23 at 8:00 p.m. Losartan potassium 100mg tab was administered by LVN A with a B/P of 88/57, P-78. Closed record review of Resident #1's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Losartan potassium medication outside of the ordered parameters on 11/18/23. Record review of Resident #2's face sheet, dated 03/12/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: cellulitis of right lower limb, essential primary hypertension, and legal blindness. Record review of Resident #2's care plan, revised 11/21/2022, revealed a focus, [Resident #2] has [diagnosis] of Hypertension. Is at risk for Hypo-/hypertensive episodes, and interventions, Check B/P as ordered and notify MD of abnormal results and Provide medications as ordered. Record review of Resident #2's physician orders revealed an order with a start date of 05/02/2023 for Metoprolol Tartrate Oral Tablet 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #2's EMAR for February 2024 revealed on 02/11/2024 at 8:00 p.m., Metoprolol Tartrate Oral Tablet 25mg tablet was administered by LVN B with a B/P of 98/63, P-79. Record review of Resident #2's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Metoprolol Tartrate medication outside of the ordered parameters on 02/11/2024. Record review of Resident #3's face sheet, dated 03/12/2024, revealed the resident was admitted on [DATE] with diagnoses including: unspecified dementia, essential primary hypertension, and heart failure. Record review of Resident #3's care plan, revised 08/05/2023, revealed a focus, [Resident #3] has a [diagnosis] of Hyperlipidemia. Is at risk for complications related to [diagnosis] and adverse reaction to medications, and interventions, Provide medications as ordered. Further review revealed a focus, [Resident #3] is at risk for chest pains, irregular pulse and adverse reaction to medications due to [diagnosis] of Heart Failure, and interventions, Hold medications within parameters from MD and indicated (example: hold digoxin if pulse is below 60). Record review of Resident #3's physician orders revealed an order with a start date of 11/14/2023 for Hydrochlorothiazide Tablet 25 mg. Give 1 tablet by mouth one time a day for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #3's EMAR for February 2024 revealed on 02/17/2024 Hydrochlorothiazide was administered by LVN B with a B/P of 149/59, P-56. Record review of Resident #3's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Hydrochlorothiazide medication outside of the ordered parameters on 02/17/2024. Closed record review of Resident #4's face sheet dated 3/12/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included ESRD (End Stage Renal Disease- medical condition in which the kidneys cease functioning on a permanent basis leading to the need for long-term dialysis or a kidney transplant to maintain life), hypertensive heart disease with heart failure (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation with the heart unable to pump enough blood to meet the body's needs for blood and oxygen), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #4 was discharged as expired on 3/3/24. Closed record review of Resident #4's physician orders revealed an order with a start date of 11/7/23 and a DC date of 2/20/24 for Losartan potassium 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for January 2024 revealed losartan potassium 25mg was administered on 1/20/24 at 8:00 a.m. by LVN A with a B/P of 103/58 P-77, and on 1/22/24 at 8:00 a.m. with a B/P of 104/37 P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed losartan potassium 25mg was administered on 2/3/24 at 8:00 a.m. by LVN A with a B/P of 102/77 P-86, and on 2/17/24 at 8:00 a.m. by LVN B with a B/P of 102/54 P-113. Closed record review of Resident #4's physician orders revealed an order with a start date of 11/6/23 for carvedilol 25mg tablet by mouth twice daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for January 2024 revealed Carvedilol 25mg tab was administered on 1/20/24 at 8:00 a.m. by LVN A with a B/P of 103/58 P-77 and at 8:00 p.m. by LVN B with a B/P of 103/58 P-77. On 1/22/24 at 8:00 a.m. it was administered by LVN A with a B/P of 104/37 P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed Carvedilol 25mg tab was administered on 2/3/24 at 8:00 a.m. by LVN A with a B/P of 102/77 P-86 and at 8:00 p.m. by LVN B with a B/P of 102/77 P-86. On 2/10/24 at 8:00 p.m. by LVN B with a B/P of 101/47 P-68, on 2/11/24 at 8:00 p.m. by LVN B with a B/P of 101/47 P-70. On 2/17/24 at 8:00 a.m. by LVN B with a B/P of 102/54 P-113. Closed record review of Resident #4's EMAR for March 2024 revealed Carvedilol 25mg tab was administered on 3/2/24 at 8:00 p.m. by LVN B with a B/P of 93/38 P-78. Closed record review of Resident #4's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure readings and or the administration of the Losartan potassium or Carvedilol medications outside of the ordered parameters. In an observation and interview on 3/13/24 at 11:45 a.m. the DON stated she was unaware of a way to copy and paste vital signs and showed surveyor a resident's vital sign list that did not have repeat vital signs for the resident listed. And after reviewing the EMAR the repeat vital signs could be seen on the EMAR documentation only and not on the residents' vital sign list in the EHR. The DON stated she would investigate the repeat vital signs. In an interview on 3/14/24 at 10:30 a.m. the DON stated she contacted her corporate entity, and they removed the use last documented vital sign option from their computer system. In an observation and interview on 3/14/24 at 4:00 p.m. CMA D was passing medications and had just taken a resident's blood pressure and was entering it in the computer system. CMA D stated he did not copy vital signs and takes his own manually each time. CMA D stated there was not a way to copy and paste vital signs but there used to be a button that had used last documented but he never used it. CMA D showed surveyor the vital signs entry screen and where the button used to be but stated it was not an available option now. CMA D was unsure when it was no longer an option. In an interview on 3/15/24 at 12:05 p.m. LVN A stated she takes her own vital signs and if she administered any medications outside of the ordered parameters then she had contacted the physician and documented in the resident progress notes or through the EMAR documentation. LVN A further stated she does not know what happened and does not copy vital signs. LVN A stated there was a use last documented vital signs button, but she did not use it. LVN A was unable to state where else the documentation of the physician being notified would be. In an interview on 3/16/24 at 5:17 p.m., LVN B stated that he personally measures and accurately recorded vital signs including blood pressure and pulse each time the physician orders call for vital signs and stated that he does not administer medications outside of the parameters noted in the physician orders. LVN B stated he always follows physician orders, including notifying the physician if and when a resident's vital signs are outside of parameters noted in the orders. When asked why he had not notified the physician on 02/11/2024 when Resident #2 received medication outside of parameters, and on 02/17/2024 when Resident #3 received medication outside of parameters, LVN B stated that he always notifies the physician when needed and stated he did not know why there was no documentation of his notification. In an interview with the DON 03/16/24 at 5:15 p.m., the DON confirmed that accurately measuring and recording vital signs as per physician order and notifying the physician of a change in the resident's condition and/or a need to alter the resident's treatment were integral to assisting the residents to maintain good health. In a telephone interview on 3/15/24 at 1:02 p.m. the MD stated he was not aware and could not recall being notified specifically with vital sign issues but was driving and did not have his patient records in front of him. The MD further stated patient safety was a priority for him and his group of physicians. In a telephone interview on 3/15/24 at 2:40 p.m. the MD stated the vital sign issues (administration of medications outside of parameters and same vital signs documented) brought to his attention by surveyor were concerning. The MD stated he and other physicians in his group were in the facility often, and at times even 2 to 3 times a week and he had not recalled seeing blood pressure or vital sign issues on what was displayed to the physician. The MD further stated the vital sign issues could make clinical decision making more difficult. Review of https://www.ncbi.nlm.nih.gov/books/NBK526065/ last updated July 18, 2022, for Losartan indicated . Losartan is FDA approved for the treatment of several medical conditions, which include the following: Hypertension . acute coronary syndrome, stable coronary artery disease . and treatment of heart failure . The onset of action of losartan is 6 hours, lasting for 24 hours . Reevaluate blood pressure (including orthostatic blood pressure), renal function, and serum potassium . Any clinician (MD, DO, NP, PA) can prescribe losartan for the treatment of hypertension and diabetic nephropathy. However, clinicians should follow the patients and regularly monitor their renal function and blood pressure. The drug is effective for hypertension and can be part of long-term therapy. However, it still requires the participation of an interprofessional team to optimize treatment. When initially prescribed, a pharmacist should verify appropriate dosing, perform medication reconciliation, and can counsel the patient about the drug. Nursing can also provide valuable patient counseling, as well as answer questions and assess therapeutic effectiveness on subsequent visits. If the pharmacist or nursing staff encounter any concerns, they should report these to the prescriber promptly so that therapeutic adjustments can take place. This interprofessional team approach to losartan therapy can optimize patient outcomes while minimizing potential adverse effects. Review of https://www.ncbi.nlm.nih.gov/books/NBK532923/ last updated August 29, 2023, indicated . Metoprolol is FDA-approved to treat angina, heart failure, myocardial infarction, atrial fibrillation/flutter, and hypertension. Off-label uses include supraventricular tachycardia and thyroid storm . The primary adverse effects of metoprolol include heart failure exacerbation, fatigue, depression, bradycardia or heart block, hypotension, bronchospasm, cold extremities, dizziness, decreased libido, diarrhea, tinnitus, decreased exercise tolerance, glucose intolerance, and may mask hypoglycemia . Metoprolol is contraindicated in patients with sick sinus syndrome, second or third-degree heart block (in the absence of a pacemaker), decompensated heart failure, hypotension . Monitoring . Oral administration, heart rate rhythm, and blood pressure require monitoring. Review of https://www.ncbi.nlm.nih.gov/books/NBK430766/ last updated November 12, 2023 indicated . Hydrochlorothiazide is a medication approved by the U.S. Food and Drug Administration (FDA) to treat hypertension and peripheral edema Patients undergoing hydrochlorothiazide treatment should be regularly monitored for electrolyte imbalances, including sodium, potassium, calcium, and magnesium levels . Blood pressure should be closely monitored to ensure patients on hydrochlorothiazide treatment achieve and maintain their target blood pressure, minimizing the risk of adverse effects associated with high or low blood pressure. Review of https://www.ncbi.nlm.nih.gov/books/NBK534868/ last updated January 10, 2024, for carvedilol indicated . Screen patients for potential contraindications, such as severe hypotension, second or third-degree AV block, and other conditions that may necessitate caution or alternative therapies . The most prevalent adverse effect of carvedilol is undesired, excessive hypotension resulting from its vasodilating properties, leading to symptoms such as dizziness, lightheadedness, fatigue, and headaches . Vital signs, such as blood pressure and heart rate, should be monitored before initiation and at each dose titration. Individuals undergoing heart failure treatment necessitate vigilant monitoring for any indications of decompensation. The facility's Plan of Removal was accepted on 03/16/2024 at 5:10 p.m. and included: Date: 03/16/2024 F 726 Immediate action: The Medical Director was notified of the Immediate Jeopardy status on 03/15/2024 at 7:35 pm. Resident Vital Signs were taken when the issue was identified on 03/14/2024. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on 03/15/2024. The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on 03/14/2024 once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. On 3/15/24, a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on 03/15/2024. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm 03/15/2024. All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of 03/14/2024 @ 12:45pm. Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on 03/15/2024 by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by 03/16/2024 11:59 pm. Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. POR Verification The Medical Director was notified of the Immediate Jeopardy status on 03/15/2024 at 7:35 pm. - Confirmed via interview with the Medical Director 03/16/2024 at 5:37 pm Resident Vital Signs were taken when the issue was identified on 03/14/2024. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on 03/15/2024. - Confirmed via interview with Medical Director 03/16/2024 at 5:37 pm - Confirmed via record review of 15 resident clinical records The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on 03/14/2024 once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. - Confirmed via interview with the DON 03/16/2024 at 5:15 pm On 3/15/24, a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on 03/15/2024. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm 03/15/2024. - Confirmed via interview with the DON 03/16/2024 at 5:15 pm - Confirmed via interview with the Medical Director 03/16/2024 at 5:37 pm - Confirmed via record review of 15 resident clinical records All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of 03/14/2024 at@ 12:45pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on 03/15/2024 by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. - Confirmed via interview with DON 03/16/2024 at 7:12 pm Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by 03/16/2024 11:59 pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. - Confirmed via interview with DON 03/16/2024 at 7:12 pm Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. - Confirmed via interview with DON 03/16/2024 at 7:12 pm The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. - Confirmed via interview with DON 03/16/2024 at 7:12 pm During an interview with the DON on 03/16/2024 at 5:15 p.m., the DON stated that only nurses and medication aides measured vital signs and administered at the facility and there were 2 medication aides and 12 nurses employed by the facility. The DON stated that 11 of the 14 staff members who administered medications had both of two in-service trainings and completed both of two skills checks. Skills checks required staff to demonstrate how to assess blood pressure using two techniques. The DON stated that the three staff members who did not yet receive training will be required to do so before their next shift. During an interview with LVN B on 03/16/2024 at 5:17 p.m., LVN B stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN B further stated he had completed two demonstrative skills checks with the DON. During an interview with Medication Aide E on 3/16/2024 at 5:22 p.m., Medication Aide E stated her work schedule was Monday through Friday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. Medication Aide E further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN A on 03/16/2024 at 5:26 p.m., LVN A stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN A further stated she had completed two demonstrative skills checks with the DON. During an interview with RN F on 03/16/2024 at 5:32 p.m., RN F stated her work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. RN F further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN G on 03/16/2024 at 5:43 p.m., LVN G stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN G further stated he had completed two demonstrative skills checks with the DON. During an interview with LVN H on 03/16/2024 at 5:50 p.m., LVN H stated her work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN H further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN I on 03/16/2024 at 5:55 p.m., LVN I stated his work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN I further stated he had completed two demonstrative skills checks with the DON. During a telephone interview with LVN J on 03/16/2024 at 6:04 p.m., LVN J stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN J further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN K on 03/16/2024 at 6:16 p.m., LVN K stated her work schedule was Monday through Friday from 6:00 a.m. to 2:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN K further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN L on 03/16/2024 at 6:24 p.m., LVN L stated her work schedule was Monday