**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. An IJ was identified on 4/12/24. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on 04/14/24 the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of choking, weight loss, decline in health, and death. The findings included: Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. Record review of Resident #1's comprehensive person-centered care plan, dated 02/20/24, revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. Record review of Resident#1's Physician Order, dated 01/18/24 revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on 02/01/24 by the physician. Record review of a nursing progress note, dated 02/12/2024, stated Patient eating breakfast and begins coughing episode directly after eating. Patient airway patent upon assessment. Patient sitting upright in bed, call light with reach. NP notified RP, MD and staff nurse. Record review of document titled Speech Therapy Plan of Care - 03/13/2024, dated 03/13/2024, revealed profound language impairments and mild pharyngeal swallow function impairments (71-85% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode > 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. Record review of Speech Therapy daily notes 03/13/2024 through 04/12/2024 stated: 03/18/2024 patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes (Osteophytes are exostoses (bony projections) that form along joint margins) and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit (the decrease of the normal curvature, near the throat, can cause increased pressure in the airway causing partial or complete block). Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. 03/21/2024 SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report. 03/29/2024 SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal. 04/09/2024 patient had 1/2 PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. During an observation on 04/10/24 at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entrée: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. During an observation on 04/11/24 at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. During an interview on 04/11/24 at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy, nursing would notify them with a paper . The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms and the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushrooms. The DM stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. The DM stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. The DM stated the cooks had substituted the cheesecake with the gelatin snack but the resident should not have been served the watery gelatin snack. During an interview on 04/12/24 at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. During an interview on 04/12/24 at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. During a joint interview on 04/12/24 at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the residents refused cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on 03/19/24 with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking. Record review of the facility's policy titled 'Nutritional Recommendations, dated 12/2017, stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference. The Administrator was given the IJ template and was notified of the IJ on 4/12/24 at 6:19 PM and a POR was requested. On 04/14/24 at 1:35 PM, the POR was accepted. It was documented as follows: 4/12/2024 Plan of Removal - F 689 Immediate Action Taken Resident Specific Resident #1 will be supervised by staff during all 3 meals daily beginning on 4/12/2024 at 7:00 pm. Resident #1 had the appropriate care plan updates completed on 4/13/2024 at 11:20 am. System Changes On 4/12/2024 at 7:00 pm a facility audit took place to ensure that all residents requiring supervision for meals will receive appropriate supervision. On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited to ensure that the care plans accurately reflect the residents need for supervision with meals. Starting on 4/12/2024 and ongoing therapy will be present in morning meetings to ensure that all orders are communicated directly between nursing and therapy to ensure that residents requiring supervision with meals will have recommendations reviewed and carried out appropriately. Starting on 4/12/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with meal supervision for those residents requiring supervision. Starting on 4/12/2024 and ongoing residents dietary and supervision statuses will be audited upon change of condition, appropriate MDS cycles or anytime necessary. Starting 4/13/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The meal ticket/diet order will be compared for accuracy. Education On 4/12/2024 at 7:00 pm the Assistant Director of Nursing provided education to all staff regarding residents needing to have supervision at meals to ensure those residents will be supervised at mealtimes. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that texture, larger utensils, cup covers etc are being utilized for the residents. On 4/12/2024 at 7:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents needing supervision for meals. On 4/12/2024 at 7:15 pm the Regional Clinical Consultant will educate DOR and clinical team as to communication and follow up during morning meetings. Starting on 4/12/2024 at 7:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the in-service/training regarding residents needing supervision during meals. Starting on 4/12/2024 the residents dietary and supervision status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photocopy and written communication. Starting on 4/12/2024 the DON will be responsible for ensuring that the residents who require supervision during meals receive supervision. Starting on 4/12/2024 at 7:00 pm during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the therapy team to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance. 100% Staff education compliance of the above mentioned by noon 4/14/24. Verification of Plan of Removal: Confirmed via Observation of lunch and dinner meals on 04/13/2024. Confirmed via Record Review of Resident #1's care plan . Confirmed via Interview with Regional Clinical Consultant and DON. They each had a list of all staff with check marks. Interviewed about their process for identifying residents who needed supervision and how they ensured no one was falling through the cracks. Interviewed each independently and they both said they went through each clinical record looking at: therapy notes and recommendations, physician notes, POC notes from CNAs, progress notes from LVNs and RNs, MDS assessments, and care plans. On 4/12/2024 at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited. Confirmed via Interview with Dir of Rehab and DON. Record review of the care plans for all eight of the residents (Resident #1 and additional seven who require assistance). Five care plans had been updated - edits were observed - and the updates clarified and added more specific language. For example, instead of saying supervision as needed the language was updated to read supervision at all times by nursing staff. The two that were not updated were already very precise and specific in their wording. Confirmed via Interview with Dir of Rehab DON, and Administrator Confirmed via Interview with DON. Record review of chart of items to check for each resident identified and had filled in the chart for each meal served since IJ was called. Confirmed via Interview with Regional Clinical Consultant, DON, MDS/Care Plan Coordinator, and Administrator. There were 52 total staff members 41 of the 52 staff have received in-service. Interview in person or by phone with 32 of the 52 staff members and confirmed they received the trainings and could verbalize understanding of the training. Of the 11 staff who did not receive the training: 1 FMLA, 1 vacation, and 9 PRN. Observation of a sign on the time clock stated for staff not to clock in for shift until they received in-service trainings dated 04/12/2024. Observation of both lunch and dinner service on 04/13/2024 revealed each meal had an assigned licensed nurse to check meal tickets against trays. Observation of weekend RN meal tickets and trays revealed checking tickets for 15 residents versus what they had been served were completed and all were correct. The DON stated she would personally check two meals per day M-F, and weekend RN would check all three weekend meals (The DON and weekend RN work 6 am to 6 pm ). Observation of the residents who required assistance in dining hall revealed staff were treating them with dignity, their tickets and meals were correct, and assistive devices(e.g. divided plate, built up utensils) were in place. Observation of Resident #1 dining in his room revealed his ticket and meal were correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there were 14 nurses on staff, and interviewed 12 of them and all have received the in-service trainings (more detail on trainings below). Interviews conducted on 4/13/24 from 3:42 p.m. to 7:45 p.m. and on 4/14/24 from 9:03 a.m. to 1:30 p.m. revealed there are 17 CNAs on staff, 13 of them were interviewed and all received the in-service trainings. Confirmed via Interview with Regional Clinical Consultant and Record Review of in-service training. Confirmed via Interview with DON and with ADON. Record review of the in-services. One of the in-services which was given to all nursing staff identified all eight residents who require supervision and/or assistance for dining. Confirmed via Interview with DON. Observation of lunch and dinner comparison of their care plans and meal tickets against the meal, assistive devices, and level of supervision for the eight residents who required assistance received during both lunch and dinner, revealed each was correct. Confirmed via Interview with Regional Clinical Consultant and DON, MDS/Care Plan Coordinator, and Administrator. During interviews staff confirmed abuse and neglect training was done in general and every staff member confirmed ANE trainings are provided at least monthly. Regional Clinical Consultant confirmed via interview that she was personally ensuring that all staff received in-service trainings. She was onsite today and planned to stay to catch the oncoming night shift. She provided her documentation via a staff list with check offs. An IJ was identified on 4/12/24. While the IJ was removed on 04/14/24, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #1) reviewed accidents and hazards in that: The facility failed to ensure Resident #1 did not elope after he was identified to be of high risk for elopement. Resident #1 eloped on 5/3/23 around 9:00 a.m. and was found on 5/4/23 around 6:47 p.m. The facility failed to implement measures to prevent future elopements. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 5/5/23 at 6:06 p.m. While the IJ was removed on 5/7/23, the facility remained out of compliance at a level of potential harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's face sheet, dated 5/5/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of complete traumatic amputation at level between knee and ankle, right lower leg, sequela-surgery [sequela is a condition following a previous disease or injury], attention and concentration deficit following cerebral infarction [a disruption in the brain's blood flow], Type 2 Diabetes Mellitus with diabetic neuropathy [nerve damage due to diabetes], unspecified, mild protein-calorie malnutrition, and essential (primary) hypertension. Further record review of this document revealed the following verbiage: Is Responsible for Self: No. Record review of Resident #1's signed admission Agreement, dated 4/17/23, revealed Resident #1 did not sign his admission agreement. CO H signed the admission agreement above the line marked Signature of Responsible Party. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS of 14, signifying little or no cognitive impairment. Record review of Resident #1's physician orders, obtained 5/5/23, revealed Resident #1 had the following medication orders: - Levemir FlexTouch U-100 Insulin (insulin detemir u-100) [a type of injectable, long-acting medication that helps control high blood sugar levels] insulin pen; 100 unit/mL (3 mL); amt: 28 units; subcutaneous . Every 12 Hours; 09:00 [9:00 a.m.], 21:00 [9:00 p.m.]. Started on 4/18/23. - Humalog U-100 Insulin (insulin lispro) [a type of injectable, fast-acting medication that helps control high blood sugar levels] solution; 100 unit/mL; amt: Per Sliding Scale . Before Meals and At Bedtime; 07:30 [7:30 a.m.], 11:30 [11:30 a.m.], 16:30 [4:30 p.m.], 20:00 [8:00 p.m.]. Started on 4/25/23. - Acidophilus-Pectin (lactobacillus acidoph-pectin) [a medication that contains bacteria meant to maintain healthy bacteria in the intestines] capsule; 75 million cell -100 mg; amt: one capsule; oral . Twice A Day; 08:00 [8:00 a.m.], 20:00. Started on 4/18/23. - ascorbic acid (vitamin C) tablet; 500 mg; amt: one tablet; oral Once A Day; 09:00. Started on 4/18/23. - docusate sodium [OTC] capsule [a stool softener]; 100 mg; amt: one capsule; oral . Twice A Day; 09:00, 21:00. Started on 4/18/23. - gabapentin tablet [a medication that can treat seizures and nerve pain]; 600 mg; amt: one tablet; oral . Three Times A Day; 09:00, 13:00 [1:00 p.m.], 21:00. Started on 4/18/23. - melatonin tablet extended release [a hormone in the body that regulates sleep cycles]; 3 mg; amt: one tablet; oral . As Needed. Started on 4/18/23. - multivit-min-iron fum-folic ac tablet [a multivitamin and iron product used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy]; 7.5 mg iron-400 mcg; amt: one tablet; oral . Once A Day; 09:00. Started on 4/18/23. - oxycodone [a narcotic medication used to treat moderate to severe pain] - Schedule II tablet; 10 mg; amt: one tablet; oral Special Instructions: Give one tablet every 4 hours as needed for pain. Started on 4/18/23. - senna [OTC] tablet [a medication used to treat constipation]; 8.6 mg; amt: two tablets; oral . At Bedtime; 21:00. Started on 4/18/23. - lisinopril tablet [a medication used to treat high blood pressure]; 20 mg; amt: one tablet; oral Special Instructions: Hold if SBP <110. Once A Day; 09:00. Started on 4/20/23. Record review of Resident #1's May 2023 MAR and TAR, obtained 5/5/23, revealed the last time it was documented Resident #1 received his medications was the evening of 5/2/23. There was no documentation Resident #1 received his earliest dose of Insulin Humalog scheduled at 7:30 a.m. on 5/3/23. Record review of Resident #1's vitals documentation, reviewed on 5/5/23, revealed CNA E documented on 5/3/23 at 7:45 a.m. that Resident #3 ate 76% - 100% of his breakfast on 5/3/23. Record review of Resident #1's Elopement/Wandering Observation, completed 4/18/23 at 9:00 a.m. written by LVN D, revealed the following section: High Risk Factors: Residents exhibiting (1) one or more of the listed high-risk behaviors will be classified as HIGH RISK TO WANDER. Facility policy and procedure for wandering residents will be immediately implemented. Within this section the following item was checked off as yes: Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization. Further record review of this document revealed the following section: Potential Interventions: Select appropriate interventions. Within this section, the following was checked off: None of the above. There was no verbiage within this document accounting for a high BIMS score. Record review of Resident #1's Care Conference, dated 5/2/23 written by the DON, revealed the following: Pt also verbalized that he does not feel as though he needs to be here and there are many things at home that require his attention and that he needs to leave to [CO H] take care of things at home. Pt was educated on need to sign out if he leaves building to smoke and/or for any other reason. Record review of Resident #1's Safety Event - Elopement electronic document, dated 5/3/23 written by ADON LVN G, revealed the following: DESCRIPTION: elopement. Further record review of this document revealed the following: Did resident exhibit any of the following behaviors prior to elopement? Verbalizing Statements about Leaving . 5/2/23 Care plan completed with this resident where he verbalized, he did not want to be here at the facility anymore. Record review of a typed document regarding Resident #1 titled, [Facility Name] Missing Person Timeline, not dated, revealed the following: 5.3.23 . 8:21am - DON arrived to work and visualized resident. 8:30 am - Resident was seen in the dining room by nurse aide [CNA E.] 9:34am - Nurse [LVN A] pulled up meds, but did not administer them as [Resident #1] had left the dining room, was waiting for [Resident #1] to come to the nurse's med cart like he always does to get them, he never came to get them. 11:00am - Therapy . verbalized she can't find [Resident #1] at this time . 12:24pm - [family member] called back and stated when resident gets his check on the 3rd of every month he takes off with his friends for a few days and that is his M.O. 5.4.23 . 1915 [7:15 p.m.] DON notified pt has been located at local [store] with friend. Pt states that he is ok but will not be returning at this time. 2206 - Pt arrives in house with [CO H] and calls DON. DON instructed pt to go to local ED to for evaluation by a doctor prior to reconsideration of re admit to this facility. There was no documentation in this facility document detailing Resident #1 was offered the AMA form, signed the AMA form, or refused to sign the AMA form. Record review of local law enforcement Offense/Incident Report, dated 5/3/23, revealed the following: UPON MY ARRIVAL I MADE CONTACT WITH (R1) [Reporting Party-1, referring to the DON] WHO INFORMED THAT (SB1) [Subject-1, referring to Resident #1] LEFT THE LISTED LOCATION AGAINST MEDICAL ADVISE AT 0600 HOURS [6:00 a.m.] [The DON] EXPLAINED THAT [Resident #1] DID NOT HAVE A HISTORY OF MENTAL HEALTH RELATED ISSUES, WAS NOT SUICIDAL/HOMICIDAL . [The DON] MENTIONED THAT [CO H] INFORMED THE STAFF THAT AT THE BEGINNING OF THE MONTH WHEN [Resident #1] GETS PAID HE DISAPPEARS FOR A FEW DAYS POSSIBLY RELATED TO HIS HISTORY OF DRUG ABUSE. Record review of Resident #1's care plan, obtained 5/5/23, revealed no care plan for elopement or elopement behavior prior to 5/3/23 at 2:21 p.m., after it was discovered Resident #1 eloped on 5/3/23 at 11:00 a.m. The care plan regarding elopement included the following problem area with a problem start date of 5/2/23: Category: Behavioral Symptoms . Resident is a threat to self and/or others R/T RESIDENT HAS VERBALLY YELLED AT STAFF, THREATENED STAFF. RESIDENT WILL WHEEL OUTSIDE OF FACILITY AND HAS STATED THAT HE CAN GO TO THE STORE HIMSELF. WHEN STAFF ASKS/EDUCATES RESIDENT TO SIGN OUT OF FACILITY SO FACILITY STAFF KNOW WHERE HE IS, RESIDENT STATES I AM A GROWN MAN, I CAN GO AND DO AS I PLEASE. RESIDENT ALSO OCCASIONALLY REFUSES MEDICATIONS/ADL/CARE. This care plan regarding elopement had the following interventions: - Convey an attitude of acceptance toward the resident. - Maintain a calm environment and approach to the resident. - Obtain a psych consult/psychosocial therapy. - Provide care, activities, and a daily schedule that resembles the resident's prior lifestyle. - When resident becomes socially inappropriate/disruptive, move to a quiet, calm environment. Record review of Resident #1's EHR revealed no signed AMA form had been uploaded to Resident #1's EHR. Record review of Resident #1's physical chart revealed no signed AMA form. Record review of Resident #1's progress notes, dated from 4/1/2023 to 5/5/23, revealed no progress note describing that Resident #1 requested for an AMA form, signed an AMA form, or refused to sign an AMA form. Record review of a facility educational in-service titled Elopement, dated 5/3/23, revealed the facility educated 23 of their 49 staff members (which was less than 50% of their staff) on their elopement policy. This elopement policy described what to do if a resident was discovered missing but did not describe interventions to prevent elopement before an elopement occurred. Observation on 5/5/23 at 8:05 a.m. revealed a camera affixed to the ceiling of the entrance lobby. The camera lenses pointed towards the entrance. During an interview on 5/5/23 at 8:38 a.m., this surveyor requested from the Administrator to provide any camera footage about Resident #1's elopement on 5/3/23. The Administrator stated the cameras did not work. During an interview on 5/5/23 at 9:13 a.m., LVN B stated she did not work on 5/3/23, the day Resident #1 left the facility. LVN B stated she worked with Resident #1 before and recalled Resident #1 threatened to leave AMA before because Resident #1 wanted breakfast tacos one morning and he did not receive breakfast tacos. LVN B stated, but then he kind of calmed down. LVN B stated she was not given any direction in regards to Resident #1's verbalization of wanting to leave the facility. LVN B stated she had not received any new education since 5/3/23. During an interview on 5/5/23 at 9:40 a.m., CNA C stated she did not work on 5/3/23. CNA C stated, I remember [Resident #1] was upset about being here . I remember a case where he didn't like the meal and he said 'I'm going to get my stuff, bring me bags so I can pack up. I let the nurse [LVN B] know. But after a while he was fine. I guess he forgot. CNA C stated Resident #1 verbalized his desire to leave the facility last week. CNA C stated she did not receive any new education since 5/3/23. During an interview and record review on 5/5/23 at 10:33 a.m., LVN B stated a resident would sign themselves out using a sign-in sheet (which was titled RELEASE OF RESPONSIBILITY WHILE OUT OF THE FACILITY, not dated) located at the nurses' station in a resident's chart. LVN B stated a resident would sign, then write the date and the time and there would be a staff member's signature next to the resident's signature. LVN B stated the staff member who signed this document was the staff member who was aware the resident was about to leave the facility premises. Resident #1's RELEASE OF RESPONSIBILITY WHILE OUT OF THE FACILITY form was reviewed with LVN B at this time and Resident #1's signature was seen on this form but there was no date or time signifying when Resident #1 signed himself out of the facility. There was no nurse's signature in the sign out section of this form to indicate which staff member was aware Resident #1 was signing himself out at this unknown date and time. There was no resident signature, staff signature, date, or time signifying when Resident #1 signed himself back into the facility. During an interview on 5/5/23 at 10:56 a.m., Resident #1 stated I had an emergency and I had to leave . I had to make a decision. I had business endeavors that I've been neglecting since I left the facility and if I didn't take care of them I would have lost my business. Resident #1 stated he left early in the morning, around 4:00 a.m. - 4:30 a.m. Resident #1 stated he thought he told one of the nurses he was going to leave before he left the premises, but could not recall who he spoke to, only that he thought he spoke to a male nurse and it was still dark outside when he left the facility. Resident #1 stated he was fine but he was currently at the hospital because the DON wanted him to be checked by a doctor to ensure nothing was wrong with his right leg amputation. Resident #1 stated the facility had a meeting with him about his care on 5/2/23 and stated he did not explicitly verbalize a desire to leave in the meeting on 5/2/23. Resident #1 stated, But I threw it out there that there's some things I had to take care of. When asked if he was planning on eloping from the facility again, Resident #1 stated, No, I wouldn't do that. I actually want my medication. I'm off my medication and I want my medication when I leave from there. During an interview on 5/5/23 at 11:50 a.m., when asked how frequently he checked on his residents, LVN A stated, the protocol says at least once every 1 hour . but a lot of it depends on what's going on. LVN A stated he considered Resident #1 an elopement risk because of his history of drug addiction. And I had many years of dealing with addicts. They're always an elopement risk . They always want to have their freedom and get their drug of choice and chase that dragon [a phrase that refers to drug usage.] We were keeping an eye on [Resident #1] about his daily routine. How he moves, how he interacts . He's also a social butterfly. That's why I assumed that's where he was [on 5/3/23.] I figured he would get back to me at some point, especially because he was taking narcotics . I'm supposed to at least be aware and visually see them at least once every 2 hours. But that doesn't always work out based on what's going on. And I had an admission pending. I had a patient that was being discharged . I had a lot going on that morning . And normally I see him going from one end [of the facility] or the other and he's active . I think [Resident #1] probably left right before breakfast or right after. I would think before breakfast. I would think around 6:30ish . I think he went out of the front door . I realized he was missing when I went to his room when I went to give him his morning meds, I would say around 9:00 a.m. But I didn't panic because he was the person who was not really in his room. He's moving constantly . I think it was coming up to around when I was coming to check his blood sugar. It was around 11:00 a.m. or so and then I didn't see him. On 5/5/23 at 12:03 p.m., a phone interview was attempted with CNA E, but there was no answer. A voicemail containing this surveyor's name, phone number, and a brief purpose of call was left. A text message was also sent on 5/5/23 at 12:06 p.m. containing this surveyor's name, phone number, and request to return this surveyor's call. On 5/5/23 at 12:12 p.m., a phone interview was attempted with LVN D, but there was no answer. A text message was also sent on 5/5/23 at 12:14 p.m. containing this surveyor's name, phone number, and request to return this surveyor's call. During an interview on 5/5/23 at 1:42 p.m., this surveyor asked the DON if she [the DON] could have LVN D and CNA E call this surveyor. The DON stated she will try to have the aforementioned staff members call this surveyor back. This surveyor also requested Resident #1's signed admission agreement to include the document titled, Signing Out Policy that either Resident #1 or his Responsible Party must sign. Resident #1's signed Signing Out Policy, was not provided to this surveyor prior to exit. During an interview and record review on 5/5/23 at 2:46 p.m., the DON stated the staff should check on the residents every 2 hours or as needed. The DON stated the facility had an elopement assessment that was done upon admission and quarterly. The DON stated, It's [the Elopement assessment was] a bunch of questions that ask cognition and whether they're ambulatory. It does low, moderate, or high risk. The DON stated Resident #1 did not trigger as a high risk. Resident #1's Elopement/Wandering Observation, dated 4/18/23, was reviewed with the DON at this time. When this surveyor brought to attention that Resident #1 had one high risk factor for elopement checked off (Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization), the DON stated, with [Resident #1's] BIMS being as high as he was-Just because they're a high risk on the assessment they're not always listed as high because their BIMS and cognitive is very high . We never saw any exit-seeking behavior. The DON stated, when I came in, I came in through [the double doors], [Resident #1] was sitting in the hallway . Nurse Aide said he saw him in the dining room at 8:30 a.m., usually by then breakfast is over. After that, therapy came down and said 'I went to get [Resident #1], have you seen him?' I said, 'no, have you checked outside in the front?' And then we started looking . We searched the grounds, we searched the building. We went to his house. We called [CO H.] The DON stated, After speaking with [CO H] .she told me that this was a comment event for him. That when he would get his check on the 3rd of the month he'd run off and he'd do 'God knows what with his friends' . Because he'd go and get his check and get drunk and come back and act like nothing happened. The DON stated, After the police came they said they couldn't issue a silver alert [a phrase meant to notify the public of missing older adults with a documented mental condition] because his cognitive status was so high and his BIMS is a 14 and he's ambulatory and able to leave at his own free will. That they were going to treat it as an AMA and they were going to put on a [NAME] as opposed to a silver alert because the patient was cognitive . [Resident #1] did end up coming back last night [5/4/23] at 10:15ish. [CO H] called me and said, 'can he come back?' I said right now I can't say that he can come back because he's left us AMA . So my suggestion is that if you feel like you need medical attention, it's better for you to go to the hospital anyway. The DON stated Resident #1 did not verbalize a desire to leave the premises during the care plan meeting of 5/2/23. The DON stated during his care plan meeting on 5/2/23, she educated Resident #1 to sign out if he left the facility property. The DON stated she was not aware Resident #1 was going to leave the facility on 5/3/23. The DON stated there were no interventions to prevent elopement prior to Resident #1's elopement on 5/3/23. The DON stated He didn't display any elopement-type behaviors so that would have been the only thing we would have done is if we saw behaviors. The DON stated the camera in the entrance lobby was a fake camera. The DON stated after Resident #1 eloped from the facility they completed an in-service on elopement on 5/3/23. The DON stated the facility was considering putting keypads on the entrance door so that way a staff member had to input a keycode in the keypad to open the door from the inside. At this point, this surveyor requested for any construction quotes or emails discussing the addition of a keypad to the entrance door. No construction quotes or emails discussing the addition of a keypad to the entrance door was provided to this surveyor prior to exit. On 5/6/23 at 4:32 p.m., a second phone interview was attempted with CNA E with no answer. A second voicemail was left with this surveyor's name, phone number, and brief purpose of call. This surveyor did not receive a return call prior to exit. On 5/6/23 at 5:13 p.m., a second phone interview was attempted with LVN D with no answer. A second voicemail was left with this surveyor's name, phone number, and brief purpose of call. A successful interview could not be conducted prior to exit. Record review of a facility policy titled, Wandering Resident, dated 12/2017, revealed it is the policy of this home that residents at risk for wandering will be identified and monitored for safety . 1. Residents will be assessed for wandering risk factors upon admission, quarterly and with any change in condition 3. The IDCPT will be responsible to develop a care plan to assure the resident receives the appropriate monitoring to assure safety. Further record review of this document revealed no verbiage accounting for a resident's high BIMS score. Record review of a facility policy titled, Elopement, dated 12/2017, revealed no verbiage regarding the identification of high risk for elopement and interventions to address high risk for elopement. Further record review of this document revealed no verbiage accounting for a resident's high BIMS score. The Administrator was notified of an IJ on 5/5/23 at 5:47 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 5/6/23 at 2:22 p.m. and included the following: Immediate Action Taken Resident Specific - Nurse administering medications to Resident #1 was given a counseling for failing to locate resident when medications were due to be given or notify DON/ADON for assistance - Nurse assigned to resident #1 was given in-service on facility policy for elopement. - Elopement protocols immediately activated when resident identified missing - Immediate search of building & outside parameters - Continued search of all possible areas around the facility the resident may have gone (Appointments, residents previous residence prior to admit & local bus stops and followed sidewalks surrounding facility) - Responsible party was notified - Physician was notified - [local police department] was notified - Resident #1 was located 5/4/23 @ 18:47 pm [6:47 p.m.] at the bus stop at [local street intersection] getting on the [local] bus, staff (Cook) followed the bus to [local store] where resident exited @ 19:04pm [7:04 p.m.] and stated he had an emergency and was not coming back. - Resident #1 came to the facility with [CO H] 5/4/23 @ 21:47pm [9:47 p.m.] to gather his belongings and refused to be assessed at this time, [CO H] encouraged to have resident assessed at the ER as he was refusing to stay or be assessed and refused to sign AMA form. - Resident stated he did not have any reason to be assessed and left the facility with his spouse. System Changes - Residents that sit outside on the porch or in front of the building will be assessed to have a BIMS establishing them to be cognitive to be outside unsupervised - On 5/5/23 100% of residents were audited for a current elopement assessment, then checked for accuracy and completeness. All residents had a current accurate elopement assessment by end of day 5/5/23. - Residents choosing to sit outside will be educated and care planned if they want to leave the facility grounds they will notify the staff and sign out via the accushield [a small computer where people can sign in and sign out of a building.] - If a resident verbalizes refusal to follow the facilities policies related to notifying the facility before leaving will be given a 30-day notice. - If resident is given a 30-day notice they will be supervised outside during the 30-days Staff will be in-serviced on facility elopement policy on hire prior to being placed on the floor alone. Education - DON/Designee will educate staff if a resident cannot be found to immediately initiate an Elopement protocol - DON/Designee will educate staff on elopement protocol - DON/Designee will educate staff on how to identify all residents at risk for elopement (Binder) - All in-servicing will be completed by Saturday 5/6/23 @ 6am and then all staff will receive the education prior to the start of their shift moving forward x 1 week to ensure all staff receives the education. Monitoring - Administrator/Designee will randomly interview staff daily on both shifts x4 weeks on elopement protocols - Maintenance/Designee will conduct elopement drills on both shifts on 5/6/23 with the 1st drill @ 8am and the second drill @ 6pm to ensure both shifts are addressed. - Maintenance/Designee will be responsible for quarterly elopement drills to ensure compliance with elopement protocols - Residents will have an elopement risk observation completed quarterly The surveyor verification of the Plan of Removal from 5/6/23 to 5/7/23 was as follows: Observation on 5/5/23 revealed Resident #1 was no longer in the facility. During an interview on 5/5/23 at 3:23 p.m., LVN A stated he had been counseled the same day Resident #1 eloped from the facility on 5/3/23. During an interview on 5/5/23 at 10:56 a.m. revealed Resident #1 stated he returned to the facility on 5/4/23 at around 10:30 p.m. but was advised by the DON to visit a local hospital. Record review of typed-up document titled [Facility Name] Missing Person Timeline, not dated, revealed the facility grounds were searched, the responsible party was notified, physician was notified, and SAPD was notified. Record review of local law enforcement report, dated 5/3/23, revealed law enforcement was notified and arrived on-site. Record review of Employee Disciplinary Report, dated 5/3/23, revealed LVN A was counseled on the need to notify the ADON/DON to follow the elopement protocol if a resident didn't receive medications within 1 hour window and resident was unable to be located. During interviews conducted from 5/6/23 at 2:05 p.m. - 5/7/23 at 11:00 a.m., 21 of the 49 staff (11 from day shift and 9 from night shift and including CNA, LVN, RNs, Dietary Staff, Housekeeping Staff) were interviewed. All staff members interviewed stated they received education on the elopement protocol and what to do if a resident eloped. During interviews conducted on 5/6/23, 2 residents stated they were educated on the importance of signing out at the nurses' station if they were going to sit outside and stated they were educated that if they had to use the accushield if they were going to leave the premises. During an interview on 5/7/23 at 10:14 a.m., the DON stated she conducted the BIMS audit, stated 6 residents had been identified as residents who like to sit outside in the facility's patio, these 6 residents had been educated on the importance of signing out when leaving the premises, and any residents who did not wish to comply with signing out will be provided with a 30 day discharge. The DON stated knowledge checks on the elopement protocol will be conducted on the staff and will be logged a facility document titled, Administrator/Designee will interview 2 staff member a day 5 times a week for 4 weeks. During an interview on 5/7/23 at 10:36 a.m., the Administrator stated 6 residents had been identified as residents who like to sit outside in the facility's patio, these 6 residents had been educated on signing out when leaving the premises, and any residents who did not wish to comply with signing out will be provided with a 30 day discharge. The Administrator stated knowledge checks on the elopement protocol will be conducted on the staff and will be logged a facility document titled, Administrator/Designee will interview 2 staff member a day 5 times a week for 4 weeks. Record review of facility's POR Binder revealed the facility has identified 6 residents who like to sit outside on the facility's patio had a BIMS score of 12 or greater. Further record review of this POR binder revealed all 50 residents in the facility have an elopement assessment within the last quarter, per their policy. Further record review of this POR binder revealed the facility did not have any residents who refused to follow the new process about signing out. Further record review of this POR binder revealed the facility's current policy titled Elopement, dated 12/20217, which detailed the protocol for residents who eloped as well as a table titled Missing Patient Action Table, not dated, which goes into further detail of what to do if a resident had eloped. Record review of the care plans of 3 of the 6 residents identified as liking to sit outside revealed there was a care plan regarding the resident liked to sit outside. Record review of a facility document titled Facility Observation Summary Report, dated 5/6/23, revealed all residents had an elopement assessment within the last quarter. Record review of Educational In-service, not dated, revealed the facility had educated their staff on the elopement policy and the elopement process. Record review of Education In-service, dated 5/5/23, revealed the facility educated their 6 residents who like to sit outside on signing out if they sit outside and to use the accushield if they have to leave the premises. Observation on 5/6/23 at 2 of 2 nurses stations revealed the facility had their Code Pink (which was the name of the facility's protocol when a resident was discovered missing) emergency code document posted in the nurses station and also a manila folder containing the Code Pink protocol. Observation on 5/6/23 at 6:30 p.m., revealed the Administrator was in-servicing his staff on the elopement (Code Pink) protocol. The elopement binder was observed at the 100-200 Hall nurses station. Record review of a facility document titled, Missing Patient Action Table, not dated, revealed the facility had a protocol listing step-by-step what to do if a resident was missing. Record review of an educational in-service, dated 5/5/23, revealed the facility educated their staff on the elopement protocol and also had post-test to confirm education. Record review of a facility document titled, Administrator/designee will interview 2 staff member a day 5 times a week for 4 weeks, not dated, revealed the facility conducted knowledge checks on 2 staff members a day since 5/5/23. Observation on 5/6/23 at 6:23 p.m. revealed the facility successfully conducted their Code Pink (elopement) Drill. During an interview on 5/6/23 at 5:04 p.m., the Maintenance Staff stated he conducted the Code Pink (elopement) Drill on 5/6/23 and stated the drills will be run quarterly. On