Health inspection·January 5, 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 interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for 1 (Resident #1) of 7 residents reviewed for accidents and supervision. Residents Affected - Few The facility failed to provide adequate supervision to Resident #1. As a result, Resident #1 eloped from the facility at night along a highway and was located approximately 2 hours later in 44° Fahrenheit weather after he had fallen into a wet drainage ditch. Resident #1 was admitted to the hospital with diagnoses including hypothermia. An Immediate Jeopardy was identified on 01/04/24 at 3:02 PM. While the IJ was removed on 01/05/24 at 6:28 PM, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents that are an elopement risk at risk for serious injury, harm, and/or death. Findings included: Review of Resident #1's admission Record, dated 1/2/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, urinary tract infection, difficulty walking, diabetes, and history of falling. Review of Resident #1's Significant Change MDS Assessment, dated 11/22/23, revealed: -He had mental status exam of 2 of 15 (indicating severe cognitive impairment) with no signs of delirium. -He used a wheelchair, and the walker was not indicated. -He had a catheter. -He received IV medications and antibiotics. There were no falls in the look back time frame. Review of Resident #1's Care Plans revealed the following: Page 1 of 11 676430 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Level of Harm - Immediate jeopardy to resident health or safety -2/24/23: The resident has impaired cognitive function or impaired thought processes related to having dementia. A Goal was the resident will maintain current level of cognitive function through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Discuss concerns about confusion, disease process, nursing home placement with resident/family/ caregiver(s). Engage the resident in simple, structured activities that avoid overly demanding tasks. Residents Affected - Few -7/19/23 The resident is at high risk for falls due to new environment and cognitive deficits. Goal the resident will be free of falls through the review date. Interventions included: Educate the resident/family/ caregivers about safety reminders and what to do if a fall occurs. -2/24/23 The resident has a psychosocial well-being problem relate to mood indicators. Goal: The resident will identify ways of increasing meaningful relationships by the review date. Interventions included: Encourage participation from resident who depends on others to make own decisions. Increase communication between residents/family/ caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options. -Dated 1/2/24 (after entrance and after elopement) resident is at high risk for elopement related to poor cognition and previous incident. Goal: the resident will not leave facility unattended through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers: (blank). Identify pattern of wandering: Is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor location every (Specify 15/30/60) minutes (Specify frequency) Document wandering behavior and attempted diversional activities in behavior log. Review of Resident #1's Brief Interview for Mental Status dated 10/26/23 revealed he had mental status score of 7 of 15 (indicating severe cognitive impairment). Review of Resident #1's Behavior Note, dated 12/26/23 at 9:29 p.m. revealed Resident #1 noted to be walking down different hallways, stopping different staff members asking in regard to a car accident, and a newspaper. Resident #1 then proceeded to be looking for his apartment on Hall 400. Nurse provided redirection, multiple times, only for patient to leave his room and continue to ambulate without assistance, or walker. Nurse aide redirected patient back to his room, patient proceeded to go and open his roommate's drawers. Redirection provided, and assisted patient into bed. Review of Resident #1'sTransfer out note, dated 12/31/23, at 10:30 p.m. revealed: Vital signs: unable to obtain: Clinical condition: elopement. Who transferred: city EMS. Time resident left facility: 10:10 p.m. Review of Resident #1's Incident Note, dated 1/1/24 at 2:22 a.m. revealed: This nurse noted resident in bistro at approximately 6:30 p.m. This nurse notified lead CNA to give resident his walker as he was walking without it. Resident then began to walk down hallway to room per lead CNA. At approximately 8:00 p.m. this nurse entered resident's room to check his blood glucose and noted resident was not sitting in his chair, his bed, or in the restroom. The nurse went down to bistro and was unable to locate the resident. The nurse was still unable to locate him. This nurse then searched every room and restroom on hall 500. The aide for the hall and MA were questioned, per MA she last saw him 676430 Page 2 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few when his family member came to visit. At this time around 9 p.m. The nurse alerted staff on skilled unit to search all rooms on skilled unit. The exit doors on units were confirmed to be locked and the alarms were active. This nurse then spoke to the responsible party and confirmed resident was not with them. A full search of the building and perimeter of building with all staff commenced and the DON and Administrator were notified. Resident was noted at approximately 9:30 p.m. on ground next door at storage facility. Actions taken: 911 was called and EMS arrived and transported resident to ER. Physician notified: yes. DON notified: yes. Review of Resident #1's incident/accident reports (7/20/23 through 12/30/23) revealed no falls since 7/20/23. Review of Resident #1's Nursing Admission/ readmission Assessment, dated 2/17/23 revealed an elopement risk assessment was completed at that time and he was assessed as not at risk for elopement at that time. Review of Resident #1's Emergency Department Triage Note dated 12/31/23 at 10:17 p.m. revealed: Resident #1 was confused and had a decreased cardiac output. He had altered mental status and was found outside laying on his side in the cold weather, patient was last seen at 6 p.m. His internal temperature was 92.5 degrees F. He was admitted to the local hospital with admitting diagnoses of heart failure, metabolic encephalopathy (condition where brain function is temporarily or permanently disturbed due to different diseases or toxins in the body), UTI, and hypothermia due to exposure. Review of the facility's Provider Investigation Report, completed 1/5/24 revealed, Description of the incident: Resident missing and was found on sidewalk next door by storage center (neighboring building to facility.) Resident was on ground. Found by staff, no injuries notes, resident was able to answer staff questions. Resident was seen by staff members a couple hours prior to being deemed missing and found. Actions and Notifications: 911 called, Administrator, DON, Family, and MDS all notified. In-service for elopement ongoing. This is resident's first occurrence of any type of elopement/wandering, will be assessed for elopement/ wander guard program in facility as he is a candidate for this intervention. Was the resident sent to the hospital: Yes What immediate actions has facility taken to protect the resident's health and safety as a result of the allegation? No injuries noted upon finding resident, staff able to stand resident and resident responsive/answering questions. Resident has been sent to hospital for further evaluation for any potential injuries/findings. Elopement in-servicer on-going and resident to be assessed for elopement / wanderguard program at facility as he a candidate for this intervention. Were the police notified? Yes. Were the physician, guardian and/or family notified? Yes. Was in-service training provided to staff as a result of this incident? Yes. 676430 Page 3 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Please provide the topic(s) of the in-services training(s): Elopement. Level of Harm - Immediate jeopardy to resident health or safety Interview on 1/2/24 at 3:33 p.m. LVN A stated she was functioning as Resident #1's charge nurse the evening of 12/31/23. LVN A stated at the beginning of the shift around 6 or 6:30 p.m. she got report and saw Resident #1 walking down the hall walking without his walker. LVN A said she instructed a CNA to give Resident #1 his walker and continued to get report. LVN A stated she did her rounds and checked blood sugars. LVN A stated when she got to Resident #1's room she noticed he was not in there and she checked the bathroom and the 'bistro' area. LVN A stated she figured Resident #1 was walking and finished her rounds. LVN A stated she returned to Resident #1's room and did not find him. LVN A said she asked the nurse aide if she had seen Resident #1 and the nurse aide told her no. LVN A said after that she alerted the 600 hall charge nurse to check her hall and they searched public areas, rooms and bathrooms of the 400, 500 and 600 halls and still did not find Resident #1. LVN A said she was told Resident #1's family was there earlier in the day and they may have forgotten to sign him out. LVN A stated she called Resident #1's family to see if they did not have Resident #1. LVN A said after the family said they did not have Resident #1, LVN A called the other Nurse's Station to do a full facility sweep of the rooms, bathrooms, and public areas while she walked around the building and she did not see Resident #1. LVN A stated an aide looked further away from the building and that aide (CNA C) found Resident #1. LVN A said Resident #1 was found right next door by the road in between the building and the fence. LVN A described Resident #1 as laying in a fetal position on his left side and would not open his eyes. LVN stated Resident #1 was cold and pale, not shivering, and was not blue or red colored. LVN A state Resident #1 did not appear to have any injuries but did have a little abrasion over his lip. LVN A stated Resident #1 was able to answer simple questions. LVN A said Resident #1 reported he was ok and not in pain. LVN A stated she left Resident #1 in position she found him and called 911. LVN A said one of Resident #1's family members was present at the scene and she guessed the responsible party called them. LVN A said she did not have a lot of history with Resident #1. LVN A said did not have knowledge of him having a previous history of wandering. LVN A stated she covered Resident #1's hall at least weekly. LVN A stated in hindsight she would have been more diligent about making sure her residents were accounted for and getting with her nurse aides. LVN A stated as a team they were going to have to figure out a better plan to monitor the front door, but she did not know what. Residents Affected - Few Interview on 1/3/24 at 12:15 p.m. LVN A stated Resident #1 was found wearing regular clothing pajama pants, she did not remember if Resident #1 was in a long sleeve shirt or a t-shirt. LVN A stated the staff were covering him up with jackets and blankets as soon as they found him. Review of CNA C's written statement (undated) revealed: I was informed that a resident went missing around 9 p.m. We went to all the rooms and all the bathrooms around the facility. Finally, I decided to go around and look outside. I walked toward the loop (highway) and when I turned to the left, I noticed a walker flipped upside down and when I walked toward it I found the resident in a fetal position. I asked him if he was ok and was he hurt and he said no. I took off my jacket and covered him. Interview on 1/3/24 at 4:05 p.m. CNA C stated she was on duty the night of 12/31/23. CNA C said she was alerted that Resident #1 was missing around 9 p.m. and checked the resident rooms on the side of the facility she worked. CNA C said then she checked outside. CNA C stated she asked if the family member took Resident #1 out and forgot to sign him out, but the family member said they had not. CNA C disclosed she worked at the facility a long time and most of the elopements had been towards the service road so that was where she went to check first. CNA C said when she looked, she saw what looked like wheels so she went to investigate. CNA C stated she found Resident #1 in a fetal position 676430 Page 4 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in a ditch and he was wet. CNA C stated Resident #1 could talk and said he was ok. CNA C said she took off her jacket and put it over Resident #1. CNA C stated she called the lead CNA and told him to get some blankets. CNA C said the nurses were the ones who called 911, but she did not know which one. CNA C said Resident #1 was so cold he could barely move. CNA C stated Resident #1 was wearing a black long-sleeved shirt, pants, and tennis shoes on. CNA C said she thought Resident #1's walker got stuck in the mud and then he rolled down the hill of the ditch because his back and side were wet and everything else was dry. CNA C repeated Resident #1 did not say he was hurt but she did notice a cut above his lip, but that was it. CNA C stated there was no way the staff could get Resident #1 up and out of the ditch and the best thing they could do was call 911. CNA C stated she heard the staff tell each other the last time they saw Resident #1 was after dinner was around 6:30 p.m. which was a bit steep. CNA C said no one said they gave Resident #1 his medication. CNA C said the charge nurse went to check his blood sugar and could not find him. CNA C said the nurse should have known then and no one saw Resident #1 for three hours. CNA C added we deserve this one, this one is bad. Review of Resident #1's Electronic Medication Administration Record revealed his medications for the evening of 12/31/23 were signed out at 8:36 p.m. Interview on 1/3/24 at 2:51 p.m. the DON stated MA D gave medication at approximately 7:30 p.m. in the bistro area so Resident #1 was out for less than two hours. The DON said Resident #1 did not have a history of exit seeking but had an increase of confusion. Review of MA D's written statement (undated) revealed: at about 6:15 p.m. or 6:30 p.m. I saw the family member walk by the nurse station and go down the hall. At around 7:45 p.m. I was standing at the cart preparing Resident #1's medications. I went to his room he wasn't in his room. I did check the restroom he wasn't there so I decided to check the bistro and he in fact was sitting in bistro. I gave him his medications and told him bye and walked back to hall 500 cart. A telephone interview was attempted with MA D on 1/4/24 at 9:39 a.m. but was unable to leave a message. Review of CNA E's written statement (undated) revealed: Saw resident headed down hall about 6:30 p.m. I stopped him and grabbed his walker from bistro. He continued down hall five. At 9 p.m. I was informed he was missing. We did a sweep inside the building checked bathrooms, beds, community showers. Then headed to parking log. Got a call from CNA A at 9:37 p.m. that she found him and to bring blankets. During an interview on 1/2/24 at 10:26 a.m. the Administrator and DON stated the facility had an elopement over the weekend (12/31/23). The DON stated the resident was in the hospital at the time of the interview. The DON said the resident was exit seeking the day of the elopement and that was not normal for him. The DON stated Resident #1 was admitted to the hospital for a Urinary Tract Infection and Hypothermia. The DON stated the LVN A last saw Resident #1 at 6:30 p.m. in the evening and at 8 p.m. the nurse was unable to find Resident #1 when the nurse went to do Resident #1's blood sugar. The DON explained the nurse completed evening rounds and then looked for him. The DON stated the nurse started checking the building and then the perimeter of the building. The Administrator added the facility's receptionist at the front door left at 5:30 p.m. that day. The DON said Resident #1 used a walker and he did not ambulate quickly. Observation on 1/2/24 at 10:59 a.m. revealed if Resident #1 left from Resident #1's room from the most direct route: Resident #1's room was the second to last room on his hallway and it was 205 small 676430 Page 5 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few steps with three (3) significant bumps (bumps that a bed side table got stuck on) between the nurse's station and the front door. Interview on 1/2/24 at 12:57 p.m. CNA B stated she usually worked Resident #1's hallway and was familiar with him. CNA B said Resident #1 liked to be in his room but had become more confused. CNA B said Resident #1 used a walker and moved very slowly. CNA B said Resident # 1 tried to leave by the end of the hall door one time, but the aides were able to redirect him. CNA B said the aides were the ones to redirect him because they were closer; she said this happened once on her shift. CNA B said she did not know if the nurses knew. CNA B stated she was surprised Resident #1 went out the front door. Interview on 1/2/24 at 1:06 p.m. CNA C stated Resident #1 was able to move around the facility. CNA C stated Resident #1 was not always aware of his surroundings but was always pretty pleasant but paced back and forth in the facility some. Interview on 1/2/24 at 2:36 p.m. the Administrator stated he was not aware if the facility had a formal elopement assessment or not and he left the interview saying he would be right back. When the administrator returned at 2:46 p.m. the Administrator stated there was an elopement risk assessment on the admission/re-admission assessment. The Administrator said Resident #1 had an Elopement assessment completed 2/17/23 with no exit seeking behaviors noted and that was the last elopement assessment completed. Interview on 1/2/24 at 3:18 p.m. the Regional Consultant stated her understanding of the elopement was the nurse went to check Resident#1's blood sugar and could not find him. The Regional Consultant said the charge nurse checked for him in the bistro the rooms, did a head count, and checked the perimeter. The Regional Consultant stated she was unsure about the timeframes. The Regional Consultant stated the report she got was Resident #1 was found in the ditch. Interview on 1/3/24 at 11:43 a.m. Resident #1's Nurse Practitioner stated he was made aware of Resident #1's elopement. The NP stated the facility reported Resident #1 was found at the storage facility next door. The NP stated there was no time frame given for how long he was out. The NP said he was just told there was no obvious injuries. The NP stated Resident#1 always had a level of confusion due to a history of UTI's so there was no way to assess his cognitive states. The NP stated the residents at the facility were free to move around the facility and could come and go unless they had a band (wanderguard). The NP said hypothermia was variable and would depend on how cold it was outside and for how long the resident was outside but could cause major damage. The NP stated the beginning stage of hypothermia began with a body temperature of 95 degrees F. The NP stated he did not know what Resident #1's body temperature was when he was picked up. Interview on 1/3/24 at 1:21 p.m. Resident #1's Responsible Party stated Resident #1 was still in the hospital but was slowly stabilizing. The RP confirmed they did visit Resident #1 after church and [NAME] Resident #1 lunch and left around 3 p.m. the RP stated the facility called them at 9:30 p.m. to report the facility did not know where Resident #1 was and could not find Resident #1. The RP stated they sent another family member to look around the neighborhood. The RP stated she called the local police department at 9:39 p.m. (from her call logs on the cell phone). The RP said the family member texted them at 9:42 p.m. to say the family member was with the resident. The RP stated they were told by the family member Resident #1 was scratched up. The RP said Resident #1 told the RP Resident #1 left the facility to go home. The RP stated one staff member they did not identify told the RP that Resident #1 was last seen at 6 p.m. The RP stated concerns about the number of times staff did 676430 Page 6 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 rounds or that no one went into Resident #1's room to check on him. Level of Harm - Immediate jeopardy to resident health or safety Interview on 1/3/24 at 3:21 p.m. the Administrator stated the investigation into Resident #1's elopement he gathered Resident #1 got out of the facility around 7:45 p.m. and was found at 9:30 p.m. The Administrator stated he figured Resident #1 was out for an hour based on how slowly he moved. The DON who was present stated the consequences of hypothermia included the potential for death and hospitalization. The DON said as long as the body temperature could be brought back up there should not be lasting consequences. The DON said she did not know who called the police department that the resident was missing, but believed it was part of the policy and part of calling 911. Residents Affected - Few m Interview and observation on 1/3/24 at 4:25 p.m. the DON and surveyor walked out the front door, across the 10 foot by 10 foot area of rock, the alley and to the ditch where Resident #1 was found. The DON said she did not know how Resident #1 got over the rocks without falling or how he fell down the ditch and only got minor injuries. Observation on 1/2/24 at 10:15 a.m. revealed the facility was built along one of the area's major highways, a divided 4 lane highway with 2 lane access road. The speed limit on the access road was 55 miles per hour. The landscaping immediately in front of the facility decorative rocks. Review of https://www.wunderground.com/history/daily/us/tx/midland/KMAF/date/2023-12-31 revealed the temperature on 12/31/23 at 8:53 p.m. was 47 degrees F. The temperature on 12/31/23 at 9:53 p.m. was 44 degrees F. Review of the facility's undated policy and procedure on Wandering/Missing Residents .To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implement with specific approaches and goals for the wanderer. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. When a resident is believed to be missing, the facility will implement the following steps: The charge nurse will be alerted the resident is missing. The charge nurse will alert all staff by announcing CODE GREY over the public announcement system and have staff report to the nurse station. Circumstances will be explained to the staff and each staff will be directed as to where to search. The entire building and grounds will be searched, including all shower rooms, closets, bathrooms, and entryways. If this search is unsuccessful, surrounding streets and yards will be checked. This search should not take longer than 15 minutes. IF the resident is not found withing 15 minutes, the administrator, director of nurses, HHS and the local police will be notified. HHS procedure will be followed regarding a missing resident. A current photograph and complete description will be given to the police of the missing resident. The charge nurse, director of nursing, or administrator will notify the family of the situation, what is being done and encourage their assistance. When the resident is located, the charge nurse will notify all previously contacted persons. Upon return to the facility, the resident will be assessed for injuries and the attending physician will be advised of the situation. A thorough incident report will be filled out by the charge nurse and given to the administrator. This will be documented in the resident's medical record. 676430 Page 7 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The charge nurse will be responsible for documenting the incident of residents leaving the facility. All documentation will be concise and reflect the actual facts as they relate to the incident, condition of the resident upon return to the facility, doctor's orders, treatment initiated, and any other information deemed pertinent by the facility. The time the police arrived and took over the search will be documented. The administrator will be responsible for preparing and investigation file of the incident, which is not a portion of the medical record. It is the responsibility of the facility administrator to ensure that the staff is fully aware of this policy. Review of the in-service on Emergency Exits, dated 12/19/23 revealed: door code is locked in emergency binder at each nurse's station. In the event that there is an alarm related to an emergency exit door ajar these are the steps to be followed: 1. See white box located at each nurse's station to verify which door is alarming. 2. Immediately report to the appropriate door. 2. Physically walk outside the door check to see if any residents are outside, if all clear step back inside and lock door. During an interview on 1/4/24 at 3:10 PM the Administrator, DON, and Corporate Consultant RN were informed that an Immediate Jeopardy Situation had been identified in the area of Quality of Care and the Immediate Jeopardy Template was emailed to the Administrator. Review of the in-service on Elopement, dated 1/1/24, revealed: Residents are to be checked every two hours to ensure safety. If a resident cannot be found in regular areas a building search is to be conducted of all patient rooms, bathrooms, common areas, parking lot, etc. Elopement binders are at both nurse's desks and front door, code grey is code for elopement. Review of the in-service on Secured Doors, dated 1/2/24, revealed: secured doors should be checked at the start of shift by nurses the code for side doors can be found in the fire book. The front door should be locked at 10 p.m. Review of the facility's Elopement Intervention, provided 1/3/24 at 4:19 p.m. revealed: Current population elopement/ wander-guard program on all current residents/ admission/ re-admission for cognition changes (BIMS score, any indication of mental changes) Change of Condition - evaluate for elopement wander-guard program, if deemed appropriate, care plan meeting with RP / family, resident to be added to facility elopement binders. * The following Plan of Removal was accepted on 01/05/2024 at and included: The facility failed to ensure the residents are Free of Accidents Hazards/Supervisions/Devices. 1. All residents have the potential to be affected. Facility census on 01/05/2024 was 128. 2. MDS, ADON's and DON will assess all currents residents for changes in condition that would cause the 676430 Page 8 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 resident to be considered a risk for elopement. All future admissions will be evaluated for elopement risk Level of Harm - Immediate jeopardy to resident health or safety and be placed on a list at both the nurse's station and reception area. Residents Affected - Few Residents identified during assessment today (and in the future) found to be elopement risks and not 3. suitable for care at will be supervised one on one until a more secure facility can be found to place the resident for their safety, such as a locked, secure unit. 4. The facility front door will be locked at 6 PM when the receptionist leaves for the day to ensure that no resident can leave or attempt to leave the facility without staff knowing and interceding. 5. DON and Lead-Aide will in-serviced and train all direct staff on the facility's elopement policy and procedure. 6. DON will in service all staff on communication priorities when any observation or issues present themselves whereas a resident has shown behaviors of wandering, either through a change in condition or increase in activity of wandering or made verbal requests to the staff concerning wanting to leave the facility. 7. All staff on leave will be educated prior to starting first shift back and completion of attestation form. 8. DON is responsible after a resident has been identified as an elopement risk to ensure that a proper assessment or care plan decision has been made and protective measures have been put in place until 676430 Page 9 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 identified. Level of Harm - Immediate jeopardy to resident health or safety 9. Residents Affected - Few The Medical Director was notified about the immediate jeopardy on 01-04-2024. Any negative outcomes will be reported to the QAPI committee. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 01/04/2024 at 3:02 pm to 01/05/2024 at 6:28 pm. Review of the facility's in service, dated 01/04/2024 presented by DON, covering Communication and Change of Condition indicated: *With and change of condition that occurs with any resident including physical, mental changes, any wandering or changes in behaviors a change of condition note needs to be initiated, DON and Administrator informed. *CNA's on floor with any changes identified with their residents will make sure to notify charge nurse. *All staff will notify DON and Administrator if any resident makes verbal requests to staff concerning wanting to leave the facility. Record review of a Facility Audit of the resident's medical records, performed by the DON, dated 01/04/2024, revealed that all residents were assessed for risk of elopement with 4 additional residents identified with wander guard orders initiated. During an interview, on 01/05/2024 at 12:10 PM, the Administrator stated if the facility identified an at risk resident for possible elopement the facility would place that resident on one-to one-supervision, the facility would call an emergency care plan meeting with the resident and/or the resident's family, the ombudsman, and the IDT. He said the facility would discuss the reasons for possible discharge and the facility would ensure the resident was discharged safely and appropriately, per regulations. The Administrator stated that the appropriate notices would be issued, and all other options would be explored before the discharge was done. Record review on 01/05/2024 at 12:45 PM revealed revised Orientation/Onboarding Power Point presentation containing slide with Elopement In-Service and attestation forms from presentation performed by administrator and DON. Review of sign in sheet of attendance revealed that 93 of 173 staff had completed on 01/04/2024 with Administrator stating that the facility was still in process of calling all staff to complete in-service. During an interview on 01/05/2024 at 2:26 PM CNA F (6PM to 6AM shift) stated that she received in-service training on 01/04/2024 for Orientation/Onboarding/Elopement. She stated she was aware that the front doors would be locked at 6:00 PM every night with entrance code posted on the outside of the door for visitors and visitors were to obtain the code to leave facility from staff. CNA F stated that she was in-serviced to report any changes to a resident's behaviors immediately to the charge nurse, DON, or Administrator. 676430 Page 10 of 11 676430 01/05/2024 Ashton Medical Lodge 801 South Loop 250 West Midland, TX 79703

F 0689 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 01/05/2024 at 2:32 PM Corporate Consultant RN stated that an assessment of all residents was performed on 01/04/2024 for all resident to identify elopement at risk. Stated that there were 5 new residents identified with physician notified to obtain wander guard orders. Corporate Consultant RN stated that there were no resident's identified as unsuitable for care at the facility during assessments. [TRUNCATED] Residents Affected - Few 676430 Page 11 of 11