Health inspection·February 19, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent elopement.for 1 of 3 residents (Resident #1) reviewed for accidents. Residents Affected - Few Resident #1 walked out of the facility unattended and was missing for 2 hours on 2/08/24 around 8:00 PM, until hospital staff contacted the facility. This failure could affect residents with diagnose of dementia at risk of elopement thus placing themselves at risk of physical harm, pain and mental anguish or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 2/16/24 at 1:00 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 2/16/24 at 1:00 PM. While the IJ was removed on 2/19/24 the facility remained in violation at a scope of Isolated at a severity level of no actual harm with potential for more than minial harm because all staff had not been trained on the facility's newly developed implementation and effectiveness of their Plan of Removal. Findings Included: Record review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of depression, hearing loss, fall, osteoarthritis, morbid obesity, muscle weakness and abnormalities of gait. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 6 cognitively impaired. She required assistance for ADL's, Ambulation and Cognition. In the care assessments interviewed done on 11/21/23 the following care area triggered were Cognitive loss/dementia, communication, ADL functional rehab potential and psychotropic use. Record review of Resident's Wandering and Elopement Risk assessment dated [DATE] revealed score of Nil minimum risk and no current observable evidence of wandering. Record review of Nursing admission assessment dated [DATE] section N wandering and elopement risk assessment revealed that Resident #1 did not have a history of being a regular walker, therefore, Resident's #1's wandering and elopement risks assessment dated [DATE] revealed a score of Nil minimum risk. Record review of Nurses Progress Notes dated 2/08/24 at 9:39 PM revealed: patient left facility and Page 1 of 6 676332 676332 02/19/2024 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was found at the hospital. Ambulance was called to go to hospital to bring Resident #1 back to the facility. Resident brought back to facility by City Ambulance, awake and alert. First reading vitals: BP 204/78 O2-99, RR 16. On second reading BP 194/84, HR 75 Temp. 99.9, RR16. In an interview with RN A on 2/10/24 at 10:45 AM she stated that on 2/08/24 at 9:00 PM she got a call from the hospital ER Charge Nurse asking was resident #1 in the facility. RN A thought Resident #1 was in her room but when she went to check Resident #1 was gone. She stated that she had arrived at work at 6:00 PM and was helping other residents. She stated that she had seen Resident #1 during the start of her shift. She also stated that Resident #1 requested that she wanted to go to her room and lie down. RN A took Resident #1 to her room and assisted her in bed. RN A stated that she put Resident #1 to bed at around 7:15 PM. Around 9:00 PM she got a call from the hospital. In an interview and observation with Resident #1 on 2/10/24 at 10:10 AM revealed she was in her room, and she was alert and oriented to self. She was confused. She acknowledged and stated that she went out for a walk and did not tell anyone. She stated that she walked outside the back (did not know which door she exited) into the parking lot. She said she did not have her car, so she kept walking towards the hospital where she works. She stated that she did not get hurt and she walked at a steady pace. In an interview with Resident #1's ROP on 2/10/24 at 10:30 AM he stated that last Sunday 2/04/24 he was visiting Resident #1. He stated that Resident #1 was walking all over the facility and he stated that he can't keep up pace with Resident #1. In an interview and observation walk through with the Administrator and Maintenance Director on 2/13/24 at 11:30 AM she stated that Resident #1 must have exited at the door closed to where the slot machines were adjacent to the dining room. She exited the side door and opened gate that was locked in the outside but for safety reason the gate can be open from the inside and makes alarm. It took us eight minutes from the parking lot to the ER . The street was not very busy when we crossed it. There were no cars observed going through the street. Observed the alarm go off and then stop once the gate closed again. The Maintenance Direcror stated that alarms were working; but once the door closes the alarm shuts off automatically. The Maintenance Director stated that he will in-service the staff to check the exit doors when the alarm goes on to make sure that no resident had exited and all residents are accounted for. In an interview with RN A on 2/13/24 at 3:30 PM she stated that she heard the alarm door, but she ignored the alarm because she stated that someone opened the door and when they came in and closed the door, the alarm shut off. Record review of google maps revealed the local hospital was about .3 miles from teh facility, an around a 6 minute walk along the feeder road to a major highway. In an interview on 2/13/24 at 4:10 PM the DON stated that the facility did not have a policy on supervision. An Immediate Jeopardy was identified on 2/16/24 at 1:00 PM. The IJ Template was provided to the facility on 2/16/24 at 1:00 PM. The following Plan of Removal submitted by the facility was accepted on 2/17/24 at 10:45 AM. 676332 Page 2 of 6 676332 02/19/2024 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0689 Date:2/17/2024 Level of Harm - Immediate jeopardy to resident health or safety PLAN OF REMOVAL Residents Affected - Few IMMEDIATE JEOPARDY FOR To Whom it May Concern, Summary of details which leads to outcomes. On 2/16/2024 an investigation on a self-report was initiated at [Facility] at 1:00 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas:

F689 - Accidents and Supervision The facility failed to ensure Resident #1 received adequate supervision to prevent Resident #1 from eloping from the facility. Immediate action: Immediate assessment of Resident #1 was completed for any bruising and or skin issues, none noted or observed. Family notified. MD notified. Inservice to all nursing and C.N.A staff was completed on 2/16/2024 by DON, regarding rounding on every patient, especially those that like to walk around. Resident #1's care plan was updated on 2/17/2024 by the Director of Nursing to reflect elopement risk with resident specific focus, goals and interventions including 1:1 supervision. Any staff not attending will be in-serviced upon their return to work, before their next shift. Identification of Others The Director of Nursing/Designee completed an elopement risk assessment of all residents to determine which residents were an elopement risk. Elopement risk assessment was completed on 2/17/2024. No other resident had any risk of elopement. Resident#1 was the only identified elopement risk and as stated above, her care plan was updated to reflect associated focus, goals and interventions to protect her from elopement by the DON. Systemic Change Hourly rounding orders implemented into system by Director of Nursing on 2/16/2024. Nurses ensured that Resident#1 is in the building every hour during each shift and record the documentation into PCC system until Resident can be transferred to a facility with a memory care unit as per the request of the responsible party. Hourly rounding to be done by CNA and Nurse and recorded on nurse MAR. The patient's responsible party states his mother needs a more secure unit such as memory care, due to wandering. Patient is being transferred to facility with locked memory care unit. Patient evaluated 2/16/2024 by receiving staff. Currently awaiting discharge date from receiving facility. Resident is 676332 Page 3 of 6 676332 02/19/2024 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few up and out of bed daily and in communal area where she can be always supervised by nurse and CNA staff, any elopement attempts are redirected by activities and snacks and staff members she can walk around with and will be supervised at all times. Education was provided to all Nurses and CNA's, by the Director of Nursing/Designee regarding the plan to complete and verify accurate head count on each patient by round every two hours and as needed. Education included that the whereabouts of each patient having elopement risks will be documented as needed per shift. All future staff to be in-serviced at time of hire regarding elopement and rounding. The above education was completed on 2/16/2024 by the Director of Nursing/designee Any staff not in attendance l for this Training will be educated upon their return prior to the next shift worked. Monitoring The Director of Nursing/designee will conduct monitoring daily Monday- Friday for 4 weeks then weekly 8 weeks to verify that rounding is being completed and documented as well as head counts and whereabouts of residents at risk for wandering. Any concerns identified through these audits will be addressed and corrected immediately and staff education and resident interventions implemented as needed. Monitoring/one on one begin 2/17/2024 as stated above. Ad hoc QAPI meeting held with the IDT and Medical Director to review policy associated with wandering and elopement risk as well as this Plan of removal/response to Immediate Jeopardy Citation 2/16/2024 @1445. The surveyor confirmed the facility implemented their plan of removal sufficiently from 2/17/24 through 2/19/24 to remove the IJ by: 1. Record reveiw of immediate assessment of Resident # 1 was completed on 02/09/24 at 1:23PM for any bruising and or skin issues, none noted or observed. Family notified and Physician notified. 2. Record reveiw of inservice to all nursing and CNA staff was completed on 2/16/2024 by DON regarding rounding on every resident, especially those that like to walk around. 3. Record review of Resident #1's care plan was updated on 2/17/2024 by the Director of Nursing to reflect elopement risk with specific focus, goals and interventions including 1:1 supervision. 4. The Director of Nursing/Designee completed an elopement risk assessment of all residents to 676332 Page 4 of 6 676332 02/19/2024 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0689 Level of Harm - Immediate jeopardy to resident health or safety determine which residents were on elopement risk. Elopement assessment risk was completed on 2/17/2024. No other resident had any risk of elopement. Resident #1was the only identified elopement risk and as stated above, her care plan was updated to reflect associates focus, goals and interventions to protect her from elopement by DON. 5. Residents Affected - Few Record review of hourly rounding orders implemented into system by DON on 2/16/2024. 6. Record reviewed of documentation of Nurses ensured that Resident #1 is in the building every hour during each shift record the documentation into the PCC System (Electronic Medical Record) until resident can be transferred to a facility with memory care unit as per the request of the responsible party. 7. Record review of Hourly rounding completed by CNAs and Nurse and recorded on nurse's MAR. 8. Resident #1's responsible party stated that Resident #1 needs a more secure unit such as memory care due to wandering. 9 Resident #1 is being transferred to facility with locked memory care unit. Resident evaluated on 2/16/2024 by receiving staff, currently awaiting discharged date from receiving facility. 10. Observation of Resident #1 is up and out of bed daily and in communal area where nurse and CNA staff can always supervise her. Activities, snack, and staff member redirect any elopement attempts. Resident #1 can walk around with and will be always supervised. 11. Education was provided to all nurses and CNAs by the DON/designee regarding the plan to complete and verify accurate head count on each resident by round every two hours and as needed. 12. Education included that the whereabouts of each residents having elopement risks will be documented as needed per shift. It was verified that Resident #1 was evaluated for discharge on 2/16, but the receiving facility was not ready to admit resident #1 at 2/16/24. 676332 Page 5 of 6 676332 02/19/2024 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review completed of Resident #1's Elopement Assessment done on 2/17/2024. Resident #2; Resident #3; Resident #4; Resident #5; Resident #6 and Resident #7 is in the process of being done, Nurses' interview re- in-services had several in services and most recent in services was 2/18/2024. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, assessing resident for pain, management, gastrostomy tube, dressing. Check exit doors when alarm activated. Do head count to make sure no resident missing. Nurses verified the training received on the updated care plan which includes 1:1 supervision for Resident #1. Interviewed RN C on 2/18/2024 at 10:15 AM; RN B on 2/18/2024 at 1:00 PM; LVN D on 2/18/2024 at 1:15 PM LVN E on 2/18/2024 at 1:30 PM; LVN F on 2/18/2024.at 8:47 PM CNAs interview- Had several in services and most recent in services was on 2/18/2044. CNAs verbalized checked all exit doors when alarm activated and do head counts to make sure no resident missing, check resident every 2 hours, check if resident still breathing, listen to alarm if people are coming in or going out. CNAs verified the training received on the updated care plan which includes 1:1 supervision for Resident #1 Interviewed CNA A on 2/18/2024 at 10:30 AM; CNA B on 2/18/2024 at 10:45 AM; CNAC on 2/18/2024 at 11:00 AM; CNA D on 2/18/2024 at 11:15 AM; CNA E on 2/18/2024 at 8:50 PM; CNA F on 2/18/2024 at 9:00PM Interview with the DON on 2/19/24 at 10:00 AM revealed that training, rounding, walking, talking with confused resident, know where they are, always do rounds, documenting hourly rounds in MAR. As per IJ the facility does not have the Wander Guard System. How the resident exited, no one heard the alarm, dropped the ball. Interview with the Administrator on 2/19/23 at 10:30 AM. As per the IJ we were not aware of Resident # 1's medical diagnosis. She stated that if she had known that resident had Alzheimer's possibility of elopement looked for a secured unit for the resident to be safe. Did not know until spoke to ROP prior to visiting resident when surveyor arrived in the facility for a P1 intake. The ROP stated he was told by a medical provider that Resident # 1 has Dementia Stage 4. Resident's history was not disclosed upon admission in November 2023. She stated that she started to work here three weeks ago. While the IJ was removed on 2/19/24 the facility remained in violation at a scope of Isolated at a severity level of no actual harm with potential for more than minial harm because all staff had not been trained on the facility's newly developed implementation and effectiveness of their Plan of Removal. 676332 Page 6 of 6