Every finding on record at Autumn Care of Fayetteville

Based on observation, record review and staff interviews, the facility failed to ensure a dependent resident's toenails were trimmed and podiatry services were arranged for 1 of 3 residents reviewed for foot care (Resident #8).The findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses that included hypertension, dementia, age-related physical debility and need for assistance with personal care.Resident #8's care plan had a care focus area initiated 3/17/26 that indicated that Resident #8 had an activity of daily living self-care deficit related to decreased functional mobility with the goal for her needs to be met with staff assistance. Interventions included assist with activities of daily living, dressing, grooming, toileting, feeding, and oral care.A bath/shower sheet dated 3/18/26 completed by Nurse Aide (NA) #1 indicated Resident #8 had received a bed bath and needed podiatry services. This sheet was signed off by Nurse #2.A bath/shower sheet dated 3/21/26 completed by NA #1 indicated Resident #8 had refused a shower, received a bed bath and needed podiatry services. This sheet was signed off by Nurse #2.An admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #8 as severely cognitively impaired. She required substantial to maximal assistance with oral and personal hygiene, showers/bathing and transfers. She was not coded for rejection of care during the assessment period.A bath/shower sheet dated 4/15/26 completed by NA #1 indicated Resident #8 had received a bed bath and needed podiatry services. This sheet was signed off by Nurse #2.A review of the facility's podiatry clinic schedule dated 4/20/26 revealed Resident #8 was not seen by the podiatrist and was not on the list to be seen on that day.A review of Resident #8's electronic medical records (EMR) on 4/21/26 revealed no consultation reports or notations in Resident #8's EMR that she was scheduled to see a podiatrist or that she had been seen by a podiatrist since admission to the facility.During an interview with NA #1 on 4/23/26 at 8:30 AM she revealed that she frequently cared for Resident #8 during the first shift (7:00 AM to 3:00 PM). NA #1 stated that she had noticed that Resident #8's toenails were long and thick from when she was admitted to the facility in March 2026 and that she had attempted to trim them without success. NA #1 stated that she had documented in the shower sheets a couple of times that Resident #8 required podiatry services which were supposed to be signed off by the primary nurse. She stated that she had mentioned it to Nurse #2 on more than one occasion and she could remember the last day she had mentioned it was on 4/15/26 and that if she had not mentioned it, Nurse #2 would still be aware because she had signed off on the shower sheets where she (NA #2) had documented on 3/18/26, 3/21/26 and 4/15/26 that Resident #8 needed podiatry services.An interview was conducted with Nurse #2 on 4/23/26 at 10:55 AM. She stated that she could not remember if NA #1 or anyone else had mentioned to her that Resident #8 needed podiatry services. She indicated that she had not seen it on the shower sheets when she signed off on them and that she should have read the shower sheets more carefully to ensure Resident #8 received footcare. Nurse #2 further stated that she should have put Resident #8 on the podiatry list and obtained consent from Resident #8's Responsible Party (RP) or asked the physician for a podiatry consult for Resident #8. An observation and interview was conducted on 4/22/26 at 10:40 AM in the company of Unit 1 and Unit 2 Managers. All of Resident #8's toenails on both feet were observed to be thick, long and curved downward past her toenail bed. When Resident #8 was asked if her toes hurt or if she wanted her toenails trimmed, she stated, I don't know. The two Unit Mangers stated that they were not aware of Resident #8's toenails condition prior to this observation and that normally the nurse aides would notify the primary nurses if a resident required podiatry services and the nurses would ask the physician for a podiatry consult.During a follow up interview on 4/23/26 at 8:58 AM with Unit 2 Manager she stated that Nurse #2 should have reached out to the physician for a podiatry consult when she signed off on Resident #8's shower sheet on 3/18/26.An interview was conducted with the Director of Nursing (DON) on 4/23/26 at 11:46 AM. The DON stated that when Nurse #2 signed off on the shower sheet on 3/18/26 she should have obtained consent from Resident #8's RP and put her on the podiatry list to be seen at the facility during the podiatry clinic on 4/20/26 or she could have requested a podiatry consult from the physician to ensure Resident #8 received appropriate foot care. The DON stated that she was not aware that Resident #8's toenails were long and that after she was made aware on 4/22/26, Resident #8 has been scheduled to be seen at an offsite podiatry clinic on 5/2/26. An interview was conducted with the Administrator on 4/23/26 at 12:55 PM. The Administrator stated nobody had mentioned to her that Resident #8's toenails were long and that if she had been made aware she would have ensured Resident #8 was seen during the 4/20/26 podiatry clinic at the facility. She stated that Nurse #2 should have reached out to the physician for a podiatry consult or put her on the podiatry list and obtained RP consent for Resident #8 to be seen in house on 4/20/26. The Administrator indicated she expected all residents to receive podiatry services when needed.

Based on record review, resident interview and staff interviews, the facility failed to honor a dependent resident's preference for a shower and provided a bed bath instead. This deficient practice affected 1 of 1 sampled resident. (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #1 coded as cognitively intact and was on hospice. The care plan dated 11/28/2024 had a focus area for Resident #1 being on hospice services and for activities of daily living (ADL) self-care deficit related to decreased functional mobility. Resident #1's shower was scheduled to be each Tuesday and Friday during 1st shift. A review of care history dated 09/01/2024 to 12/31/2024 revealed Resident #1 missed 36/36 of her scheduled showers. During an interview with Resident #1 on 01/06/25 at 3:52 PM, the resident stated she was supposed to have a shower twice a week and had not had a shower in a very long time. The staff had not asked her if she wanted a shower and just gave her bed baths. The Resident also stated she did not refuse showers. An interview with the Unit Manager (UM) was conducted on 01/07/2025 at 3:35 PM. The UM stated he never had any reports of Resident #1 refusal of showers. The Nursing Assistants (NA) were supposed to offer showers on shower days and if the showers were refused, then they were to document and report to the Director of Nursing (DON). The UM also stated he was not aware Resident #1 was not getting her scheduled showers. An interview with NA #1 was conducted on 01/08/2025 at 9:13 AM. The NA stated she has been at the facility since October 2024. The NAs were trained to ask the residents on their shower days if the residents wanted a shower. The NA explained she had not asked Resident #1 if she wanted showers because she was on hospice services and thought the hospice NAs gave the resident her showers. The NA also stated Resident #1 always received a bed bath. An interview with the Administrator was conducted on 01/08/2025 at 2:54 PM. The Administrator stated every Resident that wished to have a shower should have a shower on their scheduled shower days. The Administrator also stated she expected her staff to ask the residents if the resident would like a shower and provide the shower for the resident and not to just provide a bed bath. An interview with the DON was conducted on 01/09/2025 at 12:29 PM. The DON stated she was not aware that Resident #1 was not receiving her showers on her scheduled shower days. The nurses reported any refused showers, and she would speak with the Resident or the residents Responsible Party (RP) to update their care plans. The DON also stated she wanted all staff to give showers to the residents on their shower days and report if there were any refusals.

Based on observation, record review, resident and staff interview the facility failed to ensure the lunch meal was provided at the regularly scheduled mealtime comparable to normal mealtimes in the community for 1 of 1 hall observed (600 hall). This practice had the potential to affect meals served to other residents. The findings included: The scheduled mealtimes were as follows: breakfast 8:30 AM, lunch 12:30 PM and dinner 5:30 PM. The lunch menu for 12/11/2023 indicated the main dish was turkey. An observation of the lunch meal on 12/11/2023 revealed the tray cart arrived on the 600 hall at 1:45 PM. Resident #52 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] had Resident coded as cognitively intact. An interview with Resident #52 who resided on the 600 hall was conducted on 12/11/2023 at 1:26 PM. The Resident stated he was waiting for lunch, and it was supposed to be served around 12:30 PM but today it was late. He also stated he was not offered a mid-morning snack and was hungry. His breakfast was on time, and he expected to receive his meals according to agreed mealtimes and to at least let him know when they were running late. Resident #52 indicated meals had previously been late, but he was unable to provide specific information on frequency or dates. An observation of lunch on 12/11/2023 for Resident #52 revealed his lunch was delivered at 1:45 PM. An interview with Certified Nursing Assistant #1 was conducted on 12/11/2023 at 1:44 PM. The Assistant stated they were late with meals at times. She did not recall how late the meals were and there had not been any complaints from the residents about late meals. An interview with the Regional Registered Dietitian (RD) was conducted on 12/12/2023 at 10:19 AM. The Regional RD stated she was covering for the Dietary Manager that was out on Family Medical Leave Act (FMLA) and she was there to help them out in the kitchen. Lunch time was supposed to be 12:30 PM, but the late lunch was random. She explained the turkey that was on the lunch menu did not fully cook in time for the regularly scheduled lunch mealtime on 12/11/2023. She also stated they did not have a log that showed when the carts left the kitchen. The Regional RD further stated they would put a plan in place to avoid late meals in the future. An interview with the Director of Nursing (DON) was conducted on 12/14/23 at 9:39 AM. The DON stated the turkey was not done on time, but it was close to mealtime, so they continued to prepare it. The DON also stated they would usually offer a snack if they knew in advance that meals were going to be late but did not get a chance to offer them. An interview with the Administrator was conducted on 12/14/23 at 10:47 AM. The Administrator stated they have not had any issues with late meals but on that day the turkey that was on the menu was still cooking and they could not serve undercooked meat.

Based on observation, staff interviews, and record review, the facility failed to date and remove leftover food stored for use one of one kitchen walk-in refrigerator and failed to label leftover food in one of one (300 hall) nourishment room refrigerator. Findings included: 1. A tour was conducted on 8/22/22 at 10:45 AM of the kitchen walk-in refrigerator with the facility's Registered Dietitian (RD). Observations were made of a bag of sliced Swiss cheese dated 7/19/22, a bag of sliced provolone cheese with no date, a bag of shredded mozzarella cheese dated 7/5/22. During an interview on 8/22/22 at 10:50 AM, the RD revealed food stored in the walk-in refrigerator should be discarded after seven days of opening. Staff should date all food items placed in the walk-in refrigerator. During an interview on 8/24/22 at 11:45 AM, the Dietary Manager revealed dietary staff should label all food items placed in the refrigerators. The food should be discarded after 7 days. He revealed the cooks were responsible for monitoring refrigerators daily. He was unsure if it was checked over the weekend. 2. An observation was made on 8/22/22 at 11:05 AM of the residents' nourishment room refrigerator of a pizza box with a resident's name and room number with no date, a plastic take-out container with a resident's name and room number with no date, a take-out box with a resident's name and room number and no date, and a Styrofoam box containing food with a resident's name and room number with no date. During an interview on 8/22/22 at 11:10 AM, the RD revealed nursing staff should label food items placed in the nourishment room refrigerator with the resident's name, room number, and date. The food should be discarded by dietary staff within 7 days of being placed in the refridgerator. During an interview on 8/24/22 at 11:45 AM, the dietary manager revealed nursing staff was responsible for labeling items placed into the nourishment room refrigerators. Dietary staff was responsible for monitoring daily. During an interview on 8/25/22 at 1:35 PM, the Administrator revealed nursing staff should label items in the nourishment room refrigerator with the resident's name, room number, and the date. Dietary staff should be monitoring the nourishment room refrigerators daily.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 8/13/21 recertification survey. This was for a recited deficiency in the area of food safety requirements. This deficiency was cited again on the current recertification survey. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F 812: Based on observation, staff interviews, and record review, the facility failed to date and remove leftover food stored for use one of one kitchen walk-in refrigerator and failed to label leftover food in one of one nourishment room (300 hall) refrigerator. During the recertification survey of 8/13/21, the facility was cited at F812 Food Safety for failing the label food in the kitchen refrigerator. During an interview on 8/25/22 at 2:30 PM, the Administrator revealed they have QAA meetings monthly. She expected the dietary manager to be monitoring food in the walk-in refrigerator in the kitchen and the nourishment room refrigerators. The dietary manager attended QAA monthly or more frequently if needed.

Based on record review, observation and staff interviews, the facility failed to assess the ability of a resident to self-administer medications that were left at bedside for 1 of 1 resident (Resident #52) reviewed for self-administration of medications. The findings included: Resident #52 was admitted to the facility on [DATE]. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact. He required extensive assistance with bed mobility and transfers and required supervision with eating. Resident #52's careplan revised 8/11/22 did not include information regarding Resident #52 self-administering medications. Review of Resident #52's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52's medical records revealed no self-administration of medication assessment for Resident #52. During observation on 08/22/22 at 11:40 AM Resident #52 was observed lying in bed. Medicine was observed in a medicine cup on Resident #52's bedside table. Resident #52 stated he was not aware he had medication left at bedside. There were 8 pills in the medicine cup which was verified with Nurse #1. Review of Resident #52's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications documented as administered included [MEDICATION(S)] for hypertension, [MEDICATION(S)] for [CONDITION(S)], [MEDICATION(S)], [MEDICATION(S)] for inflammation, [MEDICATION(S)] for diabetes, [MEDICATION(S)] for hypertension, [MEDICATION(S)] for hypertension and [MEDICATION(S)] for seizures. During an interview on 08/22/22 at 11:45 AM with Nurse #1, she stated she had left the medicine at around 8:30 AM on the bedside table for resident #52 to swallow after breakfast. Nurse #1 verbalized she should not have left the medicine in Resident #52's room and she should have ensured Resident #52 had swallowed the medicine. Nurse #1 further stated she had not assessed Resident #52 for self-medication administration before she left the medicine at bedside. During an interview on 08/22/22 at 03:02 PM with the Assistant Director of nursing (ADON), he stated Nurse #1 should have assessed Resident #52's ability to self-administer the medications before leaving them at bedside and ensured the medication was swallowed before she documented them as administered. During an interview on 08/22/22 at 03:36 PM with the facility Administrator, she stated Resident #52 had not been assessed for self-medication administration. The Administrator stated she expected nurses to administer all the medication according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record review, and staff interviews, the facility failed to accurately document application of palm guards for 1 of 5 residents (Resident #33) reviewed for a decline in activities of daily living. Findings included: Resident #33 was admitted to the facility on [DATE]. Record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 8/24/22 at 9:50 AM of Resident #33 in bed without palm guards in place. During an interview on 8/24/22 at 9:55 AM, Nurse #2 indicated Resident #33 did not have the palm guards in place and she was not sure where they were. She revealed she did not have the palm guards on during her day shift. Record review of Resident #33 Treatment Administrator Record (TAR) for 8/24/22 indicated her palm guards were administered on the day shift by Nurse #2. During an interview on 8/24/22 at 4:00 PM, Nurse #2 indicated Resident #33 refused the palm guards when she attempted after lunch. She revealed she should have marked refused on the TAR for 8/24/22 day shift but she must have marked administered by mistake. During an interview on 8/25/22 at 10:00 AM, the Director of Nursing revealed nursing staff should make sure the treatment was in place before documenting it was administered. If the treatment was not in place, the nurse should attempt placement. During an interview on 8/25/22 at 1:30 PM, the Administrator revealed the nurse should observe the treatment in place before documenting administered. If the resident refused, it should be documented and reported to the unit manager.

Based on resident interview, staff interview, student nurse aide interview, student nurse aide instructor interview, and ombudsman interview, the facility failed to treat Resident #1 with respect during incontinence care. Nurse Aide #1 was observed labeling and trying to hush the resident when she expressed pain. This was for one (Resident # 1) of four residents reviewed for dignity issues. The findings included: Resident # 1 was admitted to the facility on [DATE]. One of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident # 1's quarterly minimum data set assessment, dated 4/28/22, revealed the resident was cognitively impaired and needed extensive assistance with her hygiene needs. Review of schedules for Nurse Aide Students revealed students were in the facility for their clinical rotation on Monday through Thursday during the dates of 5/11/22 to 5/24/22. Resident # 1 was interviewed on 6/24/22 at 10:04 AM and was not able to account for any past events from staff. Resident # 1 appeared confused and quickly went from one unrelated topic to another. Student Nurse Aide (SNA) # 1 was interviewed on 6/24/22 at 9:15 AM and reported that during clinical rotations she and other student Nurse Aides had some concerns with how Nurse Aide (NA) # 1 cared for residents. SNA # 1 reported NA # 1 was not respectful to Resident # 1. SNA # 1 also reported she had witnessed NA # 1 say in front of Resident # 1 that she was a drama queen when the resident complained of hurting from a perineal rash. SNA # 2 was interviewed on 6/24/22 at 10:03 AM and reported the following. She and SNA # 3 were together with NA # 1 while NA # 1 was caring for Resident # 1 during their clinical rotation. Resident # 1's private area was very red and she appeared to have a yeast infection. When NA # 1 was cleaning Resident # 1, NA # 1 was not gentle and the resident was in pain from the irritation and rash as she was being cleaned. Resident # 1 would complain of pain and NA # 1 would say She is just being a baby or she is just dramatic in the presence of Resident #1. SNA # 3 was interviewed on 6/24/22 at 10:16 AM and reported the following. She had also been in the room when SNA # 2 and NA # 1 were with Resident # 1. Student NA # 3 reported that Resident # 1 had a very bad rash and she perceived that NA # 1 was cleaning Resident # 1 too hard. The rash was painful and she heard facility NA # 1 say, You're fine-don't worry. You need to hush. Review of Resident # 1's record revealed she was started on [MEDICATION(S)] cream 2% two times per day to the groin area on 5/20/22. (This is an antifungal cream and the date corresponded to the time the student NAs were doing clinical in the facility.) NA # 1 was interviewed on 6/27/22 at 3:53 PM and reported the following. She had never told a resident to hush and did not speak to residents disrespectfully. She reported she would never do that. The Student NA Instructor was interviewed on 6/24/22 at 4:15 PM and reported the following. Although she had not witnessed a facility staff member talk disrespectfully to residents or care for them inappropriately, she felt SNA # 2 and SNA # 3 were credible students regarding anything they were reporting. The DON (Director of Nursing) was interviewed on 6/24/22 at 1:45 PM and reported the following. She recalled the ombudsman calling her and asking her to look at Resident # 1's bottom while the SNAs were there. She had looked at it and saw she had what appeared to have a yeast infection. She had talked to the SNA Instructor who indicated that the instructor felt that one of her students may have called the ombudsman. The DON did not recall any reports of any of her staff talking disrespectfully and she had not identified that this may have been happening by talking further to the SNAs to gain further information about her staff being disrespectful. The Regional Ombudsman was interviewed on 6/28/22 at 8:00 AM and reported the following. He had talked to the DON in May, 2022 when he received a report that student nurse aides were concerned regarding how facility staff were interacting with residents and being dismissive of the residents' concerns when caring for them. He had let the DON know this. He knew there had been a particular concern with Resident # 1's rash being dismissed. The facility Administrator was interviewed on 6/24/22 at 6:05 PM and again on 6/27/22 at 3:40 PM and reported the following. NA # 1 was a part time employee who had worked with Resident # 1 on the dates of 5/12/22; 5/13/22; 5/17/22; and 5/18/22. This would have corresponded to the times that the SNAs were in the facility. She perceived NA # 1 to be a very good employee and had never personally known her to be disrespectful to anyone. The Administrator reported that she did recall the ombudsman had talked to the DON about Resident # 1's rash not being treated but she thought that was the issue and taken care of. According to the Administrator if she had known that there were corroborating statements from two SNAs that NA # 1 was making the comments that she had allegedly said, then the Administrator would have investigated further and taken appropriate action.

Based on observation, record review, and staff interview the facility failed to assure a readmitted resident (Resident # 9) was placed on transmission-based precautions for COVID-19 per infection control standards of practice. This was for one of three sampled residents reviewed for COVID precautions. This occurred during a coronavirus pandemic. The findings included: Resident # 9 was initially admitted to the facility on [DATE] and hospitalized again on 6/14/22. Resident # 9 was readmitted to the facility after his hospitalization on [DATE] at 5:05 PM. Review of Resident #9's record revealed he was not vaccinated for COVID-19. Resident # 9 was observed on 6/23/22 to be in his room without any transmission-based precautions (TBP) being taken by staff. There was no signage on the door denoting that Resident #9 was on TBP. Interview with the Director of Nursing on 6/23/22 at 5:00 PM revealed the resident should be on TBP and she would investigate why he had not been placed on TBP. A follow up interview was conducted with the DON on 6/24/22 at 1:30 PM and she reported that the nurse who had readmitted Resident # 9 thought the date of his precautions should be over since he had initially started them on 6/13/22. The nurse had not taken into account the resident had been back to the hospital, and not placed him on TBP on his readmitted [DATE]. The DON stated she had tested all residents and staff on the night of 6/23/22 after learning that this had occurred. None of the residents were positive. At the current time of the survey, the DON stated she had two staff members out due to obtaining COVID while within the community, and proper precautions had been taken to deal with the staff members per CDC (Centers for Disease Control) guidelines.

Based on staff interviews and record review, the facility failed to provide written responses to grievances for 2 of 5 residents reviewed for grievances. (Resident #46 and Resident #49) Findings included: 1. Resident #46 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #46 was severely cognitively impaired and required extensive assistance for her activities of daily living (ADLs). Record review of grievances indicated Resident #46's family member filed a written grievance on 6/14/21. The grievance referenced the Resident #46 out of bedtimes. There was no evidence of a written response/summary provided to the family member who filed the grievance. During an interview with the Social Worker (SW) on 8/10/21 at 4:03 PM, the SW stated she completed the Concern Form on 6/16/21; but she had no knowledge of a written summary or written response to the concern. She stated she was not sure who was responsible for providing the written notifications. In a telephone interview with Family Member #1 on 8/12/21 at 4:44 PM, she revealed she had not received a written summary or response from the facility regarding grievance submitted on 6/14/21. A telephone interview was conducted with the Administrator on 8/13/21 at 9:10 AM. The Administrator acknowledged the family should have been provided a written resolution and summary by the facility. 2. Resident #49 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #49 was moderately cognitively impaired and needed extensive assistance or was totally dependent for Activities of Daily Living (ADLs). Record review of grievances indicated Resident #49's family member filed a written grievance on 6/16/21. The grievance referenced Resident #49 getting up too early in the morning. There was no evidence of a written response and/or summary provided to the family member who filed the grievance. During an interview with the Social Worker (SW) on 8/10/21 at 4:03 PM, the SW stated she completed the Concern Form on 6/21/21; but she had no knowledge of a written summary or written response to the concern. She stated she was not sure who was responsible for providing the written notifications. Family Member #2 returned a telephone call on 8/13/21 at 1:34 PM. She revealed she had not received a written summary or response from the facility regarding her grievance submitted on 6/16/21. A telephone interview was conducted with the Director of Nursing on 8/13/21 at 8:53 AM. The DON stated the grievance should have been summarized and a copy provided to the family. She also stated the concerns/grievance should go to the tracking committee to track concerns and resolutions. A telephone interview was conducted with the Administrator on 8/13/21 at 9:10 AM. The Administrator acknowledged the family should have been provided a written resolution and summary by the facility.

Based on the medical record reviews and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 residents sampled for Hospice. (Resident #56) Findings included: Resident #56 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #56 coded as having hospice care. The care plan dated 07/19/2021 had a focus of resident on hospice services. Review of record for resident #56 revealed resident was admitted to hospice with certification and plan of treatment in place for the certification period 06/27/2021 to 08/25/2021. During an interview with the MDS Nurse on 08/11/2021 at 1:09PM, she stated resident was on hospice since 2020, she is not coded in the quarterly MDS dated [DATE] as having had hospice and it should have been coded. It was missed due to human error. During an interview with the Director of Nursing (DON) on 08/11/2021 at 2:22PM, the DON stated Resident#56 was currently on Hospice and it should have been coded in the MDS accurately.

Based on record review and staff interviews the facility failed to request a Level II Preadmission Screening and Resident Review (PASRR) determination for residents with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1. Resident #69 was admitted to the facility on [DATE] with last re-entry on 1/20/20 after hospitalization . Review of Resident #69's annual Minimum Data Set (MDS) dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASRR Level I application dated 3/24/17 revealed no cognitive impairment diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #69's Medical Admission Record revealed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Admission Record also revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/11/21 at 11:41 AM, the MDS Nurse said that a Level II PASRR screening should have been completed for Resident #69. During an interview on 8/13/21 at 8:50 AM, the Director of Nursing stated the new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 8/13/21 at 9:10 AM, the Administrator stated there was no PASARR Level II application completed for Resident #69. He explained his staff member that does PASARR screening was out on leave and this PASARR slipped by the staff. He also stated he expected all residents be screened when entering the facility and when new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 was not currently considered by the state Level II PASRR process to have serious mental illness. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/11/2021 at 11:41 am, the MDS Nurse said that a Level II PASRR screening should have been completed for Resident #24 after the new mental illness diagnoses. During an interview on 08/11/2021 at 2:00 pm, the Facility Administrator said a Level II PASRR screening had not been completed for Resident #24. He explained a Level II PASRR screening should be completed for all new residents and for any resident with a new mental illness diagnosis. During an interview on 8/13/21 at 3:46 pm with the Director of Nursing (DON), she indicated a PASRR Level II screening should be completed with every new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record reviews and staff interview the facility failed to complete an individualized baseline care plan for two of four sampled newly admitted residents. (Residents #124 and 274). The findings included: 1. Resident #124 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no baseline care plan for the resident was completed. A record review on 08/10/18 at 2:00 PM revealed no documented evidence that a copy of the baseline care plan was given to the resident or the responsible party. The facility was unable to provide evidence that a baseline care plan had been completed for Resident 124. An interview conducted on 08/11/2021 at 2:15 PM with the Minimum Data Set (MDS) assessment nurse revealed she did not complete the 48 hours care plan. The MDS nurse indicated she was responsible for completing the 48 hours care plan for residents at the facility. MDS nurse reported she missed the notification from the Admission Coordinator to complete Resident 124's 48-hour care plan. She indicated moving forward she will complete the 48-hour care plan as soon as a resident is admitted . An interview conducted on 08/12/18 at 1:15 PM with the Director of Nursing (DON)revealed her expectation was for the baseline care plans to be completed within 48 hours of admission and a copy given to the resident or the responsible party. 2. Resident #274 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #274's medical records revealed a care plan that was initiated on 8/6/21. The Comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 274 was severely impaired and required limited to extensive assistance with activities of daily living (ADL) to include bathing, dressing, toileting, bed mobility, and transfers. During an interview on 8/12/21 at 11:41 am, the MDS Nurse communicated that the admitting nurse normally initiated the baseline care plan during admission. She could not locate the baseline care plan initiated within 48 hours of admission for Resident #274. An interview was conducted on 8/12/21 at 12:15 pm with the Director of Nursing (DON). The DON communicated that Resident #274's baseline care plan was missing which meant care areas were not triggered during admission. She indicated she expected nursing staff to initiate the care plan during the admission assessment. She further stated the baseline care plan was supposed to be initiated and completed within 48 hours of a resident's admission. During an interview on 8/12/21 at 1:00 pm with the Facility Administrator, he indicated a baseline care plan should have be completed within 48 hours of the resident's admission to effectively meet the needs of the resident.

Based on observation, record review, and staff interview, the facility failed to apply a splint as ordered to a resident with a hand contracture for 2 of 3 residents (Resident #37) reviewed for range of motion. The findings included: Resident #37 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum Data Set (MDS) dated [DATE] had resident coded as cognitively intact needing extensive assistance with ADL's. No Splint or brace assistance was coded. Upper extremity (shoulder, elbow, wrist, hand) impairment on one side. The care plan dated 07/05/2021 had focus' of Resident has potential for pain related to (r/t) right sided [CONDITION(S)]. Resident #37 has self-care deficit r/t decreased functional mobility r/t history of CVA and right sided [CONDITION(S)]. An intervention included to evaluate needs for adaptive equipment and educate/direct the use of assistive devices. An observation was conducting of Resident #37 on 08/09/21 10:09 AM. Her right hand was contracted, and she had no splint in place. Resident #37 stated she had not had her brace on for over two weeks because restorative gets pulled to help on the floor. An observation was conducted on 08/10/2021 at 4:04PM. Her right hand was resting on her lap and her brace was not on her hand and it was still sitting on her end table by her bed. Resident #37 stated restorative was pulled to the floor she had not had the brace on all day but was not in pain An observation was conducted on 08/11/2021 at 3:40PM. Resident #37 was in her room, had blue resting splint to right hand. Resident #37 stated the restorative aide put it one her and it is not hurting, and it felt more supported. An Occupational Therapy (OT) progress and discharge summary for Resident #37 dated 6/14/2019 read in part: Pt will tolerate 6 to 8 hours of splint wear for right hand/wrist splint and elbow splints. During an interview with Restorative Aide (RA) on 08/11/2021 at 1:52 PM, the RA she stated she has been in restorative for four years and is familiar with Resident #37 and she has a splint for her right hand that is applied daily after her morning ADL's. The restorative team has days when they had to be pulled to the floor due to staffing and restorative treatments are not done on those days by the restorative team. During an interview with an Occupation Therapist (OT) on 08/11/2021 at 3:18 PM, she stated she was familiar with resident has been there a year. She stated if a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She could not state if resident had any decline in her ROM in her right wrist due to her not having on the splint daily. During an interview with the Director of Nursing (DON) on 8/11/2021 at 3:33PM, the DON stated she would expect her staff to follow the orders for ROM to include splinting the resident. The nurses will be splinting the residents so when restorative must be pulled to the floor, it will be still applied. During interview with the Therapy Director (TD) on 08/13/2021 at 9:30 AM, the TD stated the orders were in her D/C summary and she was supposed to wear the splint daily after morning ADLs for 6-8 hours and those orders were ongoing. The orders are relayed to nursing to be continued. Resident #37's ROM has not declined due to her not having her splint applied but she has had weight gain and the splint she has now will be replaced as soon as the new brace comes in because it didn't fit properly.

Based on record reviews and staff interviews the facility failed to use 2 persons when transferring a resident with a mechanical lift according to the care plan for 1 of 1 resident (Resident #48) reviewed for accidents. The findings included: Resident #48 was admitted to facility 07/08/2021 with diagnosis including difficulty in walking, and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE] had resident coded as moderately cognitively impaired needed two-person physical assist to transfer between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). The Care Area Assessment (CAA) summary had physical performance limitations was not steady, only able to stabilize with staff assistance (2) resident is transferred with the use of a slide board with therapy services. The care plan dated 07/14/2021 and completed 7/26/2021 had focus' of: 7/23/2021 Actual fall and resident is at risk for further falls d/t decreased functional mobility. Intervention dated 7/21/2021: Assist with transfer with the use of total lift and two-person assist. Nurses note dated 07/22/2021 read: resident had a witnessed lowering the floor fall during transfer. Resident alert with confusion. Unaware how she got on the floor or what was happening. Resident verbalizing no distress or pain. Aide stated she was transferring with sliding board when resident stopped moving over and due to unable to bend or bear weight to right leg, she assisted to floor. Resident placed in bed via nurse and aide with mechanical lift. Head to Toe Evaluation (Initial) dated 7/22/21 read in part: Description of Occurrence resident lowered to floor during sliding board transfer Immediate Intervention: resident with 2 staff during transfers. An observation was conducted on 08/10/21 at 11:45 AM. Resident #48 was in bed, pleasantly confused. Bed was in low position, call bell within reach, mat on each side of bed. Resident #48 stated she didn't remember why or when she fell and is not in any pain. During an interview with Nurse #1 on 08/11/21 at 2:12 PM, nurse #1 stated Resident #48 had a fall on 07/22/2021. NA #1 reported resident was helped to the floor during transfer using her sliding board. Resident is a two person assist and is supposed to use a Hoyer lift for transfer. During an interview with the director of Nursing (DON) on 8/11/2021 at 2:22PM, the DON stated resident was being transferred with a sliding board that was left in the room by therapy. Resident #48 was lowered to the ground by NA #1 and was not hurt. She is a two-person mechanical lift transfer, and it is expected that staff follow the care plans and Kardex for resident's care. During an interview with NA#1 on 08/12/2021 at 3:11PM, NA #1 stated she did transfer Resident #48 using a sliding board on 07/22/2021. The sliding board was in the room and see believed the nurse stated it could be used. She did not check the Kardex which she usually does to see if she could use the sliding board. NA #1 also stated she was trying to transfer Resident #48 from the wheelchair to the bed using the sliding board and could not transfer herself using it. The resident was heavy and was lowered to the floor without any injury. She further stated she put a pillow under her head and got the nurse, she assessed her and was put in bed using the mechanical lift. During interview with the Therapy Director (TD) on 08/13/2021 at 9:30 AM, the TD stated, Resident #48 was not able to use the sliding board on 07/22/2021 because she was non weight bearing. The equipment stays in the resident rooms to be used by the therapy staff and the staff were not trained with this resident to use the sliding board.

Based on observation and staff interviews the facility failed to date and label three items discovered in the reach in refrigerator during one of two observations. Findings included: An observation and tour of the kitchen with the Dietary Manager (DM) on 08/09/21 at 10:30 AM revealed the following undated and unlabeled items: a. An undated and unlabeled clear plastic container of brown liquid was discovered in the reach in refrigerator. The Dietary Manager (DM) reported it was tea. b. An undated and unlabeled clear plastic container of yellow liquid was discovered in the reach in refrigerator. The Dietary Manager reported it was lemonade. c. An undated and unlabeled clear plastic container of yellowish creamy looking substance was discovered in the reach in refrigerator. The Dietary Manager reported it was pudding. An interview was conducted with the Dietary Manager on 08/09/21 at 10:30 AM. The DM stated the staff had forgotten to label and date the items discovered. During a telephone interview with the Dietary Manager on 08/13/21 at 8:11 AM, the DM stated she expected all staff to label and date items when the items are prepared and placed in the refrigerator. An interview was conducted with the Administrator on 08/13/21 at 09:10 AM. The Administrator stated it was his expectation for all containers in the refrigerator be labeled and dated according to the kitchen protocols.

Based on record review, staff interviews, Nurse Practitioner (NP) and the Medical Director's interview the facility failed to notify the Physician on the day a resident's Metabolic Panel returned with abnormal values for 1 of 1 resident. (Resident #1) Findings include: A review of the facility's procedures for notification of laboratory results to the physician read: When an abnormal lab or x-ray result is reported by fax, the charge nurse will call the Physician's office and report the results. The nurse may then fax the report to the Physician. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. The admissions Minimum Data Set ((MDS) dated [DATE] had Resident #1 coded as cognitively intact. The care plan dated 07/15/2020 had a focus of resident being on diuretic therapy with interventions including administer medication as ordered, assess for interactions/adverse consequences related to any other medication usage, labs per orders and report pertinent lab results to MD, may cause dizziness, postural [MEDICAL CONDITION], fatigue, and an increased risk for falls. Observe for possible side effects every shift while giving care and as needed, Physician to review for possible reduction per routine. Review of Resident #1's orders revealed a physician's orders [REDACTED]. Review of lab results for Resident #1 revealed the blood work was completed on 07/23/2020 and the report from the metabolic panel was reported by fax on 07/23/2020 at 6:02 PM. The results showed the resident's Sodium level was 129 a normal range was 136 to 145. (A low Sodium level may indicate taking diuretics, Dehydration, Kidney Disease or Kidney Failure). The Chloride level was 96 a normal range is 98 to 107. (A low Chloride level may indicate Dehydration). The CO2 (Carbon [MEDICATION NAME]) level was 20. A normal range is 21 to 32. (A low CO2 level may indicate Kidney Disease). The BUN (blood urea nitrogen) level was 128. A normal range is 7 to 18. (A high BUN value may indicate kidney injury or disease). The Creatinine level was 2.58. (A high Creatinine level may indicate [MEDICAL CONDITION]). The Glucose Random level was 162. A normal range is 74 to 106. (A high glucose level may indicate Diabetes Mellites). The Calcium level was 8.4. A normal range is 8.5 to 10.1. (A low Calcium level may indicate kidney disorders). The total Protein level was 5.7. A normal range is 6.4 to 8.2. (A low total Protein level could indicate kidney disease). The [MEDICATION NAME] level was 2.7. A normal range is 3.4 to 5.0. (A low [MEDICATION NAME] level may indicate a disorder with the liver or kidneys). The GFR (glomerular filtration rate) level was 16.1. A normal range is greater than 60. (A low GFR level may indicate kidney disease). There was no documentation in the resident's record the lab result was called to the physician on 07/23/2020. During a telephone interview with Nurse #1 on 01/28/2021 at 10:46 AM, Nurse #1 stated she remembered Resident #1 and this resident was admitted for rehab for hip surgery. The abnormal lab report on 07/23/2021 was not called in to the Physician because if she would have called the Physician, there would be a note in the residents' medical records. Nurse#1 also stated she didn't see the Metabolic Panel lab results because she was focused on the CBC (complete blood count) because the resident was having issues with her H & H (Hemoglobin and Hematocrit) levels. Nurse #1 further stated when labs come in, they are signed and dated by the nurse to indicate they were seen, and abnormal lab values are to be called in to the Physician for further orders. During a telephone interview with the Nurse Practitioner (NP) on 01/27/2021 at 4:35 PM, the NP stated she did not receive a call concerning the abnormal lab results for Resident #1 on 07/23/2020. The NP also stated she should have received a call when there were abnormal results. During a telephone interview with the Medical Director on 01/28/2021 at 11:43 AM, the MD stated she did not receive a call about the abnormal lab values from Resident #1 and there was not a note in her chart pertaining to any abnormal lab values. During a telephone interview with the Director of Nursing (DON) on 01/28/2021 at 1:23 PM, the DON stated if an abnormal lab level comes back from the lab then the nurses are to call the Physician with those lab values and document it in the resident's medical records. During a telephone interview with the Administrator on 01/28/2021 at 1:47 PM, the Administrator stated the Physician is supposed to be called when there are abnormal labs.

Based on observation, staff interviews, record review and review of the facility's policies and procedures staff failed to implement the facility's COVID-19 Plan and Protocols for wearing the personal protective equipment (PPE) required for 3 of 3 staff observed providing care and services to residents who were quarantined and on enhanced droplet precautions These failures occurred during the COVID-19 pandemic. Findings included: The facility's Enhanced Precaution Policy Titled: Transmission-Based Precautions (last revised 03/24/2020) documented, Droplet Precautions - intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. A single patient room is preferred for residents who require Droplet Precautions. A mask is worn for close contact with infectious resident. Gloves, gown, eye protection are worn adhering to Standard Precaution guidelines. This includes the following: Staff will utilize appropriate PPE (personal protective equipment) including surgical masks, gown, eye protection, and gloves when entering room. During facility tour observation on 07/21/20 at 11:20 AM Housekeeper #1 was observed entering an enhanced droplet-contact precaution room on the 500 hall without eye protection. Housekeeper #1 was wearing a surgical mask and gown. Housekeeper #1 was observed not wearing eye protection while in the resident's room. During an interview with Housekeeper #1 on 07/21/20 at 2:41 PM stated she could not have worn eye protection, because there was no eye protection on the PPE carts down the 500 hall. She stated she was very busy on her hall and did not have time to track down the 3 people with keys to the central supply room. She said it was her fault that she did not don eye protection. She said, while she was in enhanced precaution rooms, she was wearing a mask and gown and should have also put on eye protection and did not. During observation of the lunch meal on the 200 and 500 halls (quarantine halls), beginning at 12:30 PM on 07/21/20, multiple personal protection equipment (PPE) were observed in clear plastic containers outside Residents' rooms, with enhanced observation signs posted on doors. The enhanced droplet-contact precautions sign revealed the following: perform hand hygiene, surgical mask when entering room, eye protection when entering room, gown when entering room, gloves when entering room, private room and keep door closed, families and visitors - do not enter the room, and report to the nurses' station with questions. During facility observation on 07/21/20 at 1:35 PM Nurse #1 was observed entering an enhanced droplet-contact precaution room on the 200 hall without eye protection when entering room. Nurse #1 was wearing a surgical mask and gown. Nurse #1 was observed not wearing eye protection while entering the resident's room. During an interview with Nurse #1 on 07/21/20 at 2:24 PM stated she should have worn full PPE on 07/21/20 at 1:35 PM when entering a 200 hall enhanced observation precautions room as required in the facility's enhanced precautions policies, which would have included mask, gown, gloves, eye protection, and she did not. She reported it was an honest mistake on her part not to have put on eye protection. During facility observation on 07/21/20 at 1:40 PM Nursing Aide (NA) #1 was observed entering an enhanced droplet-contact precaution room on the 200 hall without eye protection when entering room. NA #1 was wearing a surgical mask and gown. NA #1 was observed not wearing eye protection while entering the resident's room. During an interview with NA #1 on 07/21/20 at 2:18 PM stated she should have worn full PPE on 07/21/20 at 1:40 PM when entering a 200 hall enhanced observation precautions room as required in the facility's enhanced precautions policies, which would have included mask, gown, gloves, eye protection, and she did not. During an interview with the facility's Central Supply Manager (CSM) on 07/21/20 at 2:00 PM stated the nursing staff were usually good at asking for PPE when the hall carts were out of supplies. CSM said the facility had plenty of PPE on-hand; masks, gowns, gloves, goggles, face shields, and eye glasses. Per facility PPE inventory sheet dated 07/16/20 revealed the facility had 57 eye protection available for staff. CSM said staff should have notified her, the DON, or the Administrator when they were out of eye protection and did not. During an interview with the Administrator and Director of Nursing (DON) on 07/21/20 at 3:00 PM stated Housekeeper #1, Nurse #1, and NA #1 should have worn complete PPE required in the facility's COVID policies to help reduce chances of cross-contamination just in case residents or staff were indeed positive or began exhibiting signs and symptoms of respiratory illness. They also reported Housekeeper #1, Nurse #1, and NA #1 should have requested additional eye protection for the depleted PPE carts from central supply and did not.

Based on record review and staff interview, the facility failed to provide showers as scheduled for 1 of 2 sampled resident reviewed for choices (Resident #40). Findings included: Resident #40 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #40 had moderate cognitive impairment. The assessment further indicated that Resident #40 required limited assistance with bathing and she had not displayed any behavior of rejection to care. The assessment further indicated that it was very important for her to choose between a tub, shower, bed bath or sponge bath. Resident #40's care plan dated 3/29/19 was reviewed. One of the care plan problems was the resident was self-care deficit related to decreased functional mobility. The goal was the resident's needs will be met. The approaches included to assist with activities of daily living (ADLs), assist with transfers, and promote independence. The shower book was reviewed and the shower schedule for Resident #40 was every Wednesday and Saturday. On 04/30/19 at 11:47 AM, Resident #40 was interviewed. She stated that the staff had been able to take a shower for 2 weeks. She would be forced to take a bird bath in cold water. She indicated that when she asked for a shower, she was told that the water would not get hot enough. She added that the hot water is often a problem in the facility. The (MONTH) and (MONTH) 2019 shower documentation for Resident #40 were reviewed. A Shower/Tub bath/Bed bath documentation sheet dated 3/23/19 indicated in the comment section, The water wasn't getting out in the shower. Resident was not able to take a shower. The sheet is signed off by the aide and the charge nurse. On (MONTH) 2, 6, 10 and 13, the Shower/Tub bath/Bed bath documentation sheets were blank, indicating that a shower was not provided to Resident #40. On 05/02/19 at 1:44 pm, the charge nurse for 03/23/19 was interviewed concerning clarification of the Shower/Tub bath/Bed bath documentation sheet dated 3/23/19. She stated that the note should have stated the water was not getting hot: rather than not getting out. She further stated that she was aware of this and the resident received a bed bath that night. She stated that the Shower/Tub bath/Bed bath documentation sheet is to be completed once the aide has performed her bathing task and the charge nurse signs off. If the resident refuses, it is noted on the Shower/Tub bath/Bed bath documentation sheet and documented in the nursing notes. She states that there have been inconsistencies with the water temperature on the unit. Some days it gets hot and other days not, however, the resident should be getting a shower in the main shower room or on another unit. On 05/02/19 at 3:35 pm, the Director of Nursing was interviewed and she stated that the water temperatures for the side of the building is being worked on by maintenance. The entire building has had problems with maintaining hot water temperatures but hs met the Health Department requirements. Currently one side of the building, which required a replacement part, is now functioning properly. The maintenance department has ordered and is awaiting the replacement part for the other side of the building, which services Resident #40. It is expected to arrive next week. The DON stated that it is her expectation that if a resident is unable to take a shower in their rooms that they would be brought out to the main shower room or taken to another hall for a shower. On 05/02/19, the Administrator stated that she was aware of the water temperature inconsistencies, however, it is her expection that every resident receive a shower as scheduled and if not that it would be reported and followed up per facility policy.

Based on record review, family interview and staff interview the facility failed to notify the residents' Responsible Party (RP) regarding a change in health condition for 1 of 1 sampled resident for notification of change. (Residents #50) Findings included: Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Nurse #1's note dated 04/27/19 read: patient up in bed coughing with clear sputum, patient's oxygen level was 91 with difficulty breathing. Lung sounds inaudible due to patient's inability to take deep breaths. This nurse called and spoke with Nurse Practitioner and received orders to increase [MEDICATION NAME] to 40 mg by mouth two times a day (BID) for two days then back to 40 mg by mouth daily, obtain a chest x-ray as well as supplemental oxygen set at 2 liters. The facility policy dated (MONTH) (YEAR)read: The resident/Physician/family/responsible party will be notified when there has been a significant change in the resident's physical/emotional/mental condition. Documentation in the medical records that stated the RP was contacted was not found. The quarterly Minimum Data Set ((MDS) dated [DATE] had resident #50 coded as moderately cognitively impaired, needing extensive assistance with activities of daily living. The comprehensive care plan dated (MONTH) (YEAR) had a focus of Resident/Responsible party has chosen DNR, Self-Care Deficit - ADL Function d/t decreased functional mobility, (L) sided [MEDICAL CONDITION], dx of dementia. A review of the (MONTH) 2019 Medication Administration Records (MAR) had new orders dated 04/27/19 for oxygen at 2 liters via nasal cannula continuously every shift for shortness of breath related to [MEDICAL CONDITION] and after resident complete 2 days of [MEDICATION NAME] 40mg BID, resume [MEDICATION NAME] 40mg every morning on 4/30/19. During an interview with Resident #50's RP on 4/29/19 at 12:03 PM, the RP stated her mother became sick on the 04/27/19 and needed to have oxygen. Nurse #1 called the physician, but she was not made aware until she arrived at the facility later that day. During a telephone interview with the Nurse #1 on 05/01/19 at 02:20 PM, Nurse #1 stated she cared for the resident on 4/27/19 and she did have a change in her condition. She could not catch her breath, and there was a need for oxygen. The physician was called but she did not call the RP. The Nurse further stated she was a new nurse, and in the future, she will make sure she will call the RP of any changes in residents' conditions. During an interview with the Director of Nursing (DON) on 05/01/19 03:10 PM the DON stated her expectation is for the nursing staff to inform the RP of any medical changes involving the residents. During an interview with the Administrator on 05/02/19 12:10 PM, the Administrator stated her expectations are for her nursing staff to notify the residents responsible party as soon as the resident is stable.

Based on record review, staff interview and observation, the facility failed to prevent 1 of 3 sampled cognitively impaired resident with exit seeking behaviors from exiting the facility. A citizen found the resident on a busy street. The Resident #1 was not injured. The Immediate Jeopardy began on 4/20/2017 when Resident #1 exited the facility unattended by the facility staff, and was found outside after a concerned citizen reported seeing a man walking with a wheelchair on the street outside of the facility. The Immediate Jeopardy was removed on 4/21/2017 at 5:00 pm when the facility completed in-servicing the staff on elopement policy and procedure. The facility also completed a review of all the residents who were at risk for elopement on 4/21/2017. The facility provided an acceptable plan of correction completed on 4/21/2017. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident's [DIAGNOSES REDACTED]. A review of the Nurse's note dated 4/13/2017 at 2:55 AM revealed Resident noted to be alert with confusion. Very pleasant. Occasionally noted wandering around hallway, but not into other residents' rooms. Noted resident has unsteady gait. Able to propel self in wheelchair. A review of the Nurse's Note dated 4/14/2017 at 2:55 PM revealed Resident compliant with care. Wandering in the halls after wife left. Verbalized wanting to go home. A review of the Nurse's Note dated 4/17/2017 at 11:58 PM documented Resident brought to facility after being in hospital for strengthening. Attended physical and occupational therapy today. Denies pain. Alert to person, confusion increases after the sun goes down and he begins to pack his belongings to leave. Redirected many times without incident. Wife in to visit this evening. Cooperative with care and redirection although he does not stay in one place for very long. Trying to get outdoors and banging on doors to see if they will open. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1's cognitive status was moderately impaired and limited assistance of one person was required with transfers. The assessment further indicated the resident was independent with locomotion on the unit and used a wheelchair for locomotion. The resident was not coded for wandering behavior. A review of the Nurse's Note dated 4/20/2017 at 8:28 PM read Resident compliant with care. Wandering in halls after wife left. Verbalized wanting to go home. A review of the Nurse's Note dated 4/20/2017 at 9:00 PM indicated Occurrence Details: A concern citizen came to facility reported seeing a man walking with wheelchair out on the street outside of facility. Nurse #1 and Nurse Aide (NA) #1 got the resident back to the facility without a conflict. Upon investigation among staff, a new nurse on 400 hall. Nurse#1, let the resident out from 400 hall door thinking that resident is a visiting family member. Immediate Intervention: Resident was assessed, no obvious physical change noted. Wanderguard was put on resident. Q (every) 15 minutes visual check was implemented. A one-on-one sitter\NA was assigned to be with resident. Vitals: BP (blood pressure) 134/68 - 4/20/2017 08:38PM Pulse Type: Regular 18.0 - 4/19/2017 08:38 PM T (temperature) 97.3 - 4/18/2017 10:21 PM Route: Temporal Artery O2 (oxygen) 97.0 % - 4/14/2017 12:14PM Method: Room air. Resident's family/responsible party was notified of occurrence. Resident's family member was called at 9:50 PM explained the occurrence and situation surrounding elopement incident. The MD (medical doctor) was also notified at 9:55 PM. One on one sitter was provided for resident who is currently in room sleeping. Q 15 visual checks initiated this shift. Wanderguard was put on resident right after incident. A review of the Nurse's Note date 4/20/2017 at 9:14 PM read A concern citizen came to facility reported seeing a man walking with wheelchair out on the street outside of facility. Wound Care Nurse and Nurse Aide #1 got the resident back to the facility without conflict. Upon investigation among staff, a new nurse on 400 hall let the resident out from 400 hall door thinking that resident is a visiting family member. Per resident statement, I would like to go home but no one would give me a ride. Interview with Nurse #2 on 4/4/2017 at 10:00 AM revealed on the night of 4/20/2017, she opened an exit door on 400 hall to let Resident #1 out thinking he was a family member. Nurse #2 stated the resident was carrying his belongings in the wheelchair and asked her to open the door so he can take his clothes to a family member. She added the resident did not have a wanderguard on and she did not recognize the resident thinking he was a family member. She further added she realized later that the person she had opened the door to let out of the building was a resident when a concerned citizen came at the facility at around 9:25 PM stating she had seen a person by the road and she was wondering whether it was one of their residents. Nurse # 2 further stated two other staff members got into their vehicles and went to 71st street to get the resident back to the facility. The Nurse further added she had been in-serviced in reference to not letting the residents out before verifying their identity During the interview on 4/27/2017 at 10:30 AM, NA #1 who was assigned to the resident on 1st (7:00 AM to 3:00 PM) shift reported the resident always went to the exits and stated he wanted to go home to see his wife. She added the resident wandered throughout the building sometimes carrying his belongings in his wheelchair. During the interview on 4/27/2017 at 10:45 AM, NA #2 who was working on the second shift but not assigned to Resident #1 reported she was sitting at the nurse's station when a lady knocked at the exit door on 200 hall at about 9:00 PM indicating she saw a man pushing a wheelchair by the main road and she was wondering whether that was a resident at the facility. NA #2 further indicated she left immediately in a vehicle with Nurse # 1 to go get the resident back to the facility after realizing Nurse #2 had opened the door letting the resident out of the building. NA#2 indicated it had been about 15 minutes before she learned that Nurse #2 had let the resident out of the building. NA #2 further reported they found the resident by the busy street picking his belongings up which had dropped on the road. During the interview on 4/27/2017 at 11:00 AM, Nurse #1 who was assigned to the resident on the night of 4/20/2017 indicated she was sitting at the nurse's station about 9:15 PM when she heard from another staff member that a lady had reported seeing a man who was identified as a resident walking by the main road. She reported she left with NA #2 to find the resident and bring him back to the facility. She added the resident always wandered around the facility and he would be found in other halls sometimes pushing his belongings in his wheelchair. Nurse #2 also stated on 4/20/2017 the day the resident exited the building at 9:00 PM she saw the resident at 8:00 PM for the last time during medication pass. She added the resident had no wander guard on the day he exited the building. During the interview with the Minimum Data Set (MDS) nurse on 4/27/2017 at 4:00 PM, she reported she had not care planned the resident as an elopement risk because it had not been reported to her that the resident was wandering throughout the facility carrying his belongings and stating he wanted to go home. MDS also stated she did not review the nurse's notes which indicated the resident was an elopement risk because she depended on staff reporting to her about any observed behaviors by the resident. She also indicated if she knew about the resident's increase in wandering behavior after his admission assessment she would have initiated a care plan which would have indicated the use of a wanderguard and 15 minute checks on the resident. The MDS nurse also indicated on 4/12/2017, the day the resident was admitted , the resident scored a 2 on his elopement risk assessment which meant he was at low risk for elopement. She further indicated the resident scored a 16 on 4/20/2017 which meant he was at high risk for elopement on the day he exited the building. During the interview on 4/28/2017 at 3:30 PM, Nurse #3 who was assigned to the resident on the third shift(11PM-7AM) reported the resident was a known wanderer and he was seen pushing his belongings throughout the facility and banging at doors trying to get out. She indicated the resident had no wander guard placed on him on the night he eloped but the wanderguard and 15 minute checks were implemented after the resident was brought back to the facility on [DATE]. During the interview with the Administrator on 4/28/2017 at 4:00 PM, he indicated the staff notified him about Resident #1's elopement on the night he exited the building on 4/20/2017. He indicated it was Nurse #1 who failed to follow the elopement policy and procedure by letting the resident out of the building. He added the staff member had been disciplined and in-serviced about the elopement policy and procedure. He also indicated all the staff at the facility had been in-serviced in reference to the elopement policy and procedure. The Administrator also indicated following the elopement of the resident a wanderguard was placed on the resident and 15 minute checks of the resident was implemented. The Administrator also indicated his expectation would be for the staff to ask questions before letting the residents out. He further reported that the ongoing compliance was to monitor all residents with wanderguards on every shift beginning 4/20/2017. He further indicated the staff will continue to be in serviced and interviewed in reference to not letting the residents out before verifications. The administrator stated that the Director of Nursing and unit managers were going to be responsible for keeping up with residents who had wander guards at the facility. The Nurse Aide who was assigned to Resident #1 on the second shift (3 PM-11PM) on 4/20/2017 was not available for an interview. The Nurse Aide was no longer employed at the facility. Observation of the building on 4/28/2017 at 1:00 PM, revealed the main entrance doors were automatic doors. Further observations of the building revealed there were no alarms by the exit doors and the employees had a code that they had to use in order to exit the building. The facility parking lot was observed to be busy with vehicles coming and leaving, and the speed limit for the main road where the resident was found was 45 miles per hour. The temperature on 4/20/2017 at 9:25 PM was 72 degrees Fahrenheit. The administrator was notified of the Immediate Jeopardy on 4/27/2017 at 5:35 PM. The corrective action for past noncompliance dated 4/21/2017 included: For the Resident Affected: On 4/20/17 the facility was notified of a possible missing resident. Facility elopement protocol was initiated and a head count was completed. Resident #1 was found off the facility grounds and assisted back to the facility by staff. Upon arrival to the facility, a head to toe assessment was completed and no injuries were noted. Resident #1 was initially placed on 15 minute checks, however one on one supervision initiated within the hour. An elopement assessment was completed on 4/20/17 with a score of 16. A wander guard was applied. The care plan was updated to indicate an elopement risk. There was no negative outcome, harm or injury for resident #1. Resident was voluntarily discharged home with his wife on 4/27/17. For other residents with the potential to be affected: The staff member who unlocked the door for resident #1 was re-educated 1:1 on 4/21/17 by the DON and Administrator on verifying non-resident status prior to unlocking a door (asking questions), the elopement policy (including reporting exit seeking behaviors), location of wandering manuals and visitor/staff door policies. This individual received a disciplinary warning on 4/21/17 as well. Completed 4/21/2017. All 100% staff members were re-educated 4/21/17 by DON/Administrator and/or designee on verifying non-resident status prior to unlocking doors, the elopement policy (including reporting exit seeking behaviors), location of wandering manuals and visitor/staff door policies. Completed on 4/21/2017. Elopement assessments 100% were completed on 4/20/17 and 4/21/17 by the DON and designee for all residents to identify potential residents at risk for elopement. No residents were identified. Completed on 4/21/2017. Facility action plan to prevent re-occurrence: An elopement assessment audit tool will be completed by the DON and/or designee for 3 months to ensure elopement assessments are completed accurately and thoroughly. The Elopement assessment audit tool will review new admissions and residents identified with exit seeking behaviors and verbalizations post admission. This audit will ensure the wander guard is placed, care plan is updated and elopement manual is updated as needed. To be completed thru 7/21/2017. New hires will be educated on verifying non-resident status prior to unlocking doors, the elopement policy (including reporting exit seeking behaviors), and location of wandering manuals and visitor/staff door policies in every orientation class indefinitely. To be completed thru 7/21/2017. The administrator and/or DON will randomly ask staff members 3 times per week how to verify non-resident status prior to unlocking doors for 3 months to be completed thru 7/21/2017. A Quality Assurance Committee meeting was completed 4/21/2017. The audits will be brought to the Quality Assurance Committee by the DON/Administrator for 3 months. Areas of continued concern will be brought back to the Quality Assurance Committee by the Administrator for further action plan. To be completed thru 7/21/2017 and ongoing if necessary. As part of the validation process on 4/28/2017 at 4:30 PM, the entire plan of correction was reviewed including interviews of all staff related to identifying residents at risk for elopement, ensuring placement and function of the wander guard. The staff was also aware of whom to report the elopement behaviors. A review of the monitoring tools revealed that the facility had completed the 100% in-service on 4/21/2017.

Based on observations, staff interviews and record review, the facility transferred a resident using a sit to stand instead of a mechanical full lift resulting in tibia and fibula fractures on 5/27/16 for 1 of 4 residents (Resident #75) reviewed for accidents. Findings included: Resident #75 was admitted [DATE] with cumulative [DIAGNOSES REDACTED].#75 had severe cognitive impairment and required extensive assistance with transfers using two staff assist and she was non-ambulatory. A review of Resident #75's Mobility/Transfer Profile dated 4/1/16 indicated she required the use of a total lift with two staff assistance. A review of an undated Care Guide which the nursing assistants utilized to provide needed care indicated Resident #75 needed a total lift with a two person transfer. A review of an incident report dated 5/27/16 at 9:44 AM indicated an aide called the nurse to room to assess Resident #75's left knee. It was noted as abnormal in color. The abnormal color extended down to the left ankle and left foot. The physician was contacted along with the responsible party (RP) and an x-ray was completed of Resident #75's left hip, femur, knee, tibia and fibula. The x-ray results indicated Resident #75 had a displaced left proximal tibia and fibula fracture and Resident #75 was sent to the hospital for further evaluation and treatment. The family opted for conservative treatment and she was placed in a left lower extremity immobilizer, bed rest and returned to the facility. A review of the facility investigation initiated 5/27/16 indicated the two involved nursing assistants were interviewed and it was determined that Resident #75 was transferred using a sit to stand rather than a total lift device resulting in her left tibia and fibula fractures on 5/27/16. The investigation indicated both aides were terminated on 5/27/16 for improperly transferring Resident #75 resulting in an injury. Resident #75 was care planned on 5/27/16 for the use of a mechanical full lift with two person assistance, a fracture of her left tibia/fibula. Orthopedic was care planned to follow up as ordered, monitor Resident #75 for pain and swelling, an immobilizer to the left lower extremity as ordered, bed rest and positioning with pillows for comfort. The most recent significant change MDS dated [DATE] indicated Resident #75 required total assistance with transfers using two staff assist and she was non-ambulatory. She was coded as having no falls. In an observation on 7/18/16 at 11:48 AM, Resident #75 was noted lying on her back. She was clean and well groomed. Resident #75 was pleasantly confused and displaced no outward evidence of pain. In a second observation on 7/20/16 at 12:10 PM, Resident #75 was observed during wound care. The treatment nurse recalled Resident #75's knee being injured during a transfer and the family opted for no surgery but an immobilizer with bed rest. Nursing assistant (NA) #1 stated she was familiar with the incident involving Resident #75's leg fracture and she was recently retrained on following the Care Guide and using the mechanical full lift and the sit to stand lift about a month ago by the staff development coordinator (SDC). In an interview on 7/20/16 at 1:40 PM, the Director or Nursing (DON) stated the facility did an investigation regarding Resident #75's injury and a four point plan of correction was initiated to prevent the occurrence from happening again. She stated once Resident #75 was stabilized and sent to the hospital on [DATE], both of the involved aides were terminated. for not following the Care Guide resulting in Resident #75's fractures. It was at this time a complete audit of all residents using both a mechanical full list and a sit to stand were identified. The DON stated retraining started immediately and the lifts were removed until the staff present were passed off on the safe usage on 5/27/16. Ongoing retraining continued with the assistance of the SDC and the therapy department on each shift until each aide had successfully completed a staff transfer using both a mechanical full lift and a sit to stand. She stated all newly hired staff since 5/27/16 must pass off on the safe usage of both types of lifts prior to working on the floor as part of their orientation. The DON stated reeducation with the aides was completed to verify the aides were following the Care Guide for instructions on how to transfer each resident requiring a mechanical lift. The DON stated since the incident on 5/27/16, the facility conducted weekly audits of proper mechanical lift usage for four weeks and now they are being done randomly. The DON stated the incident which involved Resident #75 and her injury during a transfer was addressed in the June 2016 Quality Assurance (QA) meeting. She stated there have been no other occurrences and the plan was to continue random audits periodically as needed and proper demonstration of both types of mechanical lifts would continue to be a part of the orientation process. Neither of the involved aides were available for interview and the DON stated the reporting nurse only worked as needed and was nursing school during the day. The DON stated she attempted to leave the reporting nurse a voice mail but she was unable to do so. In an interview on 7/21/16 at 9:50 AM, NA #2 was aware of an incident involving Resident #75 and stated she was recently retrained on the use of the mechanical full lift and the sit to stand lift. She stated the SDC retrained her and she had to perform a transfer using both lifts safely before she could use them on another resident. NA #2 stated she was re-educated to follow the Care Guide for how to transfer her assigned residents. In an interview on 7/21/16 at 10:00 AM, NA #3 stated she was newly hired the first on July. She stated as part of her orientation, she was trained and had to demonstrate safe usage of the mechanical full lift and the use of the sit to stand before she was allow to use them with a resident. NA #3 verified she was trained to look at the Care Guide to know how to transfer each of her assigned residents. In an observation on 7/21/16 at 10:20 AM, NA #2 and NA #4 were observed transferring Resident #103 using a mechanical full lift. There were no observed concerns. NA #4 stated she also started employment the first of July. She stated she had to demonstrate safe use of both the mechanical full lift and the sit to stand before she was allowed to use them on a resident. NA #4 stated she used the Care Guide to know how to care of her assigned residents to include how to transfer them. In an observation on 7/21/16 at 11:41 AM, NA #5 and NA #1 were observed transferring Resident #77 using a sit to stand lift. There were no observed concerns. NA #5 verified retraining using both the mechanical full lift and the sit to stand due to an injury involving Resident #75 and re-educated to follow the Care Guide and transfer each resident how the Care Guide indicated. On 7/21/16, multiple attempts to reach the reporting nurse were unsuccessful. In a telephone interview on 7/21/16 at 12:25 PM, the SDC confirmed she retrained the staff and passed them off on safe usage of the mechanical full lift and the sit to stand in response to the injury involving Resident #75. She stated she was also part of the monitoring and the QA process. In an interview on 7/21/16 at 2:00 PM, the Administrator stated at the time of the incident, the involved aides were removed from the floor along with the lifts. Once Resident #75 was sent to the hospital, the staff at the facility were immediately retrained on the use of both the mechanical full lift and the sit to stand, All residents who were at risk from the deficient practice were identified and their lift status was reassessed. Ongoing random monitoring continues and the incident was addressed in the June 2016 QA meeting and initiated as a new progress for effectiveness evaluation. The corrective action for past non-compliance dated 5/27/16 was as follows: Ad Hoc Quality Assurance & Performance Improvement Meeting Date: 5/27/16 Attendees: - Administrator - Unit Manager - Medical Director - RN - LPN - SDC Identified Opportunity: - Transfer of Resident Resulting in Injury Criteria 1: Skin Assessment (Head-to-Toe) Pain Assessment - Tylenol administered effective MD Notified and assessed on-site X-ray ordered STAT Family (RP) Notified Resident sent to CFV ED for further orthopedic assessment Criteria 2 Audit transfer status forms and complete skin assessment on all residents requiring total assistance for mechanical lift. Employees identified terminated Criteria 3 Education and training of all clinical staff (PT, PRN, and FTE) on appropriate use of mechanical lift Clinical skills audit completed on new hires Director of Nursing, Unit Manager, and/or Staff Development Nurse (SDC) will audit one Certified Nursing Assistant (CNA) per week at random on use of mechanical lift for 4 weeks. Criteria 4 Audit tools will be brought to monthly QAPI and committee will deem compliance. Deemed compliant on 6/2/16. As part of the validation process on 7/21/16, the plan of correction was reviewed including the re-education of staff and observations of the use of the mechanical full lift and the sit to stand on Resident #103 and Resident # 77. Resident #75 was prescribed bed rest therefore could not be observed for a lift transfer. Interviews with nursing assistants revealed they were retrained in the usage both lift devices and how each resident was to be transfer by looking and the Care Guide for instructions. A review of the monitoring tools revealed that the facility completed a 100% audit of mechanical lift residents and sit to stand residents, completed 100% in-servicing of the nursing assistants to include newly hired nursing assistants and provided evidence of the weekly monitoring.

Based on record review, staff and physician interviews, the facility failed to notify the primary physician of a facility acquired pressure ulcer for 1 of 3 residents (Resident # 53) reviewed for pressures ulcers. Findings included: Resident #53 was admitted [DATE] with cumulative [MEDICAL CONDITION] [MEDICAL CONDITION], left sided [MEDICAL CONDITION], dysphagia, dementia and contractures. The 30 day Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and he was coded as extensive assistance with bed mobility and eating and total assistance with transfers, toileting, hygiene and bathing. Resident #53 was coded as non-ambulatory and incontinent of bladder and bowel. Record Review revealed evidence of weekly skin assessments. The weekly skin assessment completed 9/12/14, indicated no redness, no blisters or open areas to anywhere of Resident #53's body. The weekly skin assessment completed 9/15/14 also indicated no redness, no blisters or open areas to anywhere to Resident #53's body. Record review revealed a nursing note dated 9/18/14 at 2:34 PM indicating Resident #53 developed an open are to the right outer ankle appearing to be a "busted blister." The area measured "3mm (millimeters) L (Length) and 2.3 W" Width). The unit manager gave instructions to apply wound gel (ointment use to hydrate damaged tissue) and cover with dry gauze, foam pad and wrap area. There was no indication in the nursing note how often the dressing was to be changed or that the primary physician was notified of the newly acquired open area to Resident #53's right outer ankle. Record review revealed the next mention of Resident #53's wound care needs was on 9/22/14 at 2:00 PM in a note labeled as a weekly wound assessment. The "dressing to the right leg was intact" and once removed the wound was described as an "unstageable pressure wound." The area was documented as measuring 2.0 cm (centimeters) L x 4 cm W with serous (thin, watery clear) drainage and the wound base was covered with soft yellow to black eschar (dead tissue). An "unstageable" pressure ulcer may be described as full thickness tissue loss with exposed bone, tendon or muscle. Necrosis/eschar may also be present. The note read treatment was changed to Santyl and a moisten gauze daily. A review of the "Wound Care Standing Orders" indicated a state 4 pressure ulcer with eschar or necrotic tissue was to be treated using Santyl and covered with a [MEDICATION NAME] or foam dressing daily. A review of the Treatment/Procedure Administration Record for September indicated the first documented pressure ulcer treatment was 9/22/14. In an interview on 12/11/14 at 9:35 AM, the treatment nurse stated she was not aware Resident #53 developed a blister to his right ankle on 9/18/14 until she received a copy of a skin alert sheet in her box dated 9/22/14. She recalled she assessed Resident #53's right out ankle and it was covered with eschar and considered an unstageable pressure ulcer at that time. She stated she did not recall contacting the primary physician at that time but followed the facility standing orders and recalled adding Resident #53 to the list of residents she wanted the wound consultant physician to see on his next visit on 9/29/14. In an interview on 12/11/14 at 11:13 AM, the unit manager recalled being asked to assess the area to Resident #53's right outer ankle. She stated it appeared as an open blister and she told the nurse to put wound gel on it and wrap it with gauze until the primary physician could be contacted for additional orders. She stated she did not contact the primary physician to get treatment orders but thought Nurse #1 contacted the physician. The unit manager stated wound gel was used for areas such as an open blister to keep them moist and normally were ordered to be changed every day to maintain the moisture. She stated she did not recall telling the floor nurse how often the area should re-dressed. In an interview on 12/11/14 12:18 PM, Nurse #1 recalled NA #2 informing her of an opened area to Resident #53's right outer ankle on 9/18/14. She recalled the unit manager assisting her with the assessment of the area. Nurse #1 stated the unit manager told her to put wound gel on the area and wrap it with gauze. She stated did not write any orders and was under the impression that the unit manager contacted the physician and wrote any orders given. Nurse #1 stated it was during her weekly skin assessment dated [DATE] she completed a skin alert form and put it in the treatment nurses box. She stated she did not think the area to Resident #53's right outer ankle had been redressed or assessed since its discovery on 9/18/14. Nurse #1 verified using the electronic medical record to document the care given to Resident #53 and there was no documented treatment on the treatment record for September 2014 until 9/22/14. She stated she wrote the discovery and treatment to the area in a nursing note on 9/18/14 only. In an interview on 12/11/14 at 12:50 PM the administrator, the DON and the facility consultant verified there was no evidence of treatment of [REDACTED]. The DON verified writing the nursing note 9/23/14 at 4:57 PM in which she referenced receiving new physician orders. In a telephone interview on 12/12/14 at 11:48 AM the primary physician stated she ordered interventions as soon as she became aware of a new pressure ulcer on Resident #53's right outer ankle and the delay in putting interventions in place could have contributed to the worsening of the pressure ulcer along with his co-morbidities. The primary physician stated her expectation would have been for the facility to use the wound care standing orders when the area was identified on Resident #53's right outer ankle. The primary physician further indicated that by using wound gel to the area, wound care would be indicated at minimum every other day but ideally daily to promote healing and she would have expected to be notified when the new facility acquired pressure ulcer was discovered.

Based on record review, observations and staff and physician interviews, the facility failed to treat a new stage 2 pressure ulcer found on 9/18/14 for 4 days; on 9/22/14, the wound was assessed as unstageable for 1 of 3 residents (Resident # 53) reviewed for pressures ulcers. Findings included: A review of the facility undated "Wound Care Standing Orders" indicated an intact or open/ruptured serum filled blister was considered a stage 2 pressure ulcer and the ordered treatment was to cleanse the area with Sea-Clens (saline based wound cleaning agent), pat dry and apply a regular [MEDICATION NAME] (biodegradable, non-breathable adherent) or foam dressing. This dressing should be changed on day 3, day 7 and then every week thereafter until healed. Resident #53 was admitted [DATE] with cumulative [MEDICAL CONDITION] [MEDICAL CONDITION], left sided [MEDICAL CONDITION], dysphagia, dementia and contractures. The 30 day Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and he was coded as extensive assistance with bed mobility and eating and total assistance with transfers, toileting, hygiene and bathing. Resident #53 was coded as non-ambulatory and incontinent of bladder and bowel. Record review revealed a nursing note dated 9/18/14 at 2:34 PM indicating Resident #53 developed an open are to the right outer ankle appearing to be a "busted blister." The area measured "3mm (millimeters) L (Length) and 2.3 W" Width). The unit manager gave instructions to apply wound gel (ointment use to hydrate damaged tissue) and cover with dry gauze, foam pad and wrap area. There was no indication in the nursing note how often the dressing was to be changed. Record review revealed the next mention of Resident #53's wound care needs was on 9/22/14 at 2:00 PM in a note labeled as a weekly wound assessment. The "dressing to the right leg was intact" and once removed the wound was described as an "unstageable pressure wound." The area was documented as measuring 2.0 cm (centimeters) L x 4 cm W with serous (thin, watery clear) drainage and the wound base was covered with soft yellow to black eschar (dead tissue). An "unstageable" pressure ulcer may be described as full thickness tissue loss with exposed bone, tendon or muscle. Necrosis/eschar may also be present. The note read treatment was changed to Santyl and a moisten gauze daily. A review of the Treatment/Procedure Administration Record for September 2014 indicated the first documented pressure ulcer treatment was 9/22/14. Record review revealed a nursing note stated 9/29/14 at 2:00 PM the wound care consultant physician conducted a bedside debridement and continued the treatments using Santyl. He described the wound as being "unstageable necrosis" measuring 1.9 cm L x 1.9 cm W and without drainage. In another interview on 12/11/14 at 9:35 AM, the treatment nurse stated she was not aware Resident #53 developed a blister to his right ankle on 9/18/14 until she received a copy of a skin alert sheet in her box dated 9/22/14. She recalled she assessed Resident #53's right out ankle and it was covered with eschar and considered an unstageable pressure ulcer at that time. In another interview on 12/11/14 at 10:25 AM, the facility nurse consultant confirmed there was no evidence of treatment in the electronic medical record for the blistered area to Resident #53's right outer ankle discovered 9/18/14 after the initial treatment the unit manager instructed the floor nurse to perform on 9/18/14 until again on 9/22/14. In another interview on 12/11/14 at 11:13 AM, the unit manager recalled being asked to assess the area to Resident #53's right outer ankle. She stated it appeared as an open blister and she told the nurse to put wound gel on it and wrap it with gauze until the primary physician could be contacted for additional orders. She stated she did not contact the primary physician to get treatment orders but thought Nurse #1 contacted the physician. The unit manager stated wound gel was used for areas such as an open blister to keep them moist and normally were ordered to be changed every day to maintain the moisture. She stated she did not recall telling the floor nurse how often the area should re-dressed. The unit manager state when a new area was discovered on any resident, the floor nurse completed a skin alert sheet letting the treatment nurse know there was a resident who needed to be assessed for wound care needs. The unit manager stated she was able to pull up a report of daily alerts based on the data entered into the computer. She confirmed if there was no order written regarding a new identified pressure ulcer, there would be no alert on the report for follow up. In an interview on 12/11/14 12:18 PM, Nurse #1 recalled NA #2 informing her of an opened area to Resident #53's right outer ankle on 9/18/14. She recalled the unit manager assisting her with the assessment of the area. Nurse #1 stated the unit manager told her to put wound gel on the area and wrap it with gauze. She stated did not write any orders and was under the impression that the unit manager contacted the physician and wrote any orders given. Nurse #1 stated it was during her weekly skin assessment dated [DATE] she completed a skin alert form and put it in the treatment nurses box. She stated she did not think the area to Resident #53's right outer ankle had been redressed or assessed since its discovery on 9/18/14. In an interview on 12/11/14 at 12:50 PM the administrator, the DON and the facility consultant verified there was no evidence of treatment of [REDACTED]. In a telephone interview on 12/12/14 at 11:48 AM the primary physician stated she ordered interventions as soon as she became aware of a new pressure ulcer on Resident #53's right outer ankle and the delay in putting interventions in place could have contributed to the worsening of the pressure ulcer along with his co-morbidities. The primary physician stated her expectation would have been for the facility to use the wound care standing orders when the area was identified on Resident #53's right outer ankle. The primary physician further indicated that by using wound gel to the area, wound care would be indicated at minimum every other day but ideally daily to promote healing.

Based on record review, observations and staff interviews, the facility failed to address the potential for the development of a pressure ulcer in a resident identified as "high risk" (Resident # 53) for 1 of 3 residents reviewed for pressures ulcers. Findings included: Resident #53 was admitted [DATE] with cumulative [MEDICAL CONDITION] [MEDICAL CONDITION], left sided [MEDICAL CONDITION], dysphagia, dementia and contractures. His annual Minimum Data Set (MDS) completed 4/22/14 indicated Resident #53 triggered as "high risk" for the development of pressure ulcers. The Care Area Assessment (CAA) listed extrinsic risk factors as requiring staff assistance to move sufficiently to relieve pressure, he was coded as confined to bed or chair all or most of the time and as having a pressure relieving mattress to his bed. [MEDICATION NAME] risk factors included cognitive loss, [MEDICAL CONDITION] and incontinence. The CAA directed Resident #53 to be care planned for the risk potential with interventions. The weekly skin assessment completed 9/12/14, indicated no redness, no blisters or open areas to anywhere of Resident #53's body. The weekly skin assessment completed 9/15/14 indicated no redness, no blisters or open areas to anywhere to Resident #53's body. Record review revealed a nursing note dated 9/18/14 at 2:34 PM indicating Resident #53 developed an open area to the right outer ankle appearing to be a "busted blister." The area measured "3mm (millimeters) L (Length) and 2.3 W" Width). The unit manager gave instructions to apply wound gel (ointment use to hydrate damaged tissue) and cover with dry gauze, foam pad and wrap area. There was no indication in the nursing note how often the dressing was to be changed. Resident #53's current care plan included the onset of a right outer ankle unstageable wound effective 9/22/14 with interventions to include cleaning area with Sea Clens, pat dry, apply Santyl (enzymatic [MEDICATION NAME] ointment), cover with gauze and plain foam and secure with tape daily and as needed. The only other indicated intervention dated 9/22/14 included a weekly wound measurement. There was no care plan for refusal of care regarding his lower extremities. Record review revealed the next mention of Resident #53's wound care needs was on 9/22/14 at 2:00 PM in a note labeled as a weekly wound assessment. The "dressing to the right leg was intact" and once removed the wound was described as an "unstageable pressure wound." The area was documented as measuring 2.0 cm (centimeters) L x 4 cm W with serous (thin, watery clear) drainage and the wound base was covered with soft yellow to black eschar (dead tissue). An "unstageable" pressure ulcer may be described as full thickness tissue loss with exposed bone, tendon or muscle. Necrosis/eschar may also be present. Physician orders [REDACTED]. The current care plan was updated to include the alternating air mattress on 10/1/14. Review of the record revealed a nursing note stated 9/29/14 at 2:00 PM the wound care consultant physician conducted a bedside debridement and continued the treatments using Santyl. He described the wound as being "unstageable necrosis" measuring 1.9 cm L x 1.9 cm W and without drainage. This consult note recommended bunny boots. Record review revealed a physician order [REDACTED]. In an interview and wound care observation on 12/10/14 at 9:15 AM the treatment nurse stated the area was considered a pressure ulcer and it developed at the facility. In an interview on 12/10/14 at 2:50 PM, the facility nurse consultant and the MDS nurse verified Resident #53 was identified as a "high risk" for pressure ulcers on his skin risk assessments dated 7/21/14, 10/27/14 and again on 11/3/14. The facility nurse consultant was unable to provide any policy or procedure for implementation of interventions for resident identified as a "high risk" for the development of a pressure ulcer.

Based on record review, observations and staff and physician interviews, the facility failed to implement pressure relief upon the discovery of a new stage 2 pressure ulcer on 9/18/14, failed to treat a new stage 2 pressure ulcer for 4 days; on 9/22/14, the wound was assessed as unstageable for 1 of 3 residents (Resident # 53) reviewed for pressures ulcers. Findings included: A review of the facility undated " Wound Care Standing Orders " indicated an intact or open/ruptured serum filled blister was considered a stage 2 pressure ulcer and the ordered treatment was to cleanse the area with Sea-Clens (saline based wound cleaning agent), pat dry and apply a regular [MEDICATION NAME] (biodegradable, non-breathable adherent) or foam dressing. This dressing should be changed on day 3, day 7 and then every week thereafter until healed. Resident #53 was admitted [DATE] with cumulative [MEDICAL CONDITION] [MEDICAL CONDITION], left sided [MEDICAL CONDITION], dysphagia, dementia and contractures. The 30 day Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and he was coded as extensive assistance with bed mobility and eating and total assistance with transfers, toileting, hygiene and bathing. Resident #53 was coded as non-ambulatory and incontinent of bladder and bowel. Resident #53 was coded as having a stage 3 pressure ulcer measuring 2.0 cm x 3.2 cm with slough present. He was coded for pressure relieving devices to his chair and bed. Record Review revealed evidence of weekly skin assessments. The weekly skin assessment completed 9/12/14, indicated no redness, no blisters or open areas to anywhere of Resident #53's body. The weekly skin assessment completed 9/15/14 indicated no redness, no blisters or open areas to anywhere to Resident #53's body. Record review revealed a nursing note dated 9/18/14 at 2:34 PM indicating Resident #53 developed an open area to the right outer ankle appearing to be a "busted blister." The area measured "3mm (millimeters) L (Length) and 2.3 W" Width). The unit manager gave instructions to apply wound gel (ointment use to hydrate damaged tissue) and cover with dry gauze, foam pad and wrap area. There was no indication in the nursing note how often the dressing was to be changed. Resident #53's current care plan included the onset of a right outer ankle unstageable wound effective 9/22/14 with interventions to include cleaning area with Sea Clens, pat dry, apply Santyl (enzymatic [MEDICATION NAME] ointment), cover with gauze and plain foam and secure with tape daily and as needed. The only other indicated intervention dated 9/22/14 included a weekly wound measurement. There was no care plan for refusal of care regarding his lower extremities. Record review revealed the next mention of Resident #53's wound care needs was on 9/22/14 at 2:00 PM in a note labeled as a weekly wound assessment. The "dressing to the right leg was intact" and once removed the wound was described as an "unstageable pressure wound." The area was documented as measuring 2.0 cm (centimeters) L x 4 cm W with serous (thin, watery clear) drainage and the wound base was covered with soft yellow to black eschar (dead tissue). An "unstageable" pressure ulcer may be described as full thickness tissue loss with exposed bone, tendon or muscle. Necrosis/eschar may also be present. The note read treatment was changed to Santyl and a moisten gauze daily. A review of the Treatment/Procedure Administration Record for September 2014 indicated the first documented pressure ulcer treatment was 9/22/14. Physician orders [REDACTED]. Ankle brachial index (ABI) testing was completed 9/24/14 with inconclusive results and a referral to a vascular surgeon. A review of the activities of daily living (ADLs) Administration Record for September 2014 indicated the alternating air mattress was in place as of 9/25/14. Other ADL interventions documented on this record was heel checks every shift ongoing since 11/11/13. Review of the record revealed a nursing note stated 9/29/14 at 2:00 PM the wound care consultant physician conducted a bedside debridement and continued the treatments using Santyl. He described the wound as being "unstageable necrosis" measuring 1.9 cm L x 1.9 cm W and without drainage. This consult note recommended bunny boots and repositioning. Record review revealed a physician order [REDACTED]. The facility wound care consultant physician again saw Resident #53 on 10/6/14 and described the wound as "unstageable necrosis" measuring 1.8 cm L x 2.4 cm W. He documented no change in the wound condition. Record review revealed another wound consultant physician visit on 10/20/14 described the right outer ankle wound as infected and deteriorated. It was also described with unstageable necrosis measuring 2.5 cm L x 3.0 cm W with no drainage. The note read Resident #53's lies on his right side causing undue pressure on the wound and was noncompliant with wound care. There was deep tissue injury to the area surrounding the wound and the wound bed. It was documented that Resident #53 would "kick off" his boots and the wound physician discussed with Resident #53 the need to off load and keep off his right side. It was documented Resident #53 A nurses note dated 10/20/14 at 11:00 AM indicated the primary physician was at the facility and was made aware of the lack of improvement in the wound since the wound culture on 10/13/14 and subsequent ongoing antibiotic therapy. There was no change in orders. Record review revealed Resident #53 was seen by a vascular surgeon on 11/6/14 to rule out impaired circulation and follow up of the results of the ABI completed on 9/24/14. The progress note from the vascular surgeon indicated the ABI studies were normal, the wound should heal spontaneously and there was no evidence of circulatory impairment to the right lower extremity. In an interview and wound care observation on 12/10/14 at 9:15 AM the treatment nurse stated the area was considered a pressure ulcer and it developed at the facility. She recalled it started as a blister measuring 2cm L x 4 cm W x 0.8 cm D (depth) with undermining noted at the 2 o'clock position. There was yellowish slough noted to the right upper edge of the wound bed and the drainage appeared watery, pale red/pink. There was no evidence of odor or pain. The treatment nurse verified he preferred to be on his right side in bed and in his reclining chair. In a telephone interview on 12/10/14 at 5:30 PM, the wound consultant physician stated the area on Resident #53 right outer ankle was a pressure ulcer and he had no history of any other pressure ulcers anywhere other than a few incidental areas to his left hand prior to the development of the area to his right outer ankle. He noted Resident #53's tendency to lie on his right side along with his dementia and total assistance for ADL assistance were contributing factors to the development of the pressure ulcer. He was unable to recall documenting Resident #53 understood his instructions to stay off of his right side during his bedside visit on 10/20/14. In another interview on 12/11/14 at 9:35 AM, the treatment nurse stated she was not aware Resident #53 developed a blister to his right ankle on 9/18/14 until she received a copy of a skin alert sheet in her box dated 9/22/14. She recalled she assessed Resident #53's right out ankle and it was covered with eschar and considered an unstageable pressure ulcer at that time. The treatment nurse stated she was unsure when the protective boots were actually ordered but the staff had been floating Resident #53's heels in the bed and reclining chair for as long as she could recall. In another interview on 12/11/14 at 10:25 AM, the facility nurse consultant confirmed there was no evidence of treatment in the electronic medical record for the blistered area to Resident t#53's right outer ankle discovered 9/18/14 after the initial treatment the unit manager instructed the floor nurse to perform on 9/18/14 until again on 9/22/14. She also confirmed the treatment done to the blister on 9/18/14 was not consistent with the facility's standing wound care orders, no pressure relieving mattress ordered until 9/25/14. In a telephone interview on 12/11/14 at 10:55 AM, the vascular surgeon recalled seeing Resident #53 in his office on 11/6/14 to rule out vascular versus mechanical compromise. He stated Resident #53's ABI studies were normal and the area was pressure related but contributing factors to the development of the area was his dementia and left sided weakness. In another interview on 12/11/14 at 11:13 AM, the unit manager recalled being asked to assess the area to Resident #53's right outer ankle. She stated it appeared as an open blister and she told the nurse to put wound gel on it and wrap it with gauze until the primary physician could be contacted for additional orders. She stated she did not contact the primary physician to get treatment orders but thought Nurse #1 contacted the physician. The unit manager stated wound gel was used for areas such as an open blister to keep them moist and normally were ordered to be changed every day to maintain the moisture. She stated she did not recall telling the floor nurse how often the area should re-dressed. The unit manager state when a new area was discovered on any resident, the floor nurse completed a skin alert sheet letting the treatment nurse know there was a resident who needed to be assessed for wound care needs. The unit manager stated she was able to pull up a report of daily alerts based on the data entered into the computer. She confirmed if there was no order written regarding a new identified pressure ulcer, there would be no alert on the report for follow up. In an interview on 12/11/14 12:18 PM, Nurse #1 recalled NA #2 informing her of an opened area to Resident #53's right outer ankle on 9/18/14. She recalled the unit manager assisting her with the assessment of the area. Nurse #1 stated the unit manager told her to put wound gel on the area and wrap it with gauze. She stated did not write any orders and was under the impression that the unit manager contacted the physician and wrote any orders given. Nurse #1 stated it was during her weekly skin assessment dated [DATE] she completed a skin alert form and put it in the treatment nurses box. She stated she did not think the area to Resident #53's right outer ankle had been redressed or assessed since its discovery on 9/18/14 In an interview on 12/11/14 at 12:50 PM the administrator, the DON and the facility consultant verified there was no evidence of treatment of [REDACTED]. In a telephone interview on 12/12/14 at 11:48 AM the primary physician stated she ordered interventions as soon as she became aware of a new pressure ulcer on Resident #53's right outer ankle and the delay in putting interventions in place could have contributed to the worsening of the pressure ulcer along with his co-morbidities. The primary physician stated her expectation would have been for the facility to use the wound care standing orders when the area was identified on Resident #53's right outer ankle. The primary physician further indicated that by using wound gel to the area, wound care would be indicated at minimum every other day but ideally daily to promote healing.

Based on record review, and staff interviews, the facility failed to prevent 1 of 4 sampled cognitively impaired resident who was at risk for elopement from exiting the facility without staff knowledge (Resident #1). The Immediate Jeopardy began on 10/20/2013 when Resident #1 exited the facility unattended by the facility staff, and was found outside of the facility in the parking lot in his wheelchair. The Immediate Jeopardy was removed on 11/8/13 at 5:45 pm when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1's cognitive status was severely impaired and extensive assistance of one person was required with transfers. The assessment further indicated the resident was independent with locomotion on the unit and used a wheelchair for locomotion. The resident was not coded for wandering behavior. A review of Resident #1's care plan dated 4/26/2013 revealed the resident was identified with behavior/ moods needs. The goal stated for this problem was that the resident behavior would be easily altered as needed through next review. Interventions listed for this problem included "monitor wandering." A review of the nurse's note dated 5/23/2013 read "Resident wandering around the halls in facility. Wander guard placed to right lower extremity. Wander guard checked for proper functioning." A review of the nurse's note dated 6/4/2013 stated "When up in wheelchair he propels himself aimlessly around corridors and out of other rooms." The resident was also care planned on 7/12/2013 for elopement risk needs, wander guard bracelet needs, need for cueing, re-direction, distracting, wandering, cognitive impairment and poor safety awareness. The goal stated for these problems were "resident will have no elopements through next review and resident ' s safety needs will be met daily by staff through next review." During the interview with the Minimum Data Set (MDS) coordinator on 11/8/2013 at 1:30 PM, she was asked the reason the wander guard was placed on the resident's ankle in May 23, 2013. The MDS coordinator stated that the wander guard was placed on the resident's ankle because other interventions had been tried and failed to prevent the resident from wandering and being an elopement risk. A review of the activity's note dated 9/4/2013 indicated " Resident often enters other resident's rooms as he is confused that the room is not his. When redirecting resident he raises his voice to staff. Will continue to monitor." A review of the nurse's note dated 10/2/2013 read "Patient alert, wandering this shift, continue to redirect. No acute changes noted this shift." A review of the nurse's note dated 10/4/2013 documented "Pt (patient) alert, wandering this shift, continue to redirect. No acute changes noted this shift." A review of the nurse's note dated 10/20/2013 indicated "Charge nurse notified resident outside facility, resident escorted back in facility by hall nurse. Unit manager and Director of Nursing (DON) notified. Wander guard placed on resident right ankle. Monitoring will continue." A review of the incident report dated 10/20/2013 stated "the resident found outside." Under the comments headlines section, the incident report read " wander Guard replaced." The elopement risk assessment completed on 10/21/2013 revealed the resident had a score of 22(which meant that the resident was a high risk for elopement). During an interview with Nurse #1 on 11/7/2013 at 10:50 AM, she reported that Resident #1 had a wander guard on his ankle and the staff was required to check the wander guard on the resident ' s ankle each shift. Nurse #1 also stated that Resident #1 was confused about the location of his room and the staff usually reoriented the resident where his room was located. During an interview with Nurse Aide (NA) #1 on 11/7/2013 at 11:00 AM, she indicated that Resident #1 was confused and wandered into other residents' rooms. NA #1 further reported that Resident #1 at times had been observed pushing on the 500 hall exit door. NA #1 added that Resident #1 usually made statements that he wanted to see his wife. NA #1 elaborated that she heard a report from Nurse #2 that on 10/20/2013, Resident # 1 was found outside the facility. During an interview with the Director of Nursing (DON) on 11/7/2013 at 11:30 AM, when questioned how did the facility become aware that Resident #1 was not physically present in the nursing facility, she stated that Nurse #2 was leaving the facility on 10/20/2013 at 3:00 PM and observed the resident sitting outside the facility at the main entrance. The DON added that Nurse #2 wheeled the resident back into the facility and notified the charge nurse that Resident #1 was found outside. The DON further reported that during the facility's investigation, it was discovered that the resident did not have a wander guard on his ankle when he exited the building. She indicated that the staff could not trace the location of the wander guard when the resident was found outside and brought back into the facility. The DON concluded that the last time the wander guard was checked by the staff was before the resident exited the building on 10/19/2013. During a follow up interview with NA #1 on 11/7/2013 at 2:40 PM, she reported that she was regularly assigned to Resident #1 and that she regularly had to move Resident #1 from the exit doors and at times she had to call the resident ' s responsible party to calm him down. NA #1 acknowledged that on 10/20/2013 she was working on 1st shift and did not check to make sure that the resident had on the required wander guard. NA #1 stated that Nurse #2 informed her that the resident was found outside the building in the parking lot and that an elderly couple was in the process of driving out of the parking lot and almost hit the resident with the vehicle. During an interview with Nurse #3 on 11/7/2013 at 3:15 PM, she reported that on 10/20/2013, Resident #1 was brought back into the facility from outside the building by Nurse #2 who indicated to her that the resident was found outside the building. Nurse #3 further reported that the resident must have left the facility around 3:00 PM after the activities. Nurse #3 stated that the wander guard was not observed on Resident #1's ankle on October 19, 2013, so she discharged the wander guard order in the computer. Nurse #3 added that Resident #1's wander guard was replaced on 10/20/2013 after the resident was found outside the nursing facility and was brought back into the facility. During a phone interview with Nurse #2 on 11/7/2013 at 3:30 PM, stated that she was leaving the building on 10/20/2013 at 4:30 PM, when she saw Resident #1 outside in the parking lot. She reported that she observed an elderly couple in their car actively pulling out of the parking lot and appeared not to have seen the resident in his wheelchair. Nurse #2 reported that she had to stop the elderly couple from running over the resident who was sitting in his wheelchair beside the car. Nurse # 2 stated that she wheeled Resident #1 back into the building and reported the incident to Nurse #2 who was the charge nurse. Nurse #2 added that Resident #1 was an elopement risk and that he would always go into other resident's rooms and tried to push on the exit doors. Nurse #2 concluded that she did not recall seeing a wander guard when she found the resident outside. An interview with the charge nurse (Nurse # 4) on 11/7/2013 at 4:00 pm revealed that on October 19, 2013 Resident #2, who was a new admission, exited the building. So she removed Resident #1's wander guard and placed it on Resident # 2's ankle. Nurse # 4 further added that there were no extra wander guards in the building because the Administrator was the one who ordered the wander guards During an interview with the Administrator on 11/7/2013 at 3:00 PM revealed, the staff did not know when the wander guard became missing though the staff documented that they had observed the wander guard in place on the resident's ankle. The administrator stated that after the resident exited the building that was when they realized that the resident did not have the wander guard intact on his ankle. He added that the staff searched for the wander guard but they could not locate it in the building. The administrator acknowledged that only a staff member could have taken the wander guard off the resident's ankle, because someone must use a scissors to take it off. During a follow up phone interview on 11/8/2013 at 10:00 AM, Nurse #2 reported that she saw Resident #1 last time at the nurse's station at 3:30 PM on 10/20/2013. Nurse #2 further added the next time she saw the resident was at around 5:00 PM when she was driving home and saw the resident next to the handicap parking when a car was pulling out. She stated that she stopped her car, got out, and wheeled the resident back into the facility. Nurse #2 indicated that she could not know how long the resident had been outside. She added that Resident #1 usually did not stay in any activity, so he would not have been in the church activities on 10/20/2013. During an interview on 11/8/2013 at 11:00 AM, the Activity Director reported that Resident #1 normally wandered throughout the unit and did not stay in one place for a long period of time. The activity director elaborated that the resident had never been known to stay in an activity until an activity ends. She indicated that the resident never participated in any activities. The activity director reported that the resident would come in the activity room and leave after a short period of time. She concluded that she did not believe that the resident could have stayed in the church activity for one hour on 10/20/2013. During an observation of the building on 11/8/2013 at 1:00 PM revealed the distance from the activities room to the main entrance door was 342 feet and 90 feet from Resident #1 ' s room. The main entrance doors were not automatic but manual doors. Further observations of the building revealed there were no door openers for wheel chair by the main entrance doors. There were no alarms by the exit doors and the employees had a code that they had to use in order to exit the building. The facility parking lot was observed to be busy with vehicles coming and leaving, and the handicap section where Resident #1 was located could not be seen from inside the building During an interview with the Administrator on 11/8/2013 at 2:00 PM, he stated that they had replaced Resident #1 wander guard and audited current residents with wander guards in the facility on 10/21/2013.He further reported that the ongoing compliance was to monitor all wander guards 5 times per week for one month beginning 10/21/2013, then weekly for 3 months. The administrator stated that the unit manager was responsible for keeping up with residents ' who had wander guards at in the facility. The administrator was notified of the Immediate Jeopardy on 11/8/2013 at 11:35 am. The facility provided the following Credible Allegation on November 8, 2013 at 5:15 pm: Credible Allegation of Compliance: Resident #1 was admitted to facility on 04/04/2013 and on 10/20/2013 resident was observed in the parking lot outside facility. Resident was brought back into the facility by licensed nurse who observed him sitting outside at which time Unit manager and Director of Nursing were notified. A wander-guard was place on resident at that time. Resident Power of Attorney was notified. Elopement risk was perform on 04/04/2013 day of admission by licensed nurse doing the admission risk assessment and indicated that resident is not considered an elopement risk. However with his course of stay, resident noted to be confused, disoriented and having wandering behaviors inside facility. On 10/21/2013 after resident was observed outside of the facility an elopement risk was completed by RN supervisor which indicated resident is an elopement risk. For the resident affected Resident had wander-guard in place starting 5/23/2013, then on 10/19/2013 at 3:30 PM, wander-guard was not observed on resident #1 by the licensed charge nurse, and she made the decision to not replace. Resident had an elopement on 10/20/2013, outside facility in parking lot. This facility identified Resident #1 was an elopement risk on 10/20/2013 after being observed outside facility in parking lot. Licensed nurse who observed resident assisted him back to his hall nurse, to his unit and reported to charge nurse. Charge nurse immediately applied wander-guard. There was no harm or injury or negative outcome for resident #1. For other resident ' s with potential to be affected On 10/21/2013 each resident in house had an actual elopement risk assessment completed by two RN supervisors. After completion of elopement risk assessment, two others resident, Resident # 4 and Resident # 5 were identified at being at risk for elopement. For Resident # 4, elopement risk assessment was completed on 08/09/2013, and was not considered an elopement risk. For most recent elopement risk on 10/21/2013, Resident # 4 was identified as an elopement risk and wander-guard was place on resident 10/27/2013 and licensed nurse to document placement and function every shift, ongoing. For Resident # 5, elopement risk assessment was completed on 08/12/2013 which indicated resident was an elopement risk, RN completing 8/12/2013 elopement risk assessment made the clinical decision not to place wander-guard on resident due to no efforts have been made to leave facility and had limited physical mobility. Most recent elopement risk assessment was 10/21/2013, identified resident to be at risk for elopement and wander-guard put in place on 10/27/2013 and licensed nurse to check placement and functioning every shift , on-going. Facility action plan to prevent re-occurrence Once wander guard has been placed on resident, the Director of nursing or assistant director of nursing, or licensed nurse will have authority to give approval for removal after reviewing elopement risk assessment in conjunction with care plan team, ongoing. All facility exit/entrance doors are locked at all times, requiring key pad entry with exception of the front-main entrance door, which are locks automatically as programmed. Current times include seven in the morning; doors will unlock and at six in the evening doors will lock down daily, seven days a week. Starting 11/8/2013, front - main entrance door has been programmed to unlock at nine in the morning and lock at five in the afternoon. During the times the front door is programmed to be unlocked (9-5), there will be a reception at the desk at all times, ongoing (reception included in the facility wide in-service). For new admission, an elopement risk assessment will continue to be completed by RN supervisor, Director of Nursing, or designee on day of admission, ongoing. In addition, the RN supervisor will schedule an elopement risk assessment in the electronic medical records to be completed on day seven after admission by the license nurse, ongoing. In the event once assessment completed, resident is considered to be an elopement risk, the licensed nurse completing the assessment will either place a wander-guard or assign one to one assignment(certified nursing assistant and one resident) monitoring for the resident, ongoing. Quarterly elopement risk assessment will be completed on all residents by licensed nurse, ongoing. Residents who are identified to be an elopement risk will be reviewed in Patient at Risk meeting weekly, which consist of Director of Nursing, RN supervisor, and dietitian, X 4 weeks then monthly, ongoing. For those residents who have a wander-guard in-place, it will be scheduled in the electronic health record, to be documented placement every shift by the licensed nurse, ongoing. It will be documented checking function by using the tester every shift, ongoing. The licensed nurses are required to complete a To-Do-List (task/interventions that are scheduled to be completed by licensed nurse and certified nursing assistant on their shift for their assigned hall). At the end of each shift the license nurse will print the To-Do-List to ensure there is not any task or interventions left not completed by the licensed nurse or certified nursing assistant, ongoing. In addition to completing To-Do-List, the license nurse off-going and on-coming license nurse will validate by signing the To-Do-List that there are no task or interventions left not completed prior to leaving the facility, ongoing. Facility will maintain 3 additional wander-guard bracelets, in the event there are no wander-guards available when resident has been identified to be at risk for elopement, one to one assignment (one certified nursing assistant and one resident) will be initiated until wander-guard can be obtained. In-services provided to ensure sustained compliance Licensed staff in-serviced by staff development or designee beginning 11/8/2013, on their responsibility as it relates to completion of the elopement questionnaires which identifies residents to be at risk for elopement. All license nurses will be in-serviced on interventions to be put in place once identified to be at risk. (Intervention will either be one to one assignment (one Certified nursing assistant with one resident) or wander-guard bracelet All licensed nurses will be in-serviced prior to their next scheduled tour of duty by staff development or designee. Licensed staff in-serviced by staff development or designee beginning 11/8/2013 on responsibilities of ensuring all task and interventions are completed timely on their assign shift. By completing a To-Do-List (task/ interventions that are scheduled to be completed by the licensed nurse and certified nursing assistant on their shift for their assigned hall). Licensed nurse will be in-serviced prior to the next scheduled tour of duty by staff development or designee. Licensed nurse in-serviced by staff development or designee beginning 11/8/2013 on scheduling of elopement risk assessment seven days after admission. Licensed nurse will be in-serviced prior to the next scheduled tour of duty by the staff development or designee. All staff in-serviced by staff development or designee beginning 11/8/2013 on Resident at risk for Elopement and wander-guard bracelet, ensuring placement and function, and notifying all staff of current residents that are at risk for elopement. All staff in-serviced to ensure that all staff are aware of resident at risk and the need to be aware doors, visitors and other staff exiting building, and report to supervisor any elopement behaviors-example-resident shaking exit doors. To provide basic supervision during routine care rounds to ensure resident safety. Staff will be in-serviced prior to shift ending on 11/8/2013. All staff will be in-serviced prior to the next scheduled tour of duty by the staff development or designee. Patient at Risk team members (Director of nursing, RN supervisor, and dietitian) in-serviced starting 11/8/2013, for review of resident identified to be at risk for elopement, monitored x 4 weeks, then monthly, ongoing. Staff will be in-serviced prior to shift ending on 11/8/2013 All staff will be in-serviced by staff development or designee beginning 11/8/2013 on what constitutes decision to remove wander-guard. All staff will be in-serviced prior to the next scheduled tour of duty by the staff development of designee. On 11/8/13 at 5:15 pm, verification of the credible allegation was evidenced by interviews of all staff related to identifying residents at risk for elopement, ensuring placement and function of the wander guard. The staff was also aware of whom to report the elopement behaviors.