**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately notify Resident #1's Responsible Party and practitioners when there was a significant change the resident's physical status (a deterioration in health) for one of five residents (Resident #1) reviewed for resident rights. The facility failed to inform Resident #1's Responsible Party when he refused to eat or drink from dinner on 4/9/2025 to breakfast on 4/11/2025. The resident was sent to the ER on [DATE] with altered mental status, high heart rate resulting in a diagnosis of Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/8/2025 at 12:25 pm; the facility was notified and given an IJ template. While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for immediate harm to their health and safety related to lack of self-determination, decreased nutritional status and dehydration. of a lack of a dignified existence, self-determination and quality of life. Findings include: Record review of Resident 1#'s face sheet, dated 4/17/2025, reflected a [AGE] year-old male who was admitted to the NF on 4/9/2025. Resident #1 had diagnoses which included: Cerebral Infarction (stroke - when blood flow to the brain in blocked), Hypertension (high blood pressure), Neoplasm related pain (tumor related pain), Heart Disease, Ataxia (impaired coordination) and Myocardial Infarction (heart attack). Resident #1' s face sheet indicated a FM was his RP and his emergency contact #1. Record review of Resident #1's Care Plan, dated 4/23/2025, reflected the following problem made on 4/11/2025 after the resident was sent to the ER: Potential for alteration in nutrition r/t mechanically altered diet. Resident has been found to pocket food. The following interventions were listed for this problem: document meal intake in the clinical record, notify physician as needed. Record review of Resident #1's progress notes, dated 4/9/2025 - 4/11/2025, reflected no entries regarding refusal of nutrition or hydration, no entries that practitioners were notified of refusal of nutrition/hydration and no entries that RP was notified of refusal of nutrition/hydration by Resident #1. Record review of Resident #1's EMR reflected he had not been in the NF long enough to have a BIMS assessment completed for his cognition level. Record review of Resident #1's admission Assessment, dated 4/9/2025 at 4:12 pm, by LVN-B, reflected he was drowsy/stuporous but oriented to person, place, time, situation and that his cognition was intact. Record review of Resident #1's POC, dated 4/23/25, reflected no nutrition/hydration entry for 4/9/2025 or 4/11/2025. There were 3 entries on 4/10/2025 at 8:00 AM, 12:00 PM and 5:00 PM in the 0-25% column . Record Review of Resident #1's vital signs revealed he had an admission weight of 134 pounds on 4/9/2025 at 3:35 pm. Vital signs taken between 4/10/2025 and 4/11/2025 revealed resident's oxygen saturation, blood pressure and respirations were within normal limits. Further review of Resident #1's pulse rate revealed pulse rate was elevated and outside of the normal limits (60-100 beats per minute) as follows: 4/10/2025, 10:11 am - 108 bpm (beats per minute) 4/10/2025, 11:57 am - 104 bpm 4/10/2025, 6:19 pm - 105 bpm 4/11/2025, 9:44 am - 116 bpm During an interview with RP/FM on 4/17/2025 at 11:58 am, RP stated they were not aware Resident #1 had been refusing to eat or drink since he arrived at the NF. They stated they first they new something was wrong was the morning of 4/11/2025 when a nurse called them to say Resident t#1 was being sent to the ER because he was lethargic and had low vitals. They stated when they got to the ER, Resident #1 told them he had not had anything to eat or drink since he had been admitted on [DATE]. The RP stated if they had known he wasn't eating or drinking they could have gone up to the NF and encourage him to eat, but no one notified them. The RP stated Resident #1 was diagnosed with Kidney Failure and severe dehydration and was very sick and was still in the hospital trying to recover. They stated Resident #1 had been admitted to the NF for rehabilitation and returned to the hospital less than 2 days after he left in worse shape then before. During an interview with CNA-A on 4/17/2025 at 1:52 PM, she stated if a resident refused meals, they were trained to tell the charge nurse. She stated she worked on 4/10/2025 and Resident #1 refused all his meals and hydration except for a small sip of juice. She stated resident was offered 3 meal on 4/10/2025 and refused all of them. She stated she informed the charge nurse and documented in the EMR/POC the resident had consumed 0-25% of his meals. She stated they did not have the ability to choose 0% the only option was a range from 0-25%. During an interview on 4/18/2025 at 9:54 AM, LVN - B stated she completed Resident #1's admission assessment on 4/9/2025 and was the charge nurse for Resident #1 on 4/10/2025. She stated CNA- A informed her Resident #1 had refused meals. She stated CNA-A and her both had tried a couple of times to try and get him to eat and drink and she tried as well, but she refused. She stated she didn't document any of Resident #1's refusals in the EMR because I got busy and didn't get to it. She stated she did not call the RP and notify them of his refusal to eat because I don't know, I guess I thought he was his own RP. She stated at some point during the day, NP D was in the building doing rounds, but she didn't remember if she had told NP D about Resident #1 refusing to eat or drink. She stated a resident who refused to eat or drink could have lower blood pressure, lots of issues with UTIs, dehydration and have to go to the hospital. She noted resident should have been offered at least 4 meals between 4/9/2025 and 4/11/2025 and he was offered dinner on 4/9/25 and 3 meals (breakfast/lunch/dinner) on 4/10/25 and refused all nutrition and hydration expect for a small sip of water in the evening on 4/9/2025. She sated she wasn't sure if Resident #1 had been offered breakfast on 4/11/2025 before the NP-D saw him and ultimately sent him out to the emergency room. During an interview on 4/23/2025 at 12:02 PM, NP-C stated she saw Resident #1 on 4/11/2025 in the morning and he was hard to wake up and wasn't following commands and his heart rate was high, so she gave orders to have him sent to the ER for further care. She stated she reviewed Resident #1's progress notes before going in the building and did not see anything about him refusing meals/hydration. She stated when she arrived at the NF and checked in with Nurse B, Nurse B did not mention anything about Resident #1 missing meals. She stated she would have been concerned if she had known the resident had eaten or drank for 4 meals, and she would have followed up and put interventions in place if she had known which included imagining, labs and perhaps fluid replacement via IV. She stated her concerns for residents refusing that many meals would be dehydration, AMS, and changes in electrolytes. She stated if a resident missed more than 2 meals, her expectation was that staff will reach out to the practitioner so interventions can be started . During an interview on 4/23/2025 at 12:14 PM, NP-D stated she saw Resident #1 in the morning on 4/10/2025 for his initial visit upon admission and noted Resident #1 was Awake, Alert, Calm, Cooperative, Difficulty with speech articulation; PSYCHIATRIC- Oriented times three [indicating resident was alert and oriented to person, place, situation], Clear, Lucid, Normal mood; COGNITIVE- Normal memory. She stated Nurse B did not say anything to her about the resident refusing nutrition or hydration. She stated her concerns for residents who skipped meals was dehydration, possible changes in their vital signs - low blood pressure and increased heart rate, potential changes in cognition. She stated profound dehydration could lead to cardiac disturbances [problems with the heart ]. During an interview on 4/17/2025 at 4:05 PM, the DON stated Resident #1 was seen in person by NP- C and NP-D and reviewed their notes but did not see any notes related to poor intake. She stated her expectation was if a resident missed a couple of meals the staff would notify upper management, the RP and the practitioner. She stated she was not aware the resident had refused to eat or drink and was not aware his RP had not been notified. She stated it was the Nurse B's responsibility to notify the NP and RP of refusal to eat and drink. She stated she was aware his RP was notified when he was sent to the ER on [DATE]. She mentioned the NF had NPs in the building 5 days a week and LVN- B should have notified the NPs of Resident's refusal to eat/drink so they could possibly help. During an interview on 4/17/2025 at 4:05 PM, the ADM stated he was unaware Resident #1 had refused meals. He stated his expectation was Staff would notify the DON, RP and practitioner when residents refused meals/hydration. During an interview on 4/23/2025 at 1:55 PM, MDS- E stated she reviewed Resident #1's POC in the EMR and there was not an entry for the evening meal consumption on 4/9/2025 and no entry for breakfast meal consumption on 4/11/2025. She stated three meals were documented for 4/10/2025 showing a 0-25% for each meal that day. She stated there was no way to document 0% of a meal consumed in POC, the nurse would have to put in a progress note in the EMR. She stated she had not seen any progress notes in Resident #1's EMR for 4/10/2025. During an interview on 4/23/2025 at 1:16 PM, the MD stated he was not aware of Resident #1 missing that many meals and he never got any calls about his refusal to eat/drink. He stated even with a couple of days a resident could potentially have kidney issues or dehydration. He stated he reviewed Resident #1 hospital records and noted he had an Acute Kidney Injury, and it took him several days in the hospital to return to his baseline. He stated Resident #1's labs showed he was definitely dehydrated. He stated he would like to know within 2-3 meals if a resident was refusing nutrition/hydration. The MD stated the RP should have been notified if resident was not alert or if the resident was not his own RP. Further, the MD stated, this one didn't go as planned (referring to the notification to the NP's and RP) and the NPs should have been notified of the resident refusing to eat/drink. Record review of the facility's policy, dated/copyright 2025, Resident Rights reflected: Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: a. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition . Record review of the facility's policy dated/copyright 2024, Notifications of Changes reflected: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. PLAN OF REMOVAL (Immediate Jeopardy) Tag: F580 - The facility failed to notify immediately, the physician and resident representative of a significant change. Facility: Lakeshore Village Nursing and Rehabilitation Date IJ Identified: 5-8-25 Date Plan of Removal Implemented: 5-8-25 Person Responsible for Oversight: Administrator/Designee Immediate Actions Taken to Remove the Immediate Jeopardy 1. Resident #1 (Affected Resident): Upon identification of the issue, Resident #1 no longer resides in the facility. 2. Identification of At-Risk Residents (Facility-Wide Review): DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends on 5-8-25 . This was report pulled from PCC and retained for proof. 6 residents were identified with low or declining intake (<25%) and were immediately evaluated by nursing. NP/MD and RP notifications initiated. Care plans updated accordingly by DON/Designee. No other residents with undetected nutritional significant change. No notifications were required. No other resident with undetected significant change that required notification. 3. System Correction: DON was in-serviced on 5/8/25 by Regional Nursing to notifying MD/NP and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations with return demonstration. DON/ Designee will in-service licensed nursing staff/licensed agency starting 5/8/25 re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations . This will be added to licensed nurses' general orientation for new hires. Mandatory in-services will be completed 5/9/25 with all current and oncoming nursing staff prior to start of shift worked. DON/Designee will complete competency validation conducted for licensed nurses/ licensed agency on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses' general orientation for new hires. Administrator was in-service on department head meal manager schedule and details on 5/8/25 by Texas Area President. Department Heads will be in-serviced by administrator on meal manager requirements. 4. Administrative Oversight/Monitoring: DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for 30 days and then weekly for 4 weeks ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool. Any issues will be reported to the QAPI Committee meeting monthly. Administrator will lead Ad hoc QAPI to review the deficiency and the process for POR will be completed 5/9/25. 5. Completion Date: 5/9/25 The surveyor monitored the POR on 5/10/2025 as follows: ADM was in serviced by area president on 5/8/2025 on the following: meal managing, reporting meal percentages under 25% to charge nurse, charge nurse reports to NP and RP, and audit completion of residents with poor meal intake. DON was in serviced by regional nurse staff on 5/8/2025 on the following: reporting to physician and families when resident eat less than 25% of meal, meal percentages, accurate reporting of meal percentages, and auditing meal percentages. Interviews with three Nurses, three CNAs and one CMA 5/10/2025 reflected they had been in serviced on letting the charge nurse know when residents consume less than 25% of their meals, and when resident's decline nutrition for two days straight, know percentages and how to validate and document in EMR. The facility completed a complete audit of all resident's meal percentages and identified 6 residents with declining intake and the NP and RPs were notified. AD hoc QAPI was held on 5/9/2025 and the following staff were in attendance: ADM, DON, Regional Nurse, ADONs, Medical Director. The staff reviewed the IJ template for F580 and F692 and reviewed the plan of removal and plan of correction. Record Review revealed the ADM was in serviced on 5//8/2025 on Department head meal manager schedule and details. Record review revealed nursing staff had been in serviced on meal percentages, reporting when residents decline nutrition, and notification of NP/MD and RPs when residents design nutrition for two days. While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not a possible or resident preference indicated otherwise and is offered sufficient fluid intake to maintain proper hydration and health for one of five (Resident #1) residents reviewed for nutrition and hydration. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 refusing meals and hydration from dinner on 4/9/2025 to breakfast on 4/11/2025. Resident was sent to the ER on [DATE] with altered mental status resulting in a diagnosis of Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/8/2025 at 12:25 pm; the facility was notified and given an IJ template. While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for immediate harm to their health and safety related to decreased nutritional status, dehydration, UTI's or hospitalization. Findings include: Review of Resident #'s face sheet dated 4/17/2025 reflected a [AGE] year-old male admitted to the NF on 4/9/2025 with diagnoses that included: Cerebral Infarction (stroke - when blood flow to the brain in blocked), Hypertension (high blood pressure), Neoplasm related pain (tumor related pain), Heart Disease, Ataxia (impaired coordination) and Myocardial Infarction (heart attack). Resident #1' s face sheet indicated a FM was his RP and his emergency contact #1. Resident #1's Care Plan dated 4/23/2025 reflected the following problem made on 4/11/2025 after resident was sent to the ER: Potential for alteration in nutrition r/t mechanically altered diet. Resident has been found to pocket food. The following interventions were listed for this problem: document meal intake in the clinical record, notify physician as needed. Review of Resident #1's progress notes dated 4/9/2025 - 4/11/2025 reflected no entries regarding refusal of nutrition or hydration, no entries that practitioners were notified of refusal of nutrition/hydration and no entries that RP was notified of refusal of nutrition/hydration by Resident #1. Review of Resident #1's EMR reflected he had not been in the NF long enough to have a BIMS assessment completed for his cognition. Review of Resident #1's admission assessment dated [DATE] at 4:12 pm reflected he was drowsy/stuporous but oriented to person, place, time, situation and that his cognition was intact. Review of Resident #1's POC dated 4/23/25 reflected no nutrition/hydration entry for 4/9/2025 or 4/11/2025. There were 3 entries on 4/10/2025 at 8:00 am, 12:00 pm and 5:00 pm in the 0-25% column . Record Review of Resident #1's vital signs revealed he had an admission weight of 134 pounds on 4/9/2025 at 3:35 pm. Vital signs taken between 4/10/2025 and 4/11/2025 revealed resident's oxygen saturation, blood pressure and respirations were within normal limits. Further review of Resident #1's pulse rate revealed pulse rate was elevated and outside of the normal limits (60-100 beats per minute) as follows: 4/10/2025, 10:11 am - 108 bpm (beats per minute) 4/10/2025, 11:57 am - 104 bpm 4/10/2025, 6:19 pm - 105 bpm 4/11/2025, 9:44 am - 116 bpm Record review of Resident #1's ER hospital records, dated 4/18/2025, reflected he arrived at the ER on [DATE] at 11:33 AM and upon arrival Patient hypoxic [absence of enough oxygen in the tissue to sustain bodily functions] and hypotensive [blood pressure below normal limits] enroute with BP 75/45, placed on 2L NC . presenting with c/o generalized weakness and AMS. Resident #1 was diagnosed with Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration which required him to be admitted for further treatment. The records indicated Resident #1 was still hospitalized as of 4/18/2025. During an interview with RP/FM on 4/17/2025 at 11:58 AM, the RP stated they were not aware Resident #1 had been refusing to eat or drink since he arrived at the NF. They stated they first knew something was wrong was the morning of 4/11/2025 when a nurse called them to say Resident t#1 was being sent to the ER because he was lethargic and had low vitals. They stated when they got to the ER, Resident #1 told them he had not had anything to eat or drink since he had been admitted on [DATE]. RP stated if they had known he wasn't eating or drinking they could have gone up to the NF and encourage him to eat, but no one notified them . During an interview with CNA A on 4/17/2025 at 1:52 pm she stated if a resident refuses meals, they are trained to tell the charge nurse. She stated she worked on 4/10/2025 and Resident #1 refused all his meals and hydration except for a small sip of juice. She stated she informed the charge nurse and documented in the EMR/POC that resident had consumed 0-25% of his meals. She stated they do not have the ability to choose 0% the only option is a range from 0-25%. During an interview with Nurse B on 4/18/2025 at 9:54 am she stated she was the charge nurse for Resident #1 on 4/10/2025. She stated the CNA A informed her that Resident #1 had refused meals. She stated CNA A tried a couple of times to try and get him to eat and she tried as well, but her refused. She stated she didn't document any of Resident #1's refusals in the EMR because I got busy and didn't get to it She stated she did not call RP and notify them of his refusal to eat because I don't know, I guess I thought he was his own RP. She stated at some point during the day, NP D was in the building doing rounds, but she didn't remember if she had told NP D about Resident #1 refusing to eat or drink. She stated a resident that refuses to eat or drink could have lower blood pressure, lots of issues with UTIs, dehydration and have to go to the hospital. During an interview on 4/23/2025 at 12:02 pm, NP C stated she saw Resident #1 on 4/11/2025 in the morning and he was hard to wake up and wasn't following commands and his heart rate was high, so she gave orders to have him sent to the ER for further care. She stated she reviewed Resident #1's progress notes before going in the building and did not see anything about him refusing meals/hydration. She stated when she arrived at the NF and checked in with Nurse B, Nurse B did not mention anything about Resident #1 missing meals. She stated she would have been concerned if she had known that resident had eaten or drank for 4 meals, and she would have followed up and put interventions in place if she had known including imagining, labs and perhaps fluid replacement via IV. She stated her concerns for residents refusing that m any meals would be dehydration, AMS, and changes in electrolytes. She stated if a resident misses more than 2 meals, her expectation is that staff will reach out to the practitioner so interventions can be started. During an interview on 4/23/2025 at 12:14 pm, NP D stated she had seen Resident #1 in the morning on 4/10/2025 for his initial visit upon admission and noted Resident #1 was Awake, Alert, Calm, Cooperative, Difficulty with speech articulation; PSYCHIATRIC- Oriented times three [indicating resident was alert and oriented to person, place, situation], Clear, Lucid, Normal mood; COGNITIVE- Normal memory. She stated Nurse B did not say anything to her about resident refusing nutrition or hydration. She stated her concerns for residents that skip meals is dehydration, possible changes in their vital signs - low blood pressure and increased heart rate, potential changes in cognition. She stated profound dehydration could lead to cardiac disturbances [problems with the heart]. During an interview on 4/17/2025 at 4:05 PM, the DON stated Resident #1 was seen in person by NP- C and NP-D and reviewed their notes but did not see any notes related to poor intake. She stated her expectation is was that if a resident misses missed a couple of meals that the staff will would notify upper management, the RP and the practitioner. She stated she was not aware the resident had been refusing to eat or drink and was not aware his RP had not been notified. She stated it was the Nurse B's responsibility to notify the NP and RP of refusal to eat and drink. She stated she was aware his RP had been notified when he was sent to the ER on [DATE]. She mentioned that the NF has had NPs in the building 5 days a week and that LVN- B should have notified the NPs of Resident's refusal to eat/drink so they could possibly help. During an interview on 4/17/2025 at 4:05 pm, ADM stated he was unaware that Resident #1 had been refusing meals. He stated his expectation is that Staff will notify DON, RP and practitioner when residents refuse meals/hydration. During an interview on 4/23/2025 at 1:16 pm, MD stated he was not aware of Resident #1 missing that many meals and that he never got any calls about his refusal to eat/drink. He stated even with a couple of days a resident could potentially have kidney issues or dehydration. He stated he reviewed Resident #1 hospital records and noted he had an Acute Kidney Injury, and it took him several days in the hospital to return to his baseline. He stated Resident #1's labs showed he was definitely dehydrated. He stated he would like to know within 2-3 meals if a resident is refusing nutrition/hydration. MD stated the RP should have been notified if resident was not alert or if resident was not his own RP. Further, the MD stated, this one didn't go as planned (referring to the notification to the NP's and RP) and the NPs should have been notified of the resident refusing to eat/drink. Record review of the facility's policy Nutritional Management, copyright 2025, reflected: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Nutritional Status includes both nutrition and hydration status. 5. d. The physician will be notified of: i. Significant changes in weight, intake, or nutritional status ii. Lack of improvement toward goals iii. Any complications associated with interventions. 6. Informed consent: a. The resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. b. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. PLAN OF REMOVAL (Immediate Threat) Tag: F692 - Failure to Maintain Acceptable Parameters of Nutritional Status Facility Date IJ Identified: 5-8-25 Date Plan of Removal Implemented: 5-8-25 Person Responsible for Oversight: Administrator/Designee Immediate Actions Taken to Remove the Immediate Threat 1. Resident #1 (Affected Resident): Upon identification of the issue, Resident #1 no longer resides in the facility. 2. Identification of At-Risk Residents (Facility-Wide Review): DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends on 5-8-25. 6 residents were identified with low or declining intake (25% or less) and were immediately evaluated by nursing. NP/MD and RP notifications initiated. Care plans updated accordingly by DON/Designee. No other residents with undetected weight loss No other resident with undetected significant change that required notification. 3. System Correction: DON/ Designee will in-service Licensed nursing/ licensed agency staff immediately re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations . This will be added to licensed nurses' general orientation for new hires. DON/ Designee will in-service CNAs/Agency CNA immediately re-educated and directed to notify charge nurse of missed meals or poor intake (<25%), accurate documentation and communication expectations . This will be added to CNAs general orientation for new hires. Mandatory in-services will be completed 5/9/25 with all current and oncoming nursing staff prior to start of shift worked. Competency for License staff and CNAs/Agency CNAs validation conducted on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses/CNAs general orientation for new hires. Administrator was in-serviced on department head meal manager schedule and details on 5/8/25 by Texas Area President. Department Heads will be in-serviced by administrator on meal manager requirements . 4. Administrative Oversight/Monitoring: DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for 30 days and then weekly for 4 weeks to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool. Any issues will be reported to the QAPI Committee meeting monthly. Ad hoc QAPI to review the deficiency and the process for POR will be completed 5/9/25. 5. Completion Date: 5/9/25 POR monitoring as above in F580 While the IJ was removed on 05/10/2025 at 5:50 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 8 of 8 nurses (LVN G, E, KK, CCC, GGG, NNN, OOO, and RN D ) reviewed for nursing services. 1. The facility did not ensure nursing staff was trained and educated on the LVAD (a device that is used in the treatment of end-stage heart failure). 2. The facility did not ensure nursing staff was trained on complications to monitor for Resident #231's LVAD. 3. The facility did not ensure nursing staff obtained MAP (average calculated blood pressure in an individual during a single cardiac cycle) pressures and documented them appropriately on the MAR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:07 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential more than minimal harm that is not Immediate Jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings included: Record review of Resident #231's face sheet, dated [DATE], indicated Resident #231 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that was present over a long time. Record review of the physician order summary report dated [DATE] indicated to monitor Resident #231 LVAD frequently; ensure monitor was plugged in and battery packs time six charging and if electricity goes out, immediately plug into green extension cord under bed and into red emergency outlet every shift and monitor LVAD frequently, ensure monitor was plugged with a start date [DATE]. Record review of the MDS assessment indicated Resident #231 was admitted to the facility less than 21 days ago. No MDS for Resident #231 was completed prior to exit. Record review of Resident #231's admission/baseline care plan dated [DATE] indicated Resident #231 had an LVAD. The care plan did not address any goals or interventions related to the LVAD. Record review of the blood pressure summary indicated Resident #231's blood pressures were: [DATE]; 206/74 mmHg [DATE]; 84/63 mmHg [DATE]; 114/70 mmHg [DATE]; 71/60 mmHg [DATE]; 114/75 mmHg [DATE]; 114/70 mmHg [DATE]; 114/70 mmHg [DATE]; 114/70 mmHg [DATE]; 124/70 mmHg [DATE]; 114/70 mmHg Record review of the TAR dated [DATE]-[DATE] indicated Resident #231 was receiving: *Cozaar 100 mg; 1 tablet via Peg-tube in the morning for hypertension. Hold if BP <110/60 or Pulse <60 with a start date [DATE]. * Norvasc 10 mg; 1 tablet via Peg-Tube in the morning for hypertension. Hold if BP <110/60 with a start date [DATE]. *Metoprolol Tartrate 50 mg; 1 tablet via Peg-Tube two times a day for hypertension with a start date [DATE]. *Hydralazine 25 mg; 3 tablets via Peg-Tube three times a day for hypertension. Hold if BP <110/60 or Pulse <60 with a start date [DATE]. Record review of the TAR indicated the 6:00 p.m. Hydralazine 25 mg dose was not given on [DATE]. An attempted interview on [DATE] at 10:54 a.m. with Resident #231, indicated she was non-interview able. During an interview on [DATE] at 10:55 a.m., Resident #231's family member stated she was concerned the facility was not able to provide the care that was needed for her family member. When asked if she could provide the surveyor more information, Resident #231 family member stated over the weekend she watched nurses check Resident #231 blood pressure using an automatic blood pressure cuff. Resident #231 family member stated a manual blood pressure and doppler should be used. Resident #231 family member stated she was told by the nursing staff that they were not able to get a blood pressure reading. Resident #231 family member stated the facility did not have a doppler to obtain Resident #231 radial (wrist) pulse. Resident #231 family member stated Resident #231 did not have a regular blood pressure just a MAP which was one number. Resident #231 family member stated she instructed several nursing staff on how to correctly check Resident #231 MAP. Resident #231 family stated she was told by the facility they had all the equipment needed for Resident #231's LVAD. Resident #231 family stated not knowing how to handle Resident #231 LVAD correctly could possibly cause death. During an interview on [DATE] at 12:08 p.m., RN D stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. RN D stated she attempted several times on [DATE], [DATE], and [DATE] to check Resident #231 blood pressure with an automatic blood pressure cuff. RN D stated she was told by Resident #231 family member that she must use a manual blood pressure cuff and a doppler to obtain a reading. RN D stated when she checked her blood pressure, she would only get one number. RN D stated before she realized that she would only get one number, she would document in Resident #231's chart a number that she made up because at that time, she did not know she was supposed to only get one number. RN D stated the blood pressure readings in the chart were not accurate. RN D stated even though the numbers she charted were outside the norm of the parameters she never contacted the doctor or inform anyone. RN D stated false documentation was not appropriate but there was no other way to document in the chart. RN D stated she administered Resident #231's blood medications even though she did not have an accurate reading. RN D stated she had not dealt with a LVAD in years that she felt familiar enough to provide care to without been educated on first. RN D stated it was important to know the risk and side effects to prevent possible death. During an interview on [DATE] at 12:42 p.m., LVN E stated he had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN E stated he was trained by the family member on [DATE] on how to use the doppler to get Resident #231's MAP. LVN E stated the DON provided him a pamphlet with a contact number for the representative of the LVAD clinic. LVN E stated it was important to be educated and trained on the LVAD because the LVAD kept Resident #231 alive. LVN E stated the LVAD was a life saving intervention. During an interview on [DATE] at 12:57 p.m., the DON stated she had taken care of LVAD residents before in a home setting. The DON stated she felt competent along with instructions that she received from the family that was caring for her that the facility could provide adequate care. The DON stated Resident #231 family member came in on [DATE] and showed what to do in an emergency situation. The DON stated from her knowledge she thought one could auscultate a MAP with a manual blood pressure cuff and stethoscope. The DON stated she should have notified the LVAD clinic to have them come in and do the training prior to Resident #231 admission. The DON stated the blood pressure medications should not have had parameters because Resident #231 would not have a two number blood pressure just a MAP. The DON stated she did not instruct her staff until surveyor intervention on how to document in the chart the MAP. The DON stated up until [DATE] the nurses were either guessing Resident #231 MAP or did not get one at all. The DON stated she was instructed by the family to give the blood pressure medication no matter what. The DON stated she relied on the family because they had cared for her since 2017. The DON stated she thought that Resident #231 MAP should be between 68-75. The DON stated she delegated the ADON to in-service LVN G and LVN GGG. The DON stated LVN G and LVN GGG were responsible for in servicing the other nursing staff that provided care for Resident #231. The DON stated from her knowledge there was a discussion about Resident #231 with the MD. The DON stated it was sometimes during the week of [DATE] when the facility received the referral from the hospital. The DON stated she reviewed the referral and saw that she had a LVAD and thought her and her staff were competent enough to provide care to her. The DON stated after discussing with the MD it was in agreeable that Resident #231 was appropriate for the facility. The DON stated it was important for the nursing staff to be trained, educated, and know how to document appropriate to prevent possible death. During a telephone interview on [DATE] at 1:31 p.m., LVN KK stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN KK stated she used an electronic blood pressure cuff but did not get a reading. LVN KK stated she never notified the DON or MD regarding Resident #231 blood pressure. LVN KK stated she should have notified someone. LVN KK stated it was important to be trained and educated on the LVAD device because it could have been life threatening. During an interview on [DATE] at 1:38 p.m., LVN G stated she had not been in-serviced on the LVAD prior to assuming the care of Resident #231. LVN G stated she was in service on [DATE] by LVN E. LVN G stated she did not know how to take Resident #231 blood pressure this weekend. LVN G stated she used an automatic cuff on her arm. LVN G stated she did not get a reading. LVN G stated she contacted the nurse practitioner and was told that she would not get a reading such as a top and bottom number. LVN G stated there was no additional training provided. LVN G stated she was told by the nurse practitioner that Resident #231 would need her medications and there were no parameters to monitor for. LVN G stated she administered Resident #231's blood pressure medications. LVN G stated Resident #231 had a life saving device and not knowing that how to correctly check her MAP could have cause her to have a stroke or died. LVN G stated she should have asked the DON and nurse practitioner further questions about the LVAD device. During an interview on [DATE] at 1:44 p.m., the Nurse Practitioner stated a LVAD helps the heart pump when it did not do it on its own. The Nurse Practitioner stated she was aware that Resident #231 was coming to the facility, but she was unaware of the MAP parameters. The Nurse Practitioner stated when she reconciled the medications, she did not see anything with parameters. The Nurse Practitioner stated she thought because of the cardiomyopathy she needed the medications. The Nurse Practitioner stated the nursing staff should have contacted the doctor to get parameters for the MAP. The Nurse Practitioner stated the staff should have been in serviced on the LVAD. The Nurse Practitioner stated she instructed LVN G to give Resident #231 her blood pressure medication but do not put blood pressure parameters on the medications because with a MAP you only get one number. The Nurse Practitioner stated Resident #231 MAP could only be obtained by a manual blood pressure using a doppler to check the radial pulse. The Nurse Practitioner stated not knowing how to take care of a resident with a LVAD put them at risk for dying. During an interview on [DATE] at 2:54 p.m., the LVAD consultant stated a LVAD was a lifesaving device that helped the left side of the heart push blood forward to help with perfusion (passage of bodily fluids) to Resident #231's body. The LVAD consultant stated the nurse must use a manual blood pressure and a doppler to get Resident #231 MAP. The LVAD Consultant stated not using a manual blood pressure and doppler, the nurse would not get an accurate blood pressure. The LVAD Consultant stated Resident #231 MAP parameters were between 70-90. The LVAD Consultant stated the facility contacted the clinic on [DATE] requesting someone to come out and in service their staff. The LVAD Consultant stated it was important to know about the LVAD device because it put the resident at risk for possible death. During an interview on [DATE] at 5:00 p.m., the Medical Director stated he was aware that Resident #231 was in the facility. The Medical Director stated he remembered hearing from someone after she was admitted but prior to that it was not ran by him. The Medical Director stated if he had of known prior to Resident #231 admission, he would have had to find out how stable she was and made sure the staff were aware of how to care for someone with an LVAD device. The Medical Director stated he was told that there had not been any education provided so he will be coming in that day to provide education to the nurses. The Medical Director stated the facility should have contacted him to get the MAP parameters. The Medical Director stated he considered the LVAD a life sustaining device and not knowing how to care for the device could cause the resident to die. During an interview on [DATE] at 5:26 p.m., LVN CCC stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN CCC stated she tried to check Resident #231's blood pressure using an automatic wrist cuff and it did not read. LVN CCC stated she had to do it with an automatic upper arm cuff and Resident #231 blood pressure reading was low, so she held the blood pressure medication. LVN CCC stated the only instructions she received was what to do if the electricity went out. LVN CCC stated she had never cared for anyone with an LVAD device. LVN CCC stated she did not notify the Medical Director that Resident #231's blood pressure was low. LVN CCC stated she just used the parameters on the medications to determine if the medication should be held. LVN CCC stated she should have contacted the doctor to let him know about her blood pressure. LVN CCC stated she was focused on not giving the medication because if the blood pressure was low and she gave the medication she could have possibly died. LVN CCC stated it was important to know about the LVAD device because it could have been life threatening. During a telephone interview on [DATE] at 6:10 p.m., LVN NNN stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN NNN stated she was not required to check Resident #231's blood pressure on her shift due to the time that she resumed care of Resident #231. LVN NNN stated if she had to check her blood pressure, she would have used an automatic cuff like she did on everyone else. LVN NNN stated the nurse she received report from instructed her on what to do in an emergency situation. LVN NNN stated she knew the LVAD device was a life saving device but was not familiar with it. LVN NNN stated she did not know the risk associated with monitoring a resident with a LVAD. During an interview on [DATE] at 6:25 p.m., the ADON stated she in-serviced LVN G on [DATE] what to do in an emergency situation when handling Resident #231. The ADON stated she informed LVN G to in-service the oncoming nurse about how to handle the LVAD in an emergency situation. The ADON stated herself and the DON went in on [DATE] and spoke with Resident #231's family member. The ADON stated they were instructed on what to do in an emergency situation and how to handle the device. The ADON stated they were informed that a manual cuff and doppler must be used to get her MAP. The ADON stated the family member gave them the parameters, but the ADON was unable to recall the numbers. The ADON stated the family member informed them that she would bring the doppler from home to the facility on [DATE]. The ADON stated the facility should have had their own doppler prior to Resident #231 arrival to the facility. The ADON stated she was nervous with the LVAD device coming into the facility. The ADON stated the doctor should have been informed about the parameters and just the overall care of the device. The ADON stated the risk associated with not properly knowing how to manage or monitor Resident #231 LVAD was death. During a telephone interview on [DATE] at 6:45 p.m., LVN OOO stated she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN OOO stated she checked Resident #231 blood pressure using an automatic cuff. LVN OOO stated after she checked her blood pressure, Resident #231 family member asked her about the doppler. LVN OOO stated the family stated to her while in the room with Resident #231 that she was informed that the facility knew how to take care of a resident with LVAD. LVN OOO stated she apologized and went to review Resident #231 electronic chart. LVN OOO stated after she reviewed the chart, she did not see anything about checking the blood pressure with a manual cuff or doppler. LVN OOO stated she even went and spoke with the other nurse that was on her hall and they did not know either. LVN OOO stated she knew nothing about MAP parameters. LVN OOO stated she used the parameters that was on the blood pressure medications. LVN OOO stated she administered the blood pressure medications even though she did not know if the medications should be held or not. LVN OOO stated not fully aware of the in and out of LVAD device could be detrimental to Resident #231. During an interview on [DATE] at 12:36 p.m., LVN GGG stated she was in serviced on how to connect and disconnect the machine during an emergency situation. LVN GGG stated other than that she had not been in serviced on the LVAD prior to assuming the care of Resident #231. LVN GGG stated it was important to know how to take care of someone with a LVAD device because it could be fatal, that is the only way for blood supply to the heart. During an interview on [DATE] at 6:11 p.m., the Administrator stated he expected his staff to be competent in taking care of someone with a LVAD device. The Administrator stated the DON and the ADON was responsible for reviewing the admission referral and ensuring the staff were able to properly care for the resident. The Administrator stated the DON discussed with him about Resident #231 and she felt competent in providing care for her. The Administrator stated, when she feels comfortable, I feel comfortable. The Administrator stated the facility did not ask the Medical Director to review admissions before he and the DON accepted the resident. The Administrator stated the DON should have in serviced the nursing staff prior to assuming care for Resident #231. The Administrator stated the DON should have made sure she had all the equipment in the facility. The Administrator stated this was important for the safety of the resident and to prevent death. Record review of the facility's policy titled Staffing, Sufficient and Competent Nursing last revised 08/2022, indicated, . our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . 6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment .Competent Staff (3). Staff must demonstrate the skills and techniques necessary to care for resident's needs . The Administrator was notified on [DATE] at 5:00 PM that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on [DATE] at 5:07 PM and the plan of removal was requested. The Plan of Removal was accepted on [DATE] at 9:18 a.m. and included: LETTER OF ABATEMENT FOR REMOVAL OF IMMEDIATE JEOPARDY [DATE] On [DATE], a survey was initiated at Facility XXX. The facility was notified at 5:10 pm on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at Facility XXX constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F726-Competent Staff and the facility's failure to provide training and education on the LVAD has the potential to cause death to Resident #231 Immediate Corrections Implemented for Removal of Immediate Jeopardy. On [DATE]th, 2023, at 5:10pm the following actions were taken; Action: On [DATE], Resident #231 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with LVAD monitoring and care by licensed nurses. These measures include Assessment to include monitoring for continuous humming when auscultating heart sounds to validate that the device is functioning properly, observing for s/s of infection, power management, monitoring MAP with goal of 60-90mm Hg, shortness of breath and increased MAP. Orders in place for cord and battery management and dressing changes and monitoring of MAP. On [DATE] The Director of Nursing/Designee notified resident #231's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered. The care plan was initiated to reflect LVAD and required care and monitoring. Orders in place for cord and battery management and dressing changes and monitoring of MAP. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/Designee Action: Medical director completed education with Director of nursing and nursing leadership on the purpose, function, and potential complications as well as the requirements to monitor and care for LVAD, including monitoring mean arterial pressures (MAP), battery and cord management, and cleaning and care of drive line. Start Date: [DATE] Completion Date: [DATE] Responsible: Medical Director IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: The Director of Nursing/Designee completed a sweep of all facility residents to identify any residents with LVAD to have appropriate monitoring including MAP pressures and documentation in place. There were no other residents identified as having an LVAD. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: Director of nursing completed education with licensed staff caring for resident #231 on [DATE] on requirements to monitor and care for LVAD, including monitoring blood pressure and mean arterial pressure (MAP); the goal is 60 mm Hg to 90 mm Hg. Elevated MAP decreases flow and perfusion, battery, and cord management, monitor for complications, SOB, increased pulse pressure, decrease in pump flow rate, and steady increase in the pump power over several days and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line to validate resident is cared for and receiving appropriate for care of LVAD. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/Designee Action: Director of Nursing arranged education with all licensed staff on [DATE] at 10:00am from LVAD clinic to educate on all cares and monitoring required for care of resident with LVAD, to document competencies for all licensed nursing staff in facility. Training will be recorded and any nursing staff who work infrequently or were not in attendance will be educated on the above prior to their next scheduled shift. This education will include monitoring blood pressure and mean arterial pressure (MAP); the goal is 60 mm Hg to 90 mm Hg. Elevated MAP decreases flow and perfusion, battery, and cord management, monitor for complications, SOB, increased pulse pressure, decrease in pump flow rate, and steady increase in the pump power over several days and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/designee Action: The Director of Nursing/designee will conduct daily reviews of new and admission orders to validate that nursing staff have appropriate competencies associated with any medical devices ordered or in use by residents prior to providing care. The Director of Nursing/designee if needed will arrange for additional training to ensure that nurses demonstrate competency in the care of residents with devices found to be new to the facility or infrequently used. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing Ad Hoc QAPI meeting was held on [DATE] with the Medical Director, Administrator, Director of Nursing, and Nurse Management, Area Operations Director, Corporate clinical consultant, Pharmacy consultant to review Immediate Jeopardy findings and plan of removal for identified deficient practice. Please accept this letter as our plan of removal for determination of the Immediate Jeopardy issued [DATE]. Monitoring of the Plan of Removal from [DATE]-[DATE] included the following: 1) Record review of the electronic medical records indicated Resident #231 was assessed to validate the resident was not exhibiting s/sx of physical or psychosocial distress. 2) Record review of the electronic medical records indicated the DON completed a sweep of all facility residents to identify any residents with LVAD to have the appropriate monitoring. Resident #213 was the only resident in the facility with a LVAD. 3) During an interview on [DATE] at 12:15 p.m. with the DON indicated she could explain the purpose, function, and potential complications as well as the requirements to monitor and care for LVAD. 4) During an interview on [DATE] beginning at 9:30 a.m., with the DON, LVN G, LVN GGG, LVN CCC, LVN UUU, Infection Preventionist and the Nurse Practitioner indicated they could explain the requirements to monitor and care for LVAD, monitor for complications, and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line to validate resident is cared for and receiving appropriate for care of LVAD. 5) During an interview on [DATE] beginning at 9:30 a.m. with the DON, ADON, LVN E, LVN GGG, MDS Coordinator X, MDS Coordinator L, RN D, LVN G, LVN Z indicated they could explain the education they received from the LVAD consultant on all cares and monitoring required for care of resident with LVAD, to document competencies for all licensed nursing staff in facility, symptoms of infection and to notify MD immediately if any of these problems occur. 7) Record review of the daily reviews of new and admission orders dated [DATE] indicated there was no new admissions with medical devices. 8) Record review of the LVAD Training in-service, dated [DATE], indicated the DON was provided education on the purpose, function, and potential complications as well as the requirements to monitor and care for LVAD. 9) Record review of the LVAD Training in-service, dated [DATE], indicated the DON, LVN G, LVN GGG, LVN CCC, LVN UUU, Infection Preventionist and the Nurse Practitioner were provided education on the requirements to monitor and care for LVAD, which included the procedure for obtaining the MAP using a manual blood pressure cuff and the doppler, monitor for complications, and symptoms of infection and to notify MD immediately if any of these problems occur, and cleaning and care of drive line to validate resident is cared for and receiving appropriate for care of LVAD. 10) Record review of the LVAD Education in-service, dated [DATE], indicated the DON, ADON, LVN E, LVN GGG, MDS Coordinator X, MDS Coordinator L, RN D, LVN G, LVN Z were provided education from the LVAD consultant on all cares and monitoring required for care of resident with LVAD, to document competencies for all licensed nursing staff in facility which included the procedure for obtaining the MAP using a manual blood pressure cuff and the doppler, symptoms of infection and to notify MD immediately if any of these problems occur. 11) Record review of the QAPI Plan of correction sign in sheet for [DATE]. On [DATE] at 1:35 p.m., the Administrator was informed the IJ was removed: however, the facility remained out of compliance at no actual harm with potential more than minimal harm that is not Immediate Jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and 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 laboratory services were obtained to meet the needs of 5 of 12 residents (Resident's #12, #17, #43, #61, and #65) reviewed for laboratory services. 1. The facility did not ensure Resident #61 had his routine Keppra, Tegretol, and Depakote levels monitored as ordered by the physician. 2. The facility did not ensure Resident #43 had her routine topiramate and Keppra levels monitored as ordered by the physician. 3. The facility did not ensure Resident #12 had her routine primidone and phenobarbital levels monitored as ordered by the physician. 4. The facility did not ensure Resident #65 had her routine Depakote and phenytoin (Dilantin) levels monitored as ordered by the physician. 5. The facility did not ensure Resident #17 had his routine phenytoin (Dilantin) levels monitored as ordered by the physician. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/12/23 at 2:40 PM. While the IJ was removed on 12/13/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of subtherapeutic or toxic levels of seizure medications. The finding included: 1. Record review of the face sheet, dated 12/11/23, revealed Resident #61 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of epileptic seizures related to external causes (chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Record review of the quarterly MDS assessment, dated 11/15/23, revealed Resident #61 had no speech and was rarely or never understood by staff. The MDS revealed Resident #61 was rarely or never able to understand others. The MDS revealed Resident #61 had poor short-term and long-term memory and had no memory recall ability. The MDS revealed Resident #61 rarely or never made decisions. The MDS revealed Resident #61 had continuous inattention behaviors. The MDS revealed Resident #61 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised on 11/06/23, revealed Resident #61 had a seizure disorder. The interventions included: give seizure medication as order by the physician and labs per orders. Record review of the order summary report, dated 12/12/23, revealed Resident #61 had an order for the following: Keppra, Tegretol, Depakote laboratory levels every 30 days for seizures, which started on 02/17/21. Depakote sprinkles (anticonvulsant) 125 mg - give one capsule orally one time a day, which started on 07/21/22. Valproic acid (anticonvulsant) solution 250 mg/mL - give 5 mL by mouth three times a day, which started on 07/15/21. carbamazepine suspension 100 mg/ 5 mL - give 10 mL three times a day for anticonvulsant, which started on 06/14/23. Keppra 500 mg/ 5 mL - give 5 mL two times a day related to seizures, which started on 10/23/2018. Record review of the nursing progress notes, dated 09/08/23, revealed Resident #61 had seizure activity, in which he was sent to the ER. Record review of the nursing progress notes, dated 12/06/23, revealed Resident #61 had seizure activity, in which the NP at the facility assessed the resident and ordered stat labs. Record review of the lab results, collected on 12/06/23, revealed Resident #61 had a low valproic acid (Depakote) level at 46 ug/mL (micrograms per milliliter). The reference range for valproic acid was 50 - 100 ug/mL. There were missing labs for September 2023, October 2023, and November 2023. Record review of the MAR, dated October 2023, revealed Resident #61 had no documentation of medication administration for Depakote sprinkles on 10/05/23, 10/10/23, and 10/28/23. The MAR further revealed Resident #61 had no documentation of medication administration for valproic acid on 10/05/23 and 10/28/23. Record review of the MAR, dated November 2023, revealed Resident #61 had no documentation of medication administration for Depakote sprinkles on 11/11/23, 11/12/23, and 11/20/23. The MAR further revealed Resident #61 had no documentation of medication administration for valproic acid on 11/29/23. Record review of the MAR, dated December 2023, revealed Resident #61 had no documentation of medication administration for valproic acid on 12/05/23, the day before Resident #61 experienced seizure activity. 2. Record review of the face sheet, dated 12/12/23, revealed Resident #43 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures (seizures which affect initially only one hemisphere of the brain). Record review of the comprehensive MDS assessment, dated 10/03/23, revealed Resident #43 had clear speech and was understood by staff. The MDS revealed Resident #43 was able to understand others. The MDS revealed Resident #43 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #43 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised 11/16/23, revealed Resident #43 had a risk for injury related to seizure disorder. The interventions included: give seizure medication as ordered by the doctor and monitor lab per MD orders, resident refused lab draw. Record review of the order summary report, dated 12/12/23, revealed Resident #43 had an order for the following: Routine topiramate and Keppra laboratory levels for seizures, which started on 05/02/23. No frequency was listed. Keppra (anticonvulsant) 1,250 mg two times a day related to seizures, which started on 10/11/23. Topiramate 100 mg two times a day for seizures, which started on 02/04/23. Record review of the nursing progress note, dated 06/13/23, revealed Resident #43 had seizure activity, which caused a fall with no injuries. Record review of the nursing progress note, dated 07/10/23, revealed Resident #43 had seizure activity. Record review of the nursing progress note, dated 09/13/23, revealed Resident #43 had seizure activity, which caused a fall with no injuries. Record review of the lab results from the neurologist, dated 10/10/2, revealed Resident #43 had critically high levels of Keppra. The neurologist adjusted the dosage of her medications. There were no lab results drawn for July 2023, August 2023, or November 2023. 3. Record review of the face sheet, dated 12/12/23, revealed Resident #12 was a [AGE] year-old female who initially admitted on [DATE] with diagnoses of history of cerebral infarction (stroke), multiple sclerosis (immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions), and neurologic disorders in Lyme disease (tick-borne disease caused by bacteria that results in rashes, fever, and fatigue). Record review of the quarterly MDS assessment, dated 10/16/23, revealed Resident #12 had clear speech and was understood by staff. The MDS revealed Resident #12 was able to understand others. The MDS revealed Resident #12 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #12 had an active diagnosis of seizure disorder. Record review of the comprehensive care plan, revised on 12/06/23, revealed Resident #12 had no care plan in place for her seizure disorder. Record review of the order summary report dated 12/12/23 revealed Resident #12 had the following orders: Primidone and Phenobarbital laboratory concentration every 6 months. Primidone 50 mg three times a day for an anticonvulsant, which started on 06/19/19. Record review of the nursing progress notes, dated 01/01/23 to 12/12/23, revealed Resident #12 had no seizure activity. Record review of the lab results tab in the electronic medical record, accessed 12/12/23, revealed Resident #12 had no primidone or phenobarbital level drawn in 2023. 4. Record review of the face sheet, dated 12/12/23, revealed Resident #65 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified convulsions (medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Record review of the quarterly MDS assessment, dated 11/21/23, revealed Resident #65 had clear speech and was understood by staff. The MDS revealed Resident #65 was able to understand others. The MDS revealed Resident #65 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #65 had an active diagnosis of seizure disorder. Record review of the comprehensive care plan, revised on 11/06/23, revealed Resident #65 had no care plan in place for her seizure disorder. Record review of the order summary report, dated 12/16/23, revealed Resident #65 had the following orders: Depakote laboratory level every three months, which started on 12/10/20. Phenytoin laboratory level every 6 months, which started on 04/24/20. Dilantin (anticonvulsant) 300mg one time a day for seizures, which started on 02/04/20. Depakote 250 mg twice daily, which started on 02/12/22. Record review of the nursing progress notes, dated 09/11/23 to 10/12/23 revealed no seizure activity. Record review of the lab results tab in the electronic medical record, accessed 12/12/23, revealed Resident #65 had no Depakote level drawn in March 2023, April 2023, August 2023, or September 2023. The result tab revealed Resident #65 had no phenytoin level draw in November 2023. Record review of the lab results, dated 12/13/23, revealed Resident #65 had a phenytoin level of 3.6 ug/ML, which was subtherapeutic (low). Resident #65 had a valproic acid (Depakote) level of 33 ug/mL, which was subtherapeutic. 5. Record review of the face sheet, dated 12/12/23, revealed Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of unspecified convulsions (medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking). Record review of the quarterly MDS assessment, dated 11/02/23, revealed Resident #17 had clear speech and was understood by staff. The MDS revealed Resident #17 was able to understand other. The MDS revealed Resident #17 had a BIMS of 7, which indicated severe cognitive impairment. The MDS revealed Resident #17 had an active diagnosis of seizure disorder or epilepsy. Record review of the comprehensive care plan, revised 11/06/23, revealed Resident #17 had a seizure disorder and was at risk for injury. The interventions included: give seizure medications as ordered by the physician and obtain and observe lab work as ordered. Record review of the order summary report, dated 12/12/23, revealed Resident #17 had an order for the following: Phenytoin laboratory level every 3 months, which started on 04/30/18. Dilantin (phenytoin) 400 mg at bedtime for an anticonvulsant, which started on 09/19/17. Record review of the progress notes, dated 03/09/23 to 05/10/23, revealed Resident #17 had no seizure activity. Record review of the last lab results, dated 03/16/23, revealed Resident #17 had a phenytoin level of 5.4, which was subtherapeutic (low). There were no further labs drawn for 2023. During an interview on 12/12/23 beginning at 8:06 AM, the DON stated there was no system in place for monitoring routine labs. The DON stated the NP and Medical Director no longer ordered routine labs since the NP was in the facility daily. The DON was unaware Resident's #61, #43, #12, #65, and #17 had routine labs levels ordered for their seizure medications. The DON stated it was important to ensure lab levels were obtained as ordered by the physician to ensure seizure medication levels were therapeutic and to prevent seizures. The DON stated if the labs were refused, it should have been documented in the nursing progress notes and included on the care plan. During an interview on 12/12/23 beginning at 9:02 AM, LVN P stated she had only been hired at the facility for approximately 2 months ago. LVN P stated Resident #61 had a history of seizures but was unsure when his last seizure happened. LVN P was unsure when the last routine levels were obtained for Resident #61. LVN P stated she was unaware Resident #61 had routine lab orders to monitor levels for his seizure medications. LVN P stated the charge nurse was responsible for administering medications in the secured unit. LVN P stated she was not used to the electronic monitoring system and forgot to sign out Resident #6's Depakote sprinkles and valproic acid medication for seizures. LVN P stated she gave the medications. LVN P stated it was important to document the medication administration for seizure medications because if it is not documented, it is not completed. LVN P stated if the seizure medications were not administered Resident #61 could have had a seizure. LVN P stated she was unsure if Resident #61 had routine labs drawn. LVN P stated labs were followed up on when the results came back but there was no system for tracking the labs that needed to have been drawn. During an interview on 12/12/23 beginning at 9:15 AM, the NP stated the frequency of obtaining lab levels for seizure medications was determined by the resident's clinical status. The NP stated if a resident was having seizures frequently, she expected labs to have been drawn every 30 days. The NP stated if a resident's seizures were stable, she expected lab levels to have been drawn every 3 - 6 months. The NP stated she expected lab levels on seizure medications to have been drawn per orders. The NP stated she was unaware Resident's #61, #43, #12, #65, and #17 were not receiving routine lab services to monitor levels on their seizure medications. The NP stated she reviewed labs daily that were received from the laboratory, but there was no system in place to ensure routine labs were being performed. The NP stated she was unaware Resident #61 was missing doses of his seizure medications. The NP stated missing doses of seizure medications could have led to seizures. The NP stated consistently subtherapeutic levels of seizure medications could have led to seizures. During an interview on 12/12/23 beginning at 10:33 AM, the Laboratory Tech stated there were no standing orders for routine lab levels for seizure medication in their system for Resident #61 and Resident #43. The Laboratory Tech refused to give the surveyor any more information and transferred the call to the Medical Records department. The Medical Record department did not answer, and brief message was left with a number to return the call. No call was received upon exit of the facility. During an interview on 12/12/23 beginning at 12:53 PM, the DON stated the dashboard on the electronic charting system would show missing documentation on the MARs. The DON stated if there was missing documentation on the MAR, she would have reached out to the nurse to return to the facility to complete the documentation. The DON was unsure why the documentation was missing for Resident #61 in October, November, and December. The DON stated she expected the nursing staff to sign out all medication and treatments as they were given. The DON stated, if it was not documented it was not completed. The DON stated missing doses of seizure medications could have caused adverse reaction and led to seizures. Record review of the Lab and Diagnostic Test Results - Clinical Protocol policy, revised November 2018, revealed physician will identify, and order diagnostic and lab testing based on resident's diagnostic and monitoring needs .staff will process and arrange for tests .laboratory provider will report test results to facility .a nurse will try to determine whether the test was done .to monitor a drug level . The policy did not address monitoring to ensure routine labs were completed. The Administrator was notified on 12/12/23 at 2:40 PM that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 12/12/23 at 2:45 PM and the plan of removal was requested. During an interview on 12/12/23 beginning at 6:14 PM, the Medical Director stated drawing lab levels for seizure medications did not matter. The Medical Director stated medications were adjusted based on the resident's clinical status, not the seizure medication levels. The Medical Director stated it was standard practice to order lab levels on seizure medications every 3 - 6 months, and not every 30 days. The Medial Director stated he received the orders from the facility and signed off on them but just missed the lab orders for Resident #61 and Resident #43. The Medical Director stated he was unaware the routine lab for seizure medications were not being obtained. The Medical Director stated he expected labs to have been obtained per the orders. The Medical Director stated he just reviewed his notes to ensure labs were being completed. The Medical Director stated he would have to look at his notes more closely and pay attention to the orders, to ensure labs were obtained routinely. The Medical Director stated there was no risk for seizures in residents who had a subtherapeutic level. The Medical Director stated he was more concerned with the adverse effects seizure medications could have caused the residents, such as kidney failure and decreased liver function. The facility's plan of removal was accepted on 12/13/23 at 3:08 PM and included the following: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On December 12th, 2023, at 2:40 pm the following actions were taken. Action: On 12/12/2023, Resident #61 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified resident #61's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered. All previous routine lab orders were discontinued. Resident had Keppra and Valproic acid labs on 12/6/23 and a Valproic lab on 12/8/23. New lab order for Valproic Acid order was received on 12/13/23 to be drawn on 3/8/24. The care plan was reviewed, and no changes were needed. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #43 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #43's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered, and the care plan was updated accordingly. All previous routine lab orders were discontinued. New orders for Valproic Acid, Keppra, and Topamax levels were obtained 12/12/23. Care plan was review and no changes were needed. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #12 was assessed by the Director of Nursing to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #12's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered, and the care plan was updated accordingly. New order for Primidone level was obtained on 12/12/23. Care plan was added for seizure disorder on 12-13-23. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #65 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #65's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered, and the care plan was updated accordingly. New Order obtained 12-12-23 for Valproic Acid level. Care plan was added for seizure disorder 12-13-23. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee Action: On 12/12/2023, Resident #17 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of harm associated with possible seizure activity. On 12/12/2023 The Director of Nursing/Designee notified the resident #17's responsible party and physician of the identified deficient practice. Any applicable orders were obtained and entered. All previous routine lab orders were discontinued. A Dilantin level order was obtained on 12/12/23. Care plan was reviewed and no changes were needed. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: The Director of Nursing/Designee completed a sweep of all facility residents' medication to identify any residents receiving seizure medication that require routine laboratory monitoring, to validate labs have been drawn and monitored as indicated and ordered by physician and that evidence of appropriate follow-through on any levels that fell outside of therapeutic range existed. Any missed orders, draws or follow-through on abnormal levels were addressed immediately. All residents who require lab monitoring for other medications (antipsychotics, antibiotics, anticoagulants) were reviewed an labs were completed and will be follow up on as results are received. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: Corporate Clinical Consultant completed education with Director of nursing and nursing leadership on requirements to monitor laboratory processes per physician orders, to validate labs are drawn per orders and received and follow up orders initiated as indicated by MD. DON and/or designee will review that labs have been drawn and results received timely for 7 days to ensure labs are being completed. Labs drawn and results will be reviewed daily Monday through Friday thereafter. DON and/or designee will pull the lab order listing report to track labs to ensure they are being completed and followed up on. This has been added as a tab to our in-house tracking spreadsheet tool. NP or physician will review labs Monday through Friday and give further orders as needed. Physician will be notified immediately for any critical results. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Corporate Clinical Consultant Action: Corporate clinical consultant completed education with consultant pharmacist to include in monthly medical regimen review, monitoring required for medication with laboratory levels to be drawn. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Corporate Clinical Consultant Action: Labs will be reviewed daily by the DON/Designee and followed up accordingly for one week, and then daily Monday through Friday thereafter. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Corporate Clinical Consultant Action: The Director of Nursing/Designee provided education to nursing staff regarding the requirement that residents receive labs as ordered by the physician for seizure management and that there is appropriate follow-through on any levels found to be out of range. Nurses were educated on the new process for tracking and ensuring labs are drawn. This education included residents with routine lab orders, new orders, and results. Physician will be notified immediately for any critical results. Any nursing staff who work infrequently or were not in attendance will be educated on the above prior to their next scheduled shift. Start Date: 12/12/2023 Completion Date: 12/12/2023 Responsible: Director of Nursing Ad Hoc QAPI meeting was held on 12/12/23 with the Medical Director, Administrator, Director of Nursing, and Nurse Management, Area Operations Director, Corporate clinical consultant, Pharmacy consultant to review Immediate Jeopardy findings and plan of removal for identified deficient practice. On 12/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of the nursing progress note, dated 12/12/23, revealed Resident #61 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 2. Record review of the nursing progress note, dated 12/13/23, revealed Resident #43 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 3. Record review of the nursing progress note, dated 12/13/23, revealed Resident #12 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. 4. Record review of the nursing progress note, dated 12/12/23, revealed Resident #65 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 5. Record review of the nursing progress note, dated 12/12/23, revealed Resident #17 was without signs or symptoms of physical or psychosocial distress, or signs or symptoms of seizure activity. The physician was notified to obtained new lab orders. The responsible party was notified. 6. Record review of Resident's #12 and #65 comprehensive care plan, initiated on 12/13/23, revealed the care plan was added to address the seizure disorder. 7. Record review of Resident's #61, #43, #12, #65, and #17 order summary report, accessed on 12/13/23, revealed laboratory orders were updated per the physician orders. 8. Record review of a list of residents receiving medications that required level monitoring revealed the nursing staff completed a sweep to identify potential residents at risk. 9. Record review of the Patient Service Log revealed a list of 36 resident's, who received medications that required levels, in which labs were ordered and drawn by the physician. The list included Resident's #43, #12, #65, and #17. Resident #61 had recent labs and no new labs were ordered. 10. During interviews on 12/13/23 between 4:45 PM and 7:19 PM, revealed RN D, RN AAA, RN DDD, RN EEE, MDS L, MDS X, MDS AA, LVN E, LVN G, LVN P, LVN Z, LVN CC, LVN MM, LVN CCC. LVN FFF, and LVN GGG were able to correctly identify medications that required lab levels to be drawn. They all stated they should notify the physician immediately for any labs or levels or that were abnormal. They were all able to identify the new process for tracking labs and how to follow up on labs. 11. During an interview on 12/13/23 beginning at 6:08 PM, the Corporate Clinical Consultant stated he provided education to the DON, ADON, and Infection Control Preventionist on requirements to monitor laboratory processes per physician orders daily for seven day then Monday - Friday, to validate that labs were drawn per orders by pulling a report in the electronic charting system, and to ensure labs were received and followed up on as needed by the physician and documented on an internal house tool. The Corporate Clinical Consultant stated he instructed the nurse management that the physician should review the labs daily and should have been notified immediately for abnormal results that were critical. The Corporate Clinical Consultant stated he educated the Pharmacy Consultant to include monitoring required for medications with laboratory levels to be drawn on her monthly medical regimen review. 12. During an interview on 12/13/23 beginning at 6:17 PM, the DON stated she was provided education from the Corporate Clinical Consultant regarding the process and importance of tracking the routine labs ordered by the physician. The DON stated she was to monitor daily for seven days then Monday - Friday. The DON stated she was to document the labs drawn, the follow up, and new orders that were received on an internal house tool. The DON stated she then provided education to the nursing staff on the process for obtaining labs for residents on a seizure medication and to notify the physician immediately for any critical labs. 13. During an interview on 12/13/23 beginning at 6:34 PM, the ADON stated she was provided education on new process for obtaining laboratory results on residents who took a seizure medication. The ADON stated when a new seizure medication was ordered, she was instructed to obtain laboratory orders as well. The ADON stated every morning she was to make sure an order and lab report was obtained and to verify orders and labs were followed up on. The ADON stated she was to document the new orders and follow up on an internal house tool. 14. During an interview on 12/13/23 beginning at 7:24 PM, the Pharmacy Consultant stated she was informed and provided education to include monitoring required for medications with laboratory levels to be drawn on her monthly medical regimen review. the Pharmacy Consultant stated medication pass had been observed during monthly visits to the facility. The Pharmacy Consultant stated no issues were identified during medication pass and the facility staff signed out the medication as it was given. The Pharmacy consultant stated it was important to ensure medication administration was documented on the MAR to ensure continuity of care. 15. Record review of an Ad Hoc QAPI Meeting, dated 12/12/23, revealed the Administrator, DON, Corporate Clinical Consultant, Area Director of Operations, Medical Dir[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 7 residents (Resident's #25, #68, #91, #107, #111, #127, #330, ) and 5 out of 15 staff (CNA O, CNA PP, CNA SSS, MA A, and RN D) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility did not implement antibiotic orders for Resident #127, who had signs and symptoms of an UTI, that had not resolved with treatment. 2. The facility failed to identify a resistant organism that was cultured from Resident #127's urine. 2a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #127. 3. The facility failed to identify signs and symptoms of a UTI for Resident #91. 4. The facility failed to identify a resistant organism that was cultured from Resident #107's urine. 4a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #107 until surveyor interventions. 5. The facility failed to ensure CNA PP properly cleaned the peri-area, changed gloves, and performed hand hygiene before going from dirty to clean while providing incontinent care to Resident #107 (who was positive for ESBL (resistant bacteria) and required contact isolation). 6. The facility failed to identify a resistant organism that was cultured from Resident #111's urine. 6a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #111 until surveyor interventions. 7. The facility failed to ensure staff wore appropriate PPE in Resident #330's room, who was positive for clostridium difficile (bacteria) and required contact isolation precautions. 8. The facility failed to ensure MA A performed hand hygiene while administering medications to Resident #2, Resident #16, and Resident #40. 9. The facility failed to ensure CNA PP properly cleaned the peri-area, changed gloves, and performed hand hygiene before going from dirty to clean while providing incontinent care to Resident #25. 10. The facility did not ensure CNA SSS performed hand hygiene and changed gloves while providing incontinent care to Resident #68. 11. The facility failed to ensure facility staff were educated on when to initiate isolation precautions. An Immediate Jeopardy (IJ) was identified on 12/15/23 at 12:58 PM. While the IJ was removed on 12/16/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope identified as patterned due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at increased risk for serious complications, hospitalization, and death from a communicable disease that could diminish the resident's quality of life. The findings included: 1. Record review the face sheet, dated 12/15/23, revealed Resident #127 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of malignant neoplasm of right breast (breast cancer) and UTI (infection of the urinary system, usually caused from bacteria). Record review of the discharge MDS assessment, dated 11/05/23, revealed Resident #127 had an unplanned discharge to the acute hospital. The MDS revealed Resident #127 had an indwelling catheter. The MDS revealed Resident #127 had an active diagnosis of UTI during the last 30 days. Record review of the comprehensive care plan, initiated on 10/18/23, revealed Resident #127 had no care plan that addressed UTI status or risk. Record review of the order summary report, dated 12/15/23, revealed Resident #127 had an antibiotic order for Cipro, which started on 11/05/23. Record review of the nursing progress notes, dated 10/18/23, revealed Resident #127 was complaining of dysuria (painful urination). Ordered UA with C&S. Changed foley bag and flushed. No return. Foley catheter changed using sterile technique, 16FR 10cc bulb. Dark yellow urine returned. Resident #127 tolerated well. Collected UA, as ordered by hospice. Hospice nurse, here and gave order from Dr. to start Bactrim DS one po BID x7 days for UTI. Hospice will deliver today. Resident states she already feels better after foley changed. Call light and water in reach. Record review of the nursing progress notes, dated 11/04/23 at 9:34 PM, revealed Resident #127 had zero output for shift. Tried to flush catheter without success. Replaced catheter. (16fr) Hospice nurse arrived per request of family. Hospice was updated on change of status that resident just recently had. Also advised of issues with catheter. New order for UA with C&S. This was obtained and lab notified. Hospice stated that they will likely bring antibiotics in the morning. Record review of Resident #127's nursing progress notes, dated 11/05/23 at 5:37 AM, revealed Throughout the night, the resident had change in mental status. Resident #127 was moaning off & on. She would hold a cup or pitcher of water to her mouth but not drink and would just spill. Resident's eye remained wide open for the most part of the night. She had to be prompted on taking medicine and swallowing. Record review of Resident #127's nursing progress notes, dated 11/05/23 at 9:31 PM, revealed Resident #127 was found in bed by the medication aide unable to respond to commands given. I was called because medication aide stated the resident did not look right. Patients skin was cool to the touch. Patient did not respond when given orders and just stared off into the distance. The nurses note further revealed Resident was sent to the ER. Record review of the nursing progress notes, dated between 10/17/23 and 11/05/23, revealed no further follow up was documented for Resident #127's UTI. Record review of the MAR, dated October 2023, revealed Resident #127 was started on Bactrim DS (antibiotic) on 10/18/23 for diagnosis of UTI. The MAR revealed Resident #127 completed the Bactrim DS on 10/25/23. Record review of the MAR, dated November 2023, revealed Resident #127 was not administered her antibiotic medication, Cipro that was ordered for an UTI related to a change of condition. Record review of the lab results, collected 10/18/23, revealed Resident #127 had a moderate number of bacteria in her urine. The C&S results revealed Klebsiella pneumoniae (bacteria) was present in her urine. Record review of the lab results, collected 11/04/23, revealed Resident #127 had many bacteria in her urine. The C&S results revealed the culture was considered mixed and would not be processed any further. Record review of the Infection Surveillance Form, effective 10/20/23, revealed Resident #127 was not started on isolation precautions. Record review of the hospital records, dated 12/15/23, revealed Resident #127 was suspected to have septic shock likely from a urinary source. During an interview on 12/15/23 beginning at 9:27 AM, Resident #127's family member stated she was the one that caught Resident #127's UTI. Resident #127's family member stated she informed the nurse on 11/04/23 of Resident #127's dark blue or purple colored urine and changes. The family member stated the nurses would not have done anything for Resident #127 if she had not intervened. The family member said the physician had ordered antibiotics but Resident #127 was unable to start the antibiotic because they had to wait for it to have been delivered. The family member stated Resident #127 was sent to the hospital the next evening on 11/05/23 and she was not notified of the transfer. The family member stated the hospital called her at 2 or 3 AM on the morning of 11/06/23. The family member stated when she arrived at the hospital, she was informed by the physician that her mother was dying from sepsis and had only a few hours until her last moments. The family member stated Resident #127 passed away on 11/06/23 at 8:40 PM. The family member stated she felt like Resident #127's death was unnecessary and preventable. 2. Record review of the face sheet, dated 12/16/23, revealed Resident #91 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body) and UTI (infection of the urinary system, usually caused from bacteria). Record review of the quarterly MDS assessment, dated 11/07/23, revealed Resident #91 had clear speech and was understood by staff. The MDS revealed Resident #91 was able to understand others. The MDS revealed Resident #91 had a BIMS of 8, which indicated moderately impaired cognition. The MDS revealed Resident #91 had inattention and disorganized thinking behaviors that fluctuated. The MDS revealed Resident #91 had an indwelling catheter. The MDS revealed Resident #91 had an active diagnosis of UTI during the last 30 days. Record review of Resident #91's comprehensive care plan, revised 11/06/23, did not address risk for UTIs or monitoring for signs or symptoms of an UTI. Record review of the nursing progress notes, dated 10/03/23, revealed Resident #91 was admitted to the hospital with a diagnosis of sepsis. No further documentation in the nursing progress notes regarding change of condition. Record review of the physician progress note, dated 10/02/23, revealed Resident #91 had increased confusion, fatigue, and weakness. The progress note revealed symptoms started on 10/01/23 with decreased food intake, loose stools, increased temp, dysuria, and dizziness. The progress note revealed Resident #91 was sent to the ER for evaluation and treatment. Record review of the admission history of physical completed by the hospital, dated 10/03/23, revealed Resident #91 presented to the ER with complaints of increased weakness, question of altered mental status, decreased oral intake, and temperature. Labs were obtained in the ER and his lactic acid level was elevated, which indicated Resident #91 was septic. The principal problem was sepsis, and he was started on antibiotics and placed on telemetry (monitors heart function). 3. Record review of the face sheet, dated 12/15/23, revealed Resident #107 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included Congestive heart failure (also called heart failure is a serious condition where the heart doesn't pump blood as efficiently as it should), cerebral infarction (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hypertension (high blood pressure), and Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar (glucose). Record review of the quarterly MDS assessment, dated 10/03/23, revealed Resident #107 was able to understand and understood by others. The MDS assessment revealed he had a BIMS score of 12, which indicated moderately impaired cognition. The MDS did not indicate if he required help with his ADLs. The MDS indicated he was frequently incontinent of bowel and bladder. Record review of Resident #107's comprehensive care plan, dated 12/11/23, indicated Resident #107 was at risk for UTI related to bladder incontinence. The interventions were for staff to give antibiotics as ordered, check, and change as required for incontinence care, and encourage fluids. The comprehensive care plan, dated 02/10/23, indicated Resident #107 had an ADL self-care deficit related to activity intolerance, general weakness, and cognitive impairment. The interventions were for 1 staff to assist with extensive assistance with toilet use. Record review of the order summary report, dated 12/15/23, revealed Resident #107 had an order, which started on 12/11/23 for ciprofloxacin (antibiotic) x 10 days for an UTI. No orders were in the system for contact isolation precautions. Record review of the MAR, dated December 2023, revealed Resident #107 had been taking antibiotics for a UTI since 12/08/23. Record review of the nursing progress note, dated 12/07/23, revealed Resident #107 had complained of increased frequency and urgency with urination. The NP was notified, and new orders were received for UA with C&S, stat. Record review of Resident #107/s nursing progress note, dated 12/08/23, revealed the NP was in the facility reviewing labs and a new order was obtained for Bactrim DS x 7 days because bacteria was present in the urine. Record review of the nursing progress note, dated 12/11/23, revealed Resident #107 was seen by the NP. New orders were given to discontinue the Bactrim DS (antibiotic) and start Cipro x 10 days for UTI. Record review of the nursing progress note, dated 12/14/23, revealed Resident #107 was temporarily moved to a single occupancy room related to infection requiring contact isolation. Record review of the lab results, reported 12/11/23, revealed Resident #107 was positive for ESBL (resistant bacteria that requires isolation precautions) in his urine. During an observation on 12/11/23 at 9:17 a.m., CNA PP was providing incontinent care to Resident #107. CNA PP explained what she was going to do and pulled the curtain. She wiped his genitals area using a front-to-back and back-to-front motion. She then turned him on his side while touching his shoulder and side with the same dirty gloves on. She proceeded to wipe his buttocks using the front-to-back and back-to-front motions. She then changed her gloves without hand hygiene and applied his briefs and clothes. She then removed her gloves and assisted Resident #107 up in his wheelchair. CNA PP then left the room without hand hygiene. During an interview on 12/11/23 at 10:54 a.m., CNA PP said she had been employed at this facility for almost a year. She said she was supposed to wipe front to back only, hand hygiene before applying new gloves, and in between dirty to clean. She said she did not wipe or perform hand hygiene correctly which could lead to infection. She said she was in a hurry to finish because she was helping another aide so she could get back to her assigned residents. 4. Record review of the face sheet, dated 12/15/23, revealed Resident #111 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnosis of UTI (infection of the urinary system that is usually caused by bacteria). Record review of the quarterly MDS assessment, dated 12/01/23, revealed Resident #111 had clear speech and was understood by staff. The MDS revealed Resident #111 was able to understand others. The MDS revealed Resident #111 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #111 had an indwelling catheter. Record review of the comprehensive care plan, revised, 10/02/23, revealed no care plan in place for UTI. Record review of the order summary report, dated 12/15/23, revealed Resident #111 had an order, which started on 12/01/23, for Linezolid (antibiotic) x 14 days for UTI. No orders were listed for isolation precautions. Record review of the MAR, dated December 2023, revealed Resident #111 had been taking antibiotics for an UTI since 12/02/23. Record review of the lab results, reported 12/01/23, revealed Resident #111 had critical results for positive culture of VRE (resistant organism found in urine which requires contact isolation precautions). Record review of the physician progress note, dated 12/04/23, revealed Resident #111 was positive Enterococcus faecium (bacteria) and was started on antibiotics. The progress notes did not state isolation precautions were initiated. During an observation and interview on 12/15/23 at 8:04 a.m., surveyor walked into Resident #107's room and saw the facility staff had moved him to another room. His roommate stated they moved Resident #107 last night (12/14/23) at about 8:00 pm. His roommate said people came into the room in all the gear and took him out. During an observation on 12/15/23 at 8:16 AM Resident #107 and Resident #111 had moved to another hall. They both had carts set up outside their rooms (containing gowns, gloves, face shields, and red biohazard bags) and precautions signs on their doors. During an interview on 12/15/23 at 8:49 a.m., CNA PP said she was not aware of any infection Resident #107 had until today (12/15/23). She said she had worked with Resident 107 on Monday (12/11/23) and Thursday (12/14/23) without any PPE because she was unaware of any isolation precautions needed. During an interview on 12/15/23 at 8:54 a.m., Housekeeper VVV said she worked on halls 300 and 400 Tuesday (12/12/23), Wednesday (12/13/23), and Thursday (12/14/23) and was not aware of any isolation required for Resident #107 or Resident #111. She said she had not worn any PPE that week while cleaning the rooms. She said she was informed late yesterday (12/14/23) about both residents who required isolation and she was supposed to wear PPE while cleaning those rooms. During an interview on 12/15/23 at 9:11 a.m., RN AAA said she worked Monday (12/11/23) on halls 300 and 400. She said she worked with Resident 107 and Resident #111 and was not aware they required isolation. She said she received in shift report that they were both on antibiotics for UTI. She said mostly the NP reviewed the labs and gave orders. She said she just went off whatever the NP said. She said if she had seen the labs then she would have notified the doctor, family, and DON. She said she would gather the PPE needed for that room. She said they usually did not write orders for isolation unless it was an order. She said without them isolating residents who required isolation, she could see where infection could be spread. During an interview on 12/16/23 at 2:38 p.m., LVN CC said she was the nurse who received Resident #111's lab report and notified the NP but was not aware that VRE required isolation. She said the NP gave orders for an antibiotic but never said this resident required isolation. She said she was not aware Resident #107 had ESBL. She said she was the nurse who first collected his urine because he complained of urgency. She said then she was off for two days and when she came back, she realized he had started on another antibiotic but did not think much about it because, in the shift report, she was told he had a UTI. 5. Record review of a face sheet dated 12/16/2023 indicated Resident #330 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included enterocolitis due to clostridium difficile, not specified as recurrent (Infection of the colon caused by the bacteria Clostridium difficile). Record review of Resident #330's electronic health record on 12/16/2023 indicated her MDS assessment was in progress. Record review of the admission & Baseline Care Plan/Summary with an effective date of 12/09/2023 indicated Resident #330's reason for admission/initial admission goals were weakness, pneumonia, C. diff (clostridium difficile). The admission & Baseline Care Plan/Summary indicated Resident #330 had a current diagnosis of C. diff and required contact precautions. Record review of the Order Summary Report dated 12/11/2023, did not indicate Resident #330 was on contact precautions. Record Review of Resident #330's After Visit Summary dated 12/8/2023 indicated continue precaution active isolation orders contact enteric precautions continuous. During an observation and interview on 12/11/2023 at 10:16 AM, Resident #330 was lying in bed. Resident #330 said she had recently admitted from the hospital. Resident #330 said while in the hospital she had been told he had C. diff. There was no sign posted on the door indicating Resident #330 was on contact precautions. There was a plastic bin with PPE inside Resident #330's room at the foot of the bed. Surveyor entered the room with no PPE. During an observation on 12/11/2023 at 10:28 AM, RN D took Resident #330 water and assisted her with drinking it. RN D went in Resident #330's room with no PPE. During an observation on 12/11/2023 at 10:46 AM, there was a sign on Resident #330's door indicating she required contact precautions and everyone must clean their hands including before entering and when leaving the room, providers and staff must also put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment, clean and disinfect reusable equipment before using on another person. There was a plastic bin with PPE outside the room and a regular trashcan. During an interview on 12/11/2023 at 10:55 AM, RN D said when Resident #330 arrived from the hospital she only had one day left on contact precautions. RN D said Resident #330 no longer required contact precautions, and she had even had a visitor over the weekend in the room with no PPE. RN D said she did not even think Resident #330 really had C. diff because she had smelled her stool. During an interview on 12/14/2023 at 5:05 PM, the Infection Control Preventionist said Resident #330 was admitted from the hospital with C. diff. The Infection Control Preventionist said the charge nurse who admitted a resident requiring precautions was responsible for ensuring the precautions were put in place. The Infection Control Preventionist said the charge nurse should have placed a sign on the door, and an isolation cart outside of the door and ensured all the staff were aware the resident required special precautions. The Infection Control Preventionist said Resident #330 should have had an order for contact precautions. The Infection Control Preventionist said the staff and visitors should wear PPE when in Resident #330's room. The Infection Control Preventionist said ultimately it was her responsibility to ensure the contact precautions were in place. The Infection Control Preventionist said it was important to ensure contact precautions were in place for Resident #330 to prevent the spread of infection to the residents and the staff. During an interview on 12/14/2023 at 5:31 PM, LVN G said she was supposed to admit Resident #330, but Resident #330 arrived at the end of her shift. LVN G said she was aware Resident #330 required contact precautions because she had C. diff. LVN G said she had put the isolation cart and a trashcan outside of Resident #330's room. LVN G said she had not put up a sign on Resident #330's door to alert staff and visitors that Resident #330 required contact precautions. LVN G said she did not know what happened that the isolation cart with the PPE was not outside Resident #330's room Monday morning (12/11/2023). LVN G said Resident #330 not having contact precautions in place placed people and residents at risk of catching what she had. During an interview on 12/15/2023 at 8:35 AM, Housekeeper H said she used K-Quat (disinfectant cleaner) to clean and mop the rooms. Housekeeper H said she had not been putting on PPE to clean any resident rooms. Housekeeper H said the staff would let her know if someone required special precautions. Housekeeper H said she used the same cleaning supplies to clean all the rooms even the ones that required special precautions. During an interview on 12/15/2023 at 8:43 AM, Housekeeper K said none of the resident rooms required special cleaning. Housekeeper K said she was not wearing PPE in any of the resident rooms. Housekeeper K said she used K-Quat and Enzap to clean the residents' rooms. During an interview on 12/15/2023 at 9:05 AM, the Housekeeping Supervisor said K-Quat was the disinfectant they used. The Housekeeping Supervisor said there were no rooms that required special cleaning. The Housekeeping Supervisor said if a resident had C. diff the same cleaning products would be used. The Housekeeping Supervisor said it was important to use the correct cleaning agents so infection would not spread and to keep infections contained. During an interview on 12/15/2023 at 12:25 PM, CNA M said she had cared for Resident #330 over the weekend. CNA M said she was aware Resident #330 had C. diff. CNA M said when providing care to Resident #330 she did not wear PPE. CNA M said she had worn gloves and that was all. CNA M said she had not washed her hands with soap and water that she had used alcohol-based hand sanitizer. CNA M said it was important to follow contact precautions to prevent the spread of infection and make it safer for herself and everybody else she provided care for. During an interview on 12/16/2023 at 5:10 PM, the ADON said she was not aware Resident #330 had C. diff. The ADON said they had 4 admissions Friday (12/08/2023) when Resident #330 admitted . The ADON said the nurses should follow the hospital discharge orders. The ADON said Resident #330 should have had an order for contact precautions. The ADON said an isolation cart should have been placed outside of Resident #330's room, a sign indicating she required contact precautions posted on her door, and a trashcan inside her room. The ADON said the nurses were responsible for putting Resident #330's contact precautions in place. The ADON said not having the contact precautions in place placed the residents and staff at risk for infection. During an interview on 12/16/23 at 6:41 PM, the DON said she had not reviewed Resident #330's discharge orders until Monday. The DON said she expected for the nurses to place a resident with C. diff on contact precautions. The DON said the admitting nurse should have put in the discharge orders from the hospital. The DON said the Infection Control Preventionist was responsible for overseeing that the nurses were putting necessary precautions in place. The DON said ultimately, she was responsible for ensuring the Infection Control Preventionist was putting measures in place. The DON said it was important to ensure precautions were in place as required to prevent the spread of infection. 6. During an observation of medication administration beginning on 12/12/2023 at 8:12 AM, MA A administered medications to Resident #40. After administering medications to Resident #40 MA A did not perform hand hygiene. MA A administered medications to Resident #2. MA A did not perform hand hygiene prior to preparing meds for Resident #2. MA A did not perform hand hygiene after administering medications to Resident #2. MA A administered medications to Resident #16. MA A did not perform hand hygiene prior to preparing medications for Resident #16. MA A performed hand hygiene after administering medications to Resident #16. During an interview on 12/12/2023 at 12:20 PM, MA A said she thought it was every third resident that she had to hand sanitize. MA A said she did not perform hand hygiene appropriately because she was not sure when to perform hand hygiene. MA A said it was important to perform hand hygiene to make sure no germs go on to the next resident. MA A said she had just started working at the facility in September or October 2023 because she had just received her license in April 2023. MA A said she had a check off done on hand hygiene when she started. During an interview on 12/16/2023 at 5:05 PM, the ADON said during medication administration hand hygiene should be performed before and after. The ADON said she had performed the check off for MA A and she had done fine. The ADON said she monitored the staff to ensure they were performing proper hand hygiene by walking the halls daily several times a day. The ADON said it was important to perform hand hygiene to prevent the spread of infection. During an interview on 12/16/2023 at 6:47 PM, the DON said she had instructed MA A to use alcohol hand sanitizer between residents and soap and water every third resident. The DON said clearly MA A had misunderstood. The DON said hand hygiene should be performed before and after medication administration. The DON said everybody was held accountable for performing hand hygiene. The DON said ultimately nursing management monitored through observations daily to ensure the staff were performing adequate hand hygiene. The DON said during her observations she had not noticed any issues with hand hygiene. During an interview on 12/16/2023 at 7:53 PM, the Administrator said everybody in the building was responsible for ensuring hand hygiene was performed. The Administrator said he expected for the staff to follow the policy on hand hygiene. The Administrator said not performing adequate hand hygiene during medication administration placed the residents at risk for infections and dirty meds. 7. Record review of Resident #68's face sheet dated 12/14/2023, indicated Resident #68 was a [AGE] year-old male admitted to the facility on [DATE], with diagnosis which included unspecified sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury has ended), type 2 diabetes mellitus without complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), hypertension (when the pressure in your blood vessels was too high (140/90 mmHg or higher). Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated Resident #68 had a BIMS score of 1, which suggest severe cognitive impairment. The MDS assessment indicated Resident #68 was always incontinent of bowel and bladder. Record review of Residents #68's care plan last revised 10/2/2023, indicated Resident #68 received extensive assistance with toilet use. During an observation on 12/14/2023 at 5:14 p.m., CNA SSS provided incontinent care to Resident #68. CNA SSS washed her hand, put on gloves, and unfastened Resident #68's brief. CNA SSS wiped Resident #68's front perineal area, CNA SSS tucked the dirty brief under Resident #68, turned Resident #68 onto his side and wiped his buttocks. CNA SSS then applied a clean brief without changing her gloves or performing hand hygiene. CNA SSS rolled Resident #68 to his side to remove soiled bedding and replaced with clean bedding. CNA SSS repositioned resident # 68 in the bed, removed her glove and performed hand hygiene. CNA SSS did not change her gloves or perform hand hygiene before going from dirty to clean. During an interview on 12/14/2023 at 5:45 p.m., CNA SSS stated hand hygiene should be performed prior to the start of care and at the end. CNA SSS stated hand hygiene should be performed after glove removal. CNA SSS stated she was new, just got nervous and forgot to change her gloves. CNA SSS stated it was important to provide proper incontinent care, so the residents did not get an infection. CNA SSS stated it was important to perform hand hygiene appropriately for infection control and to not spread germs. During an interview on 12/16/2023 at 11:58 a.m., the ADON stated she expected the CNAs to know how to provide incontinent care correctly. The ADON stated it was important to do incontinent care correctly to prevent infection, yeast, or UTI. The ADON stated she would monitor by doing check off's and in-service as needed. The ADON stated the harm to the resident was infection. During an interview on 12/16/2023 at 5:34 p.m., the DON stated she expected the CNAs to provide incontinent care correctly and with dignity. The DON stated it was important to do incontinent care correctly to prevent infection and any dignity issues. The DON stated she would monitor by doing in-service as needed, check offs, and 3 to 4 monthly random check off audits. The DON stated the harm to the resident was infection or psychosocial wellbeing. During an interview on 12/16/2023 at 6:10 p.m., the Administrator stated that it would be fantastic if the CNAs perform[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 6 residents (Resident # 1) reviewed for accidents and supervision. On [DATE] Resident #1 eloped from the facility and was found by facility staff on [DATE] approximately 30 feet from the facility deceased This failure placed all residents at risk for accidents, harm, and possible death. An (IJ) Immediate Jeopardy was identified on [DATE] at 5:00pm. While the (IJ) Immediate Jeopardy was removed on [DATE] at 2:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, documentation, care plans, elopements and the effectiveness of their systems. Findings included: Review of Resident #1 face sheet dated [DATE], reflected Resident # 1 was a 66- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with Vascular Dementia (general term describing problems with reasoning, planning, judgement, memory and other thought process caused by brain damage), Traumatic Subdural Hemorrhage (intercranial bleeding between the brain and the skull), Alcohol abuse (a pattern of drinking that interferes with day-to-day activities), Homelessness (individual with no permanent living arrangement), Muscle weakness ( when full effort doesn't produce a normal muscle contraction or movement), Cognitive Communication Deficit (difficulty with thinking and how someone uses language), and Hypokalemia ( low levels of potassium in your blood). Review of Resident # 1 admission MDS dated [DATE] reflected a BIMS score of 10, the resident has the cognitive ability to make his needs known. Section G of the MDS functional status reflected Resident # 1 required (supervision, oversight or cueing) with bed mobility, transfers, walk in room, walk in corridor, eating and dressing. Section GG of the MDS Functional abilities reflected Resident # 1 was independent with putting on/taking off footwear and oral hygiene. Review of Resident # 1 care plan dated [DATE] did not address any elopement /wandering behaviors. The care plan addressed discharge planning which reflected Resident # 1 would stay at the facility long term. Observation on [DATE] at12: 45 pm, reflected in Resident # 1's previous room [ROOM NUMBER] the window hinges were observed to be broken off. During an interview on [DATE] at 9:20am with LE, revealed that Resident # 1 was found near the facility on [DATE] deceased . He stated during their search of Resident # 1, that this area was searched they did not think that he was in this area at the time they were searching. He stated the judge did order that an autopsy be completed. He stated the decompensation of Resident # 1 showed that he had been deceased for more than six hours, less than three days factoring in the weather conditions the past few days. LE stated they did not suspect any foul play, stated it appeared that the resident fell and was unable to get back up. During an interview on [DATE] at 12:30pm with, Resident # 2 revealed, Resident # 1 had recently broke the hinges off the window in their room, raised the window and put his wheelchair outside the window. He stated Resident # 1 also had put all his things in trash bag. Resident #2 stated he had moved to another to the 300 hall maybe a week ago but stated he would walk back and forth to the old room with his things in is hand. He stated Resident # 1 did not talk much so he never stated that he was leaving, but he had packed up his things like he was leaving. During an interview on [DATE] at 12:50pm with Maintenance supervisor revealed, he was not able to remember the exact date, but stated he pulled up to the facility and saw that there was a wheelchair outside Resident # 1 window. He stated he got the wheelchair and stated Resident # 1 stated he did not want the chair in his room. He stated he was not aware that the hinges were broken on the window, until shown by surveyor. He stated they were in the process of replacing all the window screens on the windows at the facility. Maintenance director stated he and the social worker went to Resident #1's room and he stated again he was not using the wheelchair and did not want the chair in his room. The Maintenace supervisor reported that one of her workers was dumping rash and he smelled an odor that wasn't coming from the trash. He stated his worker came and got him and they got the tr uck back it up in the tall brush, stood in the bed of the truck and that;s when they found Resident # 1 deceased lying in the middle of the tall brush. During an interview on [DATE] at 1:15pm with maintenance worker reported dumping trash in the back dumpster and smelled a foul odor that wasn't coming from the dumpsters. Maintenance worker stated he walked closer to the area and the odor got stronger, he stated he then went and got the maintenance director and they backed t he truck up where the bushes were and stood in the inside the bed of the truck to look and that's when they discovered Resident #1 lying on the ground and appeared to be deceased . Maintenance worker stated they alerted the DON and the ADM, and contacted the police at that time During an interview on [DATE] at 1:29pm with CNA A, revealed Resident # 1 was seen on [DATE], that morning around 10:00am when she picked up his breakfast tray. She stated she observed Resident # 1 standing by the back door looking out the door, she stated he then returned back to his room on the hall 300. During a phone interview on [DATE] at 2:24pm with MA A, revealed A few weeks prior to the incident Resident # 1 had an incident in his previous room on Hall 400. MA A stated Resident # 1 had opened his window and put his wheelchair out the window. MA A stated on the day of the incident she last saw Resident # 1 around 11:00am when she took residents out to smoke. She stated prior to that Resident # 1 did not appear to be exit seeking. During an interview on [DATE] at 2:34pm with DON, revealed Resident # 1 did have an incident where he opened his room window on the 400 hall and put his roommate's wheelchair out the window. She stated the social worker should have documented this information in the progress notes of the incident. The DON stated she was not aware that the hinges on that window had been broken and not replaced, she stated she also was not aware that the screen had not been replaced at this time. The DON was not aware of the specific date of that incident. The DON stated a wander/elopement assessment was not completed after this incident because Resident # 1 did not show any signs of elopement or agitation. The DON stated Resident # 1 was not assessed for wander/elopement risk after he completed therapy because they do them quarterly and it was completed on [DATE]. In an interview on [DATE] at 3:00pm with ADM., revealed that he thinks he was on vacation during that time of the incident. The ADM. stated he was told about the hinge on the window this morning and maintenance is working on fixing that now. Stated they are replacing all the screens on all the windows at the facility. He stated he did think that Resident #1 was safe and able to go on an outing the building without supervision. The ADM. stated after Resident # 1 completed therapy there was no reason to complete wander/elopement assessment because he had not shown any signs of elopement and wander /elopements assessments are completed quarterly. During an interview on [DATE] at 6:06pm with Director of Rehabilitation, revealed Resident # 1 had completed OT (Occupational therapy) and PT (physical therapy) on [DATE]. She stated Resident # 1 was independent with ADL's (activities of daily living), Resident # 1 was ambulatory. Director of Rehabilitation was asked if an elopement assessment was completed at this time for Resident # 1since he was now independent she stated she was not aware that one had been completed. During a phone interview on [DATE] at 11:05am with PNP, revealed that she could not recall specifically what was said in the conversation, but she recalled that the facility called her regarding Resident #1 being agitated and that he had placed his wheelchair out the window. She stated that the specifics would be in her notes that she uploads to PCC. She stated that she did not have any concerns or complaints about resident care or about the facility. During an interview on [DATE] at 12:40pm with SOWK, revealed on [DATE] the Maintenance Director came and told her about the wheelchair sitting outside of a window. We went down to talk to Resident #1. The SOWK reported that when they got to the room Resident #1 was lying across the bed watching TV. She stated that she saw the window screen between the wall and the head of the bed, and the window was closed. She reported that she noticed the resident's clothing all bagged up and she asked him about it, and he told her it was how he wanted to keep them, and that he did not like using the drawers. She stated that the resident asked them to leave so he could watch mutherfucking [NAME]. She stated that she did ask him if there was any particular staff that he felt comfortable talking to if he had any issues or concerns and Resident #1 told her that he preferred to talk to the blond lady up by the office The social worked determined this to be staff from laundry. She stated that the resident denied thoughts or plans to elope. The SOWK stated that this behavior was not out of the ordinary for the resident and that he did walk around the facility with his personal items in hand at times. She stated that this incident with the wheelchair was reported to the Psychiatric nurse practitioner. She stated that after he completed therapy his cognition and physical state had improved from when he was first admitted . She stated that she had received in-service this past week on abuse, neglect, elopement. Reporting broken item, missing screen etc. to maintenance and heart injury. During an interview on [DATE] at 1:45pm with house-keeping, revealed she had been at the facility for about 2 1/5 months. She stated that she knew Resident #1 from before he entered the facility. She reported that the resident would stay in the area where she lived on the streets and everyone in the neighborhood knew him. She reported that when he came into the facility, they helped find him some clothes and personal care items because he did not have anything. She stated that when he went missing, she thought he might have gone back to the neighborhood, so she drove around looking for him after work. She stated that Resident #1 had never talked about leaving and had never tried to leave that she knew of. She reported that he would walk around with his clothes, and she thought this was because of his history of being homeless. During an interview on [DATE] at 11:27am with SOWK, revealed Resident # 1 had an incident earlier in the month as could not remember the exact date where Resident # 1 opened his room window on the 400 hall and put his wheelchair out the window. She stated she and the maintenance supervisor went down to the resident's room and stated she observed Resident # 1 had his things packed in a clear bag, his window was open, but he was sitting on the bed when they arrived. SOWK stated Resident # 1 stated the wheelchair was in his way, she stated when she asked about his clothing being in the bag stated Resident # 1 responded by stating he liked them in the bag. SOWK stated she reported this information to the nursing staff and in the morning meeting about Resident # 1 behavior. She stated it was discussed and that's when the decision was made to move Resident # 1 to the 300 hall. SOWK was asked if Resident # 1 was moved due to him opening his window, packing his things, and placing his wheelchair outside the window, she stated no. SOWK stated Resident # 1 was moved to hall 300 because he and his roommate were not getting along. SOWK was asked if an elopement assessment was completed at the time of this incident she stated no. Weather website reviewed: https://weather.com/weather/monthly/l/dab66db432c15c4b458fc6dfaa6c73a5703d4aaa8bc36cb83356ed6c80af938cc2be9a97aa3b8d3b2d1f8a0033eff4c0. Reflected, the weather temperature for Waco on [DATE] was 99 degrees, [DATE] 101 degrees, [DATE] 101 degrees, and [DATE] 96 degrees outside. Review of Resident # 1 Risk elopement/wander assessments dated [DATE] that was provided later in the investigation had written, indicating Resident # 1 was low risk for elopement, [DATE] assessment, identified Resident # 1 as low risk for wandering /elopement. No assessment was completed after Resident # 1 incident and no assessment after completion of therapy services. Record review of progress notes dated from [DATE] - [DATE] reflected, reflected no exiting behaviors. The progress notes do not reflect the incident where Resident # 1 opened his window and put his wheelchair outside his window or that he had his things packed in a bag. Review of facility Elopement policy dated [DATE] reflected the following: 1. Upon admission and re-admission residents will be assessed for elopement risk in conjunction with the nursing admission data collection. 7. Following admission, residents are evaluated for elopement risk quarterly, annually, and with significant change of condition. Review of facility Abuse/Neglect policy dated [DATE]reflected: Residents have the right to be free from abuse and neglect. The (IJ) Immediate Jeopardy template was delivered to the ADM on [DATE] at 5:00pm. While the (IJ) Immediate Jeopardy was removed on [DATE] at 2:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff have not been trained on Abuse/Neglect, documentation, care plans, elopements and the effectiveness of systems. Plan of removal submitted on 6/232023 and accepted on [DATE] at 8:49am. The Plan of Removal is as follows: LETTER OF PLAN FOR REMOVAL OF IMMEDIATE JEOPARDY [DATE] On [DATE], a survey was initiated at facility, At approximately 5:00pm on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at the facility constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F689: The facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents and hazards. 1 resident was affected by this deficient practice. All residents could be affected by this deficient practice. Immediate Corrections Implemented for Removal of Immediate Jeopardy. On [DATE]nd, 2023, at approximately 6:00pm the following actions were taken: Action: Administrator and Director of Nursing received education on elopement policy and education for all direct care and ancillary staff (including housekeeping and dietary) given by Director of Clinical Operations. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Clinical Operations. Action: Education given by Infection preventionist and ADONs to all direct care (including agency) and ancillary staff (including housekeeping and dietary) on Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, including, packing items, statements of plans to leave, moving assistive devices to locations of exits. Education will be maintained at, agency shift worked, new hire orientation and annual refresher in-services. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/designee Action: Maintenance Director and Administrator checked windows on the 400 and 300 halls validated to be fully functional, screens replaced and secured. The screen on the 400 hall was replaced on [DATE]. No repairs were necessary to any latches on either window. All windows are in working order. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: Maintenance Director and Maintenance Tech secured all resident room windows to open no greater than 6 inches to prevent the potential of residents exiting via window Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: Action: Maintenance Director and Maintenance Tech completed sweep of all facility resident room windows, to validate windows are in functional repair and screens are in place to all resident room windows. 12 screens were replaced on [DATE]. No repairs were necessary to any latches on any window. All windows are in working order. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: ADONs and MDS Coordinators completed Elopement Risk Assessment on all residents and validated all residents at high risk of elopement, score of 11 or greater, have appropriate interventions and plan of care in place per risk assessment. After IDT interventions/care plan, those deemed to be high risk residents will have information placed in the elopement risk binder at the reception desk. Elopement Risk assessment is part of the Admission/Baseline care plan Summary completed on all new admissions by the charge nurse. This assessment is reviewed by DON/designee for completeness within 48 hrs of admission. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of nursing/designee Action: MDS Coordinators and Social Services completed sweep of all residents for history of homelessness, interviews completed and education on risks of homelessness, validation completed for any potential plans of exiting facility. Care plans updated to reflect IDT interventions for risks identified. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: ADONs and Infection Preventionist in-service and education was provided to all direct care (including agency) and ancillary staff (including housekeeping and dietary) and residents regarding the process for safe discharge as well as risks associated with heat exhaustion including signs and symptoms to watch for. Education will be maintained at agency shift worked, new hire orientation and annual refresher in-services. New residents will be educated on admissions by the admissions coordinator. Start Date: [DATE] Completion Date: [DATE] and ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Education to the Maintenance Director on the requirement to validate that windows are functioning properly and that screens are in place and in good repair. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: Education provided by Infection preventionist and ADONs to all direct care and ancillary staff (including housekeeping and dietary) on Elopement policy, Abuse/Neglect/Exploitation and reporting missing or broken windows and/or screens to their supervisor and/or maintenance staff. This will be reported immediately. Maintenance orders are placed in the TELs system that is linked to Point click care and point of care electronic medical record system. Start Date: [DATE] Completion Date: [DATE] and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Education was provided by Infection preventionist and ADONs to all direct care (including agency) and ancillary staff (including housekeeping and dietary) regarding new behaviors that must be reported to nursing which could indicate an increased risk or likelihood of imminent elopement attempt including but not limited to increased wandering, packing of belongings, verbalization of intent to leave, tampering with windows or doors and exit seeking. Additional education was provided to nursing staff on the expectation that these behaviors will be monitored/documented each shift as they occur by the charge nurse through the electronic medical record system in point click care. The elopement risk assessment and care plan will be updated within 24hrs by DON/designee. Education will be maintained at agency shift worked, new hire orientation and annual refresher in-services. Start Date: [DATE] Completion Date: [DATE] and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing 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 [DATE] Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Designee Tracking and Monitoring Director of Nursing/Designee will review residents with High Risk for wandering or elopement identified or newly admitted with history of homelessness, to assure appropriate interventions and plan of care are in place 5 times per week beginning [DATE] for 4 weeks. Administrator/Designee will monitor windows for appropriate functioning, security, screens in place 5x/week beginning [DATE] for 4 weeks. Administrator/designee will complete random audit every shift for 7 days, beginning [DATE], 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 for 4 weeks. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee meeting monthly and continue until a lessor frequency deemed appropriate through QAPI review. The administrator and/or designee will be responsible for reporting any identified trends. Monitoring of Plan or Removal on [DATE] is as follows: Observation on [DATE] at 11:10am, observed facility window and screens are on all windows. Observation on [DATE] at 11:20am, observed windows in rooms on the 400 and 300 halls. Windows are fully functional, screens replaced, and secured. During an interview on [DATE] at 11:30am with Activity Assistant revealed, she has been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. Activity Assistant stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insisted on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. Activity Assistant stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. Activity Assistant stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 11:45am with LVN A, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. LVN A stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. LVN A stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. LVN A stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 12:12pm with RN revealed, she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. The RN stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The RN stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The RN stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 12:30pm with SOWK, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. The SOWK stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. The resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The SOWK stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The SOWK stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 1:30pm with the DON, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. She gave example of abuse, neglect, and exploitation. The DON stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and ADM. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The DON stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The DON stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. The DON stated that the facility identified 19 residents that are high risk for elopement. 18 of the residents are on the secured unit. The DON stated the elopement risk binder is kept at the front desk, if there is a questionable situation about their care refer to the binder or if a resident is missing a photo of every resident is located in the elopement risk binder. There was also a missing resident form in the binder for staff to complete if a resident was missing. During an interview on [DATE] at 2:15pm with CNA B, revealed she worked the day Resident # 1 opened his window and put his wheelchair outside the window. She stated they were informed right after the morning meeting by Resident # 1's roommate stated, Resident # 1 was very upset and wanted to leave the facility. CNA B stated that's when she, the SOWK and the maintenance supervisor went to Resident # 1's room. She stated the SOWK was able to calm Resident # 1 down and stop him from leaving that day. CNA B stated the Admin. was aware that Resident # 1 wanted to leave but nothing was done about, she stated she felt something could have been done about it, if the first incident had been documented. During an interview on [DATE] at 11:20am with ADM., he stated that management staff were present this weekend working on POR and staff education. He reported that the Regional Care Coordinator had worked with him and the DON and has completed their education on Elopement. The ADM. stated that Resident #1 had requested to stay in the facility long term and helped them complete the MEDICAID application. Observation completed on [DATE] at 11:45am, of windows observed in room on the 300 hall which is the room that Resident #1 was assigned to when he left the facility through the window. There was only one window in the room. The window was intact there is no damage around the casing to the wall. There was a cooling/heating unit in the wall just below the window. The locking mechanism was intact, the window was functional. There were screws placed internally to prevent the window from being raised greater than six inches. The screen is intake. The window opened to a small grassy area that meets the facility's rear parking lot. During an interview on [DATE] at 11:50am with the Maintenance Director, revealed he and his crew had checked all windows and screens this past week. He reported that the facility had ordered new solar screens and they would be replacing all screens with those when they arrive. He reported that he had not encountered any broken or damaged windows or window locks. There had been some screens with some small holes they had replaced. The Maintenance Director reported that he had in- serviced staff this week on putting in maintenance orders in the event they find something broken or that needed attention. He stated they could either text, call, come find him or put the work order into the TELS system which is connected to their electronic medical record (PCC). He stated they had performed test reports to demonstrate to staff how the order came across their phones. He stated that he had been serviced in the past and this week on elopement, abuse, and neglect. He also stated that they were in-serviced on heat-related injury. During an interview on [DATE] at 1:15pm with laundry aide, revealed she had been employed with the facility for 34 years. She stated that she had been in serviced on elopement, abuse and neglect, heat stroke and when to report broken things to maintenance this week. She stated that they are always doing some type of in-service. She denied any concerns or complaints regarding the facility or resident care or supervision. During an interview on [DATE] at 2:20pm with CNA C, revealed she had worked at the facility in her current position for about 4 years. She reported that they had been in serviced this week on [NAME][TRUNCATED]