Every finding on record at Anderson Mill Center for Nursing and Healing LLC

Based on staff interviews, record review, and review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advice], the facility failed to ensure six of 41 sampled residents (Resident (R) 3, R7, R149, R4, R15, and R72) and their resident representatives (RR) reviewed for emergency hospital transfer, were provided with a written transfer/discharge notice which contained the appeal process. This failure had the potential to affect the residents and their RR by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following hospitalization for residents transferred to the hospital. Findings include: 1. Review of R149's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 03/06/2026. Review of a document provided by the facility titled Acute Care Transfer Document Checklist dated 03/07/2026 indicated that R149 sustained a change in his condition and was transported to the hospital for evaluation and treatment. Review of R149's EMR revealed no evidence that the resident and/or her RR were provided with a written emergency transfer notice which included the appeal rights to the transfer/discharge. 2. Review of R3's Face Sheet located under the Profile tab of the EMR revealed R3 was admitted to the facility on [DATE] with the diagnoses of UTI (urinary tract infection), malnutrition and type II diabetes. Review of the Progress Notes located in the Progress Notes tab of the EMR revealed R3 was sent to the hospital on [DATE]. Review of R3 's EMR revealed no evidence that written notification regarding R3's transfer to the hospital was sent to R3's responsible party. 3. Review of R7's Face Sheet located under the Profile tab of the EMR revealed R7 was admitted to the facility on [DATE] with the diagnoses of amputation of left leg below the knee, malnutrition, peripheral vascular disease, functional quadriplegia, heart failure and type one diabetes. Review of the Progress Notes located in the Progress Notes tab of the EMR revealed R7 was sent to the hospital on [DATE]. Review of R7 's EMR revealed no evidence that written notification regarding R7's transfer to the hospital was sent to R7's responsible party. 4. Review of R15's Face Sheet located under the Profile tab of the EMR revealed R15 was admitted to the facility on [DATE] with the diagnoses of cerebral infarction, type II diabetes, and aphasia. Review of the Progress Notes located in the Progress Notes tab of the EMR revealed R15 was sent to the hospital on [DATE]. Review of R15 's EMR revealed no evidence that written notification regarding R15's transfer to the hospital was sent to R15's responsible party. 5. Review of R72's Face Sheet located under the Profile tab of the EMR revealed R72 was admitted to the facility on [DATE] with the diagnoses of cellulitis left lower limb and heart failure with a pacemaker. Review of the Progress Notes located in the Progress Notes tab of the EMR revealed R72 was sent to the hospital on [DATE]. Review of R72 's EMR revealed no evidence that written notification regarding R72's transfer to the hospital was sent to R72's responsible party. 6. Review of R4's admission Record, located under the Profile tab in the EMR, revealed R4 was admitted on [DATE] with diagnoses including morbid obesity, chronic obstructive pulmonary disease (COPD), depression, acute kidney failure, and acute respiratory failure with hypoxia. Review of R4's quarterly MDS, with an ARD of 03/01/2026 revealed a BIMS score of 14 out of 15, indicating intact cognition. Review of R4's Progress Note, dated 02/16/2026 at 19:30 [7:30] PM and located under the Progress Notes tab of the EMR, revealed R4 was diaphoretic with increased confusion and altered mental status. Report was given to the emergency medical technician, and the resident was transferred to the hospital. Review of R4's EMR revealed no evidence that the resident and/or her RR were provided with a written emergency transfer notice which included the appeal rights to the transfer/discharge During an interview on 05/13/2026 at 3:25 PM, Registered Nurse (RN) 1 stated a transfer/discharge notice was sent with residents when they were transferred to the hospital. She showed this surveyor the e-interact form which was provided to the emergency medical technician (EMT) staff. She stated no other forms were provided to the resident or the resident representative (RR) in a language the resident or representative could understand regarding the rights to appeal the transfer/discharge or that indicated where they were going and why. During an interview on 05/14/2026 at 10:10 AM, the Director of Nursing (DON) stated she was not aware of a separate transfer/discharge form that should be provided to the resident and/or the RR. Review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advice], revised March 2025, revealed, . It is the policy of this facility to permit each resident to remain in the facility, [sic] and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. Emergency Transfers to Acute Care. (g.) Provide a notice of transfer and the facility's bed hold notice policy to the resident and resident representative as indicated.

Based on resident and staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of two residents (Resident (R) 31) out of 41 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. (Cross Reference F656) Findings include: Review of R31's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 03/24/2026. Review of R31's EMR titled, Orders located under the Orders tab dated 03/29/2026 indicated that the psychiatrist ordered Mirtazapine 15 milligrams (mg) to be administered at bedtime to treat the resident's diagnosis of PTSD (post-traumatic stress disorder) and depression. Review of R31's EMR titled, admission MDS with an Assessment Reference Date (ARD) of 03/29/2026, located under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which revealed the resident was cognitively intact. The assessment failed to indicate that the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). During an interview conducted on 05/13/2026 at 2:43 PM, R31 confirmed she had a diagnosis of PTSD. During an interview conducted on 05/15/2026 at 10:10 AM, MDS Coordinator (MDSC)2 stated that when she completed the MDS assessment she looked at the hospital records, consulted with the Nurse Practitioner, and would look through the physician orders. MDSC2 stated that the facility was not notified by the psychiatrist of R31's new diagnosis of PTSD. Review of the RAI manual, dated October 2025 and located in the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual by CMS, revealed, .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .

Based on resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and interventions for one of one resident (Resident (R) 31) reviewed for mental health, specifically for post-traumatic stress disorder (PTSD). This failure had the potential for staff to provide inconsistent and incomplete care related to the resident's PTSD.Findings include: Review of R31's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 03/24/2026. Review of R31's EMR titled Orders located under the Orders tab dated 03/29/2026 indicated that the psychiatrist ordered Mirtazapine 15 milligrams (mg) to be administered at bedtime to treat the resident's diagnosis of PTSD and depression. Review of R31's EMR titled, admission MDS with an Assessment Reference Date (ARD) of 03/29/2026 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which revealed the resident was cognitively intact. Review of R31's EMR tiled, Care Plan located under the Care Plan tab did not contain evidence that the resident's diagnosis of PTSD had corresponding goals and interventions. A request was made to speak to the psychiatrist, and she was not available to be interviewed by the end of the survey to clarify the diagnosis in the physician orders dated 03/29/2026. During an interview with R31 on 05/13/2026 at 2:43 PM, she confirmed that she had a diagnosis of PTSD. During an interview conducted on 05/13/2026 at 3:53 PM, Licensed Practical Nurse (LPN) 2/Unit Manager stated that the psychiatrist had placed the diagnosis of PTSD in the original order for R31 and the use of the antidepressant. During an interview conducted on 05/13/2026 at 4:15 PM, the Social Services Director (SSD) stated that she read the psychiatrist's notes and would discuss the resident during the morning clinical meeting. The SSD confirmed she was not aware of the resident's diagnosis, Review of a facility policy titled, Comprehensive Care Plans dated October 2025 indicated . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.'Trauma-informed care' is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization.

Based on observations, staff interviews, record review, and review of the facility policy titled, Weight Monitoring, the facility failed to ensure weekly weights were implemented for one of one resident (Resident (R) 59) reviewed for nutrition out of a survey sample of 41. This lack of monitoring of residents' weight loss/gain can delay in identifying potential nutritional problems. Findings include: Review of R59's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 04/03/2026 with diagnoses that included stroke and acute kidney failure. Review of R59's EMR titled, Care Plan, located under the Care Plan tab dated 04/03/2026, indicated that the resident had a nutritional problem related to his right sided stroke. The care plan reflected that the resident's diet was upgraded to regular. Review of R59's EMR titled, Physician Orders, located under the Orders tab dated 04/04/2026, revealed the resident was to be weighed once a week for four weeks and then monthly after. Review of R59's EMR titled, Nutritional Assessment, dated 04/07/2026 at 12:36 PM located under the Assemts (Assessment) tab and completed by the Registered Dietician (RD) indicated admission height/weight are pending. The nutritional assessment indicated that the resident was independent with eating with some staff assistance. Review of R59's EMR titled, Weight located under the Weights & Vitals tab indicated that the facility weighed the resident on 04/07/2026 at 2:16 PM and the resident weighed 220.6 pounds. This was a four-day delay in obtaining the resident's initial weight upon admission. There was no documentation in the medical record that the resident was weighed on a weekly basis after the initial weights. Review of R59's EMR titled, admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/2026 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. The assessment indicated that the resident had no weight loss/gain during the assessment period. The assessment indicated that the resident weighed 221 pounds. Review of R59's EMR titled, Nutritional Assessment, dated 05/02/2026, located under the Weights & Vitals tab indicated the resident's weight was now 216.4 pounds. During an observation conducted on 05/14/2026 at 1:26 PM, R59 was able to feed himself with his left hand and stated the food was good. The resident stated that he was aware that he had lost some weight while in the hospital and was not able to eat well at that time. During an interview conducted on 05/14/2026 at 2:54 PM, the RD stated residents were to be weighed weekly for the first four weeks due to having a close eye on the resident who came from the hospital since they were considered high-risk with a disease process. The RD stated the facility had identified the lack of initial admission weights and weekly weights for the first four weeks as an issue and were in the process of correcting this as an issue. Review of a facility policy titled, Weight Monitoring dated January 2024 indicated .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable weight or desirable body weight range.A weight monitoring schedule will be developed upon admission for all residents.Newly admitted residents with weight loss-monitor weight weekly for 4 weeks.

Based on staff interview and review of the facility policy titled, Infection Preventionist, the facility failed to ensure the designated Infection Preventionist (IP) (IP6) completed specialized training in infection prevention and control. This failure had the potential to affect the well-being of any of the 138 residents and/or the staff by not ensuring all current infection prevention and control measures were being instituted. Findings include: 1. Review of a document provided by the facility titled, Timecard for IP6 (employment dates of 06/25/2025-08/30/2025) indicated that she was hired as the Staff Development Coordinator who was also the facility's IP on 06/24/2025. The facility provided no evidence of IP6's specialized training in infection and prevention. 2. Review of a document provided by the facility titled, Timecard for IP5 (employment date 09/09/2025-10/01/2025) indicated that she was hired as the Staff Development Coordinator who was also the facility's IP on 09/09/2025. The facility document failed to indicate when IP5 was no longer employed at the facility. The facility provided no evidence of IP5's specialized training in infection and prevention. 3. Review of a document provided by the facility titled, Timecard for IP4 (employment date 10/16/2025-04/04/2026) indicated that she was hired as the Staff Development Coordinator who was also the facility's IP on 10/16/2025. The document failed to indicate when IP4 was no longer employed at the facility. The facility provided no evidence of IP4's specialized training in infection and prevention. There was no documentation the facility had a quailed IP from 06/24/2025-11/28/2025. During an interview conducted on 05/15/2026 at 2:30 PM, the Director of Regulatory Compliance stated that it was the facility's process to have a full-time Staff Development Coordinator/IP in each of their buildings. The Director of Regulatory Compliance stated that the IP training should be incorporated into each employee file, and it was not. Review of the facility policy titled, Infection Preventionist dated 10/01/2022 indicated . The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. The IP must have obtained specialized IPC training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate(s) of completion or equivalent documentation.

Based on staff interview, record review, review of the facility policy titled, Pneumococcal Vaccine (Series), and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of seven residents (Residents (R) 74) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This deficient practice had the potential to increase the risk for residents to contract pneumonia. Findings include: Review of R74's electronic medical record admission Record indicated that the facility admitted the resident on 08/14/2022. Review of R74's EMR titled, annual Minimum Data Set (MDS) with an Assessment reference date of 04/07/2026, located under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which revealed the resident was cognitively impaired. Review of R74's EMR titled, Immunizations located under the Immun (Immunizations) tab, dated 01/08/2018 indicated, the resident had the Prevnar (PCV)13 vaccination and received the Pneumovax (PPSV23) on 01/30/2019. Review of a document provided by the facility for titled, Georgia Registry of Immunization Transactions and Services, dated 05/15/2026, indicated that R74 was up to date on her pneumococcal vaccines. There was no evidence in this document that reflected that the resident was offered the current CDC recommendations of the PCV20 or PCV21 vaccines. During an interview conducted on 05/15/2026 at 9:27 AM, Infection Preventionist (IP) 1, who was being trained by the Director of Nursing (DON) since the DON was the current IP at the facility, confirmed the vaccination status of R74 and the resident was [AGE] years of age at the time of her admission. Both IP1 and the DON confirmed the resident should have been offered the PCV20 or the PCV21 vaccination based on CDC recommendations. Review of the CDC website titled, PneumoRecs VaxAdvisor App (Application) for Vaccine Providers, dated 02/25/2026, indicated . Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 or PCV21 is administered, their pneumococcal vaccinations are complete. Review of a facility's policy titled, Pneumococcal Vaccine (Series) dated December 2023 indicated .It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Assessment: Nursing, the facility failed to ensure that the care plan was updated for one of three sampled residents (R) (R3). This deficient practice placed the resident at risk for unmet care needs and delayed interventions because the care plan remained inaccurate regarding the level of assistance required.Findings include:Review of the facility's policy titled, Assessment: Nursing, undated, revealed under Policy: . The assessment must accurately reflect the patient's status at the time of assessment. Under Practice Standards: .1.3 Complete focused assessments/evaluations as triggered. Section 4. Conduct a change in condition assessment as needed. Section 5. Utilize assessment data to develop the care plan.Review of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, a displaced fracture of the posterior wall of the right acetabulum resulting from a fall on 11/12/2025, with onset documented on 11/13/2025. Additional diagnoses included displaced fracture of the upper end of the right humerus, wedge compression fracture of the first lumbar vertebra, polyosteoarthritis, age-related osteoporosis, low back pain, repeated falls, and unspecified dementia without behavioral disturbances.Review of R3 significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Section GG, Functional Status, revealed R3 was impaired on both sides to lower extremity, no use of any mobility devices, however, the quarterly MDS dated [DATE] revealed use of Wheelchair.Review of R3's care plan dated 12/03/2025 indicated problems related mobility and fall risk following multiple fractures, which required assistance from two staff members for safe transfers and activities of daily living (ADLs). Goals included ensuring the resident's safety during all transfers and mobility activities, while promoting participation in ADLs to the fullest extent possible. Interventions included providing two-person assistance for transfers, bed mobility, dressing, and toileting; using assistive devices as needed; implementing fall prevention measures such as fall mats and clear environments; and coordinating physical and occupational therapy to support strength and safe mobility.Review of the Physician's Orders for R3 included but was not limited to:Order dated 01/19/2026 for PT to eval and treat as indicated:Order dated 1/19/2026 for Skilled PT (physical therapy) services 3x/wk (week) x 4 wks (weeks) for thera ex (therapeutic exercise), thera act (activities), neuroreed (neuromuscular reeducation), wheelchair mobility & pt/CG (patient/caregiver) educ (education) d/t (due to) muscle weakness.Order undated for WBAT (weight bearing as tolerated)-Work on BLE (bilateral lower extremity) strengthening, mobility and transfer 2 x wk for 6 weeks with ROM (range of motion), strengthening. Evaluate and tx (treat) of bil. (bilateral) hips (lower exts. (extremities).Review of R3's PT, provided by the facility's Rehab Director, included the PT evaluation and plan of treatment dated 01/19/2026. At that time, R3 required substantial to maximal assistance from two staff members for transfers. Subsequent PT progress notes dated 01/27/2026 indicated that R3's functional status had improved, and the resident now required moderate assistance from only one staff member for transfers. These PT notes reflected a change in the resident's level of assistance needed, that was not documented or updated in the care plan, which continued to indicate that R3 required two-person assistance for transfers and other activities of daily living.Interview on 02/4/2026 at 10:01 AM with Certified Nursing Assistant (CNA) AA revealed that R3 required one-person assistance for transfers and that she was not familiar with the resident's fall history and full care plan.Interview on 02/4/2026 at 10:05 AM with Licensed Practical Nurse (LPN) BB revealed that R3 currently required one-person assistance for transfers. LPN BB confirmed that when R3 returned from the hospital following the fracture in November 2025, the care plan was updated to reflect a two-person assist. LPN BB noted that the care plan had not been updated to reflect the resident's current functional status.Interview on 02/4/2026 at 10:27 AM with Unit Manager LPN CC revealed that while the care plan indicated R3 requiring two-person assistance, current practice reflected that she only required one-person assistance for transfers. LPN CC confirmed that the care plan continued to show two-person assistance with transfers.Interview on 02/5/2026 at 10:16 AM with Rehab Director confirmed that R3 was evaluated on 01/19/2026 and required two-person assistance, but by 01/27/2026, R3 was assessed as required one-person assistance (Moderate Assistance), as documented in the PT Daily Soap notes. The care plan had not been updated to reflect this change.Interview on 02/4/2026 at 1:45 PM with Interim Director of Nursing (I-DON) EE confirmed that staff had been instructed on the current interventions for R3, including one-person assistance for transfers. She acknowledged that the care plan should have been updated on 01/27/2026 to reflect the change in level of assistance following PT evaluation. Stated that the facility held daily clinical meetings and weekly Patients At Risk (PAR) meetings, which included review and updates to resident care plans, and that physical therapy staff attended those meetings. The care plan should have been revised during one of those meetings, but it was not. The I-DON stated that she would update the care plan immediately. Interview on 02/4/2026 at 3:38 PM with both MDS FF and MDS GG revealed that while R3's Significant Change MDS indicated a two-person assist, staff had not made then aware that the care plan should be updated to reflect current functional status, which was one-person assist. They further stated that any nursing staff may update the care plan.

Based on observations, record review, review of facility policy, and interview with facility staff, the facility failed to provide routine drugs or obtain them under an agreement for one of 32 sampled residents (R) R#119. Additionally, the facility's Pharmacy failed to notify nursing of the need for additional information in order to supply a schedule IV-controlled substance. Findings include: Review of facility's policy titled, Pharmacy Services, dated June 2023, revealed the Compliance Guidelines noted: 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.7. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals, and quality of life that are consistent with current standards of practice and meet state and federal requirements. Review of the medical record for Resident (R)#119 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type two, asthma, weakness, difficulty in walking, syncope, obesity, glaucoma, narcolepsy, and adrenocortical insufficiency. Review of Physician's Orders for R#119 revealed an order for Modafinil oral tablet 200 milligrams (mg) (Modafinil)-give one tablet by mouth one time a day for narcolepsy with a start date of 4/15/25 at 9:00 a.m.; and multiple other medications. On 4/30/25 at 9:35 am, Licensed Practical Nurse (LPN) DD was observed to administer medications to R#119. LPN DD did not administer the morning dose of Modafinil as prescribed by the physician. On 4/30/25 at 9:45 a.m., during an interview with LPN DD, she stated she was not able to administer the ordered dose of Modafinil because it was not available and had not been delivered from pharmacy. When asked how long it had not been available, LPN DD said it had never been delivered by pharmacy and had not been available for administration since it was ordered on 4/15/25. On 4/30/25 at 11:00 a.m., during an interview with the Registered Nurse (RN) Unit Manager EE, she stated she did not know why the medication was not available but would investigate and provide an update. At 2:00 p.m., RN EE stated pharmacy had not delivered the medication because it was a schedule IV-controlled substance, and they needed a prescription from the physician and not just the order in Point Click Care (PCC-electronic medical records system). She stated the pharmacy had not contacted the facility to let them know they needed a prescription in order to fill the medication. She also confirmed that nursing staff had not contacted the pharmacy to see why it had not been delivered but had continued to document it as not available. She acknowledged that the documentation on 4/19/25 and 4/23/25 that noted the morning dose of Modafinil had been administered was incorrect documentation and was probably an honest mistake because it was not available for administration on 4/19/25 and 4/23/25.

Based on observations, record review, review of facility policy, and interviews with facility staff, the facility failed to ensure the medication error rate was not five percent or greater for one of three residents (R) #119. There were two medications errors in 29 opportunities during observation of medication administration to three residents for a medication error rate of 6.89% (percent). The findings include: Review of facility's policy titled Medication Administration, dated January 2023, noted the Policy Explanation and Compliance Guidelines noted: .10. Review Medication Administration Record (MAR) to identify medication to be administered; 11. Compare medication source (bubble pack, vial, etc. [etcetera) with MAR to verify resident name medication name, form, dose, route, and time. Review of the medical record for Resident (R)#119 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type two, asthma, weakness, difficulty in walking, syncope, obesity, glaucoma, and adrenocortical insufficiency. Review of Physician's Orders for R#119 revealed orders for Hydrocortisone Oral Tablet 20 milligrams (mg) (Hydrocortisone)-Give one tablet by mouth in the morning for Inflammation with a start date of 4/19/25 at 9:00 a.m.; Hydrocortisone oral tablet 10 mg (Hydrocortisone)-Give one tablet by mouth in the afternoon for Inflammation with at start date of 4/19/25 at 12:00 p.m.; Modafinil oral tablet 200 mg (Modafinil)-give one tablet by mouth one time a day for narcolepsy with a start date of 4/15/25 at 9:00 a.m.; and multiple other medications. On 4/30/25 at 9:35 am, Licensed Practical Nurse (LPN) DD was observed to administer medications to R#119. LPN DD was observed to administer hydrocortisone 10 mg, one tablet in addition to other medications to R#119. LPN DD administered the noon dose instead of the morning dose as ordered by the physician. Additionally, LPN DD did not administer the morning dose of Modafinil as prescribed by the physician. On 4/30/25 at 9:45 a.m. during an interview with LPN DD, she stated she must have grabbed the incorrect card that had 10 mg tablets of hydrocortisone instead of the card containing hydrocortisone 20 mg tablets. LPN DD stated she was not able to administer the ordered dose of Modafinil because it was not available and had not been delivered from pharmacy. When asked how long it had not been available, LPN DD said it had never been delivered by pharmacy and had not been available for administration since it was ordered on 4/15/25. On 4/30/25 at 11:00 a.m. during an interview with the Registered Nurse (RN) Unit Manager EE, she stated she did not know why the medication was not available but would investigate and provide an update. At 2:00 p.m., RN EE stated the pharmacy had not delivered the medication because it was a schedule IV-controlled substance, and they needed a prescription from the physician and not just the order in Point Click Care (PCC). She stated the pharmacy had not contacted the facility to let them know they needed a prescription in order to fill the medication. She also confirmed that nursing staff had not contacted the pharmacy to see why it had not been delivered but had continued to document it as not available. She acknowledged that the documentation on 4/19/25 and 4/23/25 that noted the morning dose of Modafinil had been administered was incorrect documentation was probably an honest mistake.

Based on observations, staff interviews, and review of the facility's policy, the facility failed to establish an infection prevention and control program (IPCP) that included preventing and controlling infections and communicable disease for all residents, staff and other individuals by not utilizing proper personal protective equipment (PPE) and hand sanitization during administration of medications for two of three residents during observation of medication administration to Resident (R)#119 and R#53. Findings include: Review of facility's policy titled Enhanced Barrier Precaution and dated March 2024, noted: 3. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.4. High-contact resident care activities include: .g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes.9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of an undated facility's policy titled Handwashing/Hand Hygiene noted: .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% [percent] alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .c. Before preparing or handling medications; .i. After contact with a resident's intact skin; .m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Procedure .Applying and Removing Gloves instructs staff as follows: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. On 4/30 25 at 8:50 a.m. during observation of medication administration to R#53, Licensed Practical Nurse (LPN) CC was observed to prepare medications at the medication storage cart to be administered via the percutaneous endoscopic gastrostomy (PEG) feeding tube. R#53 was observed to have an enhanced barrier precautions sign on the door to his room that instructed staff to use PPE and which PPE to don when providing personal care. Each medication was prepared in a separate cup, the overbed table was cleaned and a barrier was placed. LPN CC entered the room, washed her hands and donned a pair of non-sterile gloves, approached R#53, draped the resident to prepare for administering medications via the PEG tube. LPN CC lifted the tube with her left hand and held the tubing connected to the bottle of formula in her right hand and the PEG tube came out with the balloon deflated. LPN CC did not don (put on) a gown, mask or eye protection when providing high-contact care that included a procedure involving a PEG feeding tube. On 4/30/25 at 9:35 a.m. during observation of medication administration to R#119, LPN DD was observed to prepare medications to be administered to R#119 that included oral medications, latanoprost 0.005% eye drops an Azelastine Nasal Spray 0.1%. LPN DD entered the room of R#119 and identified the resident. LPN DD then administered the oral medications to R#119 and provided water to drink. LPN DD then put on non-sterile gloves, administered the nasal spray-one spray to each nostril, removed the gloves, put on a new pair of non-sterile gloves, administered the eye drops-one drop in each eye, removed the gloves and left the room. LPN DD did not perform hand hygiene before donning gloves, after doffing gloves and between administering nasal spray and eye drop medications to R#119. On 4/30/25 at 8:55 a.m., LPN CC stated she just forgot to put on the PPE because she was nervous about having the surveyor observe her administering medications. On 4/30/25 at approximately 9:45 a.m. LPN DD confirmed she did not perform hand hygiene before and after donning and doffing gloves while administering medications to R#119.

Based on observations, staff interviews, record review, and review of the facility policy titled, Incontinence, the facility failed to provide timely and appropriate incontinence care for one of four residents (R) (R7) reviewed for incontinence care. The deficient practice had the potential to promote infection. Findings include: Review of the facility policy titled, Incontinence, dated 1/1/2019 documented: Policy Explanation and Compliance Guidelines: .4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections. Review of R7's clinical record revealed diagnoses including nontraumatic subarachnoid hemorrhage, dysphasia following cerebrovascular disease, tracheostomy status, and stage four sacral pressure ulcer. Review of R7's quarterly Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score could not be completed; the resident was rarely/never understood, had short and long - term memory problems, and had severely impaired decision-making skills. The resident required total assistance of two people for bed mobility and total assistance of one person for toileting. The MDS documented the resident was always incontinent of bowel and bladder. Review of R7's care plan, dated 7/19/2023, for Activities of Daily Living (ADL) documented the resident did not use the restroom and was totally dependent on one to two staff for toilet use, peri care, and changing her brief. Observation of R7 during pressure ulcer (PU) care, on 10/12/2023, which began at 11:14 am, revealed the resident was having a bowel movement. The Wound Care Nurse (WCN) and Consultant Wound Nurse (CWN) provided PU care to the sacral wound without first removing the stool from R7's peri area (genital area). At the end of the PU treatment, the WCN asked the CWN to ask the Certified Nursing Assistant (CNA) to come to the room because She is having a BM [bowel movement], and I don't want it to get on the dressing. A CNA did not immediately come, so the WCN took part of the incontinence pad that was not under the resident and wiped off some of the stool and then rolled up that part of the incontinence pad and placed it under the resident. The WCN covered up the resident, gathered her supplies, and left the room. The WCN and the CWN came back to the room at 11:33 am and said they were going to clean the resident up. The WCN and CWN turned R7 to her right side, then used wet wipes to clean the left buttock where there was stool, and between the buttocks. The staff then placed a new incontinence brief on R7 without providing any frontal incontinence care. Interview on 10/12/2023 at 11:39 am with the WCN, she stated the staff would provide frontal incontinence care when they provided peri care, and she did not provide frontal care because the resident Just had a bowel movement. Interview on 10/13/2023 at 10:55 am with the Director of Nursing (DON), she stated the staff should provide incontinence care by cleaning front to back, and if the resident had stool present, the staff should also provide frontal care.

Based on observations, interviews and review of policies titled Medication Storage, Administration of Eye Drops or Ointments, document provided by the facility titled Insulin Storage and Dispensing Info, and manufacturer's recommendations, the facility failed to ensure medication was stored properly on 3 of 6 medication carts (300 Hall Medication Cart, 500 Hall Medication Cart, and 600 Hall Medication Cart). Specifically the facility failed to ensure that the 500 Hall and 600 Hall medication cart were locked and secured when out of the sight of a nurse; failed to ensure eight containers of ophthalmic solutions were labeled when opened; failed to ensure three oral inhaled medication were labeled when opened; failed to ensure one nasal spray was labeled when opened; failed to ensure three multi-dose vials of Insulin and one multi-dose Insulin pen were labeled when opened; failed to ensure one container of nitroglycerin sl (sublingual) 0.4mg (milligrams) 25 count container was labeled when opened; failed to discard expired medications from the medication cart; failed to properly store one unopened latanoprost 0.005% ophthalmic solution container; and failed to properly dispose of expired medication. Findings included: A review of the undated policy titled Medication Storage: revealed: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines numbered 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. A review of the undated policy titled Administration of Eye Drops or Ointments revealed: Policy explanation and compliance guidelines: 1.d. Label new bottle with date opened and follow facility policy or manufacturer's instructions for when to discard and replace. A review of the manufacturer's recommendations for storage of latanoprost 0.005% ophthalmic solution revealed recommended storage: Store unopened bottle(s) under refrigeration at 2 to 8 C (Celsius) (36 to 46 F (Fahrenheit)). Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for six weeks. A review of the document titled Insulin Storage and Dispensing Info dated 2021 revealed expiration dates when opened: Levemir flex touch pen 100units/ml (milliliter) expired after 42 days once opened. Humalog 70/30 100units/ml 3ml vial expired after 28 days once opened. lispro 100units/ml 10ml vial expired after 28 days once opened. Novolog 100units/ml 10ml vial expired after 42 days. On 3/7/23 at 10:16 a.m. observation of one unlocked and unattended medication cart on the 500 Hall. At 10:19 a.m. an interview with Licensed Practical Nurse (LPN) HH confirmed the cart was left unlocked and unattended and she locked it. She revealed she was not the nurse working the cart. On 3/7/23 at 4:32 p.m. to 4:42 p.m. observation of one unlocked and unattended medication cart on the 600 Hall. Registered Nurse (RN) GG was observed approaching the cart two times and leaving without locking the cart. At 4:43 p.m. during an interview with RN GG she revealed the cart should be locked and secured when left unattended and she verified the cart was not locked and left unattended and out of her site. On 3/8/23 at 9:05 a.m. observation of a medication cart located on 500 Hall with LPN BB. The following medications were observed and verified by LPN BB: 1 brimonidine 0.2% 5ml ophthalmic solution with open date of 9/14. 1 Breo-Ellipta 100 mcg (microgram)/25 mcg oral inhaler - open and without an open date. 1 Tylenol ES (Extra Strength) 500mg gel caps 225 count container with expiration date of February 2023. LPN BB was observed to discard the contents of the Tylenol ES 500mg gel caps into a sharps container located on the wall located in resident room [ROOM NUMBER]. LPN BB revealed he thought it was allowed to discard medications in any sharps container regardless of location. On 3/8/23 at 9:25 a.m. observation of a medication cart located on 600 Hall with Medication Technician CC and LPN FF. The following medications were observed and verified by Medication Technician CC and LPN FF: 1 triqumeg 600-50-300mg 30 count container containing 11 tablets - expiration date 1/31/23. 1 alfuzosin hydrochloride 10mg 30 count container containing 21 tablets - expiration date 3/5/23. 1 Rocklatan ophthalmic solution 0.02-0.005% 2.5ml container - open and without an open date. 1 brimonidine 0.2% ophthalmic solution 5ml container - open and without an open date. 2 latanoprost 0.005% ophthalmic solution 2.5ml containers - open and without an open date. 1 latanoprost 0.005% ophthalmic solution 2.5ml container - not opened and stored in the medication cart and not under refrigeration. 1 tobramycin 0.3% ophthalmic solution 2.5ml container - open and without an open date. 1 timolol maleate 0.5% ophthalmic solution 5ml container - open and without an open date. 1 brimonidine tartrate/timolol maleate 0.2%/0.5% ophthalmic solution 5ml - open and without an open date. 1 nitroglycerin SL 0.4mg 25 count container - open and without an open date. 1 Levemir FlexTouch 100units/ml - open and without an open date. 1 Humalog Insulin 100units/ml 3ml vial - open and without an open date. 1 lispro Insulin 100units/ml 10ml vial - open and without an open date. 1 Novolog 100units.ml 10ml vial - open and without an open date. 1 Trelegy Ellipta 100mcg/62.3mcg/25mcg inhaler - open and without an open date. 1 Advair 115mcg/21mcg inhaler - open and without an open date. On 3/8/23 at 10:00 a.m. observation of a medication cart located on 100 Hall with LPN DD. The following medications were observed and verified by LPN DD: 1 Symbicort 160/4.5 mcg inhaler - open and without an open date. 1 calcitonin salmon nasal spray 30 dose container - open and without an open date. On 3/8/23 at 4:45 p.m. an interview with the Director of Nursing (DON) revealed her expectations were for expired medications to be discarded into the provided container, which was a gray plastic bag, labeled, and placed into the discarded medication container in the medication storage room. She revealed medications should never be discarded into any container in a resident room. She revealed her expectations were for medications to be labeled with an open date according to the facility policy, pharmacy guidelines and the manufacturers guidelines. She further revealed all Insulin products should be labeled with an open date when opened. She further revealed her expectation was for medication carts to be locked and secured when out of view of the nurse. She revealed nurses had received education on 3/10/23 to ensure medication carts were locked and secured when out of view of the nurse. She revealed she planned to re-educate nursing staff about locking and securing medication carts, disposal of expired medications, proper storage of medications, specifically ophthalmic solutions, and labeling and dating of medications when opened.

Based on observations, interviews, record reviews and policy reviews, the facility failed to ensure appropriate infection control practices for 17 of 64 sampled residents (R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, R#65, R#7, R#96, R#101, R#8, R#41, and R#119). Specifically staff failed to clean or disinfect reusable resident equipment (a blood pressure cuff) between R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, R#65; failed to ensure a clean surface area for equipment use (failed to use a barrier or clean resident's table tops or medication cart surface before placing glucometer and supplies on them) between R#7, R#96, R#101, and R#8; failed to use appropriate hand hygiene between performing glucometer checks for R#7, R#96, R#101, and R#8; failed to use appropriate hand hygiene during wound care for R#41; failed to use appropriate hand hygiene during tracheostomy care for R#119. Findings included: 1. a. Review of the policy titled Cleaning and Disinfection of Resident-Care Items and Equipment updated 12/2022 revealed: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current (Centers for Disease Control and Prevention) CDC recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Policy Interpretation and Implementation numbered 1.c. Noncritical items are those that come in contact with intact skin but not mucous membranes. (1) Noncritical resident-care items include bedpan, blood pressure cuffs, crutches, and computers. b. Review of the CDC guidelines titled Disinfection and Sterilization revealed section numbered 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). URL:https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html#:~:text=Disinfect%20noncritical%20medical%20devices%20(e.g.,contact%20time%20of%2010%20minutes. c. Review of document titled EDAN User Manual URL: https://dentaled.com/wp-content/uploads/EDAN-User-Manual.pdf, page 152 Section 25.2 Cleaning: If the device or accessory has been in contact with the patient, then cleaning and disinfection is required after every use. If there has been no patient contact and there is no visible contamination, then daily cleaning and disinfection is appropriate. d. Review of the undated policy titled Handwashing/Hand Hygiene revealed: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretations and Implementation numbered 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: 7.b. Before and after direct contact with residents, 7.i. After contact with a resident's intact skin. On 3/9/23 from 8:30 a.m. to 8:45 a.m. observation on the 500 Hall of Certified Nursing Assistant (CNA) II revealed her to roll an automatic Edan blood pressure machine into and out of rooms 501,502, 504, 505 and check each resident's blood pressure without cleaning the blood pressure cuff or equipment and without performing hand hygiene. The residents were R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, R#65. On 3/9/23 at 8:48 a.m. an interview with CNA II revealed she had documented blood pressure results written on a piece of paper and she verified she had checked blood pressures of R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, R#65 without cleaning the blood pressure cuff and without performing hand hygiene between the residents. She revealed there were no sanitizing wipes available to clean the blood pressure cuff and revealed she was aware she could ask the nurse for some. She revealed she was rushed and forgot to perform hand hygiene. She further revealed she used the hand sanitizer available from the hallway dispensers when she thought to. She revealed she does not wash her hands often. On 3/9/23 at 3:55 p.m. an interview with the Director of Nursing (DON) revealed her expectation was for equipment that was used for more than one resident to be cleaned with a sanitizing wipe between each resident. She revealed this included blood pressure cuffs. She revealed sanitizing wipes were available to all staff and located in the supply room and that staff were given the door code to access the room. She further revealed CNAs should ask the nurse if they were unable to access the supply room or needed supplies. She revealed staff should perform hand hygiene between before and after resident contact. She revealed she planned to re-educate resident care staff on cleaning noncritical equipment and hand hygiene. 2. Review of the undated policy titled Handwashing/Hand Hygiene revealed: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretations and Implementation numbered 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: 7.b. Before and after direct contact with residents; 7.d. Before performing any non-surgical invasive procedure. After removing gloves. The use of gloves does not replace handwashing/hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the undated policy titled Blood Glucose Monitoring revealed: Procedure section numbered 3. Perform hand hygiene and don gloves. Remove and discard gloves and perform hand hygiene. On 3/8/23 from 12:05 p.m. to 12:20 p.m. glucometer use observation of Licensed Practical Nurse (LPN) DD revealed her to perform fingerstick blood sugar checks on R#7, R#96, R#101, and R#8 without performing hand hygiene between residents or before donning or after doffing gloves and without cleaning the resident tabletops or medication cart surface or using a barrier on resident tabletops and medication cart surface or prior to placing the glucometer and supplies on the surfaces. On 3/8/23 at 12:25 p.m. an interview with LPN DD verified she did not perform hand hygiene before donning gloves or after doffing gloves or between resident care while performing fingerstick blood sugar checks for R#7, R#96, R#101, R#8. She verified she did not place barriers on the resident tabletops or the medication cart surface and did not clean the surfaces prior to placing glucometer, test strips container, and fingerstick device on them. She revealed she should have cleaned or placed a barrier on the medication cart and on the resident tables prior to placing supplies on them. She revealed she should have performed hand hygiene with alcohol-based sanitizer or washed hands with soap and water between resident care and before and after donning and doffing gloves. She revealed she wasn't thinking. On 3/8/23 at 2:45 p.m. an interview with the DON revealed her expectations were for hand hygiene to be performed before and after resident care in addition to the use of gloves. She revealed staff should use hand sanitizer or wash hands with soap and water even when using gloves and hand hygiene should be performed before donning and after doffing gloves. She revealed her expectations were for nurses to use a barrier or to clean surfaces of the medication cart and tabletops in resident rooms prior to placing supplies that are taken from the room and used for other residents, such as glucometers. She revealed she planned to re-educate nursing staff on hand hygiene and infection control related to cleaning surfaces and using barriers to prevent cross contamination while using equipment that is shared between residents.

Based on observations, interviews, record review, and policy review, the facility failed to ensure resident right to dignity and respect was honored related for 19 of 64 sampled residents (R#44, R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#10, R#86, R#89, R#61, R#60, R#77, R#21, R#28, and R#65) related (1) ensuring that the catheter was placed in a privacy bag for R#44; (2) ensuring staff knocked on resident doors before entering for R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#10, R#86, R#89, R#61, R#60, R#77, R#21, R#28, and R#65. Findings included: A Review of the policy titled Quality of life - Dignity dated December 2022 revealed the policy statement to be: Each resident shall be cared for in a manner that promotes and enhances quality of dignity, respect, and individuality. 1. A review of the clinical record for R#44 revealed that the resident was initially admitted to the facility on [DATE]. A Review of the resident's most recently quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of fifteen. The resident was also coded as having a suprapubic catheter and requiring extensive assistance for bed mobility, transfers, toileting. During multiple observations of R#44 on 3/7/23 at 11:30 a.m., on 3/8/23 at 10:10 a.m., and on 3/9/23 at 8:35 a.m., the resident was observed to be lying in bed, the privacy curtain was half open. The resident was observed to have a suprapubic catheter bag and tubing hanging from the bed without covering. During an interview on 3/9/23 at 8:40 a.m. with Licensed Practical Nurse (LPN) QQ regarding the care of Catheter and policy issues, LPN QQ revealed that facility practice is that all catheter bags should be placed in a privacy bag. He confirmed that R#44 catheter was not in a privacy bag and that it should have been. 2. Review of the policy titled Quality of Life - Dignity updated December 2022 revealed: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation line numbered 6: Residents' private space and property shall be respected at all times: a. Staff will knock and request permission before entering residents' rooms. On 3/9/23 at 8:30 a.m. to 8:45 a.m. observation on the 500 Hall of Certified Nursing Aide (CNA) II revealed her to enter rooms of R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, and R#65 without knocking on the doors, announcing her presence, or asking permission to enter prior to entering the rooms. On 3/9/23 at 8:48 a.m. an interview with CNA II verified she did not knock on resident doors, announce her presence, and she did not request permission to enter the rooms prior to entering the rooms. She revealed she was rushed and did not think to knock on the doors. She revealed she should knock on resident doors, announce her presence, and request permission to enter prior to entering resident rooms. On 3/9/23 at 3:55 pm an interview with the Director of Nursing (DON) revealed her expectation was for all staff to knock on resident doors, announce their presence and request permission to enter prior to entering the room. She revealed staff had been educated to knock on resident doors prior to entering and she planned to re-educate staff on the topic. On 3/10/23 at 1:40 p.m. to 1:55 p.m. an observation on the 500 Hall of CNA JJ revealed her to enter resident rooms R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#10, R#86, R#89, R#61, R#60, R#77, and R#21 without knocking on the doors, announcing her presence, and without requesting permission to enter prior to entering the rooms. On 3/10/23 at 1:56 p.m. an interview with CNA JJ verified that she did not knock on resident doors, announce her presence, or request permission to enter prior to entering the rooms and revealed she was not thinking and just forgot to knock on the doors. She revealed she should knock on resident doors, announce her presence and request permission to enter prior to entering resident rooms. 46691

Based on observations, interviews, record review and review of the policy titled Medication: Self Administration, the facility failed to ensure one of 64 sampled residents (R) (#97) was assessed to self-administer medications. Findings included: A review of the policy titled Medication: Self Administration dated December 2021, revealed the policy was for patients who request to self-administer medications will be assessed for capability. The policy revealed a physician's order is required, self-administration must be care planned, patient must be provided with a secure and locked area to maintain medications, patient must be instructed in self-administration, periodic evaluation of capability must be performed. A review of the clinical record revealed R#97 was an [AGE] year-old female admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD), prediabetes, morbid obesity, muscle weakness. A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 (indicating cognitively intact), required set-up and supervision with activities of daily living (ADLS), did not receive respiratory therapies or oxygen. A review of the physician's orders revealed an order for Trelegy Ellipta Aerosol 100/62.5/25 micrograms (mcg) per inhalation, one inhalation orally one time a day for COPD. There was not a physician's order for nebulizer treatments or for self-administration of medications. A review of the care plan revealed a focus area of resident has COPD, a goal of the resident will display optimal breathing patterns daily and interventions to include assess for shortness of breath or trouble breathing every shift, give aerosol or bronchodilators as ordered. There was not a care plan for self-administration of medications. An observation and interview of R#97 on 3/7/23 at 10:30 a.m. revealed one open box sitting on the floor next to a cabinet and containing eight boxes of ipratropium bromide 0.5 milligram (mg)/ albuterol 2.5 mg per 3 milliliters (ml) inhalations solution with an expiration date of 7/22, five boxes of ipratropium bromide 0.5 mg/albuterol 2.5 mg per 3 ml inhalations solution with an expiration date of 11/22, and two Trelegy Ellipta Aerosol 100/62.5/25 mcg per inhalation inhalers within expiration date. Observation revealed a nebulizer machine with tubing sitting on a shelf close to the bed. R#97 revealed her granddaughter had brought the medications and nebulizer machine for her to use and revealed she was capable of taking nebulizer treatments but was unsure if she had used one since admission to the facility. On 3/8/23 at 9:30 a.m. an observation revealed the open box containing the inhalers and inhalant medication sitting in the same location in R#97's room. On 3/8/23 at 4:00 p.m. an observation with Licensed Practical Nurse (LPN) MM verified the open box of medications sitting in R#97's room. LPN MM revealed the medications should not be in a resident's room and offered an explanation to R#97 and removed the medications from the room. On 3/11/23 at 10:40 am an interview with LPN NN revealed she worked through an agency. She revealed she was unaware of residents self-administering medications. She further revealed if medication was discovered in a resident room she would educate the resident about self-administration of medications, remove the medication, check the physician's order to verify if the medication was ordered and notify the unit manager. On 3/11/23 at 10:45 a.m. an interview with LPN OO revealed she worked through an agency. She revealed if she saw medications at the bedside, she would discuss with the resident, remove the medications, check the physician orders, notify the unit manager. On 3/11/23 at 11:00 a.m. an interview with LPN PP revealed she worked full time at the facility. She revealed she was unaware of residents having medications at bedside. She revealed if she discovered medications in a resident's room, she would educate the resident and remove the medication, check the physician's orders, and notify the unit nurse manager. On 3/11/23 at 11:25 a.m. an interview with the Director of Nursing (DON) revealed her expectations for resident self-administration of medication was for the resident to have a physician's order for self-administration of medication, a self-administration of medication assessment and determined to be clinically appropriate, and for the resident to be educated on and agree to the policy for self-administration of medications. She revealed there were no current residents determined clinically appropriate for self-administration of medications. She revealed she expected medications to be removed from resident rooms if discovered and the physician notified if a resident was self-administering a medication not ordered.

Based on observations, staff interviews, and review of facility documents, the facility failed to maintain a safe, clean, sanitary environment in 13 of 76 resident rooms (310, 306, 501, 502, 503, 504, 505, 506, 507, 508, 510, 512, and 514). Specifically, observations revealed buildup of brown fuzzy material on the heating and cooling units located in resident rooms on the 500 Hall (rooms 501,502, 504, 506, 508); buildup of white fuzzy material on ceiling ventilation covers in resident restrooms on the 500 Hall (rooms 501/503 (shared), 502/504 (shared), 506/508 (shared), 510/512 (shared), 505, 507, 514); black substance surrounding the base of the toilets in resident restrooms on the 500 Hall (rooms 501/503 (shared), 510/512 (shared), 505); one heating and cooling unit cover lying on the floor in room [ROOM NUMBER]; and reddish-brown colored splatter dried on wall behind the headboard of 306A. Findings included: 1. A review of the document titled Deep Clean Check Off List revealed a check off list that included line items of: A/C cleaned, Toilet cleaned front/back and included a line for staff signature and date. A review of the document titled Inspect exhaust fans for proper operation and clean if necessary revealed exhaust fans were to be checked every month. The section titled Instructions revealed line numbered 4. Clean vents using vacuum and air compressor, when needed to remove all dust. The facility did not provide a housekeeping or environmental services policy. Observations on 3/7/23 from 9:30 a.m. to 1:40 p.m. during initial resident screenings on the 500 Hall revealed the heating and cooling units located underneath the windows on the exterior walls in room [ROOM NUMBER], 502, 504, 506, and 508 to have a buildup of brown, fuzzy material in the ventilation areas. Observations on 3/7/23 from 9:30 a.m. to 1:40 p.m. during initial resident screenings on the 500 Hall revealed the restroom ceiling ventilation units in room rooms 501/503 (shared), 502/504 (shared), 506/508 (shared), 510/512 (shared), 505, 507, 514 to have a buildup of white, fuzzy material on the ceiling ventilation covers. Observations on 3/7/23 from 9:30 a.m. to1:40 p.m. during initial resident screenings on the 500 Hall revealed black substance surrounding the base of the toilets in rooms 501/503 (shared), 510/512 (shared), and 505. On 3/8/23 at 11:55 a.m. an interview with Housekeeping AA revealed she was aware of the ceiling vents having white fuzzy material in restrooms on 500 Hall, that some of the heating/cooling units had light brown fuzzy material on the vents, and that some of the toilets on 500 Hall had black substance surrounding the toilet at the floor. She further revealed maintenance was responsible for cleaning the ceiling vents, heating/cooling units, and maintenance of the toilets. She revealed she did not clean the ceiling vents, heating/cooling units, or base of the toilets. On 3/8/23 at 1:20 p.m. a walking tour of the 500 Hall resident rooms with the Maintenance Director verified resident restroom ceiling vents with white fuzzy material; heating/cooling units with brown fuzzy material on the vents; and toilets with black substance surrounding the base at the floor. He revealed housekeeping should check and clean the bathroom ceiling vents routinely and report concerns to the Director of Housekeeping. He revealed he was unsure why the identified concerns with the toilets and heating/cooling units had not been reported to the Maintenance Department. On 3/9/23 at 10:40 a.m. an interview with the Director of Housekeeping revealed housekeeping staff perform a high touch cleaning of resident rooms daily and a deep clean once a month and as needed. A housekeeping staff schedule for daily high touch cleaning and monthly deep cleaning was verified. He revealed that daily high touch cleaning included cleaning of surfaces, floors, and exterior ventilation units. He revealed the maintenance department is responsible for cleaning the ventilation units, the heating and cooling units, and the area at the base of the toilet. A review of the cleaning schedules revealed completed logs with staff signatures indicating schedules had been followed. The housekeeping schedules did not contain ceiling vents, heating/cooling units, or toilet maintenance. On 3/10/23 at 11:30 a.m. in an interview with the Director of Housekeeping, he revealed housekeeping staff can verbally report concerns to the supervisor or a nurse. He revealed the nurse may report a concern through an electronic system titled TELS and the maintenance department received the report. He revealed he was unsure if housekeeping had reported ceiling vents, heating/cooling units or toilets to anyone and was unsure if concerns had been reported to the maintenance department in the last three months. On 3/10/23 at 2:15 p.m. an interview with the Administrator revealed his expectations were for resident rooms and restrooms to be maintained in a clean and orderly fashion. He revealed that the maintenance department was responsible for cleaning the ceiling vents in resident restrooms and maintaining caulking around the toilets in the restrooms and the housekeeping department was responsible for cleaning the heating/cooling units, floors, and general surface areas. He further revealed work orders are communicated through electronic communication and by verbal communication. He revealed he planned to provide education to housekeeping and maintenance staff to ensure resident rooms and restrooms were maintained in a safe and clean manner.

Based on observations, record review, staff interviews, and review of the undated policy titled Resident Assessment - Coordination with PASARR Program the facility failed to submit an application for PASARR Level II (Preadmission Screening and Resident Review) screening for evaluation and determination of specialized services for two of 64 sampled residents (R) (R#102 and R#61). Findings Included: A review of the undated policy titled Resident Assessment - Coordination with PASARR Program revealed a policy of: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives services in the most integrated setting appropriate to their needs. The policy explanation and compliance guidelines sections line numbered 9 revealed: 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. 1. A review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed that R#102 had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact; no behaviors exhibited; Depression and Schizophrenia; ordered and receiving antipsychotic medication seven days a week. A review of the Physician's orders revealed Quetiapine Fumarate Tablet 100 MG (milligram) ordered one tablet by mouth two times a day for increased psychosis/agitation related to schizophrenia and antipsychotic medication, Seroquel ordered 300 mg orally at bedtime for psychosis related to schizophrenia. A review of R#102 diagnoses/conditions revealed the following but not limited to Schizophrenia, major depressive disorder, hypertension, and cocaine abuse. A review of the care plan dated 9/23/22 revealed that R#102 has a behavior problem such as: yelling at staff and exercises his right to not have his blood sugar taken, has been delusional at times; if reasonable, discuss the behavior with R#102. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Praise any indication of the resident's progress/improvement in behavior. The resident is resistive to care related to Schizophrenia diagnosis. The resident will cooperate with care through next review date R#102 will participate in care by allowing staff to weigh him through next review date. During an interview on 3/8/23 at 1:25 p.m. with Director of Social Services revealed a list of residents with PASARR Level II and stated that she would check for a PASARR Level II for R#102. During an interview on 3/8/23 at 3:30 p.m. with the Director of Social services confirmed that she still could not find any evidence that a PASARR Level II screening was conducted for R#102. During an interview on 3/11/23 at 1:40 p.m. Director of Social Services produced a copy of Medicaid portal showing PASARR Level II application entered on 3/11/23 for R#102. She stated that she did not know why a PASARR Level II wasn't entered sooner for R#102. 2. A review of the clinical record revealed R#61 was admitted on [DATE] with diagnosis including but not limited to major depressive disorder and spinal stenosis. On 6/29/21 a diagnosis of bipolar disorder was added. A review of the quarterly MDS dated [DATE] revealed a BIMS was coded as 15, indicating no cognitive impairment. Section A indicated there was not a PASARR Level I or PASARR Level II documented. Section E indicated exhibited verbal behavioral symptoms directed towards others one to three days and rejection of care four to six days. Section I indicated active diagnoses including depression, bi-polar disorder, psychotic disorder. Sections N indicated resident received antidepressant for seven of seven days, opioid one of seven days. Section O indicated the resident did not received psychological therapy. A review of the care plan revealed a focus area of resident had a mood problem related to bipolar diagnosis, with a goal of resident will have improved mood. Interventions included to observe for signs of mania or hypomania or euphoria. A review of physician visits revealed quarterly or monthly visits from a psychiatrist dated 11/3/19 to 1/26/23. On 3/8/23 at 1:25 p.m. an interview with the Director of Social Services revealed R#61 was admitted with a PASARR Level I and did not have a PASARR Level II and she was unsure why a PASARR Level II had not been completed. On 3/8/23 at 2:40 p.m. an interview with the Director of Nursing (DON) revealed she was unsure if R#61 needed a PASARR Level II due to a diagnosis of bipolar disorder and major depressive disorder. She revealed the Director of Social Services was responsible for ensuring residents with appropriate diagnosis have a PASARR Level II completed. On 3/9/23 at 9:00 a.m. an interview with the Director of Social Services verified R#61 had a diagnosis of bipolar and depression revealed a diagnosis of bipolar did not indicate the need for a PASARR Level II and R#61 did not have a PASARR Level II. 46691

Based on observations, record review, review of policy titled Oxygen Administration dated December 2022 and staff interview, the facility failed to ensure that one of 64 sampled residents (R) (R#49) were administered oxygen therapy in accordance with the physician orders and failed to date and label oxygen tubing. Findings included: A review of the policy titled Oxygen Administration dated December 2022 revealed under section Policy explanation and compliance guidelines number 5. B. states Change oxygen tubing, mask/cannula weekly and as needed if it becomes soiled or contaminated. During multiple observations on 3/7/23 at 10:15 a.m., on 3/8/23 at 10:41 a.m., and on 3/9/23 at 2:00 p.m. revealed R# 49 was receiving five Liters per minute (LPM) of oxygen therapy via nasal canula (NC) and the oxygen tubing was not dated. A review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#49 presented with a Brief Interview for Mental Status (BIMS) score 11, indicating moderate cognitive impairment, had a history of Shortness of breath (SOB) (always), and received oxygen therapy. A review of Physician's orders revealed that R#49 was ordered Oxygen at 3 liters via NC continuous, Albuterol 90 mcg (microgram) 2 puffs every 6 hours PRN (as needed), Ipratropium-albuterol 0.5/2.5 milligram (mg) every six hours PRN. A review of R#49 diagnoses revealed the following but not limited to emphysema, chronic obstructive pulmonary disease (COPD), hemiplegia, hypertension, muscle weakness, and intracerebral hemorrhage. A review of care plan dated 12/23/22 revealed R#49 to have altered respiratory status/difficulty breathing related to COPD, shortness of breath at rest, when lying flat and on exertion. The resident will have no complications related to SOB though the review date. Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for signs and symptoms of respiratory distress and report to doctor. Pace and scheduled activities provide adequate rest periods. Position resident with proper body alignment for optimal breathing pattern. An observation with Director of Nursing (DON) on 3/9/23 at 2:15 p.m., it was verified that R#49 oxygen setting was at five LPM and oxygen tubing was unlabeled and without date. An interview on 3/8/23 at 10:45 a.m. with R#49 revealed she does not touch the settings on her oxygen concentrator, and no one has changed the tubing that she has seen in a while. An interview on 3/9/23 at 2:15 p.m. with DON revealed R#49 should only be on 3 LPM per doctor order and tubing should be dated.

Based on observation, interviews and policy review, the facility failed to ensure that all medications were secured and stored properly for two of six medication carts. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications, Biological's, Syringes and Needles revised 10/28/2019, revealed number 3.3 facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Observation on 3/2/2021 at 11:45 a.m. during walking tour of the facility, medication cart on 100 Hall parked along the wall outside room [ROOM NUMBER] observed to be unlocked. There was no nursing staff in the hallway at the time. Observation on 3/3/2021 at 2:11 p.m. medication cart on 400 Hall parked along the wall outside room [ROOM NUMBER] was observed to be unlocked. There was no nursing staff in the hallway at the time. Observation on 3/10/2021 at 11:25 a.m. medication cart on 400 Hall parked along the wall outside room [ROOM NUMBER] was observed to be unlocked. There was one resident sitting in her wheelchair across from cart and two housekeeping staff cleaning rooms on the 400 Hall. There was no nursing staff in the hallway at the time. Registered Nurse (RN) CC was observed to be in an unoccupied resident room. Review of Education Course Attendance Sign-In Sheet dated 3/3/2021 revealed 1:1 education to Licensed Practical Nurse (LPN) BB regarding keeping medication carts locked at all times. Review of Disciplinary Action Record for RN CC revealed that there have a total of four situations pertaining to medication cart incidences. Interview on 3/2/2021 at 11:48 a.m. with RN AA, stated that she knows that she is supposed to keep the cart locked at all times. She stated that she just went to get ice for a resident and didn't think to lock the cart. Interview on 3/3/2021 at 2:15 p.m. with LPN BB, stated that she just forgot to lock the cart. She further stated that she was only gone for a few minutes. Interview on 3/10/2021 with Director of Nursing, verified that medication cart on 400 Hall was unlocked and Nurse was nowhere to be found on the hall. She stated that it is her expectation that the Nurses keep the medication carts locked when not in use. She further stated that the nurse on the 400 Hall has received multiple disciplinary actions pertaining to the medication cart incidences.

Based on interview and record review, the facility failed to provide updates to residents, their representatives and families by five p.m. the following day and/or cumulative updates on a weekly basis after five staff tested positive for coronavirus (COVID)-19. This had the potential to affect all residents, representatives and families. Findings include: Interview with the Director of Nursing (DON) on 6/23/2020 at 9:00 a.m. revealed the facility had completed testing on all their staff beginning on 6/5/2020. She further stated five staff tested positive for COVID-19 but displayed no symptoms. Review of Staff #1's Laboratory Report revealed she was tested on [DATE] and on 6/11/2020 it was reported she had a positive COVID-19 test. Review of Staff #2, #3, and #4's Laboratory Reports revealed they were tested on [DATE] and on 6/12/2020 it was reported they had all positive COVID-19 tests. Review of Staff #5's Laboratory Report revealed she was tested on [DATE] and on 6/19/2020 it was reported she had a positive COVID-19 test. Further interview with the DON on 6/23/2020 at 9:30 a.m. revealed the facility posted on their website updates to the COVID-19 status in the facility along with what the facility was doing to prevent further occurrences. She further stated the facility had not updated their website to include the facility had five staff members that had tested positive for COVID-19. Interview with the Administrator on 6/23/2020 at 1:15 p.m. revealed the Human Resource Manager (HRM) was supposed to update the website regarding the number of staff testing positive for COVID-19, but she was unaware of that until today. Interview with the HRM on 6/24/2020 at 8:53 a.m. revealed the DON would notify her of any staff testing positive for COVID-19 and then she would notify the HR Area Manager who would update the website. She further stated the HR Area Manager was on vacation, so the website was not updated until yesterday. The Administrator on 6/23/2020 at 10:00 a.m. revealed in an interview the facility did not have a policy for updating the residents, their representatives and families regarding COVID-19 status in the facility but provided a hand-written documentation of the process. Review of the written documentation revealed, cases were reported to the Regional Nurse and the Area Human Resource Manager by the facility for input into the emergency tracking system. Numbers were pulled from the emergency tracking system and posted to the website. The facility failed to update the residents, families and their representatives regarding the COVID-19 status in a timely manner. The website was updated on 6/23/2020; positive test results for staff were noted between 6/11/2020 - 6/19/2020.

Based upon observation, record review, staff and family interviews the facility failed to provide an environment that was free of accident hazards, including one resident (R#1), with wandering and elopement behaviors and was wearing a Wanderguard, who was found in the parking lot, by staff, the evening of 9/28/2016 then who eloped from the facility's main door, on Saturday, 10/1/2016, and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. This had the likelihood to affect eleven residents (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) with wandering behaviors who wore Wanderguard bracelets. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, when R#1, wearing a Wanderguard bracelet, was found by staff in the parking lot and then on 10/1/2016 eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 483.75(o)(1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans (F520 S/S: (J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (AOC) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Although based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician Orders were current and accurate and that care plans were updated for resident with wandering behaviors. Findings include: A telephone interview with the family of R#1 on 2/20/2017 at 5:02 p.m., revealed that the resident had eloped from the facility on 10/1/2016, fell on the main road (Anderson Mill Road), sustained a hematoma to the back of the resident's head and was transferred to the hospital for evaluation on the same day. The family member further revealed that the resident was wearing a Wanderguard bracelet and used a walker for ambulation at the time of the accident. Review of the care plan for R#1 dated 3/15/2016 and revised on 2/20/2017 revealed plans for: Elopement risk/wanderer by attempting to leave facility unattended with intervention including to distract resident from wandering offering pleasant diversions, structured activities, food, conversation, television, book. Wander Alert: Wanderguard bracelet. Review of the resident's care plan initiated 3/15/2016 identified R#1 had a problem with wandering due to confusion. The interventions included distracting the resident from wandering and the care plan interventions did include placement checks, of the Wanderguard, every shift as ordered by physician. Additionally, the care plan revealed a focus note dated 9/28/2016 that the resident was noted in the parking lot. Returned to facility. Further review of the care plan for R#1 revealed that new interventions to prevent elopement were not put into place which is the date the Immediate Jeopardy began. Review of the medical record for R#1 revealed that the resident was admitted into the facility 3/3/2016. Medical [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of eight (8) indicating mild cognitive impairment. Wandering behavior occurred one to three days of the look back period. Review of the functional status revealed R#1 required limited assistance for transfers, walking in her room and in corridors and on the unit and limited assistance for ambulation off the unit. Use of mobility devices include walker and wheelchair. R#1 was assessed to have no falls during the assessment period of 9/29/2016. Interview on 3/6/2017 at 3:27 p.m. with Licensed Practical Nurse (LPN) KK, MDS Coordinator, revealed that she updated R#1 care plan on 9/29/2016 due to the elopement into the parking lot. She further revealed she received the information in the Clinical meeting, where information is shared through reading or hearing the information about a resident. She also stated on the Wednesday morning of 9/29/2016, she was unable to recall, who gave her the information, that resident was found in the parking lot of facility on 9/28/2016. She further revealed that she did not ask for any paper work about the incident or discuss with staff possible new interventions to prevent another elopement. A review of the physician's orders dated 3/9/2016 revealed an order for [REDACTED]. Review of Medication Administration Record (MAR) for R#1 for September 2016 and October, 2016, revealed Wanderguard was checked for placement every shift. An interview with the former Administrator on 2/20/2017 at 6:14 p.m. revealed that she was not aware of a resident with a Wanderguard leaving the facility on 10/1/2016 nor was she aware of R#1 being found in the parking lot on 9/28/2016. She looked at the resident's record, and stated that R#1 did leave from the facility on 10/1/2016 and fell in the street outside of the facility and had to be sent to the hospital. The Administrator further revealed that she is to be called, by staff, for any unusual incident within the facility and doesn't remember getting a phone call about R#1 eloping from the facility. She stated that in the morning meeting at 9 a.m. daily, the Director of Nursing (DON) will read from the 24 Hour Report and the team members will discuss the situation. She revealed that she attends the Morning Meeting but was not certain if she was in the meeting on 10/1/2016 and that she was not aware of the resident's elopement. Review of the facility 24 hour reports for the month of September 2016 revealed there was no notation of the elopement of R#1 on 9/28/2016. Interview and observation of the door alarm system on 2/20/2017 at 6:30 p.m. with the former Maintenance Director (MD) EEE, revealed that she did not remember a resident eloping from the facility on 10/1/2016 or any resident eloping from the facility. She stated they use a Wanderguard activator to close the door at 7:00 p.m. nightly and open the door at 6:00 a.m. daily. She stated when you press on the door for twenty (20) seconds, the door will reopened and the alarms on the A hall are activated. Additional test by the MD EEE, and observed by the surveyor, of the main egress door indicated a chirping sound when the Wanderguard bracelet was near the door. All Wanderguards (11 residents) were checked at this time for functioning by MD EEE and all were functioning. Interview on 2/21/2017 at 3:41 p.m., by telephone, with LPN FF revealed she was assigned to work on 200 and 400 Halls on the 11:00 p.m. to 7:00 a.m. shift beginning on 9/30/2016 through 10/1/2016 and R#1 was one her residents. She stated that on 10/1/2016 the resident was returned to her unit by Registered Nurse (RN) HH who stated that R#1 had left the building and fell in the street, outside the facility, and was brought back in the facility in a wheelchair. She stated the resident was ok except for a bump on the back of her head. She stated the resident was sent out to the hospital for examination. LPN FF further revealed that she informed the doctor, the family member and the facility Administrator. LPN FF stated it took a minute to get in touch with the Administrator and she told the Administrator what had happen to the resident, the resident elopement and a bump to the back of R#1 head. She also told the Administrator the resident was sent to the hospital. LPN FF stated the Administrator thanked her for the information and stated that RN HH had already contacted her. She stated the Wanderguard was checked and it was working and that she conducted a neurological check on R#1 although she did not document it. She also stated the incident was recorded on the 24 Hour report. Interview on 2/21/2017 at 4:18 p.m. by telephone with RN HH revealed she was assigned to 500 and 600 Halls on 9/30/16 and at around 6:30 a.m. on 10/1/2016 a housekeeper came into Room 618 and told her a resident had fallen on the street outside of the facility. She stated she ran to the street and saw the resident on the sidewalk with her walker. She stated she assessed the resident and the CNA brought a wheelchair outside and she placed R#1 in the wheelchair and returned her to LPN FF for further assessment. RN HH stated it was a very busy night and that she sent a text to the former Administrator with information about the night shift, including the elopement and the resident's name to the Administrator. She further revealed that the Administrator responded by saying what a busy night. Interview on 2/21/2017 at 12:40 p.m. with the Director of Nursing (DON) revealed she was not present in the facility until January 2017. She further revealed she could not locate any information about the elopement addressed by the interdisciplinary team or any investigation of how the elopement occurred on either 9/28/2016 or 10/1/2016. A telephone interview on 2/21/2017 at 3:15 p.m. with Housekeeper EE revealed that she arrived at the facility on 10/1/2016 at approximately 6:30 a.m. when she saw a female parked half way in the driveway and half way on the street. She stated her husband continued into the facility's parking lot and parked the car. She further revealed that while walking into the facility she heard the lady say one of your resident has fallen in the middle of the street. The housekeeper entered the facility through an open door and got a nurse to help the resident. Two CNAs also helped her to bring the resident back into the facility. Housekeeper EE further revealed that the lady with the black car, at the driveway, was on her phone and called 911. Review of the 911 report, revealed the call came in to Fire and Rescue at 6:38 a.m. on 10/1/2016 but was canceled by the police department who was on scene. Review of Sunrise Sunset times for Austell Georgia on 10/1/2016 revealed that sunrise occurred at 7:08 a.m. and that R#1 fell in the street at approximately 6:30 a.m. on Saturday, 10/1/2016 while it was dark outside. Interview on 2/22/2017 at 2:49 p.m. with the Facility Medical Director (FMD) revealed if the documentation stated he was informed, then he was informed. He further revealed that on 10/2/2016 he was in the building, and did not discuss elopement with anyone. The FMD stated he did not remember elopement being discussed in the QAPI meeting in October 2016, but falls were discussed including the root cause analysis. Observation, by the surveyor, on Tuesday, 3/7/2017 at 6:40 a.m. until 7:05 a.m. revealed that it was dark, although with street lights, a flashlight was not needed. Observation of the cars along the road revealed a total of one hundred and ninety-four (194) motor vehicles were observed on Anderson Mill Road, directly in front of the facility's entrance to the parking lot. The road has a total of two (2) lanes, measuring twenty-five (25) feet across the street. The motor vehicles included cars, vans, small trucks, SUV, one (1) small school bus, and (1) regular size school bus. The speed limit was thirty-five (35) miles per hour. Anderson Mill Road connects to Highway 5 which is a major thoroughfare in the area. Review of the Progress Notes dated 10/1/2016 at 7:00 a.m. revealed The resident was observed outside the facility by a housekeeping employee, which notified staff at A Hall station. Nursing staff from A Hall Nurse's station observed the resident laying in the road (Anderson Mill Road), and they directed traffic around this resident to avoid her being hit by a car. They then assisted her back into the facility with a wheelchair. Upon assessment, resident able to ambulate with walker, is alert with confusion, which is normal for her. She does have a hematoma on the back of her head. Neurological check done and were within normal limits (WNL) for her. Family notified on 10/1/2016 at 7:00 a.m. and the resident's physician on 10/1/2016 at 6:45 a.m. which was signed by LPN FF. Review of the Transfer Form documents that R#1 was transferred to the hospital on [DATE]. Progress notes dated 10/1/2016 at 11:11 a.m. revealed the resident is in the emergency room . Review of the 24 hour Report/Change of Condition Report dated 9/30/2016 (to include any condition changes within the past 24 hours) revealed that R#1 was sent to the emergency room (ER) at 7:15 a.m. Review of remarks: Elopement (Wanderguard in place) visitor let her out front door. fell in road-hit head (on 10/1/2016), sent to ER 7:15 a.m. Family notified. Physician paged, awaiting response. The surveyor reviewed all 24 hour Report/Change of Condition reports for the month of September 2016 which did not contain a notation of finding the resident in the parking lot on 9/28/2016. Review of the hospital Emergency records dated 10/1/2016 from 7:45 a.m. until 11:21 a.m. revealed the resident had a small hematoma to scalp. No other complaints, but considering age and relatively frailty, in addition to being on ASA (Aspirin), will get CT scan of head, C-spine x-ray, chest x-ray and pelvis x-ray and labs. Findings on the same day at 9:55 a.m. revealed that labs and imaging unremarkable. Patient feels well and patient's sister at bedside, agrees that she is at her baseline. Will arrange EMS (Emergency Medical Services) transport back to her NH (Nursing Home). Review of the Progress Notes dated 10/1/2016 at 12:46 p.m. revealed resident returned from hospital via EMS per stretcher accompanied per family member without broken or bruised areas. No new orders. Vital signs are stable. No c/o (complaints) voiced. Review of the Direct Supply TELS LOGBOOK DOCUMENTATION for 9/19/2016 through 9/24/2016, 9/27/2016 through 10/1/2016 and 10/3/2016 through 10/8/2016 revealed that seven doors are checked daily to determine: Door is secured, Door opens freely, Door closes smoothly, Door closes quickly, Door latches properly. Review of the Logbook revealed that the current MD FFF checks these doors daily but does not indicate if the Wanderguard system is checked. An interview with the interim MD FFF on 3/7/2017 at 12:32 p.m. revealed that the company responsible for maintaining the Wanderguard system and the door locks was in the building on 2/22/2017 and found there was a cross up between the Wanderguard and the key pad on the main entrance door. He further revealed that the cross up, if someone entered the code into the key pad, would disable the Wanderguard system. The company separated the key pad and the Wanderguard system to ensure that, if someone used the key pad, it would not disable the Wanderguard system. The doors automatically lock between 8:00 p.m. and 8:10 p.m. and reopen automatically between 6:00 a.m. and 6:10 a.m. which MD FFF has checked and are working properly. Review of the Progress Notes dated 10/4/2016 at 11:50 p.m. revealed the resident was complaining of chest pain mid-sternum and transferred to the emergency room . The resident returned from the hospital on the same day at 11:50 a.m. without new orders. Review of the Progress Notes dated 10/9/2016 at 12:35 p.m. revealed the resident has increased confusion, denies pain or discomfort when voiding. Resident has tried to elope and is more confused. The hospital physician called and ordered Macrobid (antibiotic) for seven days for a Urinary Tract Infection (UTI). Record review of the facility policy titled Resident Elopement Revised August 2012 revealed: Policy: The facility strives to provide a safe environment and preventive measures for elopement. Personnel must report and investigate all reports of missing residents. Fundamental Information: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the DON and the Administrator and to document the occurrence. Procedure: Prevention, 1. Facility creates a photographic directory of residents identified at risk for elopement. a. Photograph residents identified at risk for elopement by the Nursing Admission Assessment upon admission. b. Store printed photographs, labeled with resident name and room number, in a binder. Multiple binders may be created if facility has multiple egress locations. Wander/Elopement Alarm Activation: 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm. b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement. c. If no resident is found to be exiting the facility, the employee should i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure all residents are accounted for. Attempted Elopement, 1. If an employee observes an attempted elopement, he or she should: a. Be courteous in preventing the departure and in returning the resident to the facility. b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the DON and the Administrator that a resident is attempting to leave the premises. 2. Upon return of the resident to the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (DON), b. Contract the attending physician, report what happened, and follow the physician's orders; c. Contact the resident's legal representative and inform them of the incident; d. Complete and file an Incident/Accident Report, (Briggs), e. Make appropriate notations in the resident's medical record (DON), f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventive interventions for elopement (DON). Observation of R#1 on 2/27/2017 at 11:59 a.m. revealed the resident was sitting in her wheelchair, watching television, very pleasant when approached and stated everything was ok. The resident's Wanderguard bracelet was in place. The facility could not produce evidence that the elopement of R#1 had been investigated prior to 2/20/2017, for either the 9/28/2016 or 10/1/2016 elopement, nor to determine the cause of the elopement or interventions to prevent the elopement of R#1 or the 10 residents with Wanderguard bracelets. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/20/2017 the facility Unit Managers completed a chart review and all residents that are identified at risk for elopement and had Wanderguard in place. 11 residents were reviewed and 1 resident's Wanderguard was discontinued. As of March 8, 2017 there are 11 residents remain with Wanderguards at this time. These Wanderguards will be checked for placement by the licensed nurse and documented on the Medication Administration Record every shift. These Wandergards are being checked for proper function by a Licensed Nurse and documented on the Medication Administration Record every day. New Admission residents are assessed upon admission for Elopement Risk using the Nursing Data Collection Form. If a resident is found to be at risk a physician order for [REDACTED]. The Wanderguard placement will be checked by the licensed nurse and documented on the Medication Administration Record. The Wanderguard function will be checked by the licensed nurse daily and documented on the Medication Administration Record. 3. On 2/20/2017 the facility Unit Managers completed a new Elopement Assessment on all residents documenting this assessment in the Elopement Assessment form located in Point Click Care. 4. On 2/20/2017 the facility Unit Managers reviewed and updated the care plans for residents at risk for elopement. 5. On 2/20/2017 the interdisciplinary team reviewed and updated the Elopement Risk Binders located at each Nurses station and the front desk. 6. On 2/20/2017 the facility Unit Managers reviewed and updated physician orders for check for placement and functioning of the Wanderguard for every shift. This occurred for 11 residents. 7. On 2/20/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 8. On 2/20/2017 the District Director of Clinical Services checked the front lobby Wanderguard system and it was functioning properly. 9. On 2/24/2017 the Maintenance Director checked all Wanderguards for functioning and all were functioning properly. Maintenance Director completes checks of Wandergard door system every day and documenting these checks on Weekly Checklist for Door Modules. 10. On 3/6/2017 the Contract Company installed 4 annunciators throughout the facility and installed 1 additional Annunciator panel for staff to be able to quickly tell what door has been breached. 11. On 2/20/2017 at 8:00 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms, if the door alarmed, why and what action was taken. 12. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at Anderson Mill as of 3/7/2017. 13. On 3/7/2017 signage was added to the doorways alerting visitors to please do not assist any of our residents outside without checking with the nursing staff. 14. On 2/20/2017 the managers began to educate staff on the Elopement policy. As of 3/7/2017, (89.6%) 138 out of 154 employees which includes the contracted staff were educated and 1 RCS, 1 RN supervisor, 1 Maintenance on LOA. The following employees received the education; 2 Activity employees, 2 Admissions Coordinators, 2 Business office, 1 medical records, 17 LPNs, 2 Maintenance department, 4 MDS, 15 Occupational therapists, 2 front office, 1 receptionist, 30 RCS, 1 Respiratory therapist, 2 Restorative RCS, 1 RN, 2 Social Services, 1 SDC, 1 RN unit manager, 3 LPN unit managers, 1 LPN wound care, 11 Dietary, and 12 Housekeeping/Laundry, 5 Speech Therapists, 1 Rehab aide, 14 physical therapists, 1 DON (interim contracted DON) and 4 agency nurses. Any staff that has not received this education will not be permitted to work until education is completed. Newly hired employees and any new agency staff will receive this education prior to working. The interim Administrator has been educated by the Director of Nursing related to the Elopement policy. 15. On 2/24/2017 the facility department managers began questioning 1 employee per day while in the facility on: What type of events would you report to the Administrator of DON? What would you do if the Administrator or DON did not respond to your call? What would you do if you felt your reported issue was not taken seriously? What would you do if you felt that your supervisor or another manager was not being truthful about events occuring in the facility? Are you aware of any events that have occured that may not have been reported? Do you know where the corporate compliance hotline is? What is code Yellow? What would you do if the Wanderguard system, was alarming, but when you went to the front lobby there was no resident in the area? The Staff Survey Questions monitoring forms were completed with 34 employees from 3/2/24- 3/5/17, 20 employees on3/6/2017, 19 employees on 3/7/2017 and documented on Staff Survey Question monitoring forms. 16. An Adhoc QAPI meeting was held on 3/6/2017 at 12:30pm. Medical Director attended by conference call and the following employees were present; interim Administrator, A/R coordinator, interim DON, Medical Records Coordinator, LPN DD, Unit Manager, Registered Nurse HHH, MDS Manager, Social Services (SS) Director QQ, SS assistant III, Admission Coordinator, Interim Rehab Program Manager, Business Office Director, Activity Director, interim Maintenance Director and the Director of Regulatory Compliance. Agenda items related to both complaint surveys. 17. On 2/20/2017 the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance Committee each month by the Administrator and/or the DON, to allow the QA committee to monitor staff compliance with the facility's policies and procedures regarding Resident Elopement and Elopement Response. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review on 3/8/2017 of the facility Wanderguard list revealed eleven (11) residents on the list. Review of the Medication Administration Record (MAR) for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11, revealed that the documentation of the Wanderguards are on the MARs with note to check for placement and functioning, a Physician's order for the Wanderguard was noted for each resident. Review of the Elopement Books revealed that all eleven resident's had their photographs and information entered into the Elopement Books kept at the Nurse's Station. There were no new admissions to check at this time. 3. Review of Point Click Care for the eleven residents with wandering behaviors the surveyor confirmed that all eleven residents were assessed for Elopement risk on 2/20/2017. Two residents, R#8 and R#10, were assessed with [REDACTED]. Review of the Elopement Assessment, dated 2/20/2017, for R#17, R#18, R#19, R#20, R#21, R#22, R#23, R#24, R#25, R#26, R#27, R#28, R#29, R#30, R#31 and R#32 revealed the residents were not at risk nor had behaviors that would warrant the use of a Wanderguard. 4. Review of the Care Plans for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11 revealed an update dated 2/20/2017 that the residents are an elopement risk/wander. Resident wanders aimlessly, impaired safety awareness. Interventions: Check placement and function of safety monitoring device every shift, Observe location at regular and frequent intervals. Document wandering behavior and attempted diversional interventions. The care plans were additionally personalized for each resident. 5. Review of the Elopement Risk Binders located at each Nurse's Station and the Front desk revealed the binder's had been updated to include the 11 resident's currently at risk for elopement. 6. Review of the Physician's Orders revealed the orders were updated for check for placement and functioning of Wanderguard for every shift for the eleven residents with Wanderguards. 7. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 8. Review on 3/8/2017 of the checklist titled Wanderguard System Check dated 2/20/2017 through 2/23/2017 was completed by the Director of Clinical Services three times each day. 9. Review on 3/8/2017 revealed that the interim MD was checking the Wanderguard system daily and was noted on the daily door checklist. 10. Review of the Contractor invoice dated 3/6/2017 revealed that one secondary Wanderguard annunciator had been installed on the rear Nurse's Station (B Hall) which will allow staff to see which door had been breached. Additionally, four alarms had been added throughout the facility to alarm staff of a Wanderguard breach. This was confirmed by Observation, by the surveyor, on 3/8/2017 at 3:00 p.m. with the interim MD. 11. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 12. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017, pending investigation of R#1's elopement on 10/1/2017 . Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017. 13. Observation on 3/8/2017 at 3:15 p.m. revealed the signage at the doorways stating Attention Visitors and Family Members: For the safety of our resident's please do not assist other residents outside of the facility without staff approval. 14. Review of the in-service sign-in sheets revealed that in-services were held on 2/20/2017 with 68 staff in-serviced, 2/22/2017 with 52 staff in-serviced, on 2/23/2017 with six staff members in-serviced and one staff member was in-serviced on 2/24/2017 and 10 employees in-serviced on 3/7/2017 for a total of 137 staff members (direct employees and contract employees) of

Based on family and staff interviews, record review and review of the facility's Policy and Procedure for Elopement, it was determined the facility failed to be administered in a manner to investigate an Elopement of one resident (R#1) as to the cause and to prevent the likelyhood of elopement for the additional ten (10) at risk residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) of a total of eleven residents with wandering behaviors and wearing a Wanderguard bracelet. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, the date a resident (R#1) wearing a Wanderguard, was found in the parking lot by staff on the 3:00 p.m. to 11:00 p.m. shift followed on 10/1/2017 when the resident eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 483.75(o)(1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans (F520 S/S: (J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (AOC) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician Orders were current and accurate and that care plans were updated for resident with wandering behaviors. Findings include: During a telephone interview with a family member of R#1 on 2/20/2017 at 5:00 p.m., the family member revealed that R#1 had eloped from the facility on 10/1/2016 and had fallen in the main road (Anderson Mill Road). R#1 had sustained a hematoma to the back of the resident's head and was transported to the emergency room for evaluation. The family member confirmed that R#1 was wearing a Wanderguard bracelet at the time of the elopement on 10/1/2016 and used a walker for ambulation. Review of the resident's care plan dated 3/15/2017 and revised on 2/20/2017 revealed the resident was care planned for wandering behaviors, confusion and for the use of a Wanderguard bracelet due to exit seeking behaviors. Additionally, the care plan revealed a focus note dated 9/28/2016 that the resident was noted in the parking lot. Returned to facility. Further review of the care plan for R#1 revealed that new interventions to prevent elopement were not put into place which is the date the Immediate Jeopardy began. An interview with the former Administrator on 2/20/2017 at 6:14 p.m. revealed that she was not aware of a resident with a Wanderguard leaving the facility on 10/1/2016 nor was she aware of R#1 being found in the parking lot on 9/28/2016. She looked at the resident's record, and stated that R#1 did leave from the facility on 10/1/2016 and fell in the street outside of the facility and had to be sent to the hospital. The Administrator further revealed that she is to be called, by staff, for any unusual incident within the facility and doesn't remember getting a phone call about R#1 eloping from the facility. The Administrator revealed that the facility has a morning meeting daily at 9:00 a.m. which she attends although she was not certain if she had attended the meeting on 10/1/2016 and that she was not aware of the resident's elopement. Review of the facility 24 hour reports for September 2016 revealed there was no notation of the elopement of R#1 on 9/28/2016. Interview and observation of the door alarm system on 2/20/2017 at 6:30 p.m. with the former Maintenance Director (MD) EEE, revealed that she did not remember a resident eloping from the facility on 10/1/2016 or any resident eloping from the facility. Test by the MD EEE, and observed by the surveyor, of the main egress door indicated a chirping sound when the Wanderguard bracelet was near the door. All Wanderguards (11 residents) were checked at this time for functioning by MD EEE and all were functioning. Interview on 2/21/2017 at 3:41 p.m., by telephone, with Licensed Practical Nurse (LPN) FF revealed she was assigned to work on 200 and 400 Halls on the 11:00 p.m. to 7:00 a.m. shift on 9/30/2016 and R#1 was one her residents. She stated the resident was returned to her unit by Registered Nurse (RN) HH who stated that R#1had left the building and fell in the street, outside the facility, and was brought back in the facility in a wheelchair. She stated the resident was ok except for a bump on the back of her head. She stated the resident was sent out to the hospital for examination. LPN FF further revealed that she informed the doctor, the family member and the facility Administrator. LPN FF stated it took a minute to get in touch with the Administrator and she told the Administrator what had happen to the resident, the resident elopement and a bump to the back of R#1 head. She also told the Administrator the resident was sent to the hospital. LPN FF stated the Administrator thanked her for the information and stated that RN HH had already contacted her. She stated the Wanderguard was checked and it was working and that she conducted a neurological check on R#1 although she did not document it. She also stated the incident was recorded on the 24 Hour report. Interview on 2/21/2017 at 4:18 p.m. by telephone with Registered Nurse (RN) HH revealed she was assigned to 500 and 600 Halls on 9/30/16 and at around 6:30 a.m. on 10/1/2016 a housekeeper came into room [ROOM NUMBER] and told her a resident had fallen on the street outside of the facility. She stated she ran to the street and saw the resident on the sidewalk with her walker. She stated she assessed the resident and the Certified Nursing Assistant (CNA) brought a wheelchair outside and she placed R#1 in the wheelchair and returned her to LPN FF for further assessment. RN HH stated it was a very busy night and that she sent a text to the former Administrator with information about the night shift, including the elopement and the resident's name to the Administrator. She further revealed that the Administrator responded by saying what a busy night. Record review of the facility policy titled Resident Elopement Revised August 2012 revealed: Policy: The facility strives to provide a safe environment and preventive measures for elopement. Personnel must report and investigate all reports of missing residents. Fundamental Information: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the DON and the Administrator and to document the occurrence. Procedure: Prevention, 1. Facility creates a photographic directory of residents identified at risk for elopement. a. Photograph residents identified at risk for elopement by the Nursing Admission Assessment upon admission. b. Store printed photographs, labeled with resident name and room number, in a binder. Multiple binders may be created if facility has multiple egress locations. Wander/Elopement Alarm Activation: 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm. b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement. c. If no resident is found to be exiting the facility, the employee should i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure all residents are accounted for. Attempted Elopement, 1. If an employee observes an attempted elopement, he or she should: a. Be courteous in preventing the departure and in returning the resident to the facility. b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the DON and the Administrator that a resident is attempting to leave the premises. 2. Upon return of the resident to the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (DON), b. Contract the attending physician, report what happened, and follow the physician's orders; c. Contact the resident's legal representative and inform them of the incident; d. Complete and file an Incident/Accident Report, (Briggs), e. Make appropriate notations in the resident's medical record (DON), f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventive interventions for elopement (DON). The facility could not produce evidence that the elopement of R#1 had been investigated prior to 2/20/2017, for either the 9/28/2016 or 10/1/2016 elopement, nor to determine the cause of the elopement or interventions to prevent the elopement of R#1 or the 10 residents with Wanderguard bracelets. Cross refer to F323 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/22/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 3. On 2/20/2017 at 8:00 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms and if the door alarmed, why and what action was taken. 4. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at(NAME)Mill as of 3/7/2017. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 3. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 4. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017, pending investigation of the 10/1/2016 Elopement of R#1. Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017.

Based on observation, record review and staff interview, it was determined that the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) committee that identified, developed and implemented corrective action plans to correct a problem of the Wanderguard System not functioning properly to prevent the Elopement of one resident (R#1) and to ensure that ten (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) additional residents with wandering behavior, who were wearing Wanderguards bracelets did not exit the facility unattended. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, when R#1, wearing a Wanderguard bracelet, was found by staff in the parking lot and then on 10/1/2016 eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 483.75(o)(1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans (F520 S/S: (J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (AOC) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician order [REDACTED]. Findings include: An interview on 3/8/2017 at 6:22 p.m., with the interim Administrator, revealed that the QAPI meets monthly. The interim Administrator revealed that the QAPI meetings were held on 10/19/2016 and 12/21/2016 although there was no evidence that Elopement was discussed in these meetings. The interim Administrator did produce sign-in sheets from the Adhoc QAPI meeting held on 3/6/2017 where the Immediate Jeopardy related to Elopement and Wanderguards was discussed, the Allegation of Credible Compliance (AOC) was addressed and the Action Plan, to prevent further elopement which the facility began immediately on 2/20/2017 when the problem with the main entrance was brought to the facility's attention. An interview with the Medical Director on 2/22/2017 at 2:49 p.m. revealed that he attended the October 2016 QAPI meeting but does not remember discuss anything related to elopements. He further revealed he does remember that falls were discuss during that meeting. Review of the QAPI meeting sign-in sheets revealed that on 10/19/2016 the QAPI committee met with the Administrator and the Medical Director were in attendance. Review of the QAPI sign-in sheet for 12/21/2016 revealed that the Administrator and the Medical Director were in attendance. Review of the QAPI sign-in sheet for 3/6/2017 revealed the interim Administrator, the interim Director of Nursing (DON), and the Medical Director, via conference call, plus representatives of multiple departments of the facility. An interview with the interim Administrator on 3/8/2017 at 7:30 p.m. revealed that the facility could not produce evidence that the Elopement of R#1 on 9/28/2016 and on 10/1/2016 was addressed by the QAPI committee until 3/6/2017. Cross refer to F323 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/20/2017 the facility Unit Managers completed a chart review and all residents that are identified at risk for elopement and had Wanderguard in place. 11 residents were reviewed and 1 resident's Wanderguard was discontinued. As of 3/8/2017 there are 11 residents remaining with Wanderguards at this time. These Wanderguards will be checked for placement by the licensed nurse and documented on the Medication Administration Record every shift. These Wandergards are being checked for proper function by a Licensed Nurse and documented on the Medication Administration Record every day. New Admission residents are assessed upon admission for Elopement Risk using the Nursing Data Collection Form. If a resident is found to be at risk a physician order [REDACTED]. The Wanderguard placement will be checked by the licensed nurse and documented on the Medication Administration Record. The Wanderguard function will be checked by the licensed nurse daily and documented on the Medication Administration Record. 3. On 2/20/2017 the facility Unit Managers completed a new Elopement Assessment on all residents documenting this assessment in the Elopement Assessment form located in Point Click Care. 4. On 2/20/2017 the facility Unit Managers reviewed and updated the care plans for residents at risk for elopement. 5. On 2/20/2017 the interdisciplinary team reviewed and updated the Elopement Risk Binders located at each Nurses station and the front desk. 6. On 2/20/2017 the facility Unit Managers reviewed and updated physician orders [REDACTED]. This occurred for 11 residents. 7. On 2/22/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 8. On 2/20/2017 the District Director of Clinical Services checked the front lobby Wanderguard system and it was functioning properly. 9. On 2/24/2017 the Maintenance Director checked all Wanderguards for functioning and all were functioning properly. Maintenance Director completes checks of Wandergard door system every day and documenting these checks on Weekly Checklist for Door Modules. 10. On March 6, 2017 the contractor installed 4 annunciators throughout the facility and installed 1 additional Annunciator panel for staff to be able to quickly tell what door has been breached. 11. On 2/20/2017 at 8 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms, if the door alarmed, why and what action was taken. 12. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at Anderson Mill as of March 7, 2017. 13. On 3/7/2017 signage was added to the doorways alerting visitors to please do not assist any of our residents outside without checking with the nursing staff. 14. On 2/20/2017 the managers began to educate staff on the Elopement policy. As of 3/7/2017 , (89.6%) 138 out of 154 employees which includes the contracted staff were educated and 1 RCS, 1 RN supervisor, 1 Maintenance on LOA. The following employees received the education; 2 Activity employees, 2 Admissions Coordinators, 2 Business office, 1 medical records, 17 LPNs, 2 Maintenance department, 4 MDS, 15 Occupational therapists, 2 front office, 1 receptionist, 30 RCS, 1 Respiratory therapist, 2 Restorative RCS, 1 RN, 2 Social Services, 1 SDC, 1 RN unit manager, 3 LPN unit managers, 1 LPN wound care, 11 Dietary, and 12 Housekeeping/Laundry, 5 Speech Therapists, 1 Rehab aide, 14 physical therapists, 1 DON (interim contracted DON) and 4 agency nurses. Any staff that has not received this education will not be permitted to work until education is completed. Newly hired employees and any new agency staff will receive this education prior to working. The interim Administrator has been educated by the Director of Nursing related to the Elopement policy. 15. On 2/20/2017 the facility department managers began questioning 1 employee per day while in the facility on: What type of events would you report to the Administrator of DON? What would you do if the Administrator or DON did not respond to your call? What would you do if you felt your reported issue was not taken seriously? What would you do if you felt that your supervisor or another manager was not being truthful about events occuring in the facility? Are you aware of any events that have occured that may not have been reported? Do you know where the corporate compliance hotline is? What is code Yellow? What would you do if the Wanderguard system, was alarming, but when you went to the front lobby there was no resident in the area? The Staff Survey Questions monitoring forms were completed with 34 employees from 2/24/2017 through 3/5/17, 20 employees on 3/6/2017, 19 employees on March 7, 2017 and documented on Staff Survey Question monitoring forms. 16. An Adhoc QAPI meeting was held on 3/6/2017 at 12:30pm. Medical Director attended by conference call and the following employees were present; interim Administrator, A/R coordinator, interim DON, Medical Records Coordinator, LPN DD, Unit Manager, Registered Nurse HHH, MDS Manager, Social Services (SS) Director QQ, SS assistant III, Admission Coordinator, Interim Rehab Program Manager, Business Office Director, Activity Director, interim Maintenance Director and the Director of Regulatory Compliance. Agenda items related to both complaint surveys. 17. On 2/20/2017 the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance Committee each month by the Administrator and/or the DON, to allow the QA committee to monitor staff compliance with the facility's policies and procedures regarding Resident Elopement and Elopement Response. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review on 3/8/2017 of the facility Wanderguard list revealed eleven (11) residents on the list. Review of the Medication Administration Record (MAR) for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11, revealed that the documentation of the Wanderguards are on the MARs with note to check for placement and functioning, a physician's orders [REDACTED]. Review of the Elopement Books revealed that all eleven resident's had their photographs and information entered into the Elopement Books kept at the Nurse's Station. There were no new admissions to check at this time. 3. Review of Point Click Care for the eleven residents with wandering behaviors the surveyor confirmed that all eleven residents were assessed for Elopement risk on 2/20/2017. Two residents, R#8 and R#10, were assessed with [REDACTED]. Review of the Elopement Assessment, dated 2/20/2017, for R#17, R#18, R#19, R#20, R#21, R#22, R#23, R#24, R#25, R#26, R#27, R#28, R#29, R#30, R#31 and R#32 revealed the residents were not at risk nor had behaviors that would warrant the use of a Wanderguard. 4. Review of the Care Plans for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11 revealed an update dated 2/20/2017 that the residents are an elopement risk/wander. Resident wanders aimlessly, impaired safety awareness. Interventions: Check placement and function of safety monitoring device every shift, Observe location at regular and frequent intervals. Document wandering behavior and attempted diversional interventions. The care plans were additionally personalized for each resident. 5. Review of the Elopement Risk Binders located at each Nurse's Station and the Front desk revealed the binder's had been updated to include the 11 resident's currently at risk for elopement. 6. Review of the physician's orders [REDACTED]. 7. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 8.8. Review on 3/8/2017 of the checklist titled Wanderguard System Check dated 2/20/2017 through 2/23/2017 was completed by the Director of Clinical Services three times each day. 9. Review on 3/8/2017 revealed that the interim MD was checking the Wanderguard system daily and was noted on the daily door checklist. 10. Review of the Contractor invoice dated 3/6/2017 revealed that one secondary Wanderguard annunciator had been installed on the rear Nurse's Station (B Hall) which will allow staff to see which door had been breached. Additionally, four alarms had been added throughout the facility to alarm staff of a Wanderguard breach. This was confirmed by Observation, by the surveyor, on 3/8/2017 at 3:00 p.m. with the interim MD. 11. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 12. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017. Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017. 13. Observation on 3/8/2017 at 3:15 p.m. revealed the signage at the doorways stating Attention Visitors and Family Members: For the safety of our resident's please do not assist other residents outside of the facility without staff approval. 14. Review of the in-service sign-in sheets revealed that in-services were held on 2/20/2017 with 68 staff in-serviced, 2/22/2017 with 52 staff in-serviced, on 2/23/2017 with six staff members in-serviced and one staff member was in-serviced on 2/24/2017 and 10 employees in-serviced on 3/7/2017 for a total of 137 staff members (direct employees and contract employees) of 154 employees related to the updated Elopement Policy and Procedures and the Reporting Process for direct care and indirect staff. In-services continued, including re-in-service of staff on 3/6/2017 with 12 staff receiving in-service, 3/7/2017 with two staff in-serviced and 3/8/2017 for both direct and indirect resident care staff. An interview with the Social Service Director (SSD) QQ on 3/8/2017 at 3:55 p.m. revealed that she had been in-serviced on the updated Elopement Policy and Procedures and the Reporting Process. She was questioned on her knowledge of the process and was aware of the updated policy and procedure and who to contact should someone elope or attempt to elope from the facility. Interviews with Resident Care Specialists (RCS), also known as Certified Nursing Assistant (CNAs) on 3/8/2017 revealed that RCS RR at 3:58 p.m., RCS TT at 4:05 p.m., RCS VV at 4:15 p.m., RCS XX at 4:25 p.m., RCS YY at 4:30 p.m. and RCS ZZ at 5:00 p.m. had attended in-services regarding the updated Elopement Policy and Procedures, Reporting Process and ensure that resident's with Wanderguards had them in place. They were aware of what events to report to the DON and/or Administrator and what to do if they did not respond to their call, what a Code Yellow is and what to do if the Wanderguard system is alarming. They were aware of how to report to the Corporate Compliance line and the SSA complaint number as well. An interview with Housekeeper OO on 3/8/2017 at 3:50 p.m. revealed that he had attended in-service on 2/22/2017 regarding the updated Elopement Policy and Procedure and Reporting Process. He was aware of what events to report to the DON and/or Administrator and what to do if they did not respond to their call, what a Code Yellow is and what to do if the Wanderguard system is alarming. He was also aware of how to report to the Corporate Compliance line and the SSA complaint number as well. An interview, on 3/8/2017 with Licensed Practical Nurses (LPNs) revealed that LPN NN at 3:40 p.m., LPN SS at 4:00 p.m., LPN UU at 4:10 p.m., LPN WW at 4:20 p.m. and LPN DD, Unit Manager at 5:30 p.m. had all attended in-services regarding the updated Elopement Policy and Procedure and Report Process. They were aware that Wanderguards are to be checked for placement every shift and documented. They knew what events to report to the Administrator and/or DON and who to contact should the incident no be addressed or if they did not received a response. They were aware of the Corporate Compliance line number and how to contact the SSA. Interviews on 3/8/2017 with Dietary Training Manager BBB at 6:40 p.m., Dietary Manager CCC at 6:47 p.m. and Dietary Aide DDD at 6:49 p.m. revealed that they had attended in-services on the updated Elopement Policy and Procedure and were aware of what to do if they heard the Wanderguard system alarming, who to report this incident to and who to report if there was no response. They were aware of the Corporate Compliance line and how to report to the SSA. 15. Review of the Staff Survey Questions form revealed that the facility department managers were questioning one employee per day utilizing the Staff Survey Questions form. Review of the Staff Survey Questions revealed that on 2/24/2017, 25 staff had completed questionnaires, on 2/25/2017, two staff had completed questionnaires, on 2/26/2017 one staff member had completed the questionnaire, on 2/27/2017, 14 staff had completed questionnaires, on 2/24/2017, 14 staff had completed questionnaires, on 3/1/2017, two staff had completed questionnaires, on 3/2/2017, two staff had completed questionnaires, on 3/3/2017, six staff had completed questionnaires, on 3/4/2017, one staff had completed questionnaires, on 35/2017, one staff had completed questionnaires, on 3/5/2017, one staff had completed questionnaires, on 3/6/2017, 43 staff had completed questionnaires, on 3/7/2017, 55 staff had completed questionnaires, on 3/8/2017, 30 staff had completed questionnaires and were knowledgeable of the Policy and Procedure on Elopement and what/who to contact if the DON or Administrator did not respond to a notification of events that require notification. 16. Review of the sign in sheets for the Adhoc Quality Assurance/Performance Improvement (QAPI) meeting dated 3/6/2017 revealed the following members in attendance: The Medical Director via conference call, the interim Administrator, Accounts Receivable Coordinator, the interim DON, interim Maintenance Director, Director of Regulatory Compliance, and other management staff. The Immediate Jeopardy was discussed, as well as, the related complaints. The findings of the monitoring/audit tools will be reviewed at the monthly QAPI meetings. An interview with the Medical Director on 3/8/2017 at 1:34 p.m. revealed that he participated in the 3/6/2017 Adhoc QAPI meeting where the issue of elopement was discussed and what measures had been put into place to prevent a reoccurrence.

Based on record review, and interviews, the facility failed to develop a comprehensive care plan for Diabetes, Insulin administration, antipsychotic medication use and to restore bladder function for five (5) residents (V, #226, #55, #142, and #300) of the sampled forty-seven (47) residents. The census was one-hundred-forty (140). This failure to develop an individualized comprehensive care plan for incontinence resulted in actual harm for Resident V when interventions and approaches did not promote care and services in a manner to restore or improve bladder function, and caused actual harm. It was determined that the provider's noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The noncompliance is related the administration of insulin to diabetics, in which the facility failed to follow specific doctor orders. The doctor orders indicated parameters related to notification, and to with hold insulin at HS, however the facility failed to notify the doctor as specified and administered insulin at HS. This noncompliance related to the Immediate Jeopardy was identified to have existed as of 9/1/2015, and remains ongoing. The Administrator and Facility District Clinical Consultant were informed of this immediate jeopardy on 1/19/2016 at 4:30 p.m. Cross reference to F241, F242, F309, F315 Findings include: 1. Record review for resident V revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section G-Functional Status that the resident required extensive assistance of two person physical assist with transfers and toileting. No urinary toileting trials were attempted since admission and the resident was always incontinent of bladder and always incontinent of bowel. Further record review of the Care Plan for Resident V identified a focus on incontinence on November 30, 2015, however, the Care Plan Goal documented was: skin breakdown due to incontinence and brief use. There is no evidence of Measurable Goals related to restoring or improving bladder function. The interventions include: 1. Encourage fluids during the day to promote prompted voiding responses 2. Have call light within easy reach. 3. Check for incontinence, wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. 4. Observe/document for signs and symptoms or Urinary Tract Infection [MEDICAL CONDITION]: pain, burning, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. 5. Refer the Therapy as needed. There is no evidence of individualized interventions or approaches to restore or improve bladder function. Review of the Bowel and Bladder Management Policy documented: Each resident who is incontinent is identified, assessed and provided appropriate treatment and service. Services are provided to restore or improve normal bladder function to the extent possible, after the removal the catheter. The intent of the Bowel and Bladder Management System is to clearly define the process for providing care and treatment for [REDACTED]. Interview conducted on 12/2/15 at 4:45 p.m. with the MDS/Registered Nurse (RN) LL confirmed the Care Plan Goal for Resident V was more related to skin breakdown and could see how it should have been more specific to improving bladder function. The interventions for incontinence is selected form the computer system with preset interventions to choose from. They typically select and click the same selections for residents when creating goals and interventions for incontinence. 2. Record review for resident #226 indicated an admission date of [DATE], with multiple [DIAGNOSES REDACTED]. Review of the 14 Day Minimum Data Set (MDS) assessment dated [DATE], documented in Section N- Medications that the resident received an antipsychotic medication seven (7) out of seven (7) days of the assessment period. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg at bedtime was ordered on [DATE] and discontinued on 07/01/2015. Review of the Medication Admiration Records (MAR) from March-July 2015 indicated the [MEDICATION NAME] 0.5 mg was administered as ordered. Review of the Care Plans revealed no evidence of a comprehensive care plan for the use of antipsychotic medication. An interview conducted on 12/03/2015 at 8:40 a.m. with the MDS/LPN AA confirmed there was no care plan for antipsychotic medication use for resident #226 and that one should have been developed when the resident began receiving the antipsychotic. 3. Review of the clinical record for Resident # 55 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Review of care plans dated 11/24/15 revealed care plans for nutrition, [MEDICAL CONDITION] [MEDICAL CONDITIONS], Asthma, pain, fall risk, skin breakdown risk, activities of daily living, impaired cognitive function and independence in meeting emotional, intellectual, physical and social needs. There was no care plan developed regarding the [DIAGNOSES REDACTED]. 4. Record review for Resident #142 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plans dated 7/1/15 revealed care plans for fall risk, skin integrity, ADL self care performance deficit, antianxiety medication, bladder incontinence and [MEDICAL TREATMENT]. There was no care plan to address the [DIAGNOSES REDACTED]. 5. Record review for Resident #300 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plans dated 8/19/15 revealed care plans for falls , skin integrity, ADL self care performance deficit, antibiotic therapy, potential alteration in nutrition. There was no care plan to address the [DIAGNOSES REDACTED]. Interview on 12/3/15 at 1:01 p.m. with the Director of Nurses (DON) revealed there was no Diabetic care plan. The DON acknowledged any resident with a [DIAGNOSES REDACTED].

Based on medical record review and staff interview the facility failed to ensure the care plans were followed for twelve (12) residents (#122, #286, #39, #133, #130, #155, #300, #57, #136, #232, #365, and #318) of the forty-seven (47) sampled residents. The census was one-hundred-forty (140). It was determined that the noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The noncomplaince related to insulin dependent diabetics in which the facility failed to administer insulin as ordered and failed to notify the medical doctor for specific ordered finger stick blood sugar assessments. This noncompliance related to the Immediate Jeopardy was identified to have existed as of 9/1/2015, and remains ongoing. The Administrator and District Clinical Consultant were informed of this Immediate Jeopardy on 1/19/2016 at 4:30 p.m. Cross reference to F279 and F309 Findings include: Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS), dated [DATE], revealed the resident required insulin injections every day. On review of Resident #122's care plan, dated 10/7/15, a problem was identified which read, (Resident ' s name) has Diabetes Mellitus. The goal that was documented read, (Resident ' s name) will have no complications related to Diabetes through the review date. The interventions listed included: Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Additional interventions included Observe/document/report as needed (PRN) any signs or symptoms (S/SX) of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, [MEDICATION NAME] breath, stupor,coma. Review of Physician orders for Resident #122, dated 9/30/15, revealed an order for [REDACTED]. Review of medication administration records (MAR's) dated 10/1/15 through 10/31/15, Nurses Progress Notes dated 10/1/15 through 10/31/15, and Location of Administration Reports from 10/1/15 through 10/31/15 revealed the care plan of Resident #122 was not followed related to the intervention to give Diabetes medications as ordered by doctor. Resident #122 received insulin coverage at HS, with an order for [REDACTED]. 2. Resident #286 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 9/21/15, revealed the resident was not able to complete cognitive assessment, rejected care, and required insulin injections daily. Nutritional assessment, dated 9/10/15, revealed the resident required enteral feedings by percutaneous endoscopic gastrostomy (PEG) tube. Review of the care plan for Resident # 286, dated 9/22/15, indicated the facility had identified a focus of Diabetes Mellitus. The goal for this focus was as follows (resident ' s name) will have no complications related to Diabetes through the review date . The interventions listed included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders for Resident #286, dated 10/8/15, revealed orders for [MEDICATION NAME]per sliding scale, call MD for blood sugar less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for Diabetes Mellitus (DM) before meals and nightly. Review of MAR's dated 10/8/15 through 1/19/16 , Nursing Progress Notes dated 10/8/15 through 1/19/16, and Location of Administration Reports from 10/8/15 through 1/19/16 revealed the facility failed to follow the care planned intervention to administer Diabetes medication as ordered, by failing to follow the Physician order for [REDACTED].>3. Review of the clinical record for Resident #39 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Nutritional assessment dated [DATE] indicated resident has a low body mass index (BMI) of 19.1, has restricted fluid intake and receives oral feeding and enteral feeding through PEG tube. The quarterly MDS assessment dated [DATE] indicated the resident had mild cognitive impairment and required insulin injections every day. Review of the care plan for Resident #39 dated 5/29/15 revealed the facility identified a focus of Diabetes Mellitus for Resident #39 with a goal reading, (resident name) will have no complications related to Diabetes through the review date. The interventions listed included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders dated 9/18/15 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day. Review of MAR's dated 9/18/15 through 1/19/16, Nurses Progress Notes dated 9/18/15 through 1/19/16, and Location of Administration Reports dated 9/18/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of administering Diabetes medications as ordered by doctor by failing to follow the Physician order for [REDACTED].>4. Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent MDS assessment dated [DATE] revealed this resident had no cognitive impairment, required supervision with eating and received insulin injections every day. Review of nutritional assessment dated [DATE] revealed the Resident #133 had a BMI of 39.8, indicating Grade 2 obesity and was considered a potential nutritional risk due to diagnoses, medications, and therapeutic diet. Review of the care plan for Resident #133, dated 10/26/15, indicated the facility identified a focus of Diabetes Mellitus, with a goal of no complications related to Diabetes through the review date. Interventions included the following: Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of physician orders for Resident #133, dated 10/16/15, indicate orders for Humalog insulin sliding scale coverage, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day. Review of MAR's dated 10/16/15 through 1/19/16, Nursing Progress Notes dated 10/16/15 through 1/19/16, and Location of Administration Reports for 10/16/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of administering diabetes medication as ordered by the Physician, by failing to follow the Physician order for [REDACTED].>5. Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nutrition assessment dated [DATE] reveal the resident had excessive oral intake that exceeded estimated needs, was obese, and a goal was established for no significant weight gain while meeting estimated needs. The quarterly MDS dated [DATE] indicated no cognitive impairment and required insulin administration every day. Review of the care plan for Resident #130 indicated the facility had identified a focus of Diabetes Mellitus on 6/22/15 with a goal for no complications related to Diabetes through review date. The interventions listed included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders dated 6/9/15 revealed orders for Humalog insulin per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for DM Give four times a day before meals and nightly. Review of the MAR's dated 9/1/15 through 1/19/16, Nursing Progress Notes dated 9/1/15 through 1/19/16, and Location of Administration Reports from 9/1/15 through 1/19/16 revealed the care planned intervention of Diabetes medication as ordered by Physician related to the physician order of no HS coverage, was not followed and the resident was administered covearge at HS. 6. Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 11/11/15, indicated severe cognitive impairment, required extensive assistance in all areas of ADL and required insulin administration six (6) days out of seven (7). Nutrition data collection dated 11/15/15 revealed resident was obese, with a BMI of 30.3 and consumed 51 to 75% of meals daily. The resident was identified as a potential risk for nutrition with anticipated weight fluctuations related to daily diuretic therapy. Review of the care plan dated 11/12/15 for Resident #130 revealed a focus of Diabetes Mellitus. The goal for this focus was No complications related to Diabetes through the review date. Interventions included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Physician orders dated 11/4/15 revealed an order for [REDACTED]. Review of MAR's dated 11/5/15/ through 1/19/16, Nurses Progress Notes dated 11/5/15 through 1/19/16, and Location of Administration Reports for 11/5/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by Physician, related to the Physician order for [REDACTED]. 7. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nutrition data collection completed by the Registered Dietitian on 6/17/15 revealed the resident had poor dentitian with weight above desired weight parameters and the current diet regimen providing adequate nutrition. The MDS quarterly assessment, dated 9/4/15, revealed mild cognitive impairment and required insulin administration daily. The care plan dated 6/9/15 for resident #57 indicated the facility identified a focus of Diabetes Mellitus, with a goal for No complications related to Diabetes through the review date. Interventions for this focus included the following Diabetes medication as ordered by doctor. Observe/document the side effects and effectiveness. Physician orders for Resident #57 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for DM. Review of MAR's for 9/1/15 through 1/19/16, Nurses Progress Notes dated 9/1/15 through 1/19/16, and Location of Administration Reports from 9/1/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by doctor, related to the Physician order for [REDACTED]. 8. Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nutritional assessment dated [DATE] revealed Resident #136 was expected to have weight fluctuations related to [MEDICAL TREATMENT], and was obese with a BMI of 30.6. The quarterly MDS assessment dated [DATE] revealed mild cognitive impairment, was able to eat independently and required daily insulin injections. Review of care plan dated 10/16/15 indicated the facility identified a focus of Diabetes Mellitus with a goal of No complications related to Diabetes through the review date. Interventions included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders for Resident #136, dated 11/24/15, revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MS BS greater than 200, subcutaneously four times a day. Review of MAR's dated 11/24/15 through 1/19/16, Nurses Progress Notes dated 11/24/15 through 1/19/16 and Location of Administration Reports from 11/24/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by doctor, related to the Physician order for [REDACTED]. 9. Review of the clinical record for Resident #119 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment and required insulin administration daily. Review of nutritional assessment dated [DATE] revealed the resident had skin tears and [MEDICAL CONDITION], a BMI of 40.4, and was considered a potential risk for nutrition related to [MEDICAL CONDITION]. The care planned focus of Diabetes Mellitus was dated 12/17/15 with a goal of No complications related to Diabetes through the review date. Included was an intervention of Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Additional interventions included observe/document/report as needed (PRN) any signs or symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, [MEDICATION NAME] breath, stupor,coma. Review of Physician orders dated 9/6/15 revealed orders for Humalog per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD for BS greater than 200, subcutaneously four times a day for DM II. Review of MAR's dated 9/6/15 through 1/19/16 , Nurses Progress Notes dated 9/6/15 through 1/19/16, and Location of Administration Reports from 9/6/15 through 1/19/16 revealed the facility failed to follow the care planned intervention to administer diabetes medications as ordered by the Physician, related to the Physician order for [REDACTED]. 10 Resident #232 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 9/11/15, revealed the resident had no cognitive impairment, required extensive assistance in all areas of activities of daily living except eating and required daily insulin injections. Review of the nutritional assessment dated [DATE] revealed a low BMI of 19.9, poor dentition, had dehydration risk factor of daily use of laxative, an average meal intake of 70% daily, and healing gastrostomy and [MEDICAL CONDITION] site. The facility identified a care planned focus for Resident #232 on 9/16/15 of Diabetes Mellitus. The goal for this focus was for the resident to have No complications related to diabetes through the review date. Care planned interventions included Diabetes medication as ordered by doctor. Oserve/document for side effects and effectiveness. Additional interventions included Observe/document/report as needed any signs or symptoms of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Review of Physician orders dated 9/5/15 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for DM. Review of MAR's dated 9/5/15 through 1/19/16 ,Nurses Progress Notes dated 9/5/15 through 1/19/16, and Location of Administration Reports from 9/5/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medications as ordered by Physician, related to the Physician order of no HS insulin coverage, by administering HS covearge. Additionally the facility failed to follow the care planned intervention to report signs of [DIAGNOSES REDACTED], related to the Physician order to notify the physician of FSBS results less than 70, indicating [DIAGNOSES REDACTED], one time. 11. Resident #365 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission MDS assessment, dated 11/19/15, revealed no mental status summary score could be obtained because the resident was rarely or never understood, required extensive assistance and total dependence in all areas of activity date of daily living (ADL) and required daily insulin injections. A review of the nutritional assessment dated [DATE] revealed the resident was comatose and received enteral feedings by pump. The resident was considered a potential nutritional risk due to mental status and tube feedings. Review of the care plan dated 11/20/15 revealed Resident #365 had an identified focus of Diabetes Mellitus with a goal of No complications related to Diabetes through the review date. Care planned interventions included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders dated 11/12/15 revealed orders for Humalog insulin per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for Diabetes. Review of the MAR's dated 9/5/15 through 1/19/16, Nurses Progress Notes dated 9/5/15 through 1/19/16, and Location of Administration Reports from 9/5/15 through 1/19/16 revealed the facility failed to follow the care planned intervention to administer diabetic medications as ordered by Dr., related to the physician order for [REDACTED]. 12. Resident #318 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of nutritional assessment dated [DATE] revealed a low BMI of 18.7, poor dentition, and extensive assistance required to eat. The resident consumed 26 to 51% of meals and intake was not meeting caloric needs. No further assessments were available. Review of the quarterly MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment, and required insulin injections daily. Review of the care plan dated 9/9/15 for Resident #318 revealed the facility identified a focus of Diabetes Mellitus, with a goal of No complications related to diabetes through the review date. Interventions for this focus included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Additional interventions included Observe/document/report as needed any signs or symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, [MEDICATION NAME] breath, stupor, coma. Physician orders dated 9/2/15 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70, or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously before meals and at bedtime for D.M Review of MAR's dated 9/2/15 through 1/19/16, Nurses Progress Notes dated 9/2/15 through 1/19/16, and Location of Administration Reports from 9/2/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by doctor, related to the physician order for [REDACTED]. 13. Record review for Resident #136 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Nutritional Assessment revealed Resident #136 had a BMI of 30.6 and was expected to have weight fluctuations related to [MEDICAL TREATMENT]. Review of Physician orders dated 11/24/15 revealed an order for [REDACTED]. Review of the Diabetes care plan dated 10/16/15 indicated the following interventions: Diabetes medication as ordered by doctor, discuss meal times, portion sizes, dietary restrictions, snacks, Fasting Serum Blood Sugar as ordered by doctor, if infection is present consult doctor, observe/document/report as needed any signs or symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED], refer to podiatrist or foot care nurse, refer to Registered Dietician (RD) as needed. No Physician ordered interventions were included on the care plan for no HS coverage , call MD BS greater than 200. Review of Nurses Progress Notes dated 11/24/15 through 1/19/16, MAR indicated [REDACTED] 13. Record review for Resident # 119 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of nutritional assessment dated [DATE] revealed a BMI of 40.4, skin tears and [MEDICAL CONDITION] and was at potential risk for nutrition related to [MEDICAL CONDITION]. Review of Physician orders dated 9/6/15 revealed orders for Humalog per sliding scale, call MD for BS less than 70 or greater than 400, No HS coverage, call MD BS greater than 200, subcutaneously four times a day. Review for Diabetes Care plan dated 12/17/15 revealed interventions for diabetes medications as ordered by doctor, check all body for breaks in skin, observe/document report as needed any signs or symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED], and refer to podiatrist or foot care nurse. No interventions were listed regarding the Physician orders to notify MD of BS less than 70 or greater than 400, no HS coverage, or call MD BS greater than 200 at HS. Review of Nurses Progress Notes dated 9/6/15 through 1/19/16, MAR indicated [REDACTED] The facility failed to notify the Physician of FSBS greater than 200 at HS, failed to follow the Physician order for [REDACTED]. Interview on 1/19/16 at 4:35 p.m. with the Administrator revealed the care plans for the Diabetic residents were not been followed because HS insulin was not being administered as ordered.

Based on record review, and interview, the facility failed to follow medical doctor (MD) orders related to sliding scale insulin coverage administration, titration of an antidepressant medications and failed to access a [MEDICAL TREATMENT] port site for seventeen for (17) residents (#122, #286, #55, #57, #318, #365, #232, #119, #142, #155, #130, #133, #39, #300, #136, #1 and #221) of the forty-seven (47) sampled residents. It was determined that the noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The census was one-hundred-forty (140). The failure was related to the medical doctors orders not to administer insulin at bedtime, and specific parameters at which the doctor wanted to be notified. However the facility failed to follow the doctor orders for notification and bedtime insulin, as detailed below. The Administrator and Facility District Clinical Consultant were informed of Immediate Jeopardy on 1/19/16 at 4:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/1/15, and remains ongoing. Findings include: 1. Review of the clinical record for Resident #122, revealed an admission date of [DATE] and discharge on 10/31/15, with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED].#122 revealed an order for [REDACTED].< 70 or > 400. Review of the Medication Administration Record [REDACTED]> 200 at HS, and the MD was not notified and no insulin was administered: In October 2015: On 10/1/15 at 8:00 p.m., the FSBS results were 300, without MD notification or insulin administered; on 10/2/15 at 8:00 p.m., the FSBS results were 347, without MD notification or insulin administration; on 10/3/15 at 8:00 p.m., the FSBS results were 323, with 8 units of insulin administered, without a MD order; on 10/4/15 at 8:00 p.m., the FSBS results were 233 with 4 units of insulin administered, without a MD order; on 10/5/15 at 8:00 p.m., the FSBS results were 313, without MD notification or insulin administration; on 10/7/15 at 8:00 p.m., the FSBS results were 281, with 6 units of insulin administered, without a MD order; on 10/8/15 at 8:00 p.m., the FSBS results were 248, with 4 units of insulin administered, without a MD order; on 10/9/15 at 8:00 p.m., the FSBS results were 244, with 4 units of insulin administered, without a MD order; on 10/11/15 at 8:00 p.m., the FSBS results were 237 with 4 units of insulin administered, without a MD order; on 10/13/15 at 8:00 p.m., the FSBS results were 170 with 2 units of insulin administered, without a MD order; on 10/15/15 at 8:00 p.m., the FSBS results were 209, without notification of MD, or insulin administration; on 10/16/15 at 8:00 p.m., the FSBS results were 182 with 2 units of insulin administered, without a MD order; on 10/23/15 at 8:00 p.m., the FSBS results were 246 with 4 units of insulin administered, without a MD order; on 10/26/15 at 8:00 p.m., the FSBS results were 249 with 4 units of insulin administered, without a MD order; on 10/28/15 at 8:00 p.m., the FSBS results were 321, without MD notification or insulin administration; on 10/29/15 at 8:00 p.m., the FSBS were 300, without MD notification or insulin administration, and; on 10/30/15 at 8:00 p.m., the FSBS results were 404 with 12 units of insulin administered without a MD order. Interview on 12/2/2015 at 3:57 p.m. with the Director of Nurses (DON) acknowledged a nurses note entry should be made each time a MD is called. Continued interview revealed he had been unable to find any documentation of MD notification of blood sugars > 200 at HS for Resident #122 from 10/1/2015 until 10/30/2015. Interview on 12/2/2015 at 4:25 p.m. with LPN CC revealed she had searched through nursing progress notes for MD notification of blood sugars > 200 at bedtime and of the blood sugar results > 200 for resident #122, no MD notification could be found. LPN CC acknowledged any call to a MD should always be documented. Interview on 12/2/2015 at 5:20 p.m. with LPN EE revealed their initials appeared on the MAR indicated [REDACTED]. LPN EE indicated they always document MD notification and if the MD had been notified they would have recorded this in the Nurses Progress Notes. LPN EE acknowledged the Physician had not been notified and the sliding scale insulin coverage had been administered with no order. Interview on 12/2/15 at 5:32 p.m. with LPN FF revealed they did not remember notifying the Physician of HS BS > 200 for resident #122 and gave the insulin coverage without an order. 2. Review of the clinical record for resident #286 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] indicated resident #286 requires insulin injections every day. Review of MD orders dated 10/8/15, for resident #286 revealed an order for [REDACTED].< 70 or > 400. Review of the MAR indicated [REDACTED] In November 2015: On 11/9/15 at 9:00 p.m., the FSBS results were 219, there was no insulin administered, however the MD was not notified, and; on 11/18/15 at 9:00 p.m. the FSBS results were 156, with 2 units of insulin administered, without a MD order. In December 2015: On 12/1/15 at 9:00 p.m. the FSBS results were 179, with 2 units insulin administered, without a MD order; on 12/14/15 at 9:00 p.m. the FSBS results were 349, with 8 units of insulin administered, without a MD order; on 12/21/15 at 9:00 p.m. the FSBS results were 152 with 2 units insulin administered, without a MD order; on 12/25/15 at 9:00 p.m. the FSBS results were 165, with 2 units of insulin administered, without a MD order, and; on 12/27/15 at 9:00 p.m. the FSBS results were with 2 units of insulin administered. 3. Review of the clinical record for Resident #39 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of MDS quarterly assessment dated [DATE] revealed the resident requires insulin injections every day. Review of the MD orders dated 9/18/15 revealed for resident #39 to receive sliding scale insulin coverage, to notify the MD of FSBS > 200 at HS, administer no insulin at HS, and call Physician for FSBS < 70 or > 400. Review of the MAR indicated [REDACTED] In September 2015: On 9/20/15 at 9:00 p.m., the FSBS results were 185 with 2 units of insulin administered, without a MD order, and; on 9/25/15 at 9:00 p.m., the FSBS results were 230, with no insulin administered, however the MD was not notified. In October 2015: On 10/3/15 - 9:00 p.m., the FSBS results were 320, with 8 units of insulin administered, without an MD order; on 10/9/15 at 9:00 p.m., the FSBS were 372, with 10 units of administered, without a MD order; on 10/19/15 at 9:00 p.m., the FSBS results were 201, without insulin was administered, however the MD was not notified; on 10/21/15 at 9:00 p.m., the FSBS results were 212, without insulin administered, however the MD was not notified; on 10/23/15 at 9:00 p.m., the FSBS results were 318, with 8 units of insulin administered, without a MD order; on 10/26/15 at 9:00 p.m., the FSBS results were 323, without insulin administered, however the MD was not notified, and; on 10/27/15 at 9:00 p.m., the FSBS results were 212, without insulin administered, however the MD was not notified. In November 2015: On 11/2/15 at 9:00 p.m., the FSBS was 202, without insulin administered, however the MD was not notified; on 11/7/15 at 9:00 p.m., the FSBS result were 207, without insulin administered, however the MD was not notified; on 11/9/15 at 9:00 p.m., the FSBS result were 387, with 10 units of insulin administered, without a MD order; on 11/12/15 at 9:00 p.m., the FSBS results were 210, without insulin administered, however the MD was not notified; on 11/15/15 at 9:00 p.m., the FSBS results were 288 without insulin administered, however the MD was not notified; on 11/20/15 at 9:00 p.m., the FSBS results were 155 with 2 units of insulin administered, without a MD order; on 11/21/15 at 9:00 p.m., FSBS results were 222, without insulin administered, however the MD was not notified, and; on 12/5/15 at 9:00 p.m., FSBS results were 232, without insulin administered, however the MD was not notified. In December 2015: On 12/26/15 at 9:00 p.m., FSBS results were 251, with 6 units of insulin administered, without a MD order, and; on 12/27/15 at 9:00 p.m., the FSBS results were 294 with 6 units of insulin administered, without a MD order. In January 2016: On 1/18/16 at 9:00 p.m., the FSBS results were 350, with 10 units of insulin administered, without a MD order. Interview on 1/19/16 at 4:00 p.m. with the Administrator revealed the medical records of Resident #286 had been searched for indications of Physician notification of blood sugars > 200 at bedtime and resulting Physician orders [REDACTED]. The Administrator acknowledged insulin administration had occurred without Physician order. The Administrator confirmed insulin administration at bedtime was ordered not to be given for the above resident and the Physician should have been notified of FSBS > 200 and no indication of Physician notification could be found. 4. Record review for Resident #55 reveals an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment for Resident #55, dated 11/17/15, indicated the resident receives injections of insulin every day. Review of MD orders dated 2/23/15 revealed an order for [REDACTED].> 400, administer no HS insulin coverage, and call the MD for FSBS > 200 at HS. Review of the MAR indicated [REDACTED] In September 2015: On 9/6/15 at 9:00 p.m. the FSBS results were 194, with 2 units of insulin administered, without MD order; on 9/11/15 at 9:00 p.m. 362, without insulin administered, however the MD was not notified; on 9/15/15 at 9:00 p.m., the FSBS results were 292 with 6 units insulin administered, without a MD order; on 9/20/15 at 9:00 p.m. the FSBS results were 197, with 2 units of insulin administered, without order; on 9/24/15 at 9:00 p.m. the FSBS results were 165, with 2 units of insulin administered, without MD order; on 9/25/15 at 9:00 p.m. the FSBS results were 245, without insulin administered, however the MD was not notified; on 9/27/15 at 12:00 p.m. the FSBS results were 468, there was no evidence the MD was notified; on 9/27/15 at 9:00 p.m. the FSBS results were 310, with 8 units of insulin administered, without a MD order, and; on 9/28/15 at 9:00 p.m. the FSBS results were 340, without insulin administered, however the MD was not notified. In October 2015: On 10/2/15 at 9:00 p.m. the FSBS results were 199, with 2 units of insulin administered, without MD order; on 10/4/15 at 9:00 p.m. the FSBS results were 185, with 2 units of insulin administered, without MD order; on 10/12/15 at 9:00 p.m. the FSBS results were 223, without insulin administered, however the MD was not notified; on 10/13/15 at 9:00 p.m. the FSBS results were 165, with 2 units of insulin administered, without MD order; on 10/17/15 at 9:00 p.m. the FSBS results were 224, with 4 units insulin administered, without MD order; on 10/23/15 at 9:00 p.m. the FSBS results were 254, with 6 units insulin administered, without MD order; on 10/26/15 at 9:00 p.m. the FSBS results were 345, without insulin administered, however the MD was not notified, and; on 10/31/15 at 9:00 p.m. the FSBS results were 321, with 8 units of insulin administered, without MD order. In November 2015: On 11/9/15 at 9:00 p.m. the FSBS results were 346, with 8 units of insulin administered, without a MD order; on 11/14/15 at 9:00 p.m. the FSBS results were 232, with 4 units of insulin administered, without a MD order; on 11/15/15 at 12:00 p.m. the FSBS results were 458, without MD notification; on 11/20/15 at 5:00 p.m. the FSBS results were 525 without MD notification;on 11/16/15 at 9:00 p.m. the FSBS results were 202, without insulin administered, however the MD was not notified; on 11/19/15 at 9:00 p.m. the FSBS results were 167,with 2 units of insulin administered, without MD order; on 11/23/15 at 5:00 p.m. the FSBS results were 456, without MD notification; on 11/23/15 at 9:00 p.m. the FSBS results were 213, with 4 units of insulin administered, without a MD order; on 11/26/15 at 8:00 a.m. the FSBS results were 482, there was no evidence the MD was notified; on 11/26/15 at 9:00 p.m. the FSBS results were 221, with 4 units of insulin administered, without a MD order; on 11/28/15 at 9:00 p.m. the FSBS results were 155, with 2 units of insulin administered, without MD orders, and; on 11/29/15 at 9:00 p.m., the FSBS results were 168, with 2 units of insulin administered, without a MD order. In December 2015: On 12/1/15 at 9:00 p.m. the FSBS results were 255, with 6 units insulin administered, without a MD order; on 12/4/15 at 8:00 a.m. the FSBS results were 68 without MD notification; on 12/8/15 at 12:00 p.m. the FSBS results were 437 without MD notification; on 12/18/15 at 8:00 a.m. the FSBS results were 434 without MD notification; on 12/20/15 at 9:00 p.m. the FSBS results were 270, with 6 units insulin administered, without a MD order; on 12/21/15 at 9:00 p.m., the FSBS results were 172, with 2 units of insulin administered, without MD order; on 12/22/15 at 8:00 a.m. the FSBS results were 404, without evidence of MD notification. on 12/25/15 at 9:00 p.m. the FSBS results were 255, with 6 units insulin administered, without MD order; on 12/26/15 at 9:00 p.m. the FSBS results were 388 with 10 units insulin administered, without MD order, and; on 12/27/15 at 9:00 p.m., the FSBS results were 199, with 2 units of insulin administered, without MD order. In January 2016: On 1/5/16 at 12:00 p.m. the FSBS results were 63, and; on 1/10/16 at 8:00 a.m. the FSBS results were 66, without evidence of MD notification; on 1/10/16 at 9:00 p.m. the FSBS results were 286, with 6 units of insulin administered, without MD order, and on 1/15/16 at 9:00 p.m. the FSBS results were 180 with 2 units of insulin administered, without MD order. 5. Record review for Resident #133 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS admission assessment dated [DATE] revealed the resident receives insulin injections every day. Review of MD orders, dated 10/16/15, for resident #133 revealed an order for [REDACTED].> 400, administer no insulin at HS, and call MD for FSBS result >200. In October 2015; On 10/17/15 at 9:00 p.m. the FSBS results were 310, with 8 units of insulin administered, without a MD orders; on 10/18/15 at 9:00 p.m., the FSBS results were 159 with 2 units of insulin administered, without MD order; on 10/19/15 at 9:00 p.m. the FSBS results were 184, with 2 units of insulin administered, without MD order; on 10/20/15 at 9:00 p.m. the FSBS results were 262 with 6 units insulin administered, without a MD order; on 10/22/15 at 9:00 p.m. the FSBS results were 234, with 4 units of insulin administered, without a MD order; on 10/23/15 at 9:00 p.m. the FSBS results were 168, with 2 units of insulin administered, without MD order; on 10/24/15 at 9:00 p.m. the FSBS results were 323, with 8 units of insulin administered, without a MD order; on 10/26/15 at 9:00 p.m. the FSBS results were 191, with 2 units of insulin administered, without MD order; on 10/27/15 at 9:00 p.m. the FSBS results were 190 with 2 units of insulin administered, without a MD order; on 10/28/15 at 9:00 p.m. the FSBS results were 157, with 2 units of insulin administered, without MD order; on 10/29/15 at 9:00 p.m. the FSBS results were 233,with 4 units of insulin administered, without a MD order; on 10/30/15 at 9:00 p.m. the FSBS results were 188, with 2 units of insulin administered, without MD order, and; on 10/31/15 at 9:00 p.m. the FSBS results were 298, with 4 units of insulin administered, without a MD order. In November 2015: On 11/2/15 at 9:00 p.m. the FSBS results were 201, with 4 units of insulin administered, without a MD order; on 11/3/15 at 9:00 p.m. the FSBS results were 225, without insulin administered, however the MD was not notified; on 11/4/15 at 5:00 p.m. the results of the FSBS was 417, without evidence of MD notification; on 11/6/15 at 9:00 p.m. the FSBS results were 206, with 4 units of insulin administered, without a MD order; on 11/7/15 at 9:00 p.m. the FSBS results were 210 with 4 units of insulin administered, without a MD order; on 11/9/15 at 9:00 p.m. the FSBS results were 161,with 2 units of insulin administered, without a MD order, and; on 11/10/15 at 9:00 p.m. the FSBS results were 207, without insulin administered and without MD notification. 6. Review of the clinical record for Resident #130 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #130 receives insulin injections every day. Review of Physician orders [REDACTED].< 70 or > 400, no insulin administration at HS, call MD FSBS > 200. Review of the MAR indicated [REDACTED] In September 2015: On 9/1/15, at 8:00 a.m. the FSBS result were 403, without MD notification; on 9/1/15 at 9:00 p.m. the FSBS results were 289 with 6 units of insulin administered, without MD order; on 9/2/15 at 9:00 p.m. the FSBS results were 412, with 12 units of insulin administered, without MD order; on 9/3/15 at 9:00 p.m. the FSBS results were 468 with 12 units of insulin administered, without MD order; on 9/4/15 at 9:00 p.m. the FSBS results were 282 with 6 units of insulin administered, without MD order; on 9/5/15 at 9:00 p.m. the FSBS results were 383, without insulin administered, and evidence of MD notification; on 9/6/15 at 9:00 p.m. the FSBS results were 245, with 4 units of insulin administered, without MD order; on 9/7/15 at 9:00 p.m. the FSBS results were 182, with 2 units of insulin administered, without a MD order; on 9/8/15 at 9:00 p.m. the FSBS results were 208, with 4 units of insulin administered, without MD order; on 9/9/15 at 9:00 p.m. the FSBS results were 363, without insulin administered, without evidence of MD notification; on 9/10/15 at 9:00 p.m. the FSBS results were 310, without insulin administered or MD notification; on 9/11/15 at 8:00 a.m. the FSBS result were 439 without MD notification; on 9/11/15 at 9:00 p.m. the FSBS results were 225, with 4 units insulin administered, without MD notification; on 9/12/15 at 9:00 p.m. the FSBS results were 260 with 6 units of insulin administered, without a MD order; on 9/13/15 at 8:00 a.m. the FSBS result were 409 without MD notification; on 9/13/15 at 12:00 p.m. the FSBS result were 412 without MD notification; on 9/15/14 at 9:00 p.m. the FSBS results were 398, without insulin administered; on 9/16/15 at 9:00 p.m. the FSBS results were 201, 4 units of insulin administered, without a MD order; on 9/17/15 at 5:00 p.m. the FSBS result were 407 without MD notification; on 9/17/15 at 9:00 p.m. - the FSBS results were 332, with 8 units of insulin administered, without MD order; on 9/18/15 at 9:00 p.m. the FSBS results were 268 with 6 units of insulin administered, without a MD order; on 9/19/15 at 9:00 p.m. the FSBS results were 356 with 10 units of insulin administered, without MD order; on 9/20/15 at 5:00 p.m. the FSBS result were 402 without MD notification; on 9/20/15 at 9:00 p.m. the FSBS results were 345, with 8 units of insulin administered, without a MD order; on 9/21/15 at 9:00 p.m. the FSBS results were 309, with 8 units of insulin administered without a MD order; on 9/22/15 at 9:00 p.m. the FSBS results were 233 with 4 units of insulin administered, without a MD ordered; on 9/23/15 at 9:00 p.m. the FSBS results were 270 with 6 units of insulin administered, without a MD order; on 9/24/15 at 9:00 p.m. the FSBS results were 300 without insulin administered or MD notification; on 9/25/15 at 9:00 p.m. the FSBS results were 207 with 4 units insulin administered, without a MD order; on 9/26/15 at 9:00 p.m. the FSBS results were 208 with 4 units of insulin administered, without a MD order; on 9/27/15 at 9:00 p.m. the FSBS results were 189, with 2 units of insulin administered, without a MD order; on 9/29/15 at 9:00 p.m. the FSBS results were 253 with 6 units insulin administered, without a MD order, and; on 9/30/15 at 9:00 p.m. the FSBS results were 308 with 8 units of insulin administered without a MD order. In October 2015: On 10/1/15 at 12:00 p.m. the FSBS result were 430 without MD notification; on 10/1/15 at 5:00 p.m. the FSBS result were 403 without MD notification; on 10/1/15 at 9:00 p.m. the FSBS results were 162, with 2 units of insulin administered, without a MD order; on 10/2/15 at 9:00 p.m. the FSBS results were 255, with 6 units of insulin administered, without a MD order; on 10/3/15 at 9:00 p.m. the FSBS results were 235 without insulin administered, without MD notification; on 10/4/15 at 9:00 p.m. the FSBS results were 305, without insulin administered; on 10/5/15 at 9:00 p.m. the FSBS results were 195, with 2 units of insulin administered, without a MD order; on 10/6/15 at 5:00 p.m. the FSBS result were 414 without MD notification; on 10/6/15 at 9:00 p.m. the FSBS results were 394, with 10 units of insulin administered, without a MD order; on 10/7/15 at 9:00 p.m. the FSBS results were 203 with 4 units of insulin administered, without a MD order; on 10/8/15 at 9:00 p.m. the FSBS results were 381 without insulin administered or notification of MD; on 10/9/15 at 9:00 p.m. the FSBS results were 248 without insulin administered, without MD notification; on 10/10/15 at 9:00 p.m. the FSBS results were 226 with 4 units of insulin administered, without MD order; on 10/11/15 at 9:00 p.m. the FSBS results were 274 with 6 units of insulin administered, without MD order; on 10/12/15 at 9:00 p.m. the FSBS results were 279 with 6 units of insulin administered, without MD order; on 10/13/15 at 9:00 p.m. the FSBS results were 289, with 6 units of insulin administered, without MD order; on 10/14/15 at 9:00 p.m. the FSBS results were 276 with 6 units of insulin administered, without MD order; on 10/14/15 at 5:00 p.m. the FSBS result were 422 without MD notification; on 10/15/15 at 9:00 p.m. the FSBS results were 335 with 8 units of insulin administered, without MD order; on 10/16/15 at 9:00 p.m. the FSBS results were 334 with 8 units of insulin administered, without MD order; on 10/17/15 at 9:00 p.m. the FSBS results were 225 without insulin administered, or MD notification; on 10/17/15 at 8:00 a.m. the FSBS results were 401 without MD notification; on 10/18/15 at 9:00 p.m. the FSBS results were 363 without insulin administered, without MD notification; on 10/19/15 at 12:00 p.m. the FSBS results were 444 without MD notification; on 10/20/15 at 8:00 a.m. the FSBS results were 406 without MD notification; on 10/20/15 at 12:00 p.m. the FSBS results were 467 without MD notification; on 10/20/15 at 9:00 p.m. the FSBS results were 207, with 4 units of insulin administered, without MD order; on 10/21/15 at 9:00 p.m. at the FSBS results were 315 without insulin administered, without MD notification; on 10/22/15 at 8:00 a.m. the FSBS results were 430 without MD notification;on 10/22/15 at 9:00 p.m. the FSBS results were 379, without insulin administered or MD notification; on 10/23/15 at 9:00 p.m. the FSBS results were 382, without insulin administered, or MD notification; on 10/24/15 at 9:00 p.m. the FSBS results were 300, with 8 units of insulin administered, without a MD order; on 10/25/15 at 9:00 p.m. the FSBS results were 180, with 2 units of insulin administered, without a MD order; on 10/26/15 at 9:00 p.m. the FSBS results were 292, with 6 units of insulin administered, without MD order; on 10/27/15 at 9:00 p.m. the FSBS results were 235, without insulin administered or MD notification; on 10/28/15 at 9:00 p.m. the FSBS results were 254, with 6 units of insulin administered, without a MD order; on 10/29/15 at 9:00 p.m. the FSBS results were 282, with 6 units of insulin administered, without a MD order, and; on 10/30/15 at 9:00 p.m. the FSBS results were 191, with 2 units of insulin administered without a MD order. In November 2015: On 11/1/15 at 9:00 p.m. the FSBS results were 202, with insulin administered; on 11/2/15 at 9:00 p.m. the FSBS results were 4 units of insulin administered, without a MD order; on 11/5/15 at 9:00 p.m. the FSBS results were 276, with 6 units of insulin administered, without MD order; on 11/4/15 at 9:00 p.m. the FSBS results were 218 with 4 units of insulin administered, without a MD order; on 11/5/15 at 9:00 p.m. the FSBS results were 316, without insulin administered or notification; on 11/6/15 at 9:00 p.m. the FSBS results were 242, with 4 units insulin administered, without MD order; on 11/7/15 at 9:00 p.m. the FSBS results were 231, with 4 units of insulin administered, without a MD order; on 11/8/15 at 9:00 p.m. the FSBS results were 239, with 4 units of insulin administered, without a MD order; on 11/10/15 at 9:00 p.m. the FSBS results were 285,without insulin administered or MD notification; on 11/11/15 at 9:00 p.m. the FSBS results were 220 with 4 units of insulin administered, without MD order; on 11/12/15 at 9:00 p.m. the FSBS results were 245, with 4 units of insulin administered, without a MD order; on 11/14/15 at 9:00 p.m. the FSBS results were 224,without insulin administered, without MD order; on 11/15/15 at 9:00 p.m. the FSBS results were 332 with 8 units of insulin administered, without a MD order; on 11/16/15 at 9:00 p.m. the FSBS results were 193 with 2 units of insulin administered, without a MD order; on 11/17/15 at 9:00 p.m. the FSBS results were 256 with 6 units of insulin administered without a MD order; on 11/18/15 at 9:00 p.m. the FSBS results were 263 with 6 units of insulin administered, without a MD order; on 11/19/15 at 9:00 p.m. the FSBS results were 270 with 6 units of insulin administered, without a MD order; on 11/20/15 at 9:00 p.m. the FSBS results were 200, with 4 units of insulin administered, without a MD order; on 11/21/15 at 9:00 p.m. the FSBS results were 258 with 6 units of insulin administered, without a MD order; on 11/23/15 at 9:00 p.m. the FSBS results were 209, with 4 units insulin administered, without a MD order; on 11/26/15 at 9:00 p.m. the FSBS results were 222, with 4 units of insulin administered, without a MD order; on 11/27/15 at 9:00 p.m. the FSBS results were 313, with 8 units of insulin administered, without a MD order; on 11/28/15 at 9:00 p.m. the FSBS results were 355, with 10 units of insulin administered without a MD order, and; on 11/30/15 at 9:00 p.m. the FSBS results were 162, with 2 units of insulin administered, without a MD order. In December 2015: On 12/1/15 at 9:00 p.m. the FSBS results were 250 with 6 units of insulin administered, without a MD order; on 12/2/15 at 9:00 p.m. the FSBS results were 213, with 4 units of insulin administered, without MD order; on 12/3/15 at 9:00 p.m. the FSBS results were 249, with 4 units of insulin administered, with MD order; on 12/4/15 at 9:00 p.m. the FSBS results were 192, with 2 units insulin administered, without a MD order; on 12/5/15 at 9:00 p.m. the FSBS results were 209, with 4 units of insulin administered, without MD order; on 12/6/15 at 9:00 p.m. the FSBS results were 199, with 2 units of insulin administered, without a MD order; on 12/7/15 at 9:00 p.m. the FSBS results were 266, with 6 units of insulin administered, without MD order; on 12/8/15 at 9:00 p.m. the FSBS results were 249, with 4 units of insulin administered, without a MD order; on 12/9/15 at 9:00 p.m. the FSBS results were 250, with 6 units of insulin administered, without a MD order; on 12/10/15 at 9:00 p.m. the FSBS results were 223, with 4 units of insulin administered, without MD order; on 12/11/15 at 9:00 p.m. the FSBS results were 195, with 2 units of insulin administered, without a MD order; on 12/14/15 at 9:00 p.m. the FSBS results were 275, with 6 units of insulin administered, without a MD order; on 12/15/15 at 9:00 p.m. the FSBS results were 153, with 2 units of insulin administered, without a MD order; on 12/16/15 at 9:00 p.m. the FSBS results were 191, with 2 units of insulin administered, without a MD order; on 12/17/15 at 9:00 p.m. the FSBS results were 233 with 4 units of insulin administered, without a MD order; on 12/18/15 at 9:00 p.m. the FSBS results were 172, with 2 units insulin administered, without a MD order; on 12/19/15 at 9:00 p.m. the FSBS results were 195, with 2 units of insulin administered, without a MD order; on 12/20/15 at 9:00 p.m. the FSBS results were 174, with 2 units of insulin administered, without a MD order; on 12/21/15 at 9:00 p.m. the FSBS results were 179, with 2 units of insulin administered, without a MD order; on 12/22/15 at 9:00 p.m. the FSBS results were 186, with 2 units of insulin administered, without a MD order; on 12/23/15 at 9:00 p.m. the FSBS results were 309 with 8 units of insulin administered, without a MD order; on 12/24/15 at 9:00 p.m. the FSBS results were 151, with 2 units of insulin administered, without a MD order; on 12/25/15 at 9:00 p.m. the FSBS results were 225, with 4 units of insulin administered, without a MD order; on 12/26/15 at 9:00 p.m. the FSBS results were 375 with 10 units of insulin administered, without a MD order; on 12/27/15 at 9:00 p.m. the FSBS results were 210, with 4 units of insulin administered, without a MD order; on 12/29/15 at 9:00 p.m. the FSBS results were 290 with 6 units of insulin administered, without a MD order; on 12/30/15 at 12:00 p.m. the FSBS results were 460 without MD notification, and; on 12/30/15 at 9:00 p.m. the FSBS results were 281 with 6 units of insulin administered without a MD order. In January 2016: On 1/2/16 at 9:00 p.m. the FSBS results were 281, with 6 units of insulin administered, without a MD order; on 1/4/16 at 9:00 p.m. the FSBS results were 244, with 4 units of insulin administered, without a MD order; on 1/5/16 at 9:00 p.m. the FSBS results were 296 with 6 units of insulin administered, without a MD order; on 1/6/16 at 9:00 p.m. the FSBS results were 173, with 2 units of insulin administered, without a MD order; on 1/7/16 at 9:00 p.m. the FSBS results were 168, with 2 units of insulin administered, without a MD order; on 1/8/16 at 9:00 p.m. the FSBS results were 263 with 6 units of insulin administered, without MD order; on 1/9/16 at 9:00 p.m. the FSBS results were 309 with 8 units of insulin administered, without MD order; on 1/10/16 at 9:00 p.m. the FSBS results were 346 with 8 units of insulin administered, without MD order; on 1/12/16 at 9:00 p.m. the FSBS results were 249 with 4 units of insulin administered without MD order; on 1/14/16 at 9:00 p.m. the FSBS results were 373 with 10 units of insulin administered, without a MD order, and; on 1/18/16 at 9:00 p.m. the FSBS results were 210 with 4 units of insulin administered, without a MD order. 7. Record review for resident #155 revealed an admission dat

Based on record review and staff interview the facility failed to notify the Physician of Finger Stick Blood Sugar (FSBS) assessment monitoring results as ordered for fifteen (15) residents (#122, #286, #39, #55, #133, #130, #155, #142, #300, #57, #136, #119, #232, #365, #318) of the forty-seven (47) sampled. It was determined that the noncompliance with one or more requirements of participation has caused one (1) resident (V) actual harm, and is likely to cause, serious injury, harm, impairment, or death to residents. The census was one-hundred-forty (140). It was determined that the noncompliance with one or more requirements of participation is likely to cause harm, and is likely to cause, serious injury, harm, impairment, or death to resident, related to the administration of insulin to diabetic residents. The census was one-hundred-forty (140). This noncompliance was identified to have existed as of 9/1/2015, and remains ongoing. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on 1/19/2016 at 4:30 p.m. Cross Reference to F309, F279, F282 Findings include: 1. Review of the medical record for Resident #122 revealed a [DIAGNOSES REDACTED]. The resident had been admitted to the facility on [DATE] and discharged on [DATE]. The Minimum Data Set (MDS) assessment, completed on 10/6/15, indicated the resident required insulin injections daily. Review of the Physician (MD) orders, dated 9/30/15, revealed an order to administer Humalog insulin per sliding scale, call MD for blood sugar (BS) less than (<) 70 or greater than (>) than 400, no HS coverage, call MD if BS greater than (>) than 200, subcutaneously four times a day for Diabetes. Review of the Medication Administration Record [REDACTED]> 200 at HS and > 400, however there was no evidence of MD notification as ordered. 2. Review of the medical record for Resident #286 revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident required insulin injections each day. Review of the MD orders, dated 10/18/15, revealed to administer [MEDICATION NAME]per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD for BS > 200, subcutaneously four times a day for Diabetes Mellitus (DM) before meals and nightly. Review of MAR from 10/8/15 through 1/19/16 and Nurses Progress Notes from 10/8/15 through 1/19/16 revealed the Physician was not notified of BS > 200 at HS. 3. Review of the medical record for Resident #39 revealed a [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] indicated the resident received insulin injections daily Review of the MD orders revealed to administer HumaLog insulin per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day. Review of MAR indicated [REDACTED]> 200 at HS, and > 400. 4. Review of the medical record for Resident #55 revealed a [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident received daily insulin injections. Review of Physician orders, dated 2/23/15, revealed orders to administer [MEDICATION NAME]per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of MAR indicated [REDACTED]> 200 at HS times and failed to notify the Physician of BS < 70 or > 400. 5. Review of the clinical record for Resident #133 revealed [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] required insulin administration daily. Physician orders [REDACTED].< 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day. Review of MAR indicated [REDACTED]> 200 at HS, and of BS > 400. 6. Review of the medical record for Resident #130 revealed [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed the resident required insulin administration daily and had no cognitive impairments. Nutritional assessment, dated 1/26/15, revealed the resident was at risk for weight fluctuations related to therapeutic diet, Diabetes, and Dysphasia. Physician orders, dated 6/9/15, revealed orders to administer Humalog insulin per sliding scale QID, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200,subcutaneously four times a day for DM Give four times a day before meals and nightly. Review of Nursing Progress Notes dated 9/1/15 through 1/19/16 and MAR from 9/1/15 through 1/19/16 revealed no MD notification for BS > 200 at HS and for BS > 400. 7. Medical record review for Resident #155 revealed a [DIAGNOSES REDACTED]. Review of Physician orders, dated 11/4/15, revealed administer Humalog per sliding scale, call MD for BS sugar < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of Nurses Progress Notes dated 11/5/15 through 1/19/16 and MAR indicated [REDACTED]> 200 at HS. 8. Medical record review for Resident #142 revealed a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], revealed insulin administration daily. Review of MD orders, dated 6/1/15, revealed orders to administer [MEDICATION NAME]per sliding scale, call MD for BS < 70 > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of MAR indicated [REDACTED]> 200 at HS. 9. Medical record review for Resident #300 revealed a [DIAGNOSES REDACTED]. Quarterly MDS, dated [DATE], revealed the resident received insulin injections. Physician orders [REDACTED].< 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously two times a day for DM. Review of Nurses Progress Notes dated 9/24/15 through 1/19/16 and MAR from 9/24/15 through 1/19/16 revealed the facility failed to notify the Physician of BS > 200 at HS. 10 . Review of the clinical record for Resident #57 revealed a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated the administration of insulin daily. The nutrition assessment, dated 6/17/15, revealed a MD order dated 8/31/15 to administer [MEDICATION NAME]per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of Nurses Progress Notes dated 9/1/15 through 1/19/16 and MAR from 9/1/15 through 1/19/16 revealed the MD was not notified of BS > 200 at HS. 11. Review of the clinical record review for Resident #136 revealed a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], revealed daily insulin administration. Review of the MD orders dated 11/24/15 revealed orders to administer [MEDICATION NAME]per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day. Review of Nurses Progress Notes dated 11/24/15 through 1/19/16 and MAR from 11/24/15 through 1/19/16 revealed the MD was not notified of BS > 200 at HS. 12. Review of the clinical record for Resident #119 revealed [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 9/25/15, revealed the resident required insulin administration daily. Review of the MD orders dated 9/6/15 revealed orders to administer Humalog per sliding scale, call MD for BS < 70 or> 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM II. Review of MAR indicated [REDACTED]> 200 at HS and of BS > 400. 13 Clinical record review for Resident #232 revealed a [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 9/11/15, required the administration of insulin daily. Physician orders [REDACTED].< 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of the MAR indicated [REDACTED]> 200 at HS thirty-seven (37) times, and was not notified of BS < 70 or > 400. 14 Review of the clinical record for Resident #365 indicated a [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], revealed the resident required the administration of insulin daily. Review of the MD orders, dated 11/12/15, included Humalog administer insulin per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for Diabetes. Review of Nursing Progress Notes from 9/5/15 through 1/19/16 and MAR from 9/5/15 through 1/19/16 revealed the facility failed to notify the Physician of BS > 200 at HS. 15. Review of the clinical record for Resident #318 revealed [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated administration of insulin daily. Review of the MD orders dated 9/2/15 include administer [MEDICATION NAME]per sliding scale, call MD for BS < 70 or > 400, no HS coverage, call MD BS > 200, subcutaneously before meals and at bedtime for DM. Review of the MAR from 9/2/15 through 1/19/16 and Nursing Progress notes from 9/2/15 through 1/19/16,revealed the MD was not notified of BS > 200 at HS and of BS > 400. Interview on 12/2/15 at 1:17 p.m. with Licensed Practical Nurse (LPN) CC revealed the facility standard parameter for insulin coverage at 8 p.m. is to call the Physician for blood sugar results > 200 and not to give the sliding scale coverage. LPN CC indicated most of the Diabetic residents with sliding scale insulin coverage have this order but some do not, and there is no written policy or guidelines regarding this parameter. LPN CC acknowledged that if the residents have an order for [REDACTED].> 400. Interview on 12/2/2015 at 3:11 p.m. with the Primary Care Physician for Residents #122, #286, #55, #133, #130, #155, #142, #300, #57, #119, #232, #365, and #318 revealed the nurses know they should call him at HS for FSBS results > 200, and not to give sliding scale insulin coverage to the residents with the order not to give HS covearge. He could not definitively say he was called each time the residents blood sugars were > 200 at bedtime. Interview on 12/2/15 4:25 p.m. with LPN CC revealed she had searched for documentation of Physician notification of BS > 200 at 8:00 p.m. for Resident #122 and if the Physician was notified, this should appear in the Nurses Progress Notes and of the 16 blood sugar results > 200, no Physician notification was documented. Interview on 12/2/15 at 5:20 p.m. with LPN EE revealed their initials appear on the MAR indicated [REDACTED]. LPN CC acknowledged the sliding scale coverage had been administered without Physician notification. Interview conducted on 12/2/15 at 5:32 p.m. with LPN FF revealed they do not remember calling the Physician for Resident #122, to notify of FSBS > 200 at HS, and acknowledged they gave the sliding scale coverage at HS without a Physician order.

Based on record review, review of the Bowel and Bladder Management Policy, resident interview and staff interviews, the facility failed to promote toileting in a manner that maintained or enhanced the dignity and respect for one (1) resident ( V ) of the fourty-seven (47) residents. The census was one-hundred-forty (140). This failure resulted in actual harm for Resident V when she stated The staff put an adult diaper on me and tell me to just go to the bathroom in my diaper. It is embarrassing to use the bathroom in a diaper, I'm not used to doing that. Cross reference F242, F279, F315 Findings include: Interview conducted on 12/1/15 at 8:49 a.m. with the Resident V revealed never being assisted to the bathroom since admission. Resdient V stated, the staff put an adult diaper on me and tell me to just go to the bathroom in my diaper. It is embarrassing to use the bathroom in a diaper, I'm not used to doing that. I am able to go on the toilet if someone will just help me. At home I was able to transfer from my wheel chair to the toilet. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented in Section B-Hearing, Speech, Vision that the resident had clear speech with distinct, intelligible words, is able to make self-understood and was able to understand others with clear comprehension. Section C-Cognitive Patterns documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate impairment. Section G-Functional Status documented no urinary toileting trials were attempted since admission. Review of the Bowel and Bladder Management Policy documented the services are provided to restore or improve bladder function to the extent possible, after the removal of a catheter. Review of the Caring for Residents with Dignity & Respect program guide documented when residents are able to participate in their own care, it can give them a sense of independence and self-worth. You should assure them if they have difficulty, you will provide them with the help they need. By encouraging residents to participate in their own care, some may actually show improvement. Review of the Employee Completing A Specific Course log revealed one hundred twenty (120) employee entries of completion of the online course for Dignity from January 16, 2015 through November 24, 2015. Some of the employess listed completed the course more than once. Interview conducted on 12/2/15 at 2:30 p.m. with the direct care Certified Nursing Assistant (CNA) revealed she takes care of Resident V on a regular basis during the dayshift. The resident requires extensive assistance for transfers with two (2) person assistance and mechanical lift device. When Resident V is in bed, she is able to push the call light to let her know when she needs to use the bathroom and bedpan is provided. When Resident V is out of bed in her wheelchair, she wears a brief and goes to the bathroom in her brief. Resident V is then taken back to her room, put back into the bed and cleaned up. Resident V has never been assisted to the toilet until yesterday.

Based on resident interview, staff interview, review of the 200 Hall Shower Schedule and review of the November 2015 Shower Forms, the facility failed to honor the method of bathing for one (1) resident (V) from a sample of forty seven (47) residents. The census was one-hundred-forty (140). This failure resulted in actual harm for Resident V who stated The staff put adult diapers on me and tell me to just go to the bathroom in my diaper. They wipe me up but since I never get a shower I do not feel clean. Cross reference F241, F315 Findings include: An interview conducted on 12/01/2015 at 8:49 a.m. with resident V revealed she had received bed baths but had never received a shower since her admission. She preferred a shower over a bed bath but the staff never offered her a choice and she did not know she could have one. V stated The staff put an adult diaper on me and tell me to just go to the bathroom in my diaper. They wipe me up but since I never get a shower I do not feel clean. She lived independently at home with visiting aids that showered her three (3) times a week. Record review for Resident V indicated an admitted [DATE] after a hospitalization , with multiple [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate impairment. Section F- Preferences for Customary Routine and Activities documented it was very important to choose between a shower, bed bath or tub bath. Section G- Functional Status documented the resident required physical help in part of bathing. Staff Assessment of Daily and Activity Preference was not conducted to indicate if the resident received a shower, bed bath or tub bath. Review of the Care Plan dated November 23, 2015 identified Resident V had an Activities of Daily Living (ADL) self-performance deficit with an intervention that included, but not limited to, assist by two (2) staff for bathing/showering and encourage the resident to participate to the fullest extent possible with each interaction and observe/document/report any changes, any potential for improvement, reasons for self-care deficit, expected course or declines in function. A review of the Shower Schedule indicated for Resident V, the resident was scheduled to receive a shower on Wednesday and Saturday evenings. A review of the Shower forms from November-December 2015 in the Bath Book revealed no evidence of completed Shower Forms for Resident V. An interview conducted on 12/02/2015 at 2:30 p.m. with the Direct Care Certified Nursing Assistant (CNA) MM revealed she had never taken Resident V to the shower because they are scheduled for every Wednesday and Saturday on the evening shift. An interview conducted on 12/02/2015 at 2:40 p.m. with the 300 Hall Unit Manager revealed the CNAs use the Shower Form when a resident receives a shower. They document on the shower form the date, the resident's name and if the resident received a shower or refused. The shower form is given to the nurse and signed by the nurse. The form is then kept in the Bath Book. They also document in the computer that bathing occurred, however, this documentation does not indicate the type of bathing that occurred. She confirmed there are no Shower Forms in the Bath Book for Resident V.

Based on record review, and interviews, the facility failed to promote care in a manner to improve or prevent decline of normal bladder function for one (1) resident (V) from a sample of fourty-seven (47) residents. The census was one-hundred-forty (140). This failure resulted in actuall harm for Resident V who stated I do not like going to the bathroom in a diaper. It makes me feel helpless when I am not helpless. I am able to go on the toilet if someone will just help me. Cross reference F241, F242, F279 Findings include: An interview conducted on 12/01/2015 at 8:49 a.m. with resident V revealed she had a catheter in the hospital and it was removed before she came to the nursing facility. At home she was able to transfer herself from the wheel chair to the toilet. V said she had never been taken to the toilet since her admission. The staff put an adult diaper on her on her and when she asked to be taken to the toilet, the staff tell her that Physical Therapy (PT) said they cannot get her up because she would fall and they tell her to just go in her diaper. She said PT told her not to try to go by herself and make sure she calls for assistance. Further, V stated I do not like going to the bathroom in my diaper. It makes me feel helpless when I am not helpless. It is embarrassing to use the bathroom in a diaper, I'm not used to doing that. I am able to go on the toilet if someone will just help me. Record review for resident V indicated an admitted [DATE] after a hospitalization , with multiple [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented in Section B-Hearing, Speech, Vision that the resident had clear speech with distinct, intelligible words, was able to make self-understood and was able to understand others with clear comprehension. Section C-Cognitive Patterns documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate impairment. Section G-Functional Status documented the resident required extensive assistance of two person physical assist with transfers and toileting. No urinary toileting trials were attempted since admission and the resident was always incontinent of bladder and always incontinent of bowel. Review of the Care Plan dated 11/23/2015 identified resident V as receiving rehab therapy from the services of Occupational Therapy (OT) and Physical Therapy (PT) with an intervention that included, but not limited to, encouraging the resident to be as independent as possible. In addition, identified an Activities of Daily Living (ADL) self-performance deficit with the goal set to improve the current level of function of ADLs with interventions that included but not limited to, extensive assist by two (2) staff for toileting and encourage the resident to participate to the fullest extent possible with each interaction and observe/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of the Bowel and Bladder Management Policy documented: Each resident who is incontinent is identified, assessed and provided appropriate treatment and service. Services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter. The intent of the Bowel and Bladder Management System is to clearly define the process for providing care and treatment for [REDACTED]. Review of the Nursing Admission Assessments revealed the Nursing Admission Data Collection assessment and the Bowel and Bladder Evaluation had not been conducted on admission and was not assessed until December 2, 2015. Review of the Physical Therapy Evaluation Plan of Treatment dated November 15, 2015 documented prior living description: Patient stated she lived alone in an apartment that was handicapped accessible. She was able to transfer from wheelchair to Bedside Commode (BSC) and back to wheelchair. An interview conducted on 12/2/2015 at 2:30 p.m. with the Direct Care Certified Nursing Assistant (CNA) MM revealed when the resident is in bed, she is able to push the call light and let her know when she needs to use the bathroom. When the resident is out of bed in her wheelchair, she wears a brief and goes in her brief, then she will take her back to her room and put her back in bed to clean her. She said the resident has never been assisted to the toilet until yesterday. She was not working yesterday and a different CNA cared for her. An interview conducted on 12/2/2015 at 2:55 p.m. with CNA OO revealed resident V called her yesterday to get up and go to the bathroom. She got her up with a lift and took her to the toilet and she was able to use the toilet successfully. An interview conducted on 12/2/2015 at 2:40 p.m. with the 300 Hall Unit Manager HH revealed the resident should have been evaluated for bowel and bladder function upon admission via the Admission Bowel and Bladder Evaluation. This assessment helps determine if a resident knows when they need to use the bathroom, if they are able to use the toilet and if they are a candidate for a toileting program. All residents should be checked every two (2) hours for toileting and to encourage toileting. She confirmed there is no evidence in the Electronic Medical Record (EMR) that the Nursing Admission Data Collection or the Bladder and Bowel Evaluation was conducted and should have been. Interview conducted on 12/3/2015 at 8:30 a.m. with the Director of Nursing (DON) confirmed the Admission Bowel and Bladder Assessment and the Nursing Admission Data Collection was not conducted. He said there is no written policy but the expectation is that all admission assessments which include, but are not limited to, Nursing Admission Data Collection and Bowel and Bladder Evaluation is to be conducted within 24 hours of admission. Interview conducted on 12/3/15 at 11:48 a.m. with the Rehab Program Manager PP revealed rehab would never instruct the staff not to get a resident up to use the bathroom, they would be giving strategies on safe transferring techniques. PP confirmed there have been miscommunication with the CNAs telling the residents something that is not accurate such as PT told them not to get them get out of bed. She has brought this concern to the Administrator and the DON last week during a weekly meeting. She said they do plan to re-educate the CNA staff. Further, a resident that is able to use the bathroom even when they need extensive assistance should still be toileted. The resident is able to use a bariatric bed side commode with the level of assistance indicated. This information for two (2) person assist is shared with the staff verbally and also shared in the IDT meetings. She has only been here three (3) weeks, she is not sure how it was communicated prior to that.

Based on medical record review and staff interview, the facility failed to provide care in accordance with the Care Plan of one (1) resident (#1), related to the application of a self-release seat belt with an alarm, in a survey sample of five (5) residents. The resident subsequently fell and sustained a laceration to the forehead approximately one (1) inch in length, and a skin tear to the left knee. Findings include: Cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed the resident's current Care Plan identified as a Problem that the resident had dementia with behaviors and a history of falls, requiring the use of a self-release belt. This Care Plan also indicated that the resident could release the belt upon command, and an Approach to address the resident's fall-risk specified the application of a self-release belt while up in the wheelchair. A Change Of Condition Nurse's Note timed at 6:30 p.m. documented that on 04/03/2012, the resident fell from the wheelchair to the floor, hitting the forehead and causing a laceration to the forehead about one (1) inch in length, as well as a skin tear to the left knee. However, there was no documented evidence in the medical record to indicate that a self-release seat belt with an alarm had been applied to the resident, as specified by the Care Plan, at the time of the fall. During an interview with the Social Service Director (SSD) conducted on 04/16/2012 at 10:20 a.m., the SSD stated that on 04/03/2012, he had observed Resident #1 on the floor with a wheelchair positioned on her and had removed the wheelchair, but had not released any restraint while removing the wheelchair. During a subsequent interview on 04/16/2012 at 10:30 a.m., the SSD stated that he did not recall hearing an alarm when the resident fell . During an interview with the Director of Nursing (DON) conducted on 04/16/2012 at 12:10 p.m., the DON stated that during the facility's investigation of Resident #1's fall, three (3) staff members who were interviewed did not recall hearing an alarm sound when the resident fell .

Based on medical record review and staff interview, the facility failed to provide a self-release seat belt with an alarm, as ordered by the physician, as a safety device for one (1) resident (#1) in a survey sample of five (5) residents. The resident subsequently fell and sustained a laceration to the forehead about one (1) inch in length, and a skin tear to the left knee. Findings include: Record review for Resident #1 revealed that the April 2012 physician's orders [REDACTED]. The physician's orders [REDACTED]. A Change Of Condition Nurse's Note timed at 6:30 p.m. which referenced Resident #1 documented that on 04/03/2012, the resident fell from the wheelchair to the floor, hitting the forehead and causing a laceration to the forehead about one (1) inch in length. This Note documented that the forehead laceration was cleaned and Steri Strips were applied, and that a skin tear to the left knee was cleaned and Xeroform was applied and covered with 4-by-4 gauze and tape, per a physician's orders [REDACTED].#1 had been sent to the hospital. There was no documented evidence on this Change Of Condition form, or elsewhere in the medical record, to indicate that a self-release seat belt with an alarm had been applied to the resident at the time of the fall. During an interview with the Social Service Director (SSD) conducted on 04/16/2012 at 10:20 a.m., the SSD stated that on 04/03/2012, he heard a loud sound, walked out of the office and observed Resident #1 on the floor with a wheelchair positioned on the resident's legs, from the knees down. The SSD stated he went to the resident and removed the wheelchair off the resident, further stating that he did not release any restraint while removing the wheelchair from the resident. During a subsequent interview with the SSD on 04/16/2012 at 10:30 a.m., the SSD stated that he did not remember hearing an alarm when the resident fell . During an interview with Licensed Practical Nurse (LPN) "BB" conducted on 04/16/2012 at 10:40 a.m., this LPN stated that the alarm for the self-release belt for Resident #1 was very loud when it sounded, and that staff would have heard the alarm if it had sounded. During an interview with Certified Nursing Assistant (CNA) "AA" conducted on 04/16/2012 at 11:15 a.m., this CNA stated that the seat belt alarm for Resident #1 would sound whenever the seat belt was unattached, and would continue to alarm until someone turned the alarm off. During an interview with the Director of Nursing (DON) conducted on 04/16/2012 at 12:10 p.m., the DON stated that during the facility's investigation of this 04/03/2012 fall involving Resident #1, three (3) staff members who were interviewed related to the resident's fall did not remember hearing an alarm go off when the resident fell .