Every finding on record at Avir at Cisco

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 1 of 5 employees (NA-A) reviewed for employability.The facility failed to ensure the record of the initial criminal history check, employee misconduct registry check, and nurse aide registry check was obtained for NA-A, hired on 01/01/2026, prior to working in the facility and having access to the residents. This failure could place residents at risk of receiving care by someone that was unemployable.Findings included: Record review of the NA-A's employee file, on 03/07/2026 at 4:15 p.m., reflected a hire date of 01/01/2026 and no evidence of an EMR/NAR and criminal history check were completed prior to hire. During an interview on 03/07/2026 at 4:30 p.m., the ADMN stated NA-A was hired on 01/01/2026. The ADMN stated NA-A started working the floor on 01/02/2026. He stated the BO staff quit, and her last day was on 03/03/2026. He stated he was not able to locate all the employee files. He stated there were a lot of papers in the BO office and he was attempting to go through those papers and organize them. He stated he could not say for sure, but he believed the criminal history check, EMR/NAR checks were done for NA-A.During an interview on 03/09/2026 at 1:19 p.m., the DON stated employees should be screened for criminal history checks and EMR/NAR checks prior to them being allowed access to the residents. She stated the BO was responsible for running those checks and her last day working in the facility was on 03/02/2026. She stated she did not know why NA-A's criminal history, EMR, or NAR checks were not run before she started working on 01/12/2026. She stated she did not know who monitored to ensure mandatory checks were done. She stated the effect on residents could be NA-A may potentially have convictions or charges that could make them unemployable and would put residents at risk of abuse if the facility did not know about those charges or convictions. She stated the facility needed to be compliant with the laws and regulations. During an interview on 03/09/2026 at 3:20 p.m., the ADMN stated he had not found the initial criminal history check, EMR check or NAR check for NA-A. He stated he had spoken to the previous BO employee who stated she ran the criminal history check, EMR, and NAR checks for NA-A and could not find them. He stated it was his expectation the criminal history check and EMR/NAR checks were run prior to an employee being hired. He stated Corporate HR were responsible for monitoring that those checks were performed per requirements and they were in the process of doing an audit at this time, but he did not know how often they monitored for the pre-employment checks. He stated the effect of not running the pre-employment checks could cause someone to be allowed to work that was unemployable. He stated that could potentially put residents at risk, but the facility had attempted to make things right by running the criminal history check, EMR check and NAR checks when they discovered they had no evidence of them being run and NA-A was employable. Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, reflected, 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #21) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan based on the assessed needs with measurable objectives and timeframes in area of colostomy for Resident #21. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #21 Review of Resident #21's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: colostomy (opening in the abdominal wall to allow the colon to pass waste), brain bleed, and kidney disease. Review of Resident #21's MDS dated [DATE] revealed: BIMS of 13 which indicated no cognitive impairment. Review of section H revealed the resident had a colostomy. Review of Resident #21's Comprehensive Care Plan, initiated 04/21/2025, revealed no evidence of the colostomy. Review of Resident #21's electronic physician's orders revealed: Clean area around stoma (opening in the abdominal wall to allow the colon to pass waste)with soap and water, pat dry, apply skin prep with wafer and bag, Empty colostomy bag every shift, and Colostomy care every shift. Observation and interview on 08/19/25 at 11:41 AM, revealed Resident #21 up in bed, and his colostomy bag in place. He stated that he did not maintain his colostomy bag and that the care was provided by facility staff. During an interview on 08/20/2025 at 11:13 AM, the DON stated that she was responsible for care plans. She stated all care plans had been updated and transferred over from the old computer system to the new one. She stated all things related to the resident's care and preferences should have been on the resident's care plan. The DON stated that Resident #21's colostomy and how to care for it should have been care planned. She stated not having the colostomy care planned could lead to staff not knowing that he had a colostomy or if he cared for and maintained it himself. Review of facility's policy Care Plans, Comprehensive Person-Centered revised March 2022 revealed: A comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, appearance, and temperature. The facility failed to ensure that 38 of 38 residents who received meals from the kitchen received food that was palatable, attractive, and at a safe and appetizing temperature. This failure place residents at risk of poor food intake and/or dissatisfaction of meals served. The findings were: During an observation on 07/14/2024 at 12:40 PM, the kitchen staff were plating the lunch meal and placing lids on top of meals that do not fit and some were cracked. The plated meals placed on the rolling cart were to be delivered to the residents who chose to eat in their rooms. This state surveyor monitored the test tray from the kitchen to last meal served to residents and proceeded to take the test tray to the conference room for other state surveyors to sample. During an observation on 07/14/2024 at 12:44 PM, the sample meal tray temperatures of the food were taken by the Cook. The temperatures were: pork roast was 85 degrees and was cold and tough, stuffing was 90 degrees and cool to the touch, green beans were 80 degrees and cold to taste, the roll was soggy on the bottom, and the vanilla pudding had clumps of pudding mix and did not have a smooth texture. During an interview on 07/14/2024 at 12:44 PM the [NAME] stated that she had cooked the food and did not want to test it. During an interview on 07/14/2024 at 12:48 PM the DM stated she believed the food was at the correct temperature and declined trying anything on the test tray. The DM stated her expectation was that the food temperature would be at 100 degrees or above. The DM stated all residents eat meals from the kitchen. During an interview on 07/14/2024 at 11:26 AM, Resident #37 stated vegetables were too mushy to eat and most of it was boiled, canned vegetables with no taste. During an interview on 07/14/2023 at 03:10 PM, Resident #30 stated the food was not hot, or warm. Resident #30 stated he was on a mechanical soft diet and the food did not taste good. Resident #30 stated he would have liked his food to be hot and he would put ketchup or something on it so he could eat the food. During an interview on 07/16/2024 at 12:21 PM, the DON stated she expected food to be served at the correct temperatures. The DON stated the failure occurred due to not having plate warmers and lids for the plates did not fit correctly and caused food to cool down. The DON stated residents could lose weight if not eating meals because the food was not warm or hot. During an interview on 07/16/24 at 02:46 PM the ADM stated his expectation was food served to the residents be warm, palatable, and timely. The ADM stated the effect on residents were if the food was cold residents would not eat the food. The ADM stated the DM monitors food temperatures and timeliness of food being served. The ADM stated food not being served in a timely manner caused the food to be cold when served to residents. Review of facility's policy titled and dated: Food Preparation and Service-Policy Statement-Food service employees shall prepare and serve in a manner that complies with safe food handling practices. Revised July 2014 Food Preparation, Cooking and Holding Temperatures and Times .2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese .5. The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms. a. poultry and stuffed foods-165 degrees. b. Ground meat, ground fish and eggs held for service-at least 115 degrees. c. fish and other meats- 145 degrees for 15 seconds. d. Fresh, frozen, or canned fruits/vegetables-135 degrees .

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 100 of 403 (June 8, 2023 to July14, 2024) days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 06/09/2023, 06/10/2023, 06/11/2023, 06/16/2023, 06/17/2023, 06/18/2023, 06/24/2023, 06/25/2023, 07/01/2023, 07/02/2023, 07/05/2023, 07/06/2023,07/07/2023, 07/08/2023,07/09/2023, 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/24/2023, 07/25/2023, 07/26/2023, 07/27/2023, 07/28/2023, 07/29/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/02/2023, 09/03/2023, 09/09/2023, 09/10/2023, 09/16/2023, 09/17/2023,09/24/2023, 09/30/2023, 10/01/2023, 10/07/2023, 10/08/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, 11/05/2023, 1/11/2023, 11/12/2023, 11/18/2023, 11/19/2023, 11/25/2023, 11/26/2023, 12/02/2023, 12/03/2023, 12/09/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/28/202, 12/29/2023, 12/30/2023, 12/31/2023, 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/204, 01/21/2024, 05/04/2024, 05/05/2024, 05/12/2024, and 06/23/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of the facility's RN coverage tracking from 06/08/2023 to 07/14/2024 revealed 06/09/2023, 06/10/2023, 06/11/2023, 06/16/2023, 06/17/2023, 06/18/2023, 06/24/2023, 06/25/2023, 07/01/2023, 07/02/2023, 07/05/2023, 07/06/2023,07/07/2023, 07/08/2023,07/09/2023, 07/10/2023, 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/24/2023, 07/25/2023, 07/26/2023, 07/27/2023, 07/28/2023, 07/29/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/03/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/02/2023, 09/03/2023, 09/09/2023, 09/10/2023, 09/16/2023, 09/17/2023,09/24/2023, 09/30/2023, 10/01/2023, 10/07/2023, 10/08/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, 11/05/2023, 1/11/2023, 11/12/2023, 11/18/2023, 11/19/2023, 11/25/2023, 11/26/2023, 12/02/2023, 12/03/2023, 12/09/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/28/202, 12/29/2023, 12/30/2023, 12/31/2023, 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/204, 01/21/2024, 05/04/2024, 05/05/2024, 05/12/2024, and 06/23/2024 there was no evidence of RN coverage. During an interview on 07/16/24 at 2:23 PM the DON stated she was responsible for scheduling RN coverage and her expectation was to have 8 hours RN coverage daily. The DON stated she was hired August 2023 and she monitored RN coverage by the schedule she made. The DON stated she did not feel there was a negative effect on residents not having 8-hour RN coverage. The DON stated RN coverage was to help oversee and support the LVN's. The DON stated she was available by phone and could have come to facility. The DON stated whet led to the failure were RN's not wanting to work full shifts. During an interview on 07/16/24 at 2:41 PM the ADMN stated his expectation was to have appropriate RN coverage as required. The ADMN stated he did not think there had been a negative affect to residents because staff had access to an RN and the DON. The ADMN stated the DON was responsible to create the schedule and he assisted in monitoring. The ADMN stated what led to the failure of not having 8-hour RN coverage was a shortage of RN 's in the area, and not being able to cover when staff called in and the DON was out for surgery. The ADMN stated between sister facilities staff always had the resource of contacting a RN. The ADMN did not think they had a policy for RN coverage, they followed the federal guidelines.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for halls 1 of 3 halls. The facility staff (CNA C) failed to place dirty linens in a sealed bag before being transported from resident room. The facility staff failed (CNA D) to place dirty briefs after peri-care in a sealed back before being transported from resident room. These failures could place residents at risk for the spread of infection and skin complications. Findings included: During an observation on 07/14/2024 at 8:36 PM, CNA-D was carrying unbagged dirty briefs through the hallway to the dirty bins. During an interview on 07/14/2024 at 8:36 PM, CNA-D stated she was carrying dirty briefs unbagged from resident room to the dirty bin because she had not taken an extra trash bag to place them in. She stated all dirty linens and briefs should be bagged and sealed before transporting them outside of resident rooms. She stated in doing so, she could have caused cross contamination between residents and/or staff members. During an observation on 07/15/2024 at 10:00 AM, CNA-C was carrying unbagged dirty resident sheets through hallway to the dirty bins. During an interview on 07/15/24 at 11:13 AM, CNA-C stated she was carrying linens from a resident room to the dirty linen closet that was un-bagged. She stated she had training on infection control and how to properly transport them from resident rooms to the dirty laundry. CNA-C stated she sat them down on the floor outside of the laundry room door to obtain a bag to put them in and stated she knew that was not the correct way to transport linens. She stated the linens should have been bagged and sealed before leaving resident room. CNA-C stated, carrying the unbagged linens from a resident room this way could have caused cross contamination from resident to resident. During an interview on 07/15/2024 at 4:03 PM the DON stated, all staff were to bag dirty linens and briefs before leaving rooms. She stated anything from resident's rooms should not be un-bagged when coming out to their room. The DON stated all staff should have been monitoring, but the ADON monitors most of the time. She stated the negative impact would have been cross contamination which would lead to the spreading of infection and/or germs. The DON stated the failure occurred with the CNA's rushing and hurrying to get their duties finished, that led to forgetting what was needed to finish the task properly. She stated her expectations were to have staff reeducated with infection control and the proper way of transporting linens and dirty briefs when it came to leaving resident rooms. The DON stated if linens were clean or dirty, they were to be bagged in and bagged out. During an interview on 07/16/2024 at 2:48 PM the ADON stated it was unacceptable to carry dirty briefs down the hallway without being bagged. She stated in-services were provided to all staff in May 2024 on Infection Control. She stated the negative impact to residents to residents transferring bacteria, which would lead to residents getting sick. She stated residents were immunocompromised and they could get sick easier. The ADON stated the DON and herself monitored, and the failure occurred with staff not following through with in services and competencies. She stated her expectations were to follow the policies. Record review of facility policy titled Infection Prevention and Control Program dated 1/1/2024 revealed: Policy: this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 3. Standard precautions; a. All staff shall assume that all residents are potentially infected or colonized with an Organism that could be transmitted during the course of providing resident care services 12. Linens: a. Laundry and direct staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linens shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linen unless it is properly bagged.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 14 (Resident # 29, #30, and #37) residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans that incorporated Resident #30 and #37's to include the use psychotropic medications. The facility failed to develop care plan that incorporated Resident #29's identified pressure ulcers. These failures could place the residents at risk for decreased quality of life and not having their needs met. The findings included: Record review of Resident #29's electronic face sheet, dated 07/16/2024, revealed [AGE] year-old female who admitted [DATE] with diagnoses: Unspecified dementia, repeated falls, depression, hypertension (high blood pressure) heart failure, type II diabetes mellitus with diabetic nephropathy (kidney disease), and pain disorder with related psychological factors. Record review of Resident #29's Admission MDS dated [DATE], Section C-Cognitive Pattern revealed resident #29 had a BIMS score of 8, meaning resident had moderately cognitively impaired. Section M Skin Conditions revealed no pressure ulcers. Record review of Resident #29's MAR dated 06/01/2024-06/30/2024 revealed documentation of: Soak foot in 3 quarts of water with 10 mL of Clorox/bleach daily x 2 weeks. MAR dated 07/01/2024-07/16/2024 revealed: Cleanse areas to bilateral heels, right lateral foot, right ankle with normal saline/wound cleanser pat dry, apply skin prep to bilateral heels, right lateral foot, and right ankle. Weekly skin (specify day and shift) (This was not initiated until 07/03/2024). Record review of Resident #29's Care plan dated 05/14/2024, revealed no evidence, goal, or interventions of pressure ulcers to right and left heel. Record review of Resident' #30's electronic face sheet dated, 07/16/2024, revealed [AGE] year-old male who was admitted [DATE] and readmitted [DATE] with diagnosis type II diabetes mellitus, dysphagia , retentions of urine, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood , symptomatic epilepsy, pain in left knee, depression, unspecified convulsions, and chronic kidney disease. Record review of Resident #30's Significant change MDS dated [DATE] revealed: Section C Cognitive Patterns revealed Resident #30 had a BIMS score of 13, meaning resident had intact cognitive status. Section N revealed no use of anti-depressants, or anti-anxiety medications. Record review of Resident #30's physician orders dated 07/01/2024, revealed orders for Bupropion ER (extended release) 150 mg by mouth every day, Escitalopram 10 mg by mouth every day, Mirtazapine 15 mg by mouth at bedtime, Depakote sprinkles 125 mg, 3 tabs by mouth two times a day, Phenytoin 100 mg by mouth four times a day, and Tramadol 50 mg by mouth every four hours as needed for pain. Record review of Resident #30's Care plan dated 06/12/2024, revealed no evidence, goal, or interventions for the following medications: Bupropion (anxiolytic-to treat anxiety), Escitalopram (anti-depressant), Mirtazapine (anti-depressant), Depakote sprinkles (anti-epileptic/seizure), phenytoin (anti-convulsant), and Tramadol (narcotic used for pain relief). Record review for Resident # 37's electronic face sheet dated 07/16/2024, revealed a [AGE] year-old male admitted on [DATE] with diagnoses: Hemiplegia (complete or severe paralysis on one side) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left non-dominant side, vascular dementia (brain damage caused by multiple strokes) mild, with psychotic disturbance, and psychotic disorder with delusions. Record review of Resident #37's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns revealed Resident #37 had a BIMS score 15 meaning the resident had intact cognitive status. Record review of Resident # 37's Physician orders dated 07/01/2024 revealed: Clopidogrel 75 mg by mouth once a day, Aricept (donepezil) 5 mg by mouth once a day. Record review of Resident #37's Care Plan dated 03/08/2024 revealed: there were no goals, interventions for the diagnosis of Hemiplegia, Hemiparesis, or the use of Aricept (medication for dementia) or clopidogrel (blood thinner) in the care plan. During an interview on 07/15/2024 at 2:30 PM the ADON stated, herself and the DON were responsible to update care plans. The ADON stated a new pressure ulcer should be updated in the care plan upon finding the pressure ulcer. During an interview on 07/15/2024 at 2:40 PM the DON stated her expectation was that care plans should include resident needs and address ways to support their needs. The DON stated, herself and the ADON were responsible for updating the care plans. The DON stated she did not feel there was a negative impact to residents for care plans not being accurate because staff usually go by the orders not the care plan. The DON stated what led to the failure of items not being addressed in the care plan was that she was new to the long-term care process, and she was still learning. During an interview on 07/16/24 at 12:21 PM, the DON stated not all care plans had been reviewed and updated. The DON stated medications should have been care planned. The DON stated there was no harm to residents, but the care plan does help staff to know interventions planned for resident. The DON stated that she and the ADON were responsible for auditing and ensuring accuracy of care plans. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated Revised December 2016: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment 7. The care planning process will: a. facilitates resident and/or representative involvement. b. Include an assessment of the resident's strengths and needs; 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well -being; g. Incorporate identified problem areas .

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision. The facility failed to ensure CNA-E and CNA-F locked the Resident wheelchair during the Hoyer transfer of Resident #28. This failure could place residents at risk of injuries. Findings included: Review of Resident # 28's face sheet dated 07/16/2024 revealed an [AGE] year-old female admitted on [DATE]. Review of Resident #28's diagnosis revealed: hypertension (high blood pressure), disorder of muscle, degenerative disease of the nervous system, muscle wasting, and atrophy. Review of Resident # 28's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 12 (moderately impaired). Section GG-Functional Abilities and Goals, Mobility Devices-uses Wheelchair (manual or electric), Mobility- E. Chair/bed-to chair transfer: Dependent-Helper does ALL the effort. Resident does none of the effort to complete the activity. Review of Resident #28's Care Plan dated 06/27/2024 revealed, Problem-I am limited in ability to transfer self R/T (related to) muscle weakness. Goal-Resident will be transferred with use of Hoyer lift. Approach-Use Hoyer lift for transferring. During an observation on 06/12/2024 at 10:15 AM, CNA-E and CNA-F did not lock the wheelchair while Resident #28 was being transferred from her bed to her wheelchair during a Hoyer Lift transfer. During an interview on 07/15/2024 at 2:45 PM, CNA-F stated they were not taught to lock the brakes on the Hoyer or the wheelchair during a transfer, although she was trained. She stated she did not know what the policy revealed. During an interview on 07/15/2024 at 3:30 PM the DON stated the Hoyer lift was not supposed to be locked during a transfer of residents, but the wheelchair was. She stated the DON monitored. The DON stated the failure was that some policies were confusing on when to lock the Hoyer lift and/or wheelchair. She stated the negative impact in not locking the wheelchair during a transfer was the possibility of injury to residents. She stated her expectations were that they would review the facility transfer policy, re-educate, and make sure it did not happen again. Review of facility Hoyer lift manual, https://www.manualslib.com/manual/2889017/Invacare-Reliant-450.html?page=13#manual on 07/15/2024 revealed; Invacare does not recommend locking the rear casters of the patient lift when lifting an individual. Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Review of facility policy Lifting Machine, Using a Portable dated December 2013 revealed; Purpose-The purpose of this procedure is to help lift residents using a manual lifting device. Steps in the Procedure-To transfer a resident from a bed to a chair, you should: 1. Position the chair. If it is a wheelchair, be sure the wheels are locked.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 4 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. Findings included: During an observation on 07/14/2024 at 8:38 PM, there was an unlocked medication cart on the south hallway of facility with LVN-B out of line of site. The unlocked cart contained all prescription and Over the Counter medications that included, but not limited to eye meds, stool softeners, antipsychotics, insulins, blood pressure medications, and narcotics. During an interview on 07/14/2024 at 8:40 PM LVN-B stated, she was in charge of the medication cart. She stated she was passing medications to a resident and the cart should have been locked at all times when out of sight. She stated there were 19 resident medications stored in this medication cart. LVN-B stated the residents had the potential to obtain medications that were not theirs and possibly cause an allergic reaction. During an interview on 07/14/2024 at 8:49 PM the DON stated residents had the potential to obtain medications that were unsafe for them and cause possible harm such as an overdose or an allergic reaction if the medication cart were left unlocked. She stated the charge nurses, and the Nursing Department heads were to monitor the medication carts. She stated she was unsure where the failure was as this nurse was the charge nurse at this time. The DON stated her expectations were for the medication carts to be locked at all times when not in use or out of sight. Review of facility policy Security of Medication Cart dated April 2007 revealed: Policy Statement- The medication cart shall be secured during medication passes. Policy Interpretation and Implementation; 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. Then it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on interviews, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 of 14 (Resident #29) residents reviewed for resident records. The facility failed to ensure Resident #29 had orders for weekly skin assessments. This failure could place residents at risk of having errors with their care and treatment. The findings included: Record review of Resident #29's electronic face sheet, dated 07/16/2024, revealed an [AGE] year-old female who admitted [DATE] with diagnoses: unspecified dementia, repeated falls, depression, hypertension (high blood pressure) heart failure, type ii diabetes mellitus with diabetic nephropathy (kidney disease), and pain disorder with related psychological factors. Record review of Resident #29's Admission MDS dated [DATE], Section C-Cognitive Pattern revealed resident #29 had a BIMS score of 8, meaning the resident had moderately cognitively impaired. Section M Skin Conditions revealed no pressure ulcers. Record review of Resident #29's MAR (May 2024 MAR, June 2024 MAR, and July 2024 MAR) revealed no evidence that skin assessments were completed until 07/03/2024. During an interview on 07/16/24 at 10:30 AM LVN A stated that skin assessments should have been done weekly, starting at admission. LVN A stated the admitting nurse would have been responsible to add the order for skin assessments. LVN A stated if there was an order then it would have populated on a specific day and shift weekly to be completed on the nurses MAR. During an interview on 07/15/2024 at 2:40 PM the DON stated her expectation was skin assessments were to be completed weekly, starting at the time of admission. The DON stated she did not think there was a negative effect to residents because staff were doing daily foot soaks and the resident was receiving showers, so staff were looking at her skin, it was just not documented. The DON stated there should have been an order for weekly skin assessments written at admission. The DON stated what led to failure was that the admission nurse did not follow the facility's Admission Checklist and she thought she must have used the orders from the previous facility. Review of facility document titled, Admission Checklist, not dated, revealed Add orders into Matrix Review of the facility policy titled; Pressure Ulcer Risk assessment dated [DATE] revealed Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis . Once inspection of skin is completed proceed to the Admission Assessment or Weekly Skin Integrity tool and completed documentation of findings.

Based on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 3 (Resident #2) residents reviewed for urinary catheter care. The facility failed to place Resident #2's urinary catheter in a privacy bag. This failure could place residents at risk of low self-esteem resulting in a diminished quality of life. Findings include: Record review of the MDS dated [DATE] revealed Resident #2 was a [AGE] year old female admitted [DATE], with a BIMS score of 12 indicating mild cognitive impairment. Medical Diagnoses include nausea with vomiting, muscle weakness, muscle wasting and atrophy, obesity, pressure ulcer of sacral region and cellulitis. Record review of Residents #2 Care Plan dated 10/16/23, Category Urinary Incontinence, stated 'store collection bag inside a protective dignity pouch'. Observation and interview on 12/7/23 at 9:51 a.m., revealed Resident #2 lying in bed watching tv, the urinary catheter bag was placed on the right side down by the foot of the bed, no privacy cover and urinary catheter bag can be seen from hallway. Resident #2 stated she did not know the catheter bag did not have a privacy cover and stated she would like for it to be covered. In an interview with the DON on 12/7/23 at 10:18 a.m., the DON stated she expected that all catheter collection bags on beds and wheelchairs be covered by privacy pouch. The DON stated the failure of not placing catheter collection bags in privacy pouches could compromise a residents' dignity. Observation on 12/7/23 at 11:00 a.m., Resident #2 catheter bag was placed in privacy pouch. A policy on catheter care was requested but was not provided by the time of exit.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed to ensure Resident #6's nebulizer tubing was kept in bag while not in use. These failures could place residents at risk for respiratory infections. The findings include: Record review of Resident #6's MDS Admission assessment dated [DATE], revealed Resident #6 was admitted to the facility on 10/27/23. Section C: Cognitive Patterns revealed a BIMS score of 14 (cognitive). Section I: Active diagnosis revealed Congestive heart failure. Section O did not include the use of nebulizer. Record review of Resident #6's prescription order start date 12/4/23, Resident #6 was to receive, ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1; inhalation 2x daily, once during the day and once during the night. Record review of Resident #6's Care Plan revealed reoccurring episodes of wheezing, Goals: improve by Respiratory by changing tubing weekly per facility policy. In an observation and interview on 12/7/23, at 9:30 a.m., Resident #6 was lying in bed watching tv, the nebulizer was sitting on the nightstand on the right-side of the bed, the nebulizer tube and cup was not in a plastic bag for storage when not in use. Resident #6 stated that the last treatment was last night on 12/6/23 at 9:30pm. In an interview with the DON on 12/7/23 at 10:18 a.m., the DON stated she expected the nebulizer cup and tubing be changed once per week, dated, and stored in baggie when not in use. The DON stated the failure to store nebulizer cup and tubing properly could result in infection. The DON provided facility policy and procedure. Record review of the policy titled Respiratory Therapy- Prevention of Infection, 2001 MED-PASS, Inc. (Revised November 2011) Indicated: Section: Infection Control Consideration Related to Medication Nebulizer/Continuous Aerosol: Step 7. Store the circuit in plastic bag between uses.

Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed. The facility failed to have an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed from January 1, 2023, through June 4, 2023. These failures could place all residents at risk for their clinical needs not being met. Findings included: Review of Daily Staffing Data revealed the facility did not have the services of an RN on the following dates: January 1-2, 7 - 9, 14 - 15 and 28 - 29, 2023; February 4- 5, 11 - 12, 19 and 26, 2023; March 11 - 12, 18 - 19 and 25 - 26, 2023; April 1 - 2, 7 - 9, 15 - 16, 22 - 24 and 29 - 30; 2023. May 4, 6 - 8, 13 - 14, 20 - 21 and 28 - 31, 2023; June 1 - 3, 2023. During an interview on 06/06/23 at 12:31 PM, the DON stated the facility had been having a hard time finding registered nurses to cover weekend shifts. The facility was advertising and had a Now Hiring banner in front of the building. The DON stated she would cover weekend shifts when she was able. During an interview on 06/07/23 at 2:03 PM, the Admin agreed with the DON that finding RN's was difficult in a small town. The Admin was not able to recall how long the facility had only the DON for RN coverage. Review of facility policy labeled Departmental Supervision revised August 2006 revealed: The nursing services department shall be under the direct supervision of a RN or LVN at all times. 1. A Registered or Licensed Practical/Vocational Nurse (RN/LPN, LVN) is on duty twenty-four hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a Nurse Supervisor/Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to label items in refrigerators and freezers. The facility failed to discard items in a timely manner that were stored in refrigerators and freezers. The facility failed to seal items that were stored in the refrigerators and freezers. These failures placed all residents at risk of complications of foodborne illnesses. Findings included: During an observation and interview on 06/05/23 at 08:45AM of the kitchen and food storage areas with the DM Refrigerator 1 (Near Door) 1 package of tortillas with an opened date of 4/3/23. DM said they were supposed to be thrown out after 7 days. 1 package of mozzarella shredded cheese with an opened date of 5/24/23. DM said the cheese should have been thrown out after 7 days. 1 package of sliced cheese with an opened date of 5/20/23. DM said it should have been thrown out after 7 days. 1-1-gallon container of bar-b-que sauce that was 1/2 empty with an illegible date opened on the bottle. 1 container of pimento cheese that was 3/4 empty that had no opened date on the container. DM said she did not know when it was opened. Refrigerator 2 (Near Sink) 1 carton of Thickened Orange Juice with an opened date of 5/23/23. The carton instructions state to use by 7 days after opening. DM was unaware how long the juice lasted. 1-32oz jug of Almond Milk that was 1/2 full had an opened date of 3/25/23. DM said that it should have been thrown out within 7 days. 1 Hamburger meat roll, wrapped in foil with top open and exposed to elements, which was hanging over top of pan. The hamburger meat was next to cabbage on the bottom of the icebox. DM said there was the potential for the hamburger meat to drip onto the cabbage. Chest Freezer 1 large bag of yeast rolls that was unsealed. As DM picked up the bag, several of the frozen yeast rolls fell out of bag. DM had staff go out and get a new bag and placed the torn bag inside and used a twist tie to close the bag. Stand up Freezer #1 1 clear zipper sealed bag labeled turkey was dated 5/31/23 that was stored in the door, and it had noticeable ice crystals throughout the bag, touching the meat, edges of some of the fillets were noted to be white and yellow. 1 clear plastic bag labeled Pork Riblets that was unsealed had an illegible date on the bag. DM took the bag out then got a twist tie and wrapped the bag to seal it. 1 clear zipper sealed bag labeled Pork Chops that was dated 1/18/23 was stored in the door and the bag had noted ice crystals throughout the bag touching the meat. DM said that the items in the door of the stand-up freezer were not freezer burned with ice crystals in the bags. She said they had ice crystals in the bag because of times when the freezer door was open too long. DM said that it was not that the items would briefly thaw out but that the freezer door would be left open. During an interview on 06/05/23 at 09:49 AM- DM said she checked the refrigerators daily for items that needed to be thrown out and looked in the freezers weekly on Wednesdays before the food supply trucks came in. Facility policy labeled Food Receiving and Storage last revised December 2008 revealed: Food should be received and stored in a manner that complies with safe food handling practices . All foods must be stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) . Uncooked and raw animal products and fish will be stored separately in a drip=proof containers and below fruits, vegetables and other ready-to-eat foods.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for two (Resident #21, Resident #33) of eight residents reviewed for care plans, in that: The facility failed to address the care and monitoring of Resident #21's left lower leg prosthetic and the risk for skin breakdown on the comprehensive care plan. The facility failed to address the care and monitoring of Resident #33's indwelling urinary catheter and colostomy These failures could place residents at risk for not having their needs met. Findings included: Review of Resident #21's face sheet revealed a [AGE] year-old female initially admitted [DATE] with most recent admission on 04/20/2023. Resident #21's diagnoses included peripheral vascular disease (problems with the circulation of blood in the arms and/or legs), heart failure, kidney failure, lower left leg amputation, and type 2 diabetes. Review of Resident #21's 1 - 5-day Scheduled Assessment MDS dated [DATE], Section C: Cognitive Patterns, C0500. BIMS Summary Score revealed a BIMS score of 15 on a 1- 15 scale indicating intact cognition. Observation and interview on 06/05/23 at 11:09 AM, Resident #21 was propelling self in wheelchair down the hall. Right lower leg prosthetic was in place. Resident #21 denied issues with the prosthetic. Record review of Resident #21's care plan edited 06/01/2023 revealed a problem of Resident is at risk for pressure ulcer due to activity and chairfast. Interventions included Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair, Consider PT consult for conditioning and W/C assessment, and Teach or do frequent small shifts of body weight. Record review of Resident #21's MDS 1-5 day Scheduled assessment dated [DATE] revealed in section GG0110 Prior Device Use, choice E. Orthotics/Prosthetics was checked. Record review of Resident #33 face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident was diagnosed with constipation but did not have a diagnosis that would relate to the need for a urinary catheter. Record review of Resident #33 Admission MDS dated [DATE] revealed a BIMS of 11 meaning mild cognitive decline, resident had an indwelling urinary catheter and a colostomy. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing an indwelling urinary catheter or the use of a colostomy. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for indwelling urinary catheter care, monitoring, changing, or discontinuing. Further review also revealed no orders for colostomy care, monitoring the stoma site, changing the wafer and fecal collection bag or During an observation and interview with Resident #33 on 06/05/23 at 3:30 PM revealed an indwelling urinary catheter draining to gravity with 1000 mLs of amber colored urine. He also had a colostomy on his left lower quadrant of his abdomen. Resident said he had the catheter and colostomy before he came into the facility however, he could not remember why he had either. During an interview with the DON on 06/07/23 at 3:40 PM, she said resident's that have indwelling catheters should have a diagnosis relating to the catheter. She said they should have physician's orders for the catheter that would include changing the catheter PRN, what size catheter to use when changing it, recording output each shift, and monitoring for any issues. She said evidence-based practices no longer indicated that Foley catheters should be routinely changed on a monthly basis, but that they would be changed as needed when residents were having difficulties, bladder pain, obvious sediment in the bag, leaking of the catheters, or when a resident would pull it out accidentally. DON also said that if a resident had an indwelling catheter, then the catheter would be addressed on a resident's care plan. She said resident's that had colostomies should have had a diagnosis relating to the colostomy. She said they should have physician's orders for the colostomy that would include changing the wafer and feces collection bag PRN, recording output each shift, and monitoring for any issues. DON also said that if a resident had a colostomy, then it would be addressed on a resident's care plan. DON stated there was no reason as to why the prosthetic use and skin issues were not care planned. Review of the facility policy titled Care Plans - Comprehensive revised September 2010 revealed under Policy Interpretation and Implementation item 1. Our facility's Care Planning Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Item 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem area, b. Incorporate risk factors associated with identified problems, c. Build on the resident's strengths, d. Reflect the resident's expressed wishes regarding care and treatment goals, e. Reflect treatment goals, timetables and objectives in measurable outcomes, f. Identify the professional services that are responsible for each element of care, g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and i. Reflect currently recognized standards of practice for problem areas and conditions. Item 7. The resident's comprehensive care plan is developed withing seven (7) days of the completion of the resident's comprehensive assessment (MDS). Item 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 45216

Based on interviews and record reviews the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 2 (Resident #16 and Resident #27) of 4 residents reviewed for discharge. The facility failed to notify Resident #16 or her representative of her transfer in writing. The facility failed to notify Resident #27 or his representative of his transfer in writing. These failures place residents and/or their resident representatives at risk of understanding the reasons and/or location of transfers. Findings included: Resident #16 Record review of Resident #16's Face sheet dated 06/07/23 revealed a [AGE] year-old female with an admitted [DATE]. She had a diagnosis list that included: cardiomyopathy (Primary), anxiety disorder, ankylosing spondylitis, generalized edema, adverse effect of stimulant laxative, rheumatoid arthritis, idiopathic progressive neuropathy, hypertension, hyperkalemia, CHF, heart disease, COPD, type 2 diabetes without complication, anorexia. Record review of Resident #16's Census dated 06/07/23 revealed a discharge with an expected return on 05/23/23 and 06/02/23. Record review of Resident #16's Progress Notes revealed: 05/23/2023 08:45 AM called Dr office at 0810 explained resident's current condition and MD stated to send her to (hospital) to be checked out. Called @ 0820 (emergency contact) and notified him of his mother's condition. Called dispatch at 0825 for transportation to hospital. EMT's arrived at facility at 0830. Printed ccd and gave EMT's a copy and a copy of resident's vital signs from this morning. Resident left facility at 0835 via stretcher. 06/02/2023 05:36 PM. Was called to resident's room by resident's daughter . Resident's V/S T: 97.7 P:79 R:24 B/P: 120/79 SPO2: 95% via NC. Resident is difficult to arouse, disoriented, and lethargic. Called Dr. and MD stated to send resident out to the emergency room . Dispatch called at 1735. Family with resident at this time and are aware of change in condition. Notified DON of resident being sent out. Resident #27 Record review of Resident #27's Face sheet dated 06/07/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included Acute respiratory failure with hypoxia (Primary), stage 2 pressure ulcer of sacral region, pneumonia, neuromuscular dysfunction of bladder, dementia, Record review of Resident #27's Census dated 06/07/23 revealed a discharge with an expected return on 05/05/23. During an interview on 06/07/23 at 2:30pm with ADM and DON, they said they did not provide Resident #16 or Resident #27 or their representatives written notice of their transfers. DON said both residents were transferred to the hospital and had to be admitted to the hospital for a period of time. ADM said he was not aware that the facility needed to provide them with a written notice of their transfers when they went to the hospital. Record review of facility policy labeled Transfer or Discharge; Emergency last revised September 2012 revealed: Prepare a transfer form to send with the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with a colostomy receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s goals and preferences for 1 (Resident #33) of 2 residents reviewed for colostomies. The facility failed to have a diagnosis, physician orders, and care plan for Resident # 33's colostomy. These findings place resident at risk of complications related to a colostomy. Findings included Record review of Resident # 33 Face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. He had a diagnosis list that included constipation. Record review of Resident #33 Admission MDS 05/12/23 reveal a BIMS of 11 meaning mild cognitive decline and resident had a colostomy. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing his colostomy. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for colostomy care, monitoring the stoma site, changing the wafer and fecal collection bag or. During an interview with resident #33 on 06/05/23 at 3:30 PM revealed a colostomy on his left lower quadrant of his abdomen. He said he had the colostomy before he came into the facility for the past year, however he could not remember what happened that caused him to get it. During an interview with the DON on 06/07/23 At 3:40 PM. She said resident's that had colostomies should have had a diagnosis relating to the colostomy. She said they should have physician's orders for the colostomy that would include changing the wafer and feces collection bag PRN, recording output each shift, and monitoring for any issues. DON also said that if a resident had a colostomy, then it would be addressed on a resident's care plan. Record review of facility policy labeled colostomy/ileostomy care last revised October 2010 revealed: review the resident's care plan to assess for any special needs of the resident . documentation. the following information should be recorded in the resident's medical record. the date and time the colostomy/ileostomy care was provided. The name and title of the individual who provided the colostomy/ileostomy care. Any breaks in the resident's skin, signs of infection, or excoriation of the skin. How the resident tolerated the procedure. If the resident refused the procedure, the reason why and the intervention taken. The signature and title of the person recording the data.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 (Resident #33) of 3 residents reviewed for indwelling catheters. The facility failed to have a diagnosis, physician orders and care plan interventions for Resident # 33's indwelling urinary catheter. These findings place resident at risk of complications related to urinary catheterization. Findings included Record review of Resident # 33 Face sheet dated 06/08/23 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. Resident did not have any diagnosis that would relate to the need for a urinary catheter. Record review of Resident #33 Admission MDS 05/12/23 reveal a BIMS of 11 meaning mild cognitive decline and resident had an indwelling urinary catheter. Record review of Resident #33 care plan last revised 06/01/23 revealed no care areas addressing indwelling urinary catheter. Record review of Resident #33 Physician orders dated 06/08/23 revealed no orders for indwelling urinary catheter care, monitoring, changing or discontinuing. During an observation and interview on 06/05/23 at 3:30 PM with Resident #33, he had an indwelling urinary catheter draining to gravity with 1000CC's of amber colored urine. Resident said he had the catheter before he came into the facility however, he could not remember why he had the catheter. During an interview with the DON on 06/07/23 At 3:40 PM. She said resident's that had indwelling catheters should have a diagnosis relating to the catheter. She said they should have physician's orders for the catheter that would include changing the catheter PRN, what size catheter to use when changing it, recording output each shift, and monitoring for any issues. She said evidence-based practices no longer indicated that Foley catheters should be routinely changed on a monthly basis, but that they would be changed as needed when residents were having difficulties, bladder pain, obvious sediment in the bag, leaking of the catheters, or when a resident would pull it out accidentally. DON also said that if a resident had an indwelling catheter, then the catheter would be addressed on a resident's care plan. Record review of facility policy labeled Catheter Care, Urinary last revised October 2010 revealed: review the Resident observe the resident urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident daily output, per facility policy and procedure. Check the resident frequently to be sure he or she is not laying on the catheter and to keep the catheter and tubing free of kink. Unless specifically ordered, do not apply clamp to the catheter. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Routine hygiene is appropriate. Empty the drainage bag regularly using a separate, clean collection container for each resident. Empty the collection bag at least every eight hours. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when they close system is compromised. Care plan to assess for any special needs of the resident.

Based on interviews and record reviews, the facility failed to provide a written bed hold policy for 1 of 1 facility reviewed for transfers and discharges. The facility failed to have a written bed hold policy. This failure placed residents at risk of returning to their room in the facility upon return from emergent transfers. Findings included: During an interview on 06/07/23 at 11:31AM with ADM, he said he was not sure if the facility notified residents or their representatives with a written bed hold form during transfers. During an interview on 06/07/23 at 11:38AM with BOM, she said the facility did not notify residents or their representatives with a written bed hold form during transfers. She said she was unaware of the need to inform the resident or their representatives with a written form. During an interview on 06/07/23 at 1:07PM with ADM, he said he understood that regarding a bed hold, upon transfer of a resident he does not always tell the families during each transfer but he has in the past had families ask, so it is that the resident room will be closed upon transfer, no personal belongings will be moved and the resident has the right to come back to their room when they transfer back to the facility. He said he did not know that there was any type of a form or that the facility needed to inform the resident and their family in writing about the bed hold. He said that they did not have a written policy that he could find regarding bed hold. Record review did not reveal a written policy to notify residents or their representatives in writing of a bed hold to allow them to return to the facility to their room after transfers.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents for 2 (Resident #1 and Resident #2) of 3 residents reviewed for medication regimen. 1. LVN A did not administer Resident #1's blood pressure medications within one hour before or after the scheduled administration time per facility policy. LVN A forgot to administer the medication when the resident was not immediately available for the administration. LVN A was notified by the surveyor that the resident had not recieved meds which prompted the nurse to give the meds. 2. RN A did not administer Resident #2's insulin within the one hour after the scheduled administration time per facility policy. RN A forgot to administer the medication when the resident was not immediately available for the administration. The deficient practice placed residents at risk of receiving less than therapeutic benefits from medications. Findings included: Record review of Resident #1's Face Sheet, dated 12/21/2022, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses were Chronic systolic (congestive) heart failure and Unspecified abnormalities of gait (manner or walking) and mobility. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #1's Pharmacy Order, dated 11/02/2022, revealed he was prescribed Amlodipine, for hypertension (high blood pressure), 5mg tablet, once a day, to be taken at 8:00 a.m. Record review of Resident #1' Prescription Order, dated 9/30/2022, revealed he was prescribed Carvedilol, for congestive heart failure, 6.25mg, 2 tablets, twice daily, with his first dose to be taken at 8:00 a.m. During an interview on 12/21/2022 at 10:45 a.m., Resident #1 said his knees were hurting and he had not told the nurse. Resident #1 said the reason he had not told the nurse was because he had not seen the nurse that morning. Resident #1 stated he had not taken his morning medication and said he was supposed to take them at 8:00 a.m. Resident #1 said he had pain medication he could take if he told the nurse he was hurting and asked to take the pills. During an interview on 12/21/2022 at 10:52 a.m., LVN A stated he had worked at the facility for four years. He said Resident #1 was supposed to receive his morning medication at 8:00 a.m., as documented on the eMAR. LVN A stated the first time he went to give Resident A his medication that morning, LVN A punched the pills out into a med cup and signed off on the eMAR electronic record as prepped and taken by resident #1, even though LVN A had not witnessed Resident #1 take his pills that morning. LVN A said he went down to Resident #1's room and he was not there, and he assumed Resident #1 was outside smoking. LVN A stated on his way back to the med cart, he tripped and dropped Resident #1's pills on the floor and disposed of them in the sharp's container. LVN A stated he forgot to go back and give Resident #1 his medication scheduled for 8:00 a.m. even though the time was now approximately 11:00 a.m. LVN A stated he had marked the eMAR that Resident #1 took his medication prior to the first attempt that morning, which was an error. LVN A stated he had been trained on medication administration and knew the correct time frame of giving medication was one hour before and one hour after the scheduled time. LVN A stated he had been trained on the eMAR electronic platform in October 2022 by the facility's DON and Regional Corporate staff. LVN A stated he knew he was not supposed to document on the eMAR the resident had taken his medication until he observed the resident to do so because it could cause major medication errors similar to the one he made with Resident #1. LVN A said med error could cause significant health issues. Observed Resident #1's eMAR for 12/21/2022 at 11:05 a.m. and noted the electronic record had been marked and documented that Resident #1 had taken his 8:00 a.m. medication but LVN A said he had not and prepared them and administrated them to Resident #1 at that time. Record review of Resident #2's Face Sheet, dated 12/21/2022, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses were Chronic diastolic (congestive) heart failure, Acquired absence of left leg below knee, and Type II diabetes mellitus with diabetic neuropathy (damage to the nerves). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #2's Pharmacy Order, dated 11/22/2022, revealed Resident #2 was prescribed Insulin Lispro, for diabetes, 100 unit/mL, subcutaneous (beneath the layer of skin), 3 times daily with the first dose at 9:00 a.m. During an interview on 12/21/2022 at 11:23 a.m., Resident #2 stated she was frustrated with RN A because she gave her medication to her late on Monday, 12/19/2022. Resident #2 said she was supposed to have received an insulin injection at 10 a.m. and she knew that she did not receive the medication until after lunch. Resident #2 said her blood sugar was not high due to receiving her insulin late, but she was worried it could be since it was time to receive her next scheduled shot. Resident #2 said she used her call button and called RN A several times to remind her, and RN A finally came and gave her the shot after 1:00 p.m. Resident #2 stated she thought the time was closer to 2:00 p.m. During an interview on 12/22/2022 at 10:15 a.m., RN A said she had been at the facility for approximately 1 1/2 years. RN A stated she had been late on a medication with a resident earlier in the week and the resident was a diabetic and the medication had been an insulin shot. RN A identified the person as Resident #2 and stated Resident #2 should have received her diabetic shot at 9:00 a.m. before breakfast on 12/19/2022. RN A said the Insulin shot was scheduled for 9:00 a.m., but she forgot. RN A stated every time she went to give the shot to Resident #2, Resident #2 was involved in an activity. RN A did not state if she verbally inform Resident #2 that her insulin shot was due, but she said Resident #2 did not refuse as RNA stated she was in a hurry and did not have time to wait until Resident #2 was finished with the activity she was involved in. RN A said she could not remember what time she gave Resident #2 the injection, but she was sure the shot was given by 12:00 p.m. RN A said again said she had overlooked giving Resident #2 her insulin shot but she had several residents to give medication to and could not always go back to the med cart and use the computer to look at all residents who had not received medication. RN A said she knew Resident #1 not receiving her Insulin shot within the scheduled time frame could cause her blood sugar to become high and out of therapeutic range. Observation of the electronic eMAR for 12/19/2022 showed Insulin Lispro Solution, 100 unit/mL, scheduled: 9:00am, 12:00pm, and 5:00pm was completed as given on 12/19/2022 with no time stamp. During an interview on 12/21/2022 at 1:45 p.m., the DON stated she had been at the facility for approximately 1 1/2 years. The DON said she was not aware LVN A had not administered the morning medication to Resident #1 until it was brought to her attention around 11:00 a.m. by the Surveyor. The DON stated her expectations were for the nurses or med techs to administer medication to the residents at the scheduled time within an hour before or after the time on the eMAR. The DON said if the medication was not taken within that time frame, the nurse was to document on the eMAR that the medication was missed and document the reason why. The DON said Resident #1, who received his medication late because he was outside smoking, was unacceptable and did not meet her expectation. The DON said she was not aware that Resident #2 did not receive her insulin injection until RN A came to her and told her what happened after she talked to the surveyor, which was unacceptable. The DON said this was unacceptable because the resident could have negative effects with her blood sugar which would be medically dangerous. The DON said she and the Executive Director were available if staff needed assistance and the facility provided education and held the staff accountable. During an interview on 12/12/2022 at 12:50 p.m., the Executive Director said she was not aware nursing staff were administering medication outside the required time frame and this did not meet her expectation and was not how the staff were trained. The Executive Director said policy stated the timeframe was within an hour of the scheduled med time, meaning an hour before or after. She also stated the nurse should document if the medication was late and notify the DON or herself. The Executive Director said she was not aware that RN A had given Resident #2 her insulin injection late until after it was discovered during the review on this date and that was unacceptable. Record review of the Performance Improvement Plan for (electronic) eMARs & POC Uplift, dated 10/20/2022, revealed on-site eMAR/POC training with staff by DON/Nurse Managers, MDS - would train staff on the units with Regional support. Record review of the Administering Medication Policy, dated 12/2012, revealed medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time. Record review revealed the individual administering the medication must initial on the resident's MAR (eMAR) on the appropriate space after giving each medication and before administering the next ones. For residents not in their rooms or unavailable, the MAR (eMAR) must be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication.

41871 45437 Based on observation, interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for five of twelve residents (Residents #10, #11, #14, #15 and #33) reviewed for Comprehensive Care Plans. This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. Findings include: Record review of Resident #10's face sheet revealed he was a [AGE] year-old male, admitted to the facility on [DATE]. Record review of Resident #10's MDS, dated [DATE], revealed diagnoses included: Coronary artery disease, end stage renal disease, and diabetes mellitus. Record review , Resident #10 did not have a comprehensive care plan completed from the MDS admission assessment on 02/15/22. Record review of Resident 11's electronic medical record revealed an [AGE] year old female readmitted [DATE] with the following diagnoses: Other seizures(Primary), Unspecified dementia without behavioral disturbance(Admission), Ulcerative colitis, unspecified, without complications, Bronchitis, not specified as acute or chronic, non-COVID (nCoV) acute respiratory disease, Neuromuscular dysfunction of bladder, unspecified, Unspecified abnormalities of gait and mobility, Urinary tract infection, site not specified, Dysphagia, unspecified, Unspecified atrial fibrillation, Dysphagia following unspecified cerebrovascular disease, Cognitive communication deficit, Temporal sclerosis, Acute gingivitis, non-plaque induced, Pain in unspecified knee, Anxiety disorder, unspecified, Disorder of adrenal gland, unspecified, Cerebral infarction due to embolism of unspecified cerebral artery, Chronic obstructive pulmonary disease, unspecified, Constipation, unspecified, Difficulty in walking, not elsewhere classified, Muscle weakness (generalized), Unspecified lack of coordination, Other specified depressive episodes. Record review on 04/28/2022 of Resident 11's face sheet showed an order for an indwelling urinary catheter. Record review on 4/28/2022 of Resident 11's electronic medical record for comprehensive Care plans revealed there was no care plan for indwelling urinary catheters. Resident #14 was a [AGE] year-old female, originally admitted on [DATE]; last admitted to the facility on [DATE]. Diagnoses included: acute respiratory disease, hypertension (HTN), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), myocardial infraction, chronic pain, peripheral vascular disease (PVD), anxiety and depression. Record review of Resident #14's baseline Care Plan, dated 04/15/2022, revealed no comprehensive care plan had been conducted. Record review on 04/28/2022 of Resident #15 electronic medical record revealed he was a [AGE] year-old male, latest admission was on 04/11/2022. Diagnoses included: Fracture of unspecified part of neck of left femur, sequela; Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, Hypotension of hemodialysis, Muscle weakness (generalized), Traumatic subdural hemorrhage without loss of consciousness, Bell's palsy, Obstructive sleep apnea, Morbid (severe) obesity due to excess calories, Type 2 diabetes mellitus with diabetic dermatitis, Chronic diastolic (congestive) heart failure, Chronic atrial fibrillation, and Other specified depressive episodes. In an interview on 04/26/22 at 09:32 AM, Resident #15 stated he receives nebulizer treatments daily. In an interview on 04/26/22 at 09:38 AM, Resident #15 said that he has not been invited to a care plan meeting and as far as he knows he hasn't had one. Record review of Resident #15's orders revealed an order for albuterol sulfate for nebulization, 2.5 mg /3 mL (0.083 %), PRN every 4 hours, via nebulizer. Start date: 04/21/22. Record review of Resident 15's electronic medical record revealed the resident does not have a comprehensive care plan. Record review of Resident #33 was an [AGE] year-old female originally admitted on [DATE]; last admitted to the facility on [DATE]. Diagnoses included: acute respiratory disease, unspecified atrial fibrillation, diabetes mellitus with diabetic neuropathy, chronic pain, chronic kidney disease, hypertension, dry eye syndrome of bilateral lacrimal glands, and major depressive disorder. Record review of Resident #33's, dated 04/28/2022 revealed an order for nebulizer treatments. Record review of Resident #33's Care Plan, dated 11/10/2021 revealed no care plan for nebulizer treatments. In an interview on 4/28/2022 at 10:22 AM with the DON she said Comprehensive Care plans were not completed accurately because she has not been trained on them yet. She has been in this position for almost a year but has not covered every area yet. She revealed that she is responsible for them and she reviews and signs the Care Plans when completed. She said that she was unsure on how to chart various assessments and that led to the care plans not being done or meetings being held. She scheduled the care plans for a STAT meeting to catch up and address the comprehensive issues. She was going to start making a schedule to help her with care plans. Record review of a facility policy titled; Care Area Assessments taken from the facility's Nursing Services Policy and Procedure Manual, 2001 MED-PASS, Inc (Revised December 2011) revealed the following: Policy Statement Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS and to develop individualized care plans. CAAs are the link between assessment and care planning. Policy Interpretation and Implementation 2. The Care Area Assessments (CAAs) process consists of the following steps: a. Identify areas of concern triggered on the MDS: (1) This can be done using software or by manually using the CAT logic tables in the RAI User's Manual. b. Review the triggered CAAs by doing an in-depth, resident-specific assessment of the triggered condition: (1) History taking; (2) Physical assessment; (3) Gathering relevant information (labs, tests, etc.); and (4) Sequencing of clinically significant events. c. Define the problem(s): (1) Identify the functional, physical, and/or behavioral implications of the problem(s); (2) Identify the relationships between risk factors, triggers and problems; (3) Distinguish between causes and consequences; and (4) Look for common causes of multiple issues. d. Make decisions about the care plan: (1) Determine whether the problem(s) needs intervention; (2) Evaluate the resident's goals, wishes, strengths and needs; (3) Design interventions that address causes, not symptoms; and (4) Establish which items need further assessment or additional review. e. Document interventions on the care plan: (1) Include specific interventions, including those that address common causes of multiple issues; and (2) Include recommendations for monitoring and follow-up timeframes.

Based on interview and record reviews, the facility failed to ensure residents have the right to be free from abuse for one (Resident #1) of six residents reviewed for abuse and neglect. The facility failed to: Failed to identify and Protect Resident #1 from physical and psychosocial abuse on 08/18/21, specifically feelings of humiliation, embarrassment, anger, physical bruising and pain to both her knees when the Former Administrator asked Resident #1 to reenact how Resident #1 was able to get up independently from a self-reported fall; during the reenactment the Former Administrator spoke in a derogatory and demeaning tone to Resident #1, instructed staff to wait before providing assistance to Resident #1 with help off the floor and onto her bed after a duration of approximately 20 minutes, the Former Administrator also gained knowledge prior to the reenactment that Resident #1 would be physically unable to independently get herself up from the floor without staff assistance. This failure could place residents at risk of abuse, physical harm, pain and mental anguish and emotional distress. Findings Include: Record review of Resident #1's electronic face sheet undated revealed Resident #1 was a [AGE] year old female, readmitted to the facility on [DATE] with an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's electronic physician orders, dated 11/03/21, unsigned, revealed the following orders were active: Acetaminophen tablet 325mg, Administer 2 tablets every four hours as needed for Mild Pain 1-3 .Document level of pain (0-10) and specify scale used to determine pain level . Start Date 02/05/21 End Date .Open Ended PRN Medications . Record review of Resident #1's most recent Quarterly MDS dated [DATE] revealed in Section C that Resident #1 had a BIMS score of 10, which indicated moderate cognitive impairment .Section C1310 indicated that Resident #1 displayed disorganized thinking but that it fluctuated,(comes and goes, changes in severity) .rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) .Section D Mood revealed that Resident #1 indicated she had feelings of being down, depressed or hopeless for several days and felt tired and lethargic for more than 7-11 days during a 14 day look back. Section G revealed Resident #1 required supervision and setup help only to walk in room and required limited assistance by one staff member for toileting. Section J revealed that Resident #1 had not received any PRN pain medication or non-medication interventions for pain and Resident #1 reported occasional pain that limited her day to day activities. Section J indicated that Resident #1 had not had any falls since admission or reentry. Record review of Resident #1's care plan dated 08/13/20 .Resident is at risk for falls r/t requires assistance and unsteady gait; [Resident #1] has had 0 falls in the last 90 days .Goal Long Term Goal: 09/22/20 Resident will have fall risk assessment score of 16 maintain or decrease, will have 2 or fewer falls and be free from significant injury through next quarter .Approach .assistive devices as needed .walker .call bell in reach .document resident participation and staff assistance as per policy .Provide ADL assistance as needed to complete task Problem: Cognitive Loss/Dementia .Goal: Will maintain current level of cognitive function aeb: BIMS of 12 or higher through review date .Approach: promote dignity: Converse with resident and ensure privacy while providing care .observe, document, report to MD prn: Dementia s/sx decision making problem, memory problem, difficulty expressing self or understanding others . Record review of Resident #1's incident report dated 08/18/21 at 4:25pm, entered by RN A, revealed the following: Date and Time of Incident: 08/18/21 at 1:30pm . Description .Fall Describe injury .No injury .Type of Incident: Fall .incident Reported By .Former Nurse Aid A .Location of Occurrence: Resident Room .First Aide Provided, none needed .Other Notifications .Administrator and Physician A Record review of Resident #1's progress notes dated 8/18/21-8/24/21 revealed the following entries: .8/18/21 5:03pm .The nurse aide came to this nurse and reported that this resident stated to him that she fell in the bathroom floor when trying to exit the bathroom. This nurse asked resident about the incident and the resident stated that her roommate was trying to enter the room, quickly and that is when she fell in the bathroom. This nurse assessed resident. No injuries noted. All applicable parties have been notified. Neuro checks started . e-Signed by [RN A] .8/19/21 at 12:32am .Day 1 f/u fall with neuro checks WNL, No delayed injury noted .e-Signed by [RN B] .8/19/21 at 12:47pm .Resident c/o knee pain, upon assessment noted some swelling and discoloration to right knee [Physician A] here, received new order for right knee x-ray, ordered with [mobile x-ray company]. E-signed [LVN A] .8/19/21 at 10:08pm V/S WNL, Resident complains of pain on Bilateral knees. Some bruising noted to knees .e-Signed [LVN B] .8/21/21 at 10:25pm V/S WNL Resident continues to complain of pain on Bilateral Knees, bruising noted, dark purple in the center with edges fading yellow, noted to knees .e-Signed by [LVN B] .8/22/21 7:18am .Noted 2 small bruises to right lower knee, 1 small bruise to lower left knee, C/O Pain 4/10, APAP (acetaminophen) x 2 given at this time .e-Signed by [LVN C] . 8/24/21 at 11:41am .Social worker was asked to speak to the resident about a prior incident. Resident told Social Worker that she fell coming out of the bathroom and she got mad at her roommate and told her she shouldn't close the door like that. Resident said she crawled from the bathroom to bed and pulled herself up at the end of the bed to get in her chair. She wanted to report that she had hurt herself, so she went down to tell the [Former Administrator] but she said [Former Administrator] did not believe her. [Former Administrator] did not believe that the resident had crawled and gotten up on her own, so the resident said that [Former Administrator] took her to a room that looked like hers and made her get on the floor and crawl in the same directions as the way she had done it before, and told [Resident #1] that was the only thing that would convince her she was telling the truth. The resident told the social worker that she got on the floor and crawled some, but it really hurt her knees because she had already done it and they were sore, so she couldn't go as far as the bed. She said she stopped and collapsed and then [Former Administrator] got her in the bed and told [Resident #1] she had proved to her that it did not happen that way. [Resident #1] said she didn't tell anyone at first, but then [LVN A] told her two people had reported that she had been made to crawl. [LVN A gave her an 800# to call and said she had also called to report it .E-Signed by [Social Worker]. Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Order: pain evaluation every shift. Document level of Pain (0-10) and specify scale to determine pain level .every shift .8/9/21 from 10:00 pm - 6:00am Resident #1 had a pain level of 4/10; on 8/13/21 from 2:00pm - 10:00pm, Resident #1 had a pain level of 3/10; from 8/14/21-8/18/21 Resident #1's pain evaluation was documented as a zero, indicating, no pain. On 8/18/21 from 6:00am-2:00pm Resident #1 reported pain 6/10, 8/19/21 during both the 6am-2pm and 2pm-10pm shift Resident #1 had a pain scale of 3/10 documented; 8/20/21 shifts 6am-2pm and 10pm-6am documented a 2/10 pain scale; 8/21/21 all shifts reported 4-5/10 on the pain scale; 8/22/21 all shifts reported 2-3/10; 8/23/21 all shifts reported 3/10 on the pain scale, 8/24/21 6am-2pm and 2pm-10pm reported 3-4/10 on the pain scale; 8/25/21 6am-2pm and 2pm-10pm reported 2/10 on the pain scale; From 8/26/21-8/31/21 Resident #1 did not have any documentation of pain. On 8/22/21 Resident #1 received Acetaminophen tablet; 325mg 2 tablets as needed for mild pain on two occasions. Record review of the PRN Medication Notes for Resident #1 revealed the following: .Date: 8/22/21 0915 .Reason: Bilateral knee pain .Result: effective .Date 8/22/21 2300 (11:00pm) .Reason: Bilateral Knee pain .Result: effective . Record review of Resident #1's Portable Service Requisition for a x-ray to right knee for Pain in right knee dated 08/19/21 at 1516 (3:16pm) revealed the following: .Date of Service: 8/19/21 .Referring Physician: Physician A .Procedure .Right Knee 1-2 views, Findings: See Impressions .Impressions: Examination Radiographs of the knee Indication: Pain .Findings: .There is no evidence of periprosthetic fracture or knee dislocation. Surrounding soft tissues are within normal limits. No evidence of [CONDITION(S)] .Impression: Normal knee arthroplasty . In an observation and interview on 11/01/21 at 1:25pm, Resident #1 was calm, resting on her bed, smiling at times throughout the interview and was oriented to her name, place but she did not know the year or the name of the current president. Resident #1 said that she recalled the incident when the Former Administrator came into her room after Resident #1 had reported that while attempting to come out of her bathroom, her roommate was attempting to enter into the room, both the entry door and bathroom doors collided and Resident #1 reported that the bathroom door came back on her and made her lose her balance and fall to the floor. Resident #1 said that she reported to nursing staff (could not recall staff name) that she had fallen but was able to get herself up. Resident #1 said that shortly after she reported that she had fallen to the nursing staff, the Former Administrator came to her room with several staff members and that she was asked by the Administrator what happened. Resident #1 said that she did not realize what was going on and was assisted by staff back onto the floor; Resident #1 said she started to crawl like she did and after she went as far as I could, I told the Former Administrator My knees are killing me! I can't do it anymore, my knees hurt! Resident #1 said it hurt it hurt a lot. Resident #1 said the next day she could not go to therapy because her knees hurt and were very sore. Resident #1 recalled the former administrator telling me I was lying and that was her way of proving it. Resident #1 said that the Former Administrator did not believe that she had fallen and was able to get herself up. Resident #1 said that it made her feel ridiculous and embarrassed and she had pain, swelling and bruising for almost a week. Resident #1 said that the Administrator attempted to come to her room the next day but she refused to speak with her and was fearful of her. Resident #1 stated that after that day, she never saw the Former Administrator again and since she has not been in the building she felt safe now. In an interview on 11/1/21 at 1:40pm the Occupational Therapy Aid said that he recalled the incident with Resident #1. The Occupational Therapy Aid said that he recalled the Former Administrator coming into the therapy room after the incident with Resident #1 and was speaking to the Physical Therapist in a boastful manner and recalled the Former Administrator telling the Physical Therapist that she was proud of herself because she found out that Resident #1 was lying, and told staff that her roommate had pushed her on the floor. The Occupation Therapy Aid said that the Former Administrator then proceeded to tell the Physical Therapist that she didn't believe Resident #1 so RN A assisted Resident #1 to the floor and had her reenact how she got herself up, but was not able to get herself up, staff had to help her back up. Then, the Occupational Therapy Aid said that he recalled Resident #1 reporting to him that very same day that she did not want to participate in therapy because she was in pain from being left on the floor for about thirty minutes, the Occupational Therapy aid said that Resident #1 said she was asked to try and try to get up by the Former Administrator and couldn't do it. The Occupational Therapy Aid said that he discussed with his management team and it was already being discussed with other interdisciplinary team members that the Former Administrator was being reported to corporate. The Occupational Therapist Aid said that he was contracted by another company and followed their protocol as well to report the incident. In an interview on 11/1/21 at 2:50pm, the Social Worker said she did recall the incident with the Former Administrator and Resident #1. The Social Worker said that the Corporate Administrator called her and asked her to come and visit Resident #1 as soon as possible to discuss an incident that occurred between her and the Former Administrator. The Social Worker said that Resident #1 was able to recall the incident but on the day, she interviewed her (8/24/21) she did not appear particularly upset but understood she was when it first happened (8/18/21). The Social Worker said that Resident #1 was not sure and didn't understand why it happened. The Social Worker said that after she learned of the incident she did not feel that resident's should ever be treated that way, the Social Worker indicated that residents are often confused and will be wrong at how something happened many times and that the Former Administrator should not have tried to prove that Resident #1 was wrong by doing what she did, making her get on the floor; the Social Worker said it was both physically and emotionally abusive, [Resident #1] is an elderly person and if you make someone get on the floor it could hurt them even more, [Resident #1] indicated that she felt safe in the facility since the [Former Administrator] was no longer in the facility. In a telephone interview on 11/2/21 at 8:34am, Nurse Aid A said that he recalled the incident with Resident #1 and the Former Administrator. Nurse Aid A said that he recalled the Former Administrator coming out in the hallway and asking him and another staff member to come to Resident #1's room. Nurse Aid A said that he and CNA A walked in and found Resident #1 on the floor in the bathroom, RN A was standing behind Resident #1 and the Former Administrator was standing over Resident #1 with her arms folded looking down at her. Nurse Aid A said that Resident #1 was visibly upset appeared angry and distraught. Nurse Aid A said the Former Administrator was talking down to Resident #1 in a harsh tone, Nurse Aid A said he did not recall exactly what she said but recalled she was telling her to show her how she got herself up. Nurse Aid A said that at this time he and CNA A attempted to get Resident #1 off the floor and was told to wait, not to pick her up, the former administrator wanted Resident #1 to show her how she got up. Nurse Aid A said that he recalled being in the room for at least 20 minutes, perhaps even more with Resident #1 being on the floor. Nurse Aid A said he felt that what was happening was not right but he wasn't sure what to do since the former Administrator was in the room, Nurse Aid A said he did not feel that he had a choice to intervene since the Former Administrator was in the room. Nurse Aid A said that after approximately twenty minutes, the Former Administrator asked us to assist Resident #1 from the floor and we placed her in bed . Nurse Aid A said that during his shift Resident #1 did not report any pain or injury to him. Nurse Aid A said after the incident Resident #1's demeanor really changed, at first she seemed ashamed and embarrassed about the incident then she seemed angrier; lasted for a few weeks. Nurse Aid A said that Resident #1 normally did not participate in activities and pretty much stayed in her room. In a telephone interview on 11/2/21 at 9:15am, Physician A recalled being notified while in the facility of Resident #1 having Right Knee Pain and ordered an x-ray for her; was not aware that the Former Administrator asked Resident #1 to reenact a fall by having Resident #1 get back on the floor and show the Former Administrator she could get up herself. Physician A said that it was not necessary to have a resident reenact a fall unless it would be something the physical therapy was trying to assess for therapy purposes, Physician A said that there certainly should have been questions to have asked after a reported fall from a resident. Physician A said that he was not contacted to his knowledge by any Regional Staff from the facility regarding the possibility of an abuse investigation. Physician A said that it would not have been comfortable for Resident #1 to have been asked to reenact and certainly would have been mentally stressful for her to reenact. In a telephone interview on 11/2/21 at 9:45am, the Former Administrator said she recalled the incident with Resident #1. The Former Administrator said that she was notified by RN A that Resident #1 reported that she fell and got herself up on her own. The Former Administrator said she went to the nurse's station and asked RN A to come to Resident #1's room to discuss her fall. The Former Administrator said she was in the room talking with Resident #1 and asked her how that happened. The Former Administrator said that Resident #1 got up out of the bed, walked to the bathroom and told her that [Resident #1's] roommate just plowed into the door and knocked her down. The Former Administrator said that when I asked her if she could tell me how she fell Resident #1 replied In order to do that I would have to show you The former Administrator said she asked Resident #1 if she minded showing us and Resident #1 said no and at that time RN A lowered Resident #1 to the floor; the Former Administrator said Resident #1 then explained and tried to grab the over the toilet seat and the Former Administrator said at that time RN A and myself tried to tell Resident #1 we would help her up but Resident #1 told her No, I can do it and after a few minutes she was helped from the floor. The Former Administrator said that two CNAs assisted Resident #1 up off the floor. Former Nurse Aid A and CNA A were the two staff members that assisted Resident #1 up from floor and back to her bed. The Former Administrator then stated that she asked Resident #1 if she was hurting anywhere and she denied pain. The Former Administrator stated that Resident #1 was in the floor for approximately 2-3 minutes and that she was consistently asking her to get up but Resident #1 kept replying No, I can do it, No, I can do it. The Former administrator said that she tried to get up in front of the toilet. The Former Administrator could not recall where she was in the floor when she was assisted up by staff. The Former Administrator said that it was not a normal process that she was aware of for a resident to be asked to get in the floor to show staff how they got themselves up after a fall. The Former Administrator said that therapy has at times asked residents to reenact a fall. The Former Administrator said she was pretty sure therapy was not present in Resident #1's room. The Former Administrator said the purpose of Resident #1 reenacting how she was able to get herself up after she reported she fell was that the Former Administrator wanted to make sure that if she was falling she was actually getting up and stated I just needed a picture in my head. The Former Administrator said that Resident #1 displayed attention seeking behaviors and did not like having a roommate. The Former Administrator denied telling Resident #1 to remain on the floor after Nurse Aid A and CNA A attempted to get her up. The Former Administrator said that looking back at it now she should not have allowed Resident #1 to have gotten in the floor to show her how she got herself up because it was upsetting for her. The Former Administrator said that it was a normal process to be notified when someone falls to ensure there was no injury or if there were any resident to resident issues that needed to be investigated and reported. The Former Administrator said that she had never had any other residents reenact how they fell or got themselves up, normally just take an interview and document what the resident reports. The Former Administrator said the purpose of Resident #1 getting on the floor was to know if it was actually happening, needed to see if she needed any interventions or if she could reach her call light. The Former Administrator said it was necessary for her [resident #1] to reenact how she was getting up in order to provide education for her, make sure she had shoes on when she goes to the bathroom, and to make sure the facility provided a safe environment for her. The Former Administrator said that she did not know if Resident #1 could have just been asked to describe the incident verses getting on the floor to show her because Resident #1 tells different stories to different people. The Former Administrator said she didn't know when Resident #1 said she fell but that it was not something the Former Administrator was trying to prove Resident #1 was lying about. The Former Administrator said that the next day LVN A reported that Resident #1 was upset over the incident that had happened and I went in to talk to Resident #1 with LVN A present, Resident #1 did not want to talk to me. By that time, Regional Staff were involved due to staff reporting the incident to the Regional Nurse and I was suspended pending the outcome of the investigation, I asked staff to write statements of the incident. The Former Administrator said that she typed Nurse Aid A's statement because his handwriting was horrible, and that Nurse Aid A signed it and did not indicate it was incorrect. The Former Administrator said that the Corporate Administrator became involved because they felt it was reportable and were going to conduct an investigation. The Former Administrator said that she had no knowledge of Resident #1 being upset after the incident until the next day, she reported to LVN A and I took a grievance form in her room but she was upset about how I talked to her when she reported falling. The Former Administrator said she did not know why she was upset; she wouldn't talk to her. I called the Corporate Administrator and explained the situation, was told by the Corporate Administrator it was not okay for me to have asked her to get on the floor. The Former Administrator denied talking about the incident outside on the patio to other staff members on 8/18/21 and the Former Administrator said she did not remember if she spoke to the physical therapist the morning of 8/19/21 regarding the incident. In an interview on 11/02/21 at 10:47am, RN A said that she was asked to go to Resident #1's room with the Former Administrator on 08/18/21 to discuss Resident #1's fall that she had reported. RN A said that her and the Former Administrator went in to talk to Resident #1 and the Former Administrator seemed adamant about having Resident #1 show her what happened when she [Resident #1] fell . RN A said that Resident #1 walked the Former Administrator through how she fell by getting up from her bed and going into the bathroom, at this time RN A said that the Former Administrator asked Resident #1 how she got up from the floor and Resident #1 said she needed to get on the floor to show her and proceeded to get down into the floor. RN A said that she told Resident #1 she did not have to get in the floor to show the Former Administrator but by this time Resident #1 was insistent about showing the Former Administrator. RN A said that she did assist Resident #1 onto the floor and kept telling her she didn't have to do this. RN A said the Former Administrator was standing over Resident #1 and seemed herself very adamant about having Resident #1 demonstrate how she was able to get herself up from the floor. The whole thing just didn't seem right RN A said. RN A said that Resident #1 was unable to pull herself up in the bathroom and then proceeded to pull herself across the room towards her bed, RN A said that the Former Administrator called two CNAs into the room and asked both of them CNA A and former Nurse Aid A if they had answered Resident #1's call light earlier, at that time. RN A said that she did not recall if the Former Administrator instructed the aides to not assist Resident #1 up, but do recall Resident #1 seemed angered and kept trying to prove to the Former Administrator how she got up and after a period of time, RN A could not recall how long but it seemed like a while Resident #1 was assisted up by CNA A and Former Nurse Aid A to her bed. RN A recalled the Former Administrator asking Resident #1 How could you possibly have gotten up on your own? .she kept repetitively insinuating she couldn't so it. RN A said Resident #1 was upset during the incident and felt that Resident #1 wanted to prove the Former Administrator wrong. RN A said that she didn't agree with what Resident #1 was doing and offered several times to Resident #1 that she didn't have to do this. RN A said looking back now, she should have intervened and told the Former Administrator to stop and not have allowed Resident #1 to get on the floor but at the time RN A said she felt that if she didn't help Resident #1 she would try and do it again without staff being present just to prove she could do it. RN A said she did not recall Resident #1 suffering any injuries after the incident and did evaluate her when she reported that she fell and there were no injuries. RN A said she was suspended the next day following an investigation regarding the incident, was asked to write a statement and that was all she recalled after the incident. RN A said it was not a normal process for the Former Administrator to go into residents' rooms and ask them to reenact falls or how they got up from a fall. RN A said that having Resident #1 get on the floor did not change any interventions for her safety. In an interview on 11/2/21 at 11:45am, Resident #1's responsible party recalled being notified of the incident and stated that Resident #1 seemed angry about what the Former Administrator had made her do and recalled her having bruising to her knees. The Responsible Party of Resident #1 said she visited weekly and did not feel that Resident #1 suffered long term effects from the incident but knew she was pretty upset when it happened. In an interview on 11/02/21 at 1:15pm, Resident #1 said that she normally did not participate in activities too much other than attending church services occasionally; Resident #1 said that after the incident she was asked by staff if she wanted the police to be contacted and she told them no. Resident #1 said that she did not feel that she needed psychiatric services after the incident either. Resident #1 reported that since the facility terminated the Administrator she felt safe in the facility and has not had any problems with staff or treatment since the incident. In an interview on 11/02/21 at 1:18pm, CNA B said she recalled the day of the incident between Resident #1 and the Former Administrator, however the only participation she had was prior to the incident, Resident #1 had reported to her that Resident #1's roommate slammed the door into the bathroom door as Resident #1 was coming out of the bathroom and that she did not report a fall but wanted someone to talk to her roommate about opening the doors abruptly. CNA B said it was at the end of her shift and she reported to former Nurse Aid A as he was coming on shift about Resident #1's concern and he agreed he would talk to Resident #1's roommate. CNA B said about 5:00pm that same day after she was already home she received a phone call from the Former Administrator asking her if Resident #1 had reported a fall and I told them no. The following day I came to work at 6:00am and was told by a staff member from the therapy department (unable to recall the name) that Resident #1 wanted to talk to me. CNA B said that Resident #1 confided to her that the Former Administrator had put her on the floor and made her reenact the fall CNA B said Resident #1 at this time reported pain to her knees so CNA B said she went immediately and reported to the nurse what Resident #1 had reported. CNA B said that again later that day after she was off she received a phone call from the Former Administrator telling her that Resident #1 had wanted to get back on the ground to show her how [Resident #1] got herself up off the floor. CNA B said that the nurse that she reported Resident #1's pain and incident to no longer worked at the facility. CNA B said that after the incident Resident #1 told her the incident upset her and embarrassed her when they made her get on the floor like that and CNA B said Resident #1 seemed angry, she stayed in her room more right after the incident and would tell therapy she had a headache but after about a week, she seemed to be herself again. CNA B said that she did have bruising to her knees and increased pain after the incident. In an interview on 11/2/21 at 2:00pm, the Corporate Administrator said that she recalled the incident between Resident #1 and the Former Administrator. The Corporate Administrator said that both her and the Regional Nurse became aware of the situation by facility staff on 08/19/21 and immediately started an investigation and suspended the Former Administrator and RN A. The Former Administrator had already begun an investigation after multiple staff from the facility had contacted both the Regional Nurse and herself. The Corporate Administrator requested written statements from staff due to becoming apprised of Resident #1 reporting she was upset with the Former Administrator. The Corporate Administrator said that after the investigation was conducted she felt that the Former Administrator had lied about what transpired between her and Resident #1 and that she felt the Former Administrator had lied about the incident, specifically that Resident #1 was agreeable to get in the floor and reenact how she got herself up after reporting she fell . The Corporate Administrator said she spoke with RN A and that RN A felt that the Former Administrator had been very inappropriate with Resident #1. The Corporate Administrator said that it was learned that Resident #1 did agree to get on the floor but did not anticipate having to remain in the floor for approximately 20-30 minutes. The Corporate Administrator felt that the Former Administrator had caused both physical and psychosocial harm to Resident #1 as evidenced by Resident #1 having bruising and pain to her knees following the incident and reporting being emotionally upset by the way the Former Administrator had made her feel and the way she talked to her during the incident. Resident #1 was fearful of the Former Administrator after the incident and it was immediately determined that she was terminated on 08/20/21 and the incident was self-reported immediately to the state agency. The Corporate Administrator said that the Social Worker was asked to come and evaluate Resident #1 and safe surveys were conducted with other alert and oriented residents. The Regional Nurse conducted an abuse/neglect in-service on 08/20/21 for all staff after the incident and that Resident #1 did report feeling safe in the facility after knowing that the Former Administrator would no longer be working there. The Corporate Administrator said that Resident #1 did not want to contact the police. The Corporate Administrator said that several staff members were reporting to the corporate nurse and herself during the investigation that the Former Administrator was heard bragging about what she had made Resident #1 do and the fact that she proved her wrong and caught her in a lie. The Corporate Administrator said something like this should never have happened and that if the Former Administrator wanted to prove someth [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance necessary to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents. On 12/21/18 CNA A failed to ensure the area around Resident #1's geriatric (geri) chair was clear of environmental hazards prior to lowering the footrest of the geri chair. While the footrest of her geri chair was being lowered Resident #1's left leg hit the corner of a broken trash receptacle resulting in a laceration to Resident #1's left calf that required fourteen (14) staples. This failure resulted in actual harm to Resident #1 on 12/21/18. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could put residents at risk of accidents, exposure to hazards and serious injuries which could result in a reduced quality of life. Findings included: Review of Resident #1's face sheet dated 12/28/2016 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's fourteen-day (14) Minimum Data Set (MDS) assessment, dated 12/22/18, revealed Resident #1 was unable to participate in the Brief Interview for Mental Status (BIMS) interview which indicated she had severe cognitive impairment. Resident #1 was totally dependent on two people and a Hoyer Lift for transfers. She required extensive assistance of two people for bed mobility, dressing and toileting. Resident #1 was dependent one person for locomotion on and off the unit. Review of Resident #1's care plan dated 01/09/19 indicated Resident #1 had sustained a laceration to her left lateral lower leg when her leg hit the corner of a trash receptacle while the leg/footrest on her Geri-chair was being lowered. Goals: Laceration to left lateral lower leg will show measurable decrease in size, no redness, warmth, [MEDICAL CONDITION], or signs/symptoms of infection through review date. (3/18/19). Resident #1 will have no further complications/injury related to environmental factors through review date. Approach: Housekeeping to replace trash receptacle and inspect periodically for cracks/damage. Staff was in-serviced on Geri-chair leg/foot rest chair safety and on inspecting environmental factors before providing care (12/21/18). Staff was also in-serviced on Hoyer Lift transfers (12/23/18). Trash can receptacles are to be placed against wall away from the bed. Review of Resident #1's care plan dated 10/01/18 indicated Resident #1 required a geri chair due to her poor trunk control as evidenced by fall from sliding out of the wheelchair. Geri chair does not impede movement, nor does it prevent access to oneself. Goals: Resident #1 will be free from injury related to fall and will benefit from staff assisted mobility through review date (01/01/19). Approach: A staff member will provide assistance with mobility in geri-chair. Staff will notify physicians and family of any dramatic change in condition, review date 10/01/18. Record review of Resident #1's Nurses Notes dated 12/21/18 at 1:40 p.m. by LVN A she documented that CNA A called her to Resident #1's room. Resident #1 had a large laceration to her left lower extremity (LLE). CNA A assisted LVN A with transferring Resident #1 from the Geri-chair to the bed. LVN A assessed Resident #1's laceration and provided first aide. She applied pressure to the laceration with 4 x 4's (gauze pads) to minimize the bleeding. LVN A called for assistance from LVN B. LVN B folded the skin flap from the laceration back in place with 4 x 4's and wrapped the wound with cling wrap. LVA A contacted the Primary Care Physician (PCP) and obtained an order to send Resident #1 to the emergency room (ER) for evaluation and treatment .CNA A reported while lowering the leg/footrest of Resident #1's Geri-chair Resident #1 bumped the top of the trash can causing a laceration to Resident #1's LLE. On 2:55 p.m. Resident #1 was transferred to theER on stretcher for injury to her LLE. Record review of an Event Report dated 12/21/18 at 2:29 p.m. and written by LVN A revealed the following: * Description: Resident #1 cut her left lower extremity on side of trash can while foot of Geri-chair was being lowered. * Physical Observation: Laceration * Depth of laceration: Deep * Blood Loss: Moderate amount * Wound edges: Irregular * How does resident rate intensity of pain, from scale of 0-10: six (6) * Activity during occurrence: Foot of chair being lowered. * Iterventions: First aid, Pressure bandage * Orders: Treatment; cleanse LLE with wound cleanser, apply Triple Antibiotic Ointment (TAO) and non-adhesive pad twice daily (BID) * Evaluation: No signs or symptoms of infection noted, laceration is healing well. No drainage noted. Scabbing on incision noted. PCP made visit to follow up on laceration. Will continue to monitor. Record review of Nurses Notes dated 12/21/12 at 7:20 p.m. by LVN C revealed she documented Resident #1 returned to the facility via nursing home van and staff member. Report from the ER nurse was Resident #1 was treated with staples and steri-strips. Orders received from the ER physician was to keep Resident #1's wound to her LLE clean and dry and no washing for at least 24 hours. She was also to follow-up with her PCP for wound care as soon as possible. During an interview on 01/09/19 at 1:35 p.m. the Administrator said that Resident #1 was reclined in a Bariatric Geri-chair, and when CNA A went to lower the leg/foot rest it came down on top of the trash can. He stated the leg/foot rest came down with such a force that it caused the trash can to crack and left a serrated edge on the lip of the trash can, almost like a knife blade, and gouged the resident's leg. The Administrator stated Resident #1 sustained a large laceration to her left lower leg. He said that CNA A just didn't see the trash can. The Administrator said that he had not been able to determine if the trash can had been broken previously or it happened the day of the incident. He said that they immediately examined the trash cans in all the resident rooms and the offices to ensure there were no others that were broken or defective in a way that could cause injury. He said they did identify a couple of trash cans they felt needed to be thrown away. During an interview on 01/09/19 at 1:45 p.m. CNA A said she was present when the incident involving Resident #1 occurred 12/21/18. She said Resident #1was sitting in the reclining position in her Bariatric Geri-chair with her feet elevated. CNA A said that she was going to put Resident #1 back to bed before her shift was over. She said that when lowered the leg/foot rest of the Geri-chair it went down forcefully, and Resident #1's left lower extremity (LLE) hit the top of the trash can which caused a pretty deep laceration to the resident's leg. CNA A said that the trash can was the standard trash can that was in every resident's room. She said she had noticed about a month ago that the trash had a piece missing out of the lip of the can. CNA A she noticed the trash can was broken when housekeeping forgot to put a trash liner in the can. She said she thought the trash can was broken when Resident #1's bed was lowered onto it, but she was not positive. CNA A said she could not remember if she had reported the broken trash can to anyone, but did remember she did not put it in the maintenance log where they write down anything that needs repair. She said there was another CNA who had seen the broken trashcan. CNA A said the accident could have been avoided if she had looked around the Geri-chair to make sure everything was out of the way. She said the trashcan should have been removed. CNA A said that Resident #1's Geri-chair is taller and wider than the other resident's Geri-chairs because it was a bariatric Geri-chair, and that she could not see over the top of the chair very well. CNA A said she lowered the footrest of the chair by using her foot to push on the bar located at the back of the chair used for lowering the leg/foot rest. CNA A said again the leg/foot rest came down forcefully, hitting the trash can, and that she did not see that the trash can was in the way of lowering the leg/foot rest. During an interview on 01/09/19 at 2:05 p.m. LVN A said on 12/21/18 CNA A reported to her that Resident #1 sustained a large gash to her lower left leg while the CNA was lowering the leg/footrest on Resident #1's Geri-chair . LVN A said CNA A reported the leg/foot rest of the Geri-chair hit the resident's trashcan which caused the large gash to the resident's leg. LVN A said it really laid her leg open. LVN A said that she cleansed the laceration with wound cleanser and she used gauze pads to put the flap of skin that was hanging down from the wound back in place, and then she covered the wound with gauze pads and placed cling dressing around the wound to apply pressure to stop the bleeding. LVN A said she called 911 and Resident #1 was sent to the emergency room (ER). She said that the force of the leg/foot rest from the Geri-chair coming down on the top of that trash can probably caused it to break. She said that the laceration looked like it came from the corner of the trashcan and was in a triangle pattern. LVN A said that she did not recall seeing the trash can being broken until the after the incident. LVN A said that the trash cans always have liners in them, so she might not have noticed if the trash can was cracked or had a piece missing out of the side. LVN A said that the incident could have been avoided if the CNA had been more alert of the surrounding's and been more careful. She said that it was really a tight squeeze in that room. LVN A said the room contained both resident's beds, a recliner, an oxygen concentrator and Resident #1's large bariatric Geri-chair. She said that the facility staff was in-serviced the day of the incident on being more aware of the surroundings during care. She said that after Resident #1 returned to the facility the wound started to look a little angry and was warm to touch. LVN A said Resident #1 was sent to the ER, and the resident was in the hospital a couple of days to receive Intravenous antibiotic (IV) antibiotics. During an interview on 01/09/19 at 2:30 p.m. the Housekeeping Supervisor said he was told the footrest on Resident #1's Geri-chair come into contact with the top of the trashcan and it cracked and broke a piece out of the top of the trashcan which then caused a laceration to Resident #1's LLE. He said after the incident that the trashcan had about a six (6) inch diagonal crack in it and there was a piece missing out of the top. He said that he changed out that trash can immediately, and that they looked in all the resident's rooms and the offices to make sure there were no other trashcans that were broken. He said that he now checks the trash cans once a month. The Housekeeping Supervisor said staff were supposed to write down in the Maintenance Log any issues they found that needed repair or replacement. He said that he did not recall anyone telling him Resident #1's trash can needed to be replaced. He said that it was not written on any of his log sheets. He said the facility had an in-service the same day (12/21/18) regarding removing/replacing any items that would be an environmental hazard for the residents. Observation and interview with CNA A on 01/10/19 at 9:55 a.m. revealed the following: CNA A recreated the incident involving Resident #1 that occurred on 12/21/18 using Resident #1's geri chair and a trash can identical to the one that injured Resident #1. The geri chair was observed to be a large, high back, padded chair on wheels that could be placed into several different positions, including a padded rest that started at the seat of the chair and extended for users to rest their legs and feet on. CNA A demonstrated how she went around to the back of the geri chair to lower the leg/foot rest. She demonstrated that due to the height and the width of the chair she was unable to see the parameters around or over the top of the Geri-chair. At the back of the chair she demonstrated how she had to use her foot to manually release the locking bar, located at the bottom of the chair, which enabled the leg/footrest to go down. CNA A said that because of the resident's weight (233 lbs.) and her body shape, Resident #1 would slide down in the Geri-chair and position her left leg so the lower part of her leg laid more directly on the foot rest. CNA A was observed released the locking bar for the footrest on the Geri-chair. The footrest made a loud popping sound and came down quickly and forcefully. CNA A stated this was what happened on 12/21/18. She stated the footrest of the geri chair hit the top of the trashcan causing the left lower leg to slide over towards the left side of the footrest, and because of the force and position of the resident's legs the broken trashcan hit Resident #1's left lower leg and caused a deep laceration. During an interview on 01/10/19 at 11:00 a.m. CNA B said Resident #1's trash can had been broken for approximately 4-6 weeks, and that she noticed it when she removed the liner to take out the trash. She said the trash can had piece broken from the lip of the can. CNA B said she did not write it down in the Maintenance Log, Observation on 01/10/19 at 10:50 a.m. of Resident #1's LLE revealed a laceration in the shape of a triangle that had 7 staples intact on both sides of the wound for a total of 14 staples. The wound was clean, dry and intact. There were no observable signs of infection noted. Resident #1's trash can was observed to be sitting against the wall across the room with a clear plastic liner. Record review of the Facility Maintenance Log for the last six months did not reveal any entry regarding the resident's trash cans. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Record review of in-service dated 12/21/18 revealed the following: Geri-chair safety for residents and staff: When assisting a resident that has a Geri-chair ensure you have a clear pathway around all sides of the Geri-chair before lifting, or lowering the leg/foot rest for resident and staff safety. * Ensure the back wheels of the Geri-chair are in locked position before trying to transfer or reposition resident for safety. * Make sure the resident's arms and legs are inside the Geri-chair before transporting resident for safety. * Always have enough staff assistance when transferring resident to and from Geri-chair for resident and staff safety. * Immediately report any broken or defective equipment to Maintenance and DON. * If you have any questions or concerns about assisting a resident that has a Geri-chair, contact Therapy Department or the DON/ADON for additional training. Review of in-service dated 12/23/18 attended by all staff revealed the following: * CNA staff educated about safety and environment checks during transfers. Staff to do a complete walk around to check objects around patient and transferring area. * Staff to check resident's arms and legs before transfer, make sure chairs are locked, Geri-chairs are lowered slowly and controlled. Separate interviews were conducted with staff regarding the content of the in-services they had received regarding this incident. The following staff were interviewed: The Administrator on 01/09/19 at 1:35 p.m., CNA A on 01/09/19 at 1:45 p.m., LVN A on 01/09/19 at 2:05 p.m., the Housekeeping Supervisor on 01/09/19 at 2:30 p.m., Housekeeper A on 01/09/19 at 3:00 p.m. and CNA B on 10/12/18 at 3:15 p.m. Each staff member was able to correctly identify the process for safety and environment checks during transfers, to include a walk around to check objects around the resident and transferring area and to lower the footrest on the geri-chairs slowly and controlled. Observation's throughout this investigation from 01/09/19 through 01/10/19 on Halls One, Two and Three revealed there were no broken or defective trash cans in any of the resident's rooms. Trash cans were observed to be sitting in different areas of the rooms. Some were at resident bedside, others were under their rolling overbed tables, while others were sitting across the room. Resident #1's trash can was observed across the room against the wall away from the bedside.

Based on observations, interviews, and record review the facility failed, based on a comprehensive assessment, to ensure 1of 1 residents (Resident #1) reviewed for enteral nutrition, received the appropriate care and services to prevent complications of enteral feedings. The facility changed the schedule of Resident #1's [DEVICE] feedings established by hospital A that alternated his feedings with water and as a result Resident #1 began receiving feedings and water at the same time which increased the volume of fluid he received at one time; facility failed to consistently position the head of Resident #1's bed at an appropriate level to decrease the risk of aspiration before, during and after his feedings; failed to clarify physician's orders [REDACTED]. As a result, Resident #1 was admitted to the hospital on [DATE]; discharged on [DATE] with a [DIAGNOSES REDACTED]. This deficient practice resulted in an Immediate Jeopardy (IJ) on 6/8/18. While the IJ was lowered on 6/12/18 the facility remained out of compliance at a level of Actual Harm that was not IJ and a scope of isolated due to the facility continued to monitor the effectiveness of the Plan of Removal. This failure affected Resident #1's quality of life and placed him at risk for life-threatening complications and possible death due to aspirating his [DEVICE] feedings and secretions that resulted in his inability to breathe effectively to ensure appropriate oxygen saturation. Findings Included: Review of Resident #1's electronic Face Sheet printed on 6/8/17 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1's admission MDS (Minimum Data Set) dated 5/24/18 revealed he had a BIMS (Brief Interview for Mental Status) score of 1 which indicated his cognitive function was severely impaired. He required extensive assistance with his ADLs (Activities of Daily Living). The assessment indicated he had a feeding tube and that he received 51% or more of his total calories through the feeding tube and his average daily intake of fluid through the feeding tube was 501 cc (cubic centimeters) or more per day. Documented [DIAGNOSES REDACTED]. Review of Resident #1's Hospital Records from Hospital A revealed a Progress Note dated 5/15/18. Documentation on the progress note revealed: Impression: .[MEDICAL CONDITION] dysphagia secondary to progressive dementia, with inability to eat safely because of aspiration risk, status [REDACTED]. status [REDACTED]. Review of Resident #1's discharge MEDICATION ORDERS FOR [REDACTED] [MEDICATION NAME] 1.5 gastrostomy tube/PEG. Volume 237 ml/feed rate; bolus .start 5/8/18 9:00 a.m. every 4 hours (1, 5, 9 21) (1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m.) .last dose given 5/17/18 at 8:55 a.m. Continue medication: yes Water 200 ml, per feeding tube every 6 hours, first dose 5/9/18 at 12:00 p.m., last dose given 5//17/18 at 6:12 a.m. Continue medication: yes Review of Resident #1's care plan last reviewed on 5/23/18 revealed: Problem Start Date: 5/18/18. Category: Feeding Tube. (Resident #1's name) has a feeding tube due to [MEDICAL CONDITION] Dysphagia and severe protein-calorie malnutrition prior to admission .Long Term Goal Target Date: 8/15/18 (Resident #1's name) will receive prescribed nutrition through review date. Approach Start Date: 5/23/18. Nurse will administer prescribed [MEDICATION NAME] 1.5 cal (calorie) 237 ml (milliliters) (1 can) every 4 hours with 200 ml (200 ml substance/fluid was not identified) every 6 hours via feeding tube. Problem Start Date: 5/21/18. Category Feeding Tube. (Resident #1's name) is at risk for abdominal complications and possible nutritional inadequacy due to having pulled out his feeding tube more than twice while abdominal binder was in place, resulting in having to go to emergency room for tube replacement. Long Term Goal Target Date: 8/15/18. (Resident #1's name) will receive adequate nutrition and not experience internal injury related to pulling out of tube through review date. Approach Start Date: 5/23/18. Staff to monitor position of abdominal binder each shift. Staff will check placement prior to administration of any fluids, medications, or nutrition via tube. Staff will ensure abdominal binder is covering feeding tube when tube is not being utilized. Staff will notify physician of any complications with tube. There was no documentation on the care plan that addressed how to position the resident before, during or after the administration of the tube feedings, water, or medications. Review of Resident #1's physician's telephone orders dated 5/17/18 signed by Physician A on 5/24/18 included the following: [MEDICATION NAME] 1.5 per PEG tube 237 ml every four hours (5 a.m., 9 a.m., 1 p.m., 5 p.m. 9 p.m., 1 a.m.) Sterile water 200 ml per peg every 6 hours. The times for the administration of the water (6 a.m., 12 p.m., 6 p.m., 12 p.m.) were marked through and written above those times were the following: 5 a.m., 11 a.m., 5 p.m., 11 a.m. The space on the order for the signature of the nurse receiving/transcribing the order was blank. In an interview on 6/8/18 at 3:35 p.m. the ADON said she transcribed the 5/17/18 orders from Hospital A onto the physician's telephone orders for Physician A to sign and she changed the timing for the water to coincide with the some of the administrations of the [DEVICE] feedings to make it easier for the nurses to administer. She said she was not aware that Resident #1 was at risk for aspiration when he was admitted . She said she talked to the people at the hospital several times before Resident #1 was transferred to the facility and they told her he was pleasant-all the things to get him here. The ADON said she received no specific training for Resident #1's [DEVICE]. She said the policy and procedure for [DEVICE] feedings was on the front of the MAR (Medications Flow Sheet). The ADON said no one told her Resident #1 was an aspiration risk. In an interview on 6/8/18 at 5:05 p.m. the ADON said when a resident was admitted from the hospital she reviewed the records that came with him or her. She said the resident might come with only a discharge summary and the other records would come later, but she would review the records when they came. She said if the records arrived at the facility after she was gone for the day, she would review them the next day. Review of Resident #1's recapitulated electronic physician's orders [REDACTED]. Diet: Nothing by mouth. Start date for the order was 5/17/18 and the end date was open ended. Flush [DEVICE] with 200 ml (milliliters) of Sterile Water every six hours for [DIAGNOSES REDACTED]. The orders did not include an order for [REDACTED].>Review of Resident #1's Medications Flowsheet dated 5/17/18-5/31/18 revealed documentation that indicated he received both the 237 ml of [MEDICATION NAME] and the 200 ml of sterile water together twice daily at 5:00 a.m. and 5:00 p.m. on 5/18/18, 5/19/18, 5/20/18, 5/22/18, 5/23/18, 5/24/18, 5/25/18, 5/26/18, 5/27/18, and 5/28/18; and he received the [MEDICATION NAME] and water together at 5 a.m. on 5/21/18 and 5/29/18. Documentation on the MAR indicated [REDACTED]. Review of Resident #1's Nurse Progress Notes revealed: 5/29/18 11:18 a.m. resident began coughing up moist clear to white colored sputum, wheezing and rattling noted, 26 respirations per minute, O2 (oxygen) sat (saturation) 88% with O2 at 2L (two liters) via NC (nasal cannula). Resident was suctioned multiple times with no change in respiratory status. EMS was called to transport resident to hospital, son was notified via telephone, PCP notified via telephone .signed by LVN B Review of a Triage Report from Hospital B dated 5/29/18 at 11:48 a.m. revealed: Chief Complaint: Respiratory distress. Patient came from nursing home with reported difficulty breathing. EMS suctioned approximately 50 ml of milk secretions from oral airway, with positive results .signed by ER Nurse Review of a history and physical from Hospital B dated 5/29/18 signed by Physician B revealed: Chief complaint shortness of breath. History of Present Illness: A [AGE] year old gentleman brought in from the nursing home via ambulance to the emergency department with a dyspneic episode. He was hypoxic in the high 80s on arrival and was placed on a facemask at 4 liters and O2 saturations jumped up to 95%. He has had fever and coughing, apparent aspiration at the nursing home .Assessment and Plan: 1. Respiratory distress, [MEDICAL CONDITION]. Continue O2 mask, nonrebreather at 4 liters .CT scan of the lungs did return and it does show [MEDICAL CONDITIONS] with bilateral [MEDICAL CONDITION] infiltrates consistent with pneumonia and aspiration pneumonitis likely .3. The patient has likely dysphagia, difficulty swallowing .Clinical Impression: Workup consistent with healthcare associated pneumonia given fever, cough, and findings on CT scan . In a telephone interview on 6/11/18 at 11:20 a.m. Paramedic B said he received the 911 call on 5/29/18 for Resident #1 in respiratory distress. He said when he arrived at the facility, the head of Resident #1's bed was not at 45 degrees but was at approximately 15-20 degrees and he just had a pillow underneath his back. He said the nurses had been suctioning him and giving breathing treatments. Paramedic B said Resident #1 was gurgling in his upper airway and there was a milky substance in the suction cannister that looked like Ensure. He said the substance did not look like secretions. Paramedic B said once in the ambulance he had Resident #1's head elevated to 90 degrees and he had to do a lot of deep suctioning to clear Resident #1's airway. He said he suctioned 50-60 ml of the milky substance from his airway and said the substance was not phlegm. He said the facility nurse who was in the room was unable to tell him how long Resident #1 had been having difficulty, but she said he had been like this for too long and the staff had worked with him during the night with breathing treatments. Paramedic B said Resident #1 was non-verbal and was unable to cough and had no gag reflex. Review of a Discharge Summary from Hospital B dated 6/5/18 revealed: Discharge Diagnoses: [REDACTED]. 2. Significant [MEDICAL CONDITION] reflux disease with aspiration evidence no doubt contributing to the significant right lung condition .5. History of [MEDICAL CONDITION] .6. History of PEG tube placement because of chronic dysphagia with choking and aspiration .Hospital Course: The patient initially was not talking and requires complete care with PEG tube feedings. At the time of discharge he was much more alert with the nurses stating he was more responsive and even trying to talk a little bit. Hopefully his continued clinical improvement can continue. Plan: .5. Continue with [MEDICATION NAME], but give only a half a can via the PEG tube every 3 hours to decrease volume and frequency of aspiration exposure. 6. Must keep the head of the bed elevated and tilted 20 degrees plus, to prevent aspiration as possible .Signed by Physician C Review of a Nurse Progress Note written by LVN C at 11:30 p.m. revealed Resident #1 was transported back to the facility from Hospital B at 11:00 p.m. on 6/5/18. Review of the discharge orders from Hospital B dated 6/5/18 revealed: 1. discharge to (name of facility). 2. Diagnosis: [REDACTED]. (probable) aspiration .7. Continue with [MEDICATION NAME] ½ can via PEG tube every 3 hours .8. Must keep HOB (head of bed) elevated and bed tilted 20 degrees to prevent aspirations. 9. Oral hygiene. The orders did not include schedule for the administration of water. Review of the facility's 24-hour report for 6/5/18 and 6/6/18 following Resident #1's re-admission to the facility from Hospital B revealed the following remarks: PEG, NPO, Foley with amber urine, ABT (antibiotic) X 6 days, O2 at 3 liters/minute continuous, dressing coccyx Stage 1, give [MEDICATION NAME] every 4 hours .There was no documentation to inform staff of the change in Resident #1's [MEDICATION NAME] from 1 can to ½ can and no documentation related to administration of water. Review of Resident #1's physician's telephone orders dated 6/6/18 transcribed by LVN C revealed: .3. Continue nursing home routine orders. 4. Continue nursing home meds 7. continue [MEDICATION NAME] 1.5 ½ can via PEG tube every three hours .8. Must keep head of bed elevated and bed tilted 20 degrees to prevent aspiration .12. (MONTH) suction prn. The orders did not address the administration of water. Review of Resident #1's electronic recapitulated physician's orders [REDACTED]. Flush [DEVICE] with 200 ml sterile water every six hours for [DIAGNOSES REDACTED]. [MEDICATION NAME] 1.5 cal .1/2 can (118.5 ml) gastric tube .Diagnosis: [REDACTED]. Review of Resident #1's Medications Flowsheet (MAR) dated 6/1/18-6/30/18 revealed the administration of the ½ can of [MEDICATION NAME] and the 200 ml of water were timed for him to receive both fluids 4 times daily at 5:00 a.m., 11:00 a.m., 5:00 p.m., and 11:00 p.m. Review of the documentation on the medication flowsheet indicated the [MEDICATION NAME] and water were administered together four times on 6/6/18 and 6/7/18 at 5:00 a.m., 11:00 a.m., 5:00 p.m. and 11:00 p.m. The [MEDICATION NAME] and water were administered together three times on 6/8/18 at 5:00 a.m., 11:00 a.m., and 5:00 p.m. Documentation on the MAR indicated [REDACTED]. Review of a Nurse Progress Note dated 6/7/18 at 1:59 p.m. revealed: .productive cough with large amount of white thick secretion, done suction. Has SOB (shortness of breath) done nebulization with [MEDICATION NAME]. Telephone order from Physician A to send resident to Hospital B. at 14:00 (2:00 p.m.) send resident to Hospital B by ambulance. Signed by LVN D Review of an Emergency Department Physician Note from Hospital B dated 6/7/18 at 3:55 p.m. revealed: Chief Complaint: shortness of breath .aspiration pneumonia .Context: .Lives at a nursing home and being fed via a [DEVICE]. Was admitted here few days ago for aspiration pneumonia. discharged 2 days ago. Back to the hospital because of same problem. Poor caring by caregivers .Signed by Physician D Review of an Emergency Department Triage Record dated 6/7/18 revealed: Chief Complaint: Respiratory distress. Patient came from nursing home with reported difficulty breathing. EMS suctioned approximately 100 ml of milk secretions from oral airway, with positive results. Reports 300 ml suctioned at nursing home prior to arrival of EMS to nursing home facility .Nursing Assessment: .respiratory rate 86 .Respiratory: respiratory distress, rhonchi, stridor, retractions, dull on percussion, decreased breath sounds .signed by ER Nurse Review of physician's orders [REDACTED]. Keep head of bed above 45 degrees at all times especially when feeding. 2. Dilute tube feed by 50% (half water, half [MEDICATION NAME], etc) 3. Aggressive suctioning and [MEDICAL CONDITION] toilet. 4. Get family to consider Hospice care. Signed by Physician D. The orders did not address administration of the 200 ml of water that Resident #1 had been receiving in the facility. Review of a Nurse Progress Note dated 6/7/18 revealed: 9:00 p.m. resident returns from Hospital B ER via ambulance, transferred from stretcher to bed .lung sounds diminished with crackles to upper lobes, no distress noted at this time .received orders from Hospital B to keep head of bed at 45 degrees at all times, dilute [MEDICATION NAME] with H2O by 50%, aggressive suctioning, son at bedside aware of new orders, is agreeable with hospice consult. Signed by LVN A Review of a Nurse Progress Note dated 6/8/18 revealed: 1:30 a.m. Res resting quietly in bed with eyes closed, doesn't open eyes or respond verbally at all, but can move hands in response to physical stimuli, especially when suctioned, raises hand to brush away. HOB up 45 degrees or more at all times as per new order from ER, even when incontinent care provided. Signed by LVN F Review of Resident #1's physician telephone orders revealed there were no orders written for Physician A to sign that reflected the 6/7/18 orders sent to the facility from Hospital B that included the order to dilute the [MEDICATION NAME] by 50%. Documentation on the MAR indicated [REDACTED]. The start dated was 6/7/18 and the end date was open-ended. Review of Resident #1's MAR indicated [REDACTED]. Review of the facility's 24-hour report for 6/7/18 revealed following Resident #1's transfer to and from theER on this date documentation included to Hospital B at 1400 (2:00 p.m.) back at 2100 (9:00 p.m.) dilute feeding by 50%. Observation on 6/8/18 at 11:40 a.m. revealed Resident #1 in bed with the head of his bed elevated. There were no markings on the bed to indicate that the head of his bed was elevated 45 degrees. His eyes were closed and his breathing through his mouth was labored and raspy. The nasal cannula for his oxygen was positioned at his mouth and oxygen was being delivered at 2.5 liters per minute. A fall mat was at the bedside. In a telephone interview on 6/7/18 at 4:53 p.m. the ER Nurse from Hospital B said Resident #1 was brought to the emergency room at Hospital B on 5/29/18 with aspiration from his PEG tube feeding. He was admitted and kept in the hospital until 6/5/18 and was being treated for [REDACTED].#1 came back to the ER today (6/7/18) with the same issue. She said EMT (Emergency Medical Transport) personnel reported Resident #1 had been suctioned by the facility prior to their arrival and there was 300 ml (milliliters) of a white substance in the cannister. She said EMT suctioned an additional 100 ml of the substance enroute to Hospital B. The ER Nurse said Resident #1 was in respiratory distress when he arrived at the ER and his respiration rate was 86 breaths/minute. She said she felt the facility was feeding Resident #1 and then laying him down too soon after the feeding. In a face to face interview on 6/8/18 at 10:55 a.m. the ER Nurse from Hospital B repeated that Resident #1's respiration rate was 86 breaths per minute when he arrived in theER on [DATE] and he had tears in his eyes. She said the respiratory rate was counted by both she and the Respiratory Therapist. The ER Nurse said Resident #1 had no gag reflex. Normal respiratory rates for older patients are12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care. Referenced 6/21/18: Medscape at https://www.medscape.com/viewarticle/ 2 In a telephone interview on 6/11/18 at 11:05 a.m. Paramedic A said when she arrived at the facility for the 911 call for respiratory distress on 6/7/18 she observed Resident #1 in bed in a semi-fowler's position with a pillow behind his head. She said he was not in the position for feeding. She said Resident #1's breathing was rattling. She said when she was getting Resident #1 ready to transport, she saw the cannister on the bedside table with 300 ml of a milky substance. She said the nurse (identified as LVN A) who came into the room had just come on shift and was unable to tell her how long Resident #1 had been in respiratory distress. Paramedic A said the nurse was able to tell her that Resident #1 had breathing treatments ordered but she was unable to say how many he had had that day. Paramedic A said after transferring Resident #1 to the ambulance she suctioned 100 ml of a yellow/milky substance from the back of his throat. Paramedic A said when she arrived at the facility, someone who worked there, wearing street clothes, pointed her to the hall Resident #1 was in. She said when she arrived in the room, there was no staff with him. She said LVN A entered the room about a minute later. In an interview on 6/11/18 at 1:05 p.m. LVN A said she had just come on shift on 6/7/18 when the EMTs arrived and she followed them into the room. She said the paramedic kept asking her how long Resident #1 had been having difficulty breathing and she told him she didn't know because she had just come on shift. In an interview upon entry to facility on 6/7/18 at 5:30 p.m. the DON said the census was 46, but the facility had sent one resident to ER earlier that day, but she had not heard back whether he was going to be admitted or not. She identified the resident as Resident #1. Observation of Resident #1's room on 6/7/18 at 5:45 p.m. revealed a suction cannister on his bedside table with 250 cc of a creamy/white milky substance with curdles and approximately ½ inch of foam on top. In an interview on 6/8/18 at 11:45 a.m. LVN D said she fed Resident #1 on 6/7/18 at 11:00 a.m. and a little past 12:00 p.m. he started coughing and gagging. She said fluids were moving in an out of his PE[DEVICE]. She said he was sent out at 2:00 p.m. to the hospital. LVN D said Resident #1 came back to the facility last night (6/7/18) around 9:00 p.m. She said she did his feeding this morning (6/8/17) at 11:00 a.m. but even though his 200 ml of water was also timed for 11:00 a.m., she gave it at 10:00 a.m. so to not overfill him. In an interview on 6/8/18 at 1:20 p.m. CNA A said Resident #1 could not use his call light to call staff for assistance, nor could he adjust the head of his bed himself. She said she had performed his oral care using a swab. She said he would grab at the swab and chew on it and said he would cough with oral care. CNA A said Resident #1 didn't like a toothbrush and toothpaste for oral care. She said she no longer used a toothbrush because he tried to chew on it. She said she positioned him upright on his back, and sometimes she positioned him on his side and placed a pillow behind him, but he would slump down and didn't stay straight in the bed. CNA A said since his choking episode on 5/29/18, Resident #1 was to be kept upright. She said since he returned to the facility on [DATE], he didn't do much for himself. CNA A said before he went to the hospital this last time on 6/7/18, the head of Resident #1's bed was elevated to about 15 degrees. She said the nurses did not tell her to raise the head of his bed before he left the faciity on [DATE] but on 6/5/18 when he returned, the head of his bed was to be elevated 45 degrees. CNA A said she was not allowed to put the head of his bed down. She said when he had a bowel movement and required incontinent care, she laid him flat to clean him. She said Resident #1 could not talk but he would make sounds and move around, moving his arms and legs. She said she had not been inserviced regarding positioning in relation to [DEVICE] feedings on Resident #1 since his initial admission. In an interview on 6/8/18 at 1:30 p.m. CNA B said Resident #1 was required to have the head of his bed elevated 30 degrees and could not be laid flat. She said if he had a bowel movement, she would lower the head of the bed and roll him to clean him. She said she had never been told how long he could lay flat. CNA B said she used green foam swabs to provide oral care. She said she dipped them in liquid then cleaned his mouth and dunked them in water to wash his mouth out. CNA B said she tried to reposition Resident #1 every 2 hours or whatever was most comfortable for him. She said she did not position him on his side or lay his head down. CNA B said Resident #1 was not able to adjust the bed himself. She said he would try to say some words over and over and that usually meant something was wrong. She said she had not been inserviced on oral care or positioning for Resident #1 since his admission. In an interview on 6/8/18 at 1:47 p.m. LVN D said she had not been inserviced since Resident #1's admission regarding positioning and [DEVICE] care. She said he was very confused when he was first admitted and had a feeding tube. She said he would pull his feeding tube out and required the doctor to be called and the physician ordered Klonopin to calm him down. She said he had also had an order for [REDACTED]. She said she was not sure what to do for his oral care. LVN D said if he had liquid in his mouth she used suction. She said for positioning Resident #1 was supposed to stay 45 degrees or higher at all times. She said they could lower the head of his bed a little. She said she had administered feedings at 8am, 11am and his next feeding was at 2pm. She said she was not sure what the night shift gave him. LVN D said staff could lower the head of the bed to 30 degrees to change him for example if he had a bowel movement. LVN D said she administered Resident #1's feedings today (6/8/18). She said Resident #1 could not lower the head of the bed himself. LVN D said she may have failed to tell the CNAs to wait an hour after feedings to change Resident #1. She said if he had grimacing or got agitated, she knew something was wrong. LVN D said Resident #1 had been sleepy lately. She said yesterday before he went to the ER she was the nurse caring for him. She said his vital signs were within normal limits. She said his blood pressure was about 106/60, and he had oxygen on at 4 liters per minute. LVN D said when she suctioned him with a [MEDICATION NAME] suction tip Resident #1 was gagging and that she had administered a feeding to him about one hour before that. She said she obtained about 250cc and suctioned a large amount of formula from Resident #1 before sending him to theER on [DATE]. She said his pulse was 104-106. She said she didn't count his respirations but they were rapid. She said his oxygen saturation was initially 88% but went up to 94% after suctioning and he was positioned upright during this time. In an interview on 6/8/18 at 1:53 p.m. the DON (Director of Nursing) said when a resident was admitted from a hospital with orders that specified times of administration of medications or feedings, the facility tried to follow those times established by the hospital. She reviewed the 5/17/18 discharge orders from Hospital A and confirmed that the administration time for [MEDICATION NAME] was documented as 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. She confirmed that her understanding of the times for the administration of the 200 ml of water was 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. In an interview on 6/8/18 at 2:05 p.m. the Speech Therapist said when she evaluated Resident #1, he did not have a swallow reflex. She said she evaluated him by placing a spoon in his mouth on his tongue. She said she did not evaluate whether Resident #1 had a gag reflex because he did not like anything being put into his mouth. In an interview on 6/8/18 at 2:10 p.m. Physician A said Resident #1 had progressive chronic problems and was going to have aspiration risks with his [DEVICE]. He said Resident #1 would have an aspiration risk even with the head of his bed elevated to 45 degrees, especially since he had [MEDICAL CONDITION] dysphagia. Physician A reviewed the 5/17/18 telephone orders that he had signed for the can of [MEDICATION NAME] and 200 ml of water and discussed the scheduled times that the [MEDICATION NAME] and water had been administered at the same time and said, that's too much volume, Resident #1 cannot not tolerate it. Physician A did not comment on the order dated 6/7/18 from Hospital B to dilute the [MEDICATION NAME] by 50%. In an interview on 6/8/18 at 2:10 p.m. CNA C said she had not received an inservice regarding positioning, oral care or [DEVICE] on Resident #1. She said he had to be upright at all times at 45 degrees since returning to the facility on [DATE] but previously he had to be at 30 degrees. She said it changed after his last hospital visit on 6/7/18. She said a nurse named (LVN B's name) didn't know how to care for [DEVICE]s or how to give a feeding thru a [DEVICE]. She said she had worked around [DEVICE] residents in the past and could walk her through the procedure. CNA C said she knew not to turn Resident #1 after he had had a feeding. She said she provided oral care using toothettes. She said she dipped them in water and if he had problems she would get the nurse to help. She said she couldn't put a lot of fluid in his mouth because it would cause him to choke. She said he went to the hospital on [DATE] because he had too much mucous. CNA C said when the nurse was suctioning Resident #1, it didn't seem like it helped. She said Resident #1 was a mouth-breather so he wore the oxygen cannula in his mouth. She said the only information she had received on Resident #1 since admission was at shift change and that was limited. Observation of the ADON preparing to provide the [DEVICE] feeding to Resident #1 on 6/8/18 at 2:38 p.m. revealed Resident #1 in bed with the head of the bed elevated approximately 45 degrees, but Resident #1 was slumped down in the bed and his breathing was labored with rattling and gurgling. The ADON suctioned Resident #1 by placing the tip of the suction tip 1-3 inches into Resident #'1s mouth repeatedly and only suctioned out what was in his mouth. Resident #1 continued to gurgle and rattle with each breath. At 2:44 p.m. LVN E entered the room and began suctioning Resident #1 but was unable to clear his airway. Prior to suctioning, the LVNs checked Resident #1's O2 saturation and it was 90% and after suctioning, his O2 saturation was 92%. The ADON then administered Resident #1's [DEVICE] feeding without repositioning him so that he was upright in the bed and not slumped causing pressure on his abdomen and airway. The ADON said Resident #1 had to be upright 1 hour after feedings. A sign was observed on the floor under Resident #1's bed that stated: Please keep the head of my bed elevated above 45 degrees at all times. The RDO was in the room assisting and said the sign was to be on the wall above the head of his bed. In an interview on 6/8/18 at 3:11 p.m., LVN E said she worked 2 p.m. to 10 p.m. and was assigned to care for Resident #1 tonight. She said she was not inserviced regarding positioning, oral care or [DEVICE] on Resident #1. She said he had pulled his feeding tube out at least twice. LVN E said she had not wor (TRUNCATED)

Based on observation, interview, and record review the facility failed to provide effective pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 4 (Resident #1, #2, #3 and #4) of 7 residents reviewed for pain management. The facility failed to: a. consult Physician B for pain management for Resident #1 according to Physician D's order, notify Physician D when Resident #1's pain medication was not effective b. administer [MEDICATION NAME] for pain and notify Physician D of [MEDICATION NAME] not being administered to Resident #2 c. administer [MEDICATION NAME] for pain to Resident #3 according to Physician A's order d. consult Physician F for pain management according to Physician F's order This failure could affect 30 residents who are on a pain management program and put them at risk for further decline in their mental and physical functioning. Findings include: Resident #1 Record Review of Resident #1's Resident face sheet dated 04/26/17 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses; gastrointestinal hemorrhage, muscle weakness, chronic pain, dementia, constipation, [MEDICAL CONDITION], abdominal pain, abnormalities of gait and mobility, lack of coordination, gout, [MEDICAL CONDITION], bilateral hearing loss, hypertension, [MEDICAL CONDITION]. Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating moderate cognitive impairment. Her speech was noted as clear and usually had ability to express ideas and wants and usually understood others. Resident #1 was noted to have presence of pain that was frequent. Her pain had made it hard for her to sleep at night and limited her day to day activities. She rated her pain over the last 5 days as 7 on a scale of 0-10 with 10 being the worst pain she could imagine. Review of Resident #1's Care plan for pain dated 03/02/18 noted she was at risk for complications related to pain due to history of abdominal pain and arthritis. Goal was she would not experience pain above tolerable level through review date. Approach was for staff to administer medications as prescribed, staff to assist with repositioning as needed and staff to notify physician of intolerable pain level. Resident #1's pain evaluation was requested 05/08/18, 05/09/18 and 05/10/18 but not received. Review of Resident #1's order history from 11/01/17-5/8/18 noted [MEDICATION NAME] 100mg two tablets at bedtime with start date of 01/05/18; [MEDICATION NAME] -[MEDICATION NAME] 10/325mg one tablet every 4-6 hours as needed for pain with start date of 08/08/17; Salonpas with [MEDICATION NAME] 4% one patch topically with special instructions: no more than one patch at a time. Observation on 05/07/18 at 12:45 p.m., Resident #1 sitting in recliner at bedside eating lunch. Resident #1 said she was in pain and that her hips hurt, they are bone on bone. Resident #1 said she told the nurse and they gave her Tylenol about 11:00 a.m. Review of Resident #1's physician orders [REDACTED]. In an interview on 05/07/18 at 3:40 p.m., ADON Resident #1 complains throughout the day of severe pain. She would request pain medication before it was time for another dose of pain med. [MEDICATION NAME] alternating with Tylenol for pain. She was seen by Physician C in (MONTH) (YEAR) and he did not recommend surgery. Physician D did see her and did not change her medication but did refer her to Physician E in Abilene. Resident #1's son cancelled the appointment with Physician E twice due to resident saying she could not make the long trip and was hurting too bad. Repositioning had been tried to help with pain, warm towels and she had requested ice packs to her knee. She had an order to see Physician B to evaluate her pain but ADON was unaware of that had been done or if the son cancelled the consult. ADON was asked how consults were tracked to completion and she was not aware of how they were tracked to ensure they were completed. ADON said she had not contacted Physician D regarding status of consult to Physician B for pain management. Review of Resident #1's physician progress notes [REDACTED]. Now she has complaints of some low back pain and pain down into her legs. This was kind of a new onset for her and she had not had that problem in the past. Exam noted tenderness in the lumbar spine that radiates down into the greater trochanters bilaterally. There was decrease ROM in her knees and weakness bilaterally in her legs. Plan included to get x-rays of her lumbar spine .We might be able to look at those and do some types of injections if possible. She was already on [MEDICATION NAME] at that time. As well, she takes [MEDICATION NAME] as needed for this pain. Review of Resident #1's Radiology Result Report dated 3/27/18 of CT of pelvis noncontrast with impression of advanced [MEDICAL CONDITION] in hip joints, no acute fracture or malalignment, large periumbilical abdominal wall hernia. Review of physician progress notes [REDACTED]. A CT scan was done of the hip to be sure there was no occult fracture there. It was negative except for severe [MEDICAL CONDITION] disease. She was complaining of some low back pain and some mild dysuria. Impression was [MEDICAL CONDITION] arthritis, hips bilaterally with plan he discussed with her son and the patient about having some injections done at the hospital with Physician B, saving her a trip to Brownwood or Abilene making it easier on her. Review of Resident #1's Nursing Progress notes revealed on 4/2/18 at 4:01 p.m., family requested a pain pill for Resident #1. LVN E checked and informed family member she could have one at 6 p.m He stated she was moaning when incontinent care was being given. LVN E told family member she could give Resident #1 a Tylenol. Family member requested a pain pill for her at 6 p.m. and said I don't want her to be in pain. Nursing Progress notes or Medication flowsheet for Resident #1 did not contain follow-up for effectiveness of pain medication. Review of physician progress notes [REDACTED]. She suffered from [MEDICAL CONDITION] disease of that left hip. We have even done a CT scan on it recently but there was no evidence of any fracture .We were getting her set up to see Physician B. I don't know if that was still in the works or if we can get her over to Physician B at this time. Exam noted severe tenderness over the left greater trochanter and swelling noted as well as significant pain with any rotation of the hip whatsoever. CT of the left hip did show advanced [MEDICAL CONDITION]. Review of Resident #1's Nursing Progress notes revealed on 4/7/18 at 1:36 a.m., LVN A noted Resident given [MEDICATION NAME] 10/325mg for complaints of left hip pain, with groaning and moaning heard with no easiness given after being turned and repositioned. No follow-up documentation by nursing regarding effectiveness of pain medication. Review of Resident #1's Nursing Progress notes revealed on 04/24/18 at 4:11 p.m., she complained of pain at onset of shift (2:00 p.m.) One [MEDICATION NAME] given 8/10 on pain scale. At 3:30 p.m., Resident #1 said pain was 6/10 on pain scale. Periodically will cry out during incontinent care and repositioning. Family member requested a pain pill but was informed she could have one at 6:00 p.m. Signed LVN E Review of Nursing Progress notes did not note the Physician was notified of inadequate pain relief. Review of Resident #1's Nursing Progress notes revealed on 4/24/18 was administered [MEDICATION NAME] 10/325mg at Midnight (12:00 a.m.) for complaints of left hip pain. At 3:00 a.m. resident began to moan loudly. Resident #1 was repositioned. Review of Resident #1's Nursing Progress notes revealed on 4/27/18 she was complaining of pain at onset of shift (2:00 p.m.) One [MEDICATION NAME] was given for pain. Family member requesting a pain pill for Resident #1 at 4:00 p.m. but was informed she had a pain pill at 2:15 p.m. and would have to wait until 6:00 p.m. for the next dose. Resident #1 was transferred to recliner for repositioning. Resident said she felt better in the recliner and stopped crying out. In an interview on 05/07/18 at 3:51 p.m., CNA D said Resident #1 can turn but cannot turn much because of the excruciating pain. She said the resident was never comfortable and yelled a lot. She could barely sit in the chair but was more comfortable there and could not get comfortable in the bed. Resident calls out several times an hour. She may be repositioned frequently in the bed because she could not get comfortable. Sometimes she was repositioned every 15 minutes on a bad day. She had several bad days a week. You can barely touch her. She will yell out when touched. Her pain has gotten worse since CNA D has worked here. She said she reports her pain to the nurses. In an interview on 05/08/18 at 11:13 p.m., LVN F she said Resident #1 slept in her bed at night and didn't always request pain medication. She said there were times she would moan and groan, cries out and can't have pain medication because it was too soon. She said sometimes repositioning her helps. She said there are times Resident #1 will stay awake at night. She said Resident #1 would cry out when staff repositioned her. She said Resident #1 could tell her if she was hurting and could tell you the level of pain using numbers and could tell you where her pain was. She said the pain medication was not always effective for her. She said there were times she had difficulty resting at night. In an interview on 05/10/18 at 2:00 p.m., CNA E stated when Resident #1's in pain or refuses showers, she tells the nurse. CNA E said Resident #1 was always asking for pain medication and said she was in pain so we would reposition her and tell the nurse. Review of Resident #1's Narcotic Record from 4/14/18-4/30/18 revealed she received 60 doses of [MEDICATION NAME]/APAP 10/325mg. 18 of 60 doses documented in nurse's notes. No PRN medication notes for 4/14/18-4/30/18. 23 doses documented on back of Medication Administration Record [REDACTED]. Two doses on 4/29/18 with [MEDICATION NAME] given at 3pm but she still complained of pain. At 4:30 p.m. a Salonpas patch placed on. On 4/29/18 at 7:00 p.m., Resident #1 continued to complain of pain, [MEDICATION NAME] one given and at 9 p.m., resting, eyes closed. Review of Resident #1's Narcotic Record from 4/30/18-5/9/18 at 9:18 a.m. she received 35 doses of [MEDICATION NAME]/APAP 10/325mg tabs for pain. Review of Resident #1's prn medication notes revealed on 5/4/18 at 1830 (6:30 p.m.) and 5/5/18 at 1600 (4pm) LVN D noted [MEDICATION NAME] was administered for hip pain with some relief documented as result. Observation and interview on 05/08/18 at 4:30 p.m., Resident #1 was sitting in chair at bedside. She told CNA's her pain level was a 7 on a scale of 1-10. CNA's in room to provide incontinent care. She was transferred from recliner to bed using a hoyer lift. Resident #1 was observed moaning and tearful and said she was in pain. In an interview on 05/09/18 at 2:40 p.m., LVN D said Resident #1 was never totally without pain. She reviewed the PRN medication notes for Resident #1 dated 5/4/18 at 6:30pm and 5/5/18 at 4pm in which she administered [MEDICATION NAME] 10/325mg one tablet for hip pain. LVN D documented result of [MEDICATION NAME] as some relief. When she was asked what that meant, she said because Resident #1 was asleep when she checked on her, she documented some relief. She said Resident #1 would ask for pain medication every 2-3 hours and she didn't know why but [MEDICATION NAME] does work better at times for her. She said when Resident #1's son came to visit, she would moan and groan. She seemed to carry on and she didn't want to wake her up to ask her about her pain. She said if a medication was not effective the staff would change the residents position, such as up to the chair or back to bed. She said Resident #1 doesn't tolerate the hoyer lift because it was hard on her and she seemed to be in a lot of pain with transfers. She said she had not reported to anyone when the pain medication was not effective because it was usually when her son was there because everybody just knew that is just how she is kind of thing. She always complained of hip pain. She said she was not aware of any issues with Resident #1's hips. She said for Resident #1 she didn't notify her physician because it was an ongoing situation. In an interview on 05/10/18 at 2:00 p.m., LVN A said Resident #1 complained of pain to left hip. She had bad arthritis that was bone on bone. She received [MEDICATION NAME] 10-325mg one tablet for pain and her pain was assessed by facial grimace. Will check on resident one hour after medication being given. She normally slept after receiving medication. She said the resident #1 would request the pain medication every 4-6 hours. She said Resident #1 will cry out in pain at night when turned for incontinent care. In an interview on 05/10/18 at 2:40 p.m., CNA C said Resident #1 was always in pain. The pain medication may relieve pain for a hot minute. Every touch was painful for her. She was transferred using hoyer lift and calls out in agony all the time. She sleeps in her bed and will move to the recliner during the day. She does not feel her pain was ever relieved. She notifies the nurse of Resident #1's complaints of pain. In an interview on 05/10/18 at 4:00 p.m., LVN E said Resident #1 was in pain all the time. If you touched her, she would cry out. She had a chronic condition with her hip. The staff would turn and reposition her, use hot packs, salonpas patches if she needed it. It seemed whatever was done for her pain, it didn't seem to make her comfortable. She didn't get out much because she was never comfortable. She said she hadn't notified the physician Resident #1's pain was not relieved because she felt she had some relief from the pain medication. She would rest and calm down at times. She had walked by her room and Resident #1 would have facial expressions of being in pain and would not always ask for pain medication. She felt she could ask for pain medications at times and at other times she did not call out for pain medication. She said some staff members did not take Resident #1 seriously. Some do not look at the signs that she was in pain. There were days she would come on duty at 2pm and Resident #1 had not received pain medication during the 6/2 shift. In an interview on 05/09/18 at 11:15 a.m., Physician D said he ordered a consult with Physician B for Resident #1 because he was Interventionist Radiologist that treats bone disease/pain. He said there are other physician's in the area that address pain management and he may refer Resident #1 to them. He said he was not aware of the amount of pain medications ([MEDICATION NAME]) Resident #1 had received for pain. (4/14/18-4/30/18 she received 60 doses of [MEDICATION NAME] and 4/30-5/9/18 she received 35 doses of [MEDICATION NAME]). He said he was not aware resident was refusing showers. He said his expectation was staff should notify him if pain medication was not effective. He said Resident #1 was [AGE] years old and had significant [MEDICAL CONDITION] joint disease. He said she doesn't move, goes from chair to bed and bed to chair. He said she had slipped out of bed and was sent to ER earlier today. He said she does complain of pain when he visits. He has ordered [MEDICATION NAME] ([MEDICATION NAME]) every 4-6 hours for her pain. He said she was previously on Tylenol #4 last year but changed to [MEDICATION NAME] ([MEDICATION NAME]). He said if he prescribed her pain medication routinely, it could buildup in her system and she would not do well. He said Resident #1 was also on [MEDICATION NAME] and he had increased the dose. He said physical therapy was not helpful for Resident #1 in the past. He sent her to an orthopedist in Brownwood and was told she was not a candidate for surgery on her hips. He said some people do not break down the medication and if that was the case, the medication would not be effective. He said he could check this by doing a drug screen. He said he may try [MEDICATION NAME], a [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] but he would need to see her first and evaluate her. He said the x-rays she had today at the ER (post fall at 3:30 am) did not show any fractures. He said looking at her x-rays, the head of the femur is bone on bone. He said he would get with Director of Nurses and discuss Resident #1 and evaluate her pain medication. Resident #2 Review of Resident #2 resident face sheet dated 05/08/18 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses; heart failure, fracture of left acetabulum, cough, lack of coordination, disorientation, pain, fracture of left pubis, history of venous [MEDICAL CONDITION] and embolism, chronic [MEDICAL CONDITION], idiopathic gout, muscle weakness, muscle spasm, age related [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of Resident #2 Quarterly MDS dated [DATE] revealed a BIMS score of 8 indicating moderate cognitive impairment. MDS also noted he had frequent pain. MDS noted the pain had made it hard for him to sleep at night and had limited his day to day activity. Review of Resident #2 care plan dated 04/18/18 noted he was at risk for experiencing pain due to history of fractures, [MEDICAL CONDITION], arthritis, and generalized chronic pain. The goal was for Resident #2 not to experience intolerable pain through review date. Approach to include staff would administer medication per physician orders. Staff will assess for pain each shift and staff will notify physician and family of any dramatic change in condition. Review of Resident #2 physician's orders [REDACTED]. [MEDICATION NAME] was used to relieve pain, tenderness, swelling, and stiffness caused by [MEDICAL CONDITION] (arthritis caused by a breakdown of the lining of the joints) and [MEDICAL CONDITION] arthritis (arthritis caused by swelling of the lining of the joints). [MEDICATION NAME] was in a class of medications called nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDs). It works by stopping the body's production of a substance that causes pain, fever, and inflammation. https://medlineplus.gov/druginfo/meds/a 2.html (Accessed 05/22/18) Review of Resident #2 Medication Flowsheet dated 04/01/18-04/30/18 noted [MEDICATION NAME] 15mg tablet one tablet by mouth once a day at 9am for pain. Review noted 16 of 30 doses were not administered and was marked N/A (not available). Review of Resident #2 Resident Progress notes from 04/01/18- 04/30/18 revealed no documentation regarding [MEDICATION NAME] not being available or notification to physician of medication not available for administration. (Daily doses from 4/3/18-4/18/18 were circled as not being administered) In an interview on 05/10/18 at 2:15 p.m., LVN D said N/A means medication was not available and was not administered. Review of Resident #2's Nursing Progress notes revealed on 4/19/18 at 4:05 a.m., LVN A documented Resident #2 unable to get comfortable due to his roommate (Resident #1) crying and loudly calling out his name, Resident #2 requested pain medication for his bilateral leg and knee pain. At 2:00 a.m., Resident #1 was given [MEDICATION NAME] for pain to his bilateral leg and knee pain. At 4:00 a.m., pain med effective with resident resting quietly. In an interview on 05/10/18 at 2:00 p.m., LVN A said Resident #2 complained of pain and requested pain medication for pain to his knees. In an interview on 05/10/18 at 2:17 p.m., CNA B said Resident #2 requested pain medication all night. He complained of pain to knees and to back. Observation on 05/08/18 at 4:30 p.m., Resident #2 lying in bed on right side, moaning in pain. He stated his legs and back hurt. Family member in room rubbing Resident #2's legs and back. Resident #2 said his legs hurt him all the time. Resident #3 Review of Resident #3 resident face sheet (undated) noted he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses; dysphagia, cerebral infarction, [MEDICAL CONDITION], cognitive communication deficit, chronic pain, loss of coordination, anxiety disorder, hypertension, [MEDICAL CONDITION] arthritis, flaccid [MEDICAL CONDITION] affecting left dominant side, lupus anticoagulant syndrome, major [MEDICAL CONDITION], muscle weakness. Review of Resident #3 significant change MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Resident was noted to have presence of pain almost constantly with pain making it hard to him to sleep at night and limited his day to day activities. The intensity of his pain was rated as very severe, horrible. Review of Resident #3 Care plan edited on 03/19/18 noted he was at risk for alteration in comfort and/or pain. The approach included administration of medications as ordered and monitor for side effects, effectiveness. Review of Resident #3 Physician order [REDACTED]. [MEDICATION NAME] was a painkiller in the opioid family (related to [MEDICATION NAME]). [MEDICATION NAME] was an over-the-counter medicine used to treat pain and inflammation. They may be combined in one prescription medicine to treat pain. https://medlineplus.gov/ency/article/ 0.htm (accessed 05/22/18) In an interview on 05/10/18 at 2:55 p.m., LVN B said Resident #3 did run out of [MEDICATION NAME] around end of April. She said Physician A was notified and called in the [MEDICATION NAME] prescription to the pharmacy. She said if he complained of pain when he was out of pain medication, she would have called the physician to get an order for [REDACTED]. Review of Resident #3's Individual Patient's Narcotic Record he received a dose of [MEDICATION NAME] ([MEDICATION NAME]/APAP 10/325mg on 4/24/18 at 8pm. He was scheduled to receive [MEDICATION NAME] ([MEDICATION NAME]/APAP 10/325mg) routinely at 7am, 12 noon, 7pm and 12 MN. His next dose was administered on 4/27/18 at 12:05 am. resulting in missing 12 routine doses of [MEDICATION NAME] ([MEDICATION NAME]/APAP). Review of Resident #3's Medication Flowsheet for 4/1/18-4/30/18 revealed [MEDICATION NAME] was circled as not being administered 4/24/18 at MN, 4/25/18 at 7am, 12 noon, 7pm and MN, 4/26/18 at 7am, 12 noon, 7pm and 12 MN and on 4/27/18 at 7am, 12 noon and 7pm resulting in 12 missed doses. Review of Resident #3 Nurses notes for 4/24/18-4/27/18 did not note why [MEDICATION NAME] was not administered on the above dates and times or that physician was notified of [MEDICATION NAME] not being available or any complaints of pain. In an interview on 05/10/18 at 3:05 p.m., ADON said Resident #3 did not go without [MEDICATION NAME]. She said Physician A ordered pain medication by phone due to her being out of town. She said the pain medication was received on 04/26/18. ADON then said she was not sure what the nurses administered to Resident #3 for pain from 4/24/18 to 4/26/18. She said [MEDICATION NAME] ([MEDICATION NAME]/APAP) was not in the Emergency Drug Kit. Review of Resident #3 Resident Progress Notes did not note from 4/15/18 to 4/27/18 that nurses notified Physician A for order for pain medication or notification he was out of [MEDICATION NAME] ([MEDICATION NAME]/APAP) for pain. In an interview on 05/07/18 at 2:20 p.m., CNA C said Resident #3 fell and broke his hip in (MONTH) (YEAR). Since that time, he had become more withdrawn. He complains of pain almost constantly. In an interview on 05/09/18 at 2:15 p.m., Resident #3, said his pain was not relieved with his current pain medication. He said his legs hurt. When he was asked if he had told staff, he said he had in the past and he said it wouldn't do any good because they wouldn't do anything. He was asked if when he was hurting, did the staff reposition him or do anything to relieve the pain and he shook his head no. When Resident #3 was asked if he had gone without pain medication, he said he didn't know. In an interview on 5/9/17 at 2:40 p.m., LVN D said if you wake Resident #3 up, he would complain of pain. She said she didn't like to wake Resident #3 up to assess for pain. She would ask him about his pain when it was time for a meal or something. She said since his fall and fracture, he didn't go out of his room. Last week he played dominoes once. She said when giving any resident pain medication, she was to document on the medication flowsheet and the prn medication note with effectiveness of medication. She said if a resident refused a medication or medication was not available, she would just circle the medication on the medication flow sheet and document in the nurses' notes. She said it had only happened once or twice that a medication was unavailable but could not tell which medications or when medications were not available. In an interview on 05/09/18 at 2:27 p.m., DON said she was unaware pain was not being relieved for Resident #3. She said he had a history of [REDACTED]. She said her expectation was nurses should notify the physician if a resident's pain was not relieved and document in nurses notes if they notified a physician. She said her expectation was for nurses to administer medications as ordered by physician and to have medications available. In an interview and observation on 05/10/18 at 2:45 p.m., Resident #3, he was lying in bed, eyes open and complained of pain in bilateral legs. He was asked if he notified the nurse his legs were hurting, and he said it wouldn't do any good because they wouldn't do anything. In an interview on 05/08/18 at 2:20 p.m., LVN C said resident #3's pain isn't controlled, and he takes [MEDICATION NAME] 10/325 Mg routinely every 6 hours for pain. In an interview on 05/09/18 at 2:45 p.m., Physician A said her expectation was for nurses to call her with any concerns or if pain was not controlled. She said Resident #3 had a stroke and had made a remarkable recovery through therapy. He suffered a fracture of his left hip requiring surgery in (MONTH) (YEAR). Following the hip surgery, he leg had become more contracted and he had not progressed. In an interview on 05/10/18 at 2:15 p.m., LVN D said that she would tell the next nurse if she noticed the medication was not available and she would notify the MD if patient was out of medication. In an interview on 05/10/18 at 4:04 p.m., LVN E said N/A on the Medication Administration Record [REDACTED]. She said if she was aware, she would let the doctor know that the medication was not available. In an interview on 05/10/18 at 4:10 p.m., ADON stated that the nurses need to follow the chain of command by notifying her or go to DON, then the administrator if medication was not available. She would call the pharmacy to order the medication. ADON stated the nurse should notify the physician if medication was not available. In an interview on 05/09/18 at 5:01 p.m., with Administrator she said the charge nurse can order medications for residents. She said medications should be available for administration to residents. She said if a nurse had an issue obtaining medications, they should communicate that to their supervisor. Resident #4 Review of Resident #4's resident face sheet dated 04/11/18 revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION], post hemorrhagic [MEDICAL CONDITION], rash, anxiety disorder, malignant neoplasm of liver, [MEDICAL CONDITION], gastritis with bleeding, chronic pain due to trauma, hypertension, [MEDICAL CONDITIONS], chronic [MEDICAL CONDITIONS], muscle weakness, tremor, difficulty in walking, weakness. Review of Resident #4's 60-day MDS dated [DATE] noted a BIMS score of 11 indicating moderate cognitive impairment. MDS noted he was able to make self-understood and had the ability to understand others. MDS noted he had pain or did hurt within the last 5 days of MDS. He described his pain as frequent and made it hard for him to sleep at night and had limited his day to day activities because of pain. He rated his pain as 4 on a scale of 0-10 with ten being worst pain he could imagine. Review of Resident #4's care plan dated 03/06/18 for Pain due to resident being at risk for experiencing complications related to experiencing chronic pain. Approach was for staff to administer medication as prescribed, staff will assess pain each shift, and staff will notify physician and family of any dramatic change in condition. Care plan dated 03/19/18 for Resident #4 was at risk for development of a pressure ulcer due to prolonged periods in bed and/or chair, desensitized skin to be unable to determine the need to relieve pressure, and impaired circulation. Approach to include staff will assist with transfers to aid in pressure relief and positioning, staff will assist with turning and repositioning as needed, and staff will notify physician and family of any dramatic change in condition. Review of Resident #4's physician's orders [REDACTED]. Review of fax to Physician F regarding Resident #4 dated 03/04/18 noted resident would like something stronger for pain. Currently has over the counter Tylenol 650mg. Signed LVN I with Reply from Physician F documented visit needed for pain. Review of Resident #4's Nursing progress notes dated 4/14/18-4/20/18 revealed no documentation of resident complaining of pain or having difficulty sleeping. Review of Resident #4's physician orders [REDACTED]. Resident #4's pain assessment was requested on 05/08/18, 05/09/18 and 05/10/18 but was not received. Review of Resident #4's Medication flow sheet for (MONTH) (YEAR) revealed he received [MEDICATION NAME] 650mg one tablet as needed for chronic pain on 4/29/18 and has not received [MEDICATION NAME] 650mg in (MONTH) (YEAR). In an interview on 5/10/18 at 5:30 p.m., Physician F said Resident #4's office notes go back to 3/8/18. He said Resident #4 was diagnosed with [REDACTED]. He said he was more concerned with evaluating/treating that and never addressed his pain. He said he saw Resident #4 on 03/09/18 and the resident didn't complain of pain at that time. He said he had [MEDICAL CONDITION] due to the progressive [MEDICAL CONDITION]. He said he did not address Resident #4's pain. Requested Physician F's note addressing pain evaluation and facility provided Resident #4's emergency room visit note. Review of Resident #4's emergency room visit on 03/06/18 noted chief complaint of shortness of breath and chest pressure. Clinical Impression was dyspnea with note of acute exacerbation of [MEDICAL CONDITION]. He was discharged back to home in stable condition with follow-up with PCP as scheduled this week. CT of chest dated 03/06/18 revealed No evidence of [MEDICAL CONDITION] embolism, evidence for widespread hepatic metastases, left upper lobe [MEDICAL CONDITION] nodule measuring 0.9cm. Malignancy cannot be excluded. < (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for elopement. a) Resident #1, who was wearing a wander guard, exited the facility 08/11/16 sometime between 8:25 p.m. and the time she was located 08/11/16 at 11:40 p.m. No alarm sounded when Resident #1 left the facility. Resident #1 was found outside the facility with a fractured right hip and right wrist. An Immediate Jeopardy was identified 08/14/16. The Immediate Jeopardy was lowered to a harm level at an isolated event on 08/15/16. The facility remained out of compliance as they had not yet monitored their plan for effectiveness. These failures resulted harm to Resident #1 and could place the two other residents the facility identified as wanderers at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. Findings include: Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Physician order [REDACTED].Wander guard on at all times D/T (due to) poor safety awareness/exit seeking . Initiate date of 05/14/2015. Review of Resident #1's clinical record revealed a safety consent for a physical device, Wander guard, with telephone consent given by Resident #1's family 05/14/15. Review of Resident #1's most current Elopement (risk assessment) dated 11/05/15 revealed, .Increased confusion after evening meal. Unable to locate room within 30 minutes of completing meal .Mental status .Restlessness . Review of Resident #1's Quarterly MDS dated [DATE] revealed she had impaired vision, wore corrective lenses, a BIMS of 5, (severe cognitive impairment), had inattention that was present and fluctuated, needed supervision for transfers, ambulation, dressing, eating hygiene, was dependent for bathing with one person assistance, was occasionally incontinent of bladder and always continent of bowel. The MDS revealed Resident #1 had not had any falls since admission. Review of Resident #1's Care Plan dated 03/22/16 revealed, .Resident requires the use of adaptive equipment: Wander Guard r/t (related to) exit seeking, cognitive impairment r/t DX Dementia . Review of Resident #1's Care Plan dated 03/22/16 revealed, .Falls: Potential for falls related to: cognitive impairment, unsteady gait, Norco (an opioid analgesic), Gabapentin (an antiepileptic also used for nerve pain), Requip (an anti-Parkinson medication), lack of safety awareness . (Medications reviewed at www.drugs.com <http://www.drugs.com>) accessed on 08/18/2016 Review of Resident #1's Event Report dated 08/11/16 at 11:45 a.m. (p.m.?) revealed, .Brief description of incident: Found res (resident) lying on sidewalk on north side of building. Describe injury-c/o right hip pain .Assessed res for injury, VS obtained, neuro check performed .lying on left side .08/11/16 11:45 p.m Confused, normal .Taken to hospital-yes . Review of Resident #1's Resident Progress Notes dated 08/12/16 at 1:00 a.m. revealed, For 08/11/16 at 23:45 CNA noted res not in room, door open and lights on, res had not returned to room by 23:30. Confirmed res not signed OOP (out on pass) in report books, tel (telephone) call to 2-10 nurse to confirm also. Res wears wanderguard, door alarms had not been set off this shift. After searching facility room-by-room for res, search outside premises, north side first, with LVN (nurse's name) calling to res. Immediately heard res respond to call and indicate presence on north side of building. At 23:40, noted res lying on sidewalk in dark beyond smoking/break area. Res. responsive, alert, confused per normal. Immediately assessed for injury @ 23:45, VS 140/90, 130, 18, 97.7. Asked res if she fell , res stated, No, honey, I didn't fall. But, when asked how she ended up lying on the sidewalk, res stated I have no idea. Res lying on left side, 1 shoe on and 1 shoe off. Res w/ right leg drawn up, flexed at knee. Res able to move left leg, but states she can't right leg because her hip hurts. Neuro check performed; WNL: PERRL, hand grips weaker but equal. Noted edema to face, especially left side. AROM X 3, won't move RLE on recheck. LVN (nurse's name) stayed w/ res while this LVN returned inside to notify physician, and request transfer to ER. @23:55: Tel call to DON (name) to notify res condition; tel call to 911, request transfer to (hospital name) ER for res c/o Rt. Hip pain, and for facial edema, following possible fall. @24:00 Tel call to on-call physician (physician's name), notified of res condition after finding res lying on sidewalk and res c/o rt hip pain, and that 911 called for immed transfer to ER for evaluation- (physician's name) approved order. Tel call to family, spoke w/ d-i-l (daughter-in-law) (name) stated, Thank you, I'll go tell (name of resident's son). @00:15, res transferred to EMT care for transport- all paperwork and orders provided for EMS/hosp (hospital). Though noted on tel order and transfer assessment paper that reason for s/p (status [REDACTED]. noted on sidewalk- a possible fall. Signed by LVN B. Review of Resident #1's Resident Progress Notes dated 08/13/16 at 3:00 a.m. revealed, Received tel call from (hospital nurse's name) at ER to notify us that res (resident's name) has a Fx Rt femur and Fx Rt wrist, and will be transferred to (name of larger hospital) and ER to ER transfer, not direct admit. This LVN asked ER RN (name of hospital nurse) if a CT (Cat Scan) of head had been done due to res facial edema, she stated that she didn't think so, the doctor didn't order one that she'd seen. This LVN requested that when res is transferred to (name of larger hospital), that they request CT scan of head to be done due to unusual facial edema, (name of hospital nurse) stated she would. Signed by LVN B. Review of Resident #1's emergency room record dated 08/12/16 revealed, .Chief complaint injury to: R leg and R wrist .Patient was walking out behind the NH at about 23:30 and fell .Full body (diagram). Marker 1 (to right thigh)=pain. Marker 2 (to right wrist)tenderness .Joint exam: Limited ROM . Review of Resident #1's emergency room Report of Radiology Examination dated 08/12/16 at 1:42 a.m. revealed, .An acute intertrochanteric fracture in the proximal aspect of the right femur is present with lateral apex angulation and medial impaction. The femoral head remains within the acetabulum with joint space narrowing, eburnation, and marginal osteophyte formation at the right hip joint. The bones of the pelvis are diffusely osteopenic, which can obscure subtle nondisplaced paevic rim fractures in the patient population. The distal femoral epiphyses are partially obscured . Review of Resident #1's emergency room Record dated 08/12/16 at 2:20 a.m. revealed, .An acutely mildly impacted intraarticular comminuted fracture of the distal radius is present. The bones are diffusely osteopenic. Carpal bone alignment is maintained. Joint space narrowing, eburnation, and marginal osteophyte formation are seen within the visible interphalangeal, metacarpal phalangeal, and first carpometacarpal joints. Soft tissue swelling surrounds the wrist . Observation on 08/13/16 at 2:05 p.m. revealed LVN A to take the wander guard to the northwest door of the facility. No alarm sounded. LVN A then pushed on the door which read at the bar on the middle, Push door for 15 seconds before opening-alarm will sound. The door alarm sounded. LVN A then pulled the door shut. The magnet at the top of the door did not latch. No staff were monitoring the northwest door. Observation on 08/13/16 at 2:10 p.m. revealed the ADON to put in the code of the northwest door and opened it. The ADON then closed the door. The magnet at the top did not latch. The ADON then unplugged the electric box at the top and plugged it back in. The magnet at the top of the door then latched. Observation on 08/13/16 at 2:15 p.m. revealed the Maintenance Director to check the northwest door. The red light, which read, armed was lit, but the door was not latched via the magnet at the top of the door. Observation on 08/13/16 at 2:50 p.m. of the back of the facility revealed a small platform and then a downhill ramp that led to a sidewalk outside the northwest door. A wooden fence with a gate was about 35 feet from the northwest door. Observation on 08/13/16 at 3:20 p.m. revealed Resident #1's wander guard that had been cut off at the hospital by the ADON to have a battery expiration date of 02/2019. Observation with the Administrator and ADON on 08/15/16 from 1:45 p.m. to 2:25 p.m. revealed the Administrator to push the northwest door. The door opened without an alarm sounding. The Administrator said the door should have alarmed for 15 seconds. The northwest door had a red light on that read, armed, but the door did not alarm when it was opened. The Administrator tried the northwest door several times. The door's red armed or green disarmed lights would illuminate, but the magnetic latch took 25 seconds to secure the door. During this time, the northwest door alarm was red, meaning armed, but the magnet at the top was not latched. The Administrator said he thought it was strange that the red light was on but no alarm sounded when he exited via the door. The ADON confirmed that on Saturday, 08/13/16, the red light was on but the door opened without an alarm sounding. The Administrator pushed to northwest door stop down and propped the door open. The alarm sounded. After putting the door stop back up, the Administrator pushed in the numerical code to unlock the door, but the door did not open. He repeated the code and the door opened. When the door closed, the red light immediately lit, without the 25 second delay. The Administrator said that when the door alarm company left on Friday afternoon 08/12/16, the only door of concern was the northeast door that was connected to the wander guard system. In an interview on 08/13/16 at 2:10 p.m., the ADON said the wander guard system was not connected to the northwest door, but that the northwest door was supposed to latch at the top via the magnet when it closed. The ADON said, It's not working. In an interview on 08/13/16 at 2:50 p.m., the ADON said Resident #1 was found on the sidewalk and showed the investigator a place that was about 12 feet west of the fence and gate. She pointed at the sidewalk and said Resident #1's head was facing the gate, so the staff concluded that Resident #1 had exited the facility via the northwest door. The ADON said when EMS arrived; they put Resident #1 on a stretcher and brought her through the facility via the northwest door and through the facility to the ambulance in the front of the building. She said the facility staff wanted to know what happened and how Resident #1 was able to exit the building without alarms sounding. She said she went to the hospital and cut the wander guard off Resident #1 and took it back to the facility and checked to make sure it was working, which it was. The ADON said staff held the door open while EMS got Resident #1 on the stretcher and brought her through the facility to the ambulance in the front of the facility. In an interview on 08/13/16 at 2:15 p.m., the Maintenance Director said the door alarm company had come to the facility 08/12/16, after Resident #1 eloped on 08/11/16, and checked all of the facility's doors. He said the alarm company informed him that all doors were working properly. He said when the green light was on the door was disarmed and would open without making any sound. He said he did weekly checks of all doors, making sure the wander guard and 15 second hold alarms worked properly. In an interview on 08/13/16 at 2:25 p.m., the DON said Resident #1 was found outside on the sidewalk between the northwest and northeast door of the facility around 11:40 p.m. 08/11/16 after CNA A yelled her name and Resident #1 responded. The DON said Resident #1 was assessed by LVN B. The DON said Resident #1 complained of pain to her right leg, so LVN B went inside and notified the on-call physician, who ordered for Resident #1 to be sent to the local hospital. The DON said staff were interviewed from the 2:00 p.m.-10:00 p.m. shift as well as the 10:00p.m.-6:00 a.m. shift, and no one recalled hearing the door alarm sound, indicating someone had opened the northwest door. The DON said CNA B, who worked the 10:00 p.m.-6:00 a.m. shift, which she came on duty and made rounds to check on all residents. CNA B told the DON she did not see Resident #1 in her room around 10:30 p.m. and then answered a couple of call lights. CNA B told the DON she went back to Resident #1's room and still did not find her, so she informed her charge nurse, LVN B that Resident #1 was unable to be located. The DON said at that time, possibly around 10:45 p.m., staff on duty started looking inside the building for Resident #1. She said Resident #1's light was on and her window was shut. She said LVN B called the 2:00-10:00 p.m. nurse and confirmed Resident #1 was not out on a pass with her family. The DON said Resident #1 must have gone out the northwest door and the alarm did not sound. In an interview on 08/13/16 at 3:30 p.m., CNA A said she was notified by the 10:00 p.m.-6:00 a.m. staff that Resident #1 could not be located. She said all staff started looking for Resident #1, and that she went outside via the northeast door and yelled Resident #1's name outside and Resident #1 responded. CNA A said Resident #1 was on the west side of the gate with her head toward the gate (toward the east). She said staff did not move Resident #1, and that she stayed with Resident #1 until the EMS arrived. CNA A said Resident #1 complained of right leg pain and had facial swelling on the left side with her left eye being swollen shut. In an interview on 08/13/16 at 3:51 p.m., LVN C said she saw Resident #1 around 8:25 p.m. 08/11/16, when she administered Resident #1 her evening medications. LVN C said Resident #1 was in her usual confused state and felt a little hungry, so she gave Resident #1 a cookie and some lemonade. LVN C said Resident #1 was sitting on the side of the bed when she left the room. In an interview on 08/13/16 at 3:56 p.m., NA C said she saw Resident #1 lying in her bed after dinner on 08/11/16 around 6:45 p.m. NA C said Resident #1 normally ambulated independently, and walked around the facility often. In an interview on 08/13/16 at 4:10 p.m., the DON said she had assigned staff to sit by all doors 24/7 starting 08/13/16 at 4:00 p.m. (This was not initiated until the surveyor entered the facility) until the facility was sure all door alarms were working properly. In an interview on 08/13/16 at 4:20 p.m., the Maintenance Director said he had the door alarm company come to the facility Friday, August 12th to check all doors after Resident #1 getting out the door without an alarm sounding on Thursday, August 11th. He said the door alarm company tested the northwest door 2 or 3 times and it alarmed appropriately each time. He said he did not understand why the red light (indicating it was armed) was on yet the door was not locking via the magnet at the top. He said the northwest door alarm was older and there were problems with the control box, but the alarms at the front and northeast entrance were newer. Review of a memo from the alarm company dated 08/12/16 revealed, .To Whom It May Concern, (name of door alarm company) was called out to this facility on 08/12/16 due to an elopement of a resident. We were asked to check all egress doors in the facility for proper operation. The admin hall exit with roam alert (wander guard) was checked and found that there was interference with the controller. The interference culprit was found with the facility's tester and it was a fan in the DON's office. (This is the northeast door, which is connected to the wander guard.) Once the fan was removed from the facility, the door was tested again and the controller functioned properly the majority of the times tested , but it failed to function properly consistently. The cause of this could be that the controller is starting to malfunction. There were some minor adjustments made to the front door, which wasn't related to the incident, and it functioned properly consistently . Review of the facility's Maintenance Door Weekly Monitor Log for January-August, 2016 revealed all doors working properly. In an interview on 08/13/16 at 10:00 p.m., CNA B said she worked the night of 08/11/16, 10:00 p.m.-6:00 a.m. CNA B said she made rounds on her assigned residents around 10:30 p.m. and did not see Resident #1 in her room. CNA B said she finished her rounds about 10:30-10:40 p.m. and then asked the charge nurse, LVN B, if Resident #1 was out of the facility on pass. She said LVN B answered 'no'. CNA B said she checked Resident #1's bathroom and other staff searched the inside of the facility. She said she then went outside the northeast door and CNA A went out the northwest door. CNA A called Resident #1 ' s name and Resident #1 responded, so CNA B went through the gate to find Resident #1 lying on the sidewalk. CNA B said LVN B came and assessed Resident #1. CNA B said there were lights at the end of the building that were not very bright. CNA B said she did not hear any door alarms sound at any time, and that she thought the door alarms must not have been working. In an interview on 08/13/16 at 10:50 p.m., LVN B said she worked the night of 08/11/16 from 10:00 p.m.-6:00 a.m. LVN B said around 10:40 p.m., CNA B asked her if Resident #1 was out of the facility on pass, so she checked the book and did not find Resident #1 to be signed out. She said she then called LVN C, who worked 2:00 p.m.-10:00 p.m. and confirmed that Resident #1 was not out on pass. She said LVN C reported seeing Resident #1 around 8:25 p.m. when she administered her evening medications. LVN B said after searching the inside of the facility, CNA A went outside via the northeast door, and CNA B went outside via the northwest door. LVN B said CNA A called Resident #1's name and Resident #1 responded. LVN B said according to CNA A, Resident #1 was her 'confused normal self ', and CNA A asked Resident #1 if she fell . Resident #1 responded, no, honey I didn't fall. LVN B said she arrived and took Resident #1's vital signs. She said Resident #1 moved her left leg and turned her head to look at staff. LVN B said she noticed left side facial edema on Resident #1. She said Resident #1 complained of right leg pain so staff did not move her. She said CNA A stayed with Resident #1 while she called the physician, 911, the DON and family and prepared paperwork for EMS. LVN B said it was around 11:40 p.m. when Resident #1 was found outside. She said she did not hear any alarms when or after she arrived to work at 10:00 p.m. LVN B said she received a telephone call from the hospital around 3:00 a.m. 08/12/16 informing her that Resident #1 had a fractured right femur and fractured right wrist and was being transferred to a larger hospital for evaluation and treatment. In an interview on 08/15/16 at 1:33 p.m., the Administrator said he was called around 12:30 a.m. Friday, August 12th by the facility's charge nurse (LVN B) and informed that Resident #1 had eloped and fallen outside on the sidewalk in back of the facility. The Administrator said he did not know which door Resident #1 exited. He said he had the alarm company, Inca, at the facility Friday morning (August 12th) and that the northwest door was opened 13 times and alarmed appropriately each time. He said he did not know what happened or how Resident #1 got out, but that the door must not have alarmed when she opened it. In an interview on 08/15/16 at 3:50 p.m., Supervisor A (from the door alarm company), said he was called to the facility 08/12/16 after Resident #1 was found outside without a door alarm sounding. Supervisor A said the northwest door of the facility would alarm correctly except for every 5th to 10th time he opened it. Supervisor A said the northwest door alarm was not connected to the wander guard system. He said the alarm system for the northwest door was around [AGE] years old. He said he had ordered a new system for the northwest door alarm that would be installed upon delivery. Review of a document received by the facility 08/14/16 at 2:40 p.m., Guidelines for the Wander Guard System, read as follows: All resident will be assessed for elopement risk on admission, quarterly and when they have a change in condition that might affect the elopement risk. Residents determined to be at risk for elopement will have the following completed: 1. The resident/responsible party will be notified of the elopement assessment results showing the resident is at risk for elopement and the facility wishes to place a wander guard bracelet on the resident at this time. 2. The attending physician will be notified of the elopement assessment and a physician order [REDACTED]. 3. After consent is obtained, a wander guard bracelet will be placed on the resident's ankle or wrist and the resident will be informed of the use of the bracelet, the risk and benefits to the bracelet, the actions of the bracelet, and the staff response to the alarms. 4. The resident's plan of care will be updated to reflect the placement of the wander guard bracelet. Managing the wander guard system: 1. The wander guard bracelet on a resident will be checked every shift by the nursing staff. 2. The Maintenance Director will check the doors that have the wander guard system installed at least weekly. 3. All residents will be checked at the beginning of every shift, during routine rounds by the nursing staff, and as indicated to ensure they are safe in the facility. 4. If a wander guard bracelet is found to be malfunctioning, the bracelet will be replaced by the nursing staff. 5. If a door is not functioning properly, the Maintenance Director will immediately notify the supplier that repairs are required and the staff will monitor the exit doors until the door is properly repaired. Review of the facility's policy, Wandering, Unsafe Resident, dated 2001 and revised 02/14, received 08/13/16 at 3:10 p.m. revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 4. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file and incident report; and f. Document relevant information in the resident's medical record . Review of a document received by the facility 08/14/16 at 2:40 p.m., Guidelines for the Wander Guard System, read as follows: All resident will be assessed for elopement risk on admission, quarterly and when they have a change in condition that might affect the elopement risk. Review of the facility's policy, Elopement, dated 2001 and revised 02/14, revealed, .Staff shall investigate and report all cases of missing residents . 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file a Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file and incident report; and f. Document relevant information in the resident's medical record . Immediate Jeopardy was identified and the DON was notified 08/14/16 at 2:20 p.m. While the Immediate Jeopardy was lowered on 08/15/16 to potential for more than minimal harm, the facility remained out of compliance because it had not had time to monitor the plan for effectiveness. Review of the facility's Plan of Removal, dated 08/15/16, read as follows: Areas of Concern: Resident Safety Exit Door not working properly-The facility placed a staff person at the exit door at all times to ensure the safety of all residents. During break time or lunch time of the staff person watching the door, another staff person will relieve that person for these designated breaks. All residents that have a wander guard bracelet or are assessed as a potential elopement risk will be monitored at least every 15 minutes until the exit door is repaired and working properly. Date of Completion: 08/13/16 Staff education related to exit doors and elopement-The DON/designee in-serviced all the facility staff on elopement and neglect in reference to wandering residents and door alarms. The in-service included the monitoring of the exit door that is not functioning at all times, reporting any malfunction of any exit door to the maintenance director/designee immediately, and reporting any exit seeking of any resident to the nursing staff for immediate intervention. Completed on 08/13/16 Monitoring of Exit Doors and wandering residents-The facility will: · The nursing staff will check all exiting doors every shift to verify that they are working properly. If a malfunction is noted at any time, the facility will place a staff person at the exit door at all times as above. The nursing staff will also notify the Administrator/designee immediately. · A controller to repair the door has been ordered on Monday (08/15/16) morning and will be installed by the company as soon as it is received. Once the door is repaired, the facility will begin 15 minute checks for 24 hours then hourly checks for 24 hours then per shift for 3 days. After these checks, the doors will be checked every shift by nursing staff and at least weekly by the maintenance supervisor. Verification of the facility's Plan of Removal revealed the following: Review of the facility's Q15 Minute Door Monitor sheets revealed a start date of 08/13/16 at 2:00 p.m. (although not observed in place until 3:40 p.m.) through 08/15/16 at 3:00 p.m. Review of an in-service dated 08/14/16 entitled, Elopement, Neglect, Door alarms was signed by all facility staff and read as follows: If a resident is at risk for elopement (wears a Wander guard bracelet), exhibits exit-seeking behavior, demonstrates unusual disorientation to place and/or time, or states I'm getting out of here . Staff will monitor the resident's location a minimum of every shift if no behavior of exit-seeking or increased wandering is exhibited. Staff will monitor an exit-seeking/wandering resident a minimum of every 15 minutes. Staff will provide one-on-one accompaniment if a resident has actively exited the building until the resident is safe (Physician and family notified, orders for safety measure received and put in place). Staff will respond immediately to any door alarm. Failure to provide for safety of a resident-including preventing elopement is being neglectful. Failure to implement appropriate measures to ensure a resident's safety is being neglectful. All residents have the right to be safe in their environment. Review of the facility's in-service dated 08/13/16 at 3:45 p.m. revealed, Residents have the right to freedom. Residents who have been assessed and determined to lack a sense of safety awareness will be monitored per facility policy. Residents have the right to be free of abuse (including-but not limited to-physical and emotional). A resident will not be restrained in any fashion and will not have their movement limited without proper assessment, physician order, and consent. Facility policies will be adhered to accordingly. If it has been determined that a resident is experiencing confusion, disorientation, lack of safety awareness to the extent that elopement may occur: assessment will be completed, physician and family will be notified, physician recommendations/orders will be followed. Review of the facility's In-service Training Report dated 08/14/16; untimed, titled Doors-secured, revealed it signed by all facility staff and read as follows: If you find a door that is not locking properly or is not closing properly, (maintenance director's name) is to be notified immediately and a staff member will remain at that door at all times until informed by (maintenance director's name) door is repaired/operating properly . Review of the facility's In-service Training Report, dated 08/13/16, untimed, titled Monitor Sheets, revealed it signed by all staff and read as follows: Q (every) 15 minute door monitoring sheets, Q (every) 30 minute monitor sheets, will be completed as timed until notified otherwise

Based on interviews and record reviews the facility failed to provide 1 of 2 residents (Resident #1) reviewed for elopement risk adequate supervision to prevent elopement from the facility. Resident #1, who was confused, cognitively impaired, and had a history of [REDACTED]. On 09/17/12, the facility was notified by a neighbor, Resident #1 was walking down the street, approximately eight blocks from the facility (0.5 miles or 2535 feet). The facility was located approximately 450 feet from a major four lane highway. This was determined to be past immediate jeopardy from 09/17/12 to 09/24/12 due to the facility having taken some corrective measures, but did not incorporate this into their quality assurance program. This failure could have affected the two residents identified as elopement risk and could have placed them at risk for serious injury or death. Findings included: Record review of Resident #1's Record of admitted d 04/04/12 revealed she was a [AGE] year old female, admitted to the facility 03/07/12 with [DIAGNOSES REDACTED]. Record review of Resident #1's admission orders [REDACTED]. Record review of Resident #1's Admission Data Summary dated 03/07/12 revealed she was able to transfer independently and her mobility was independent with an assistive device. Cognitively she was assessed to be alert, with short and long term memory problems, severely impaired for decision making, with behavioral symptoms of wandering, and verbally and physically abusive. Record review of Resident #1's Monthly Resident Condition Review dated 04/17/12 revealed wandering behaviors exhibited 4-6 days within the last seven days, moderately impaired cognitively for daily decision making. The assessment revealed Resident #1 "...ambulates in hallways with wheelchair, walks short distances in room ..." Record review of Resident #1's Monthly Resident Condition Review dated 05/17/12 revealed wandering behaviors exhibited 4-6 days within the last seven days, moderately impaired cognitively for daily decision making. The assessment revealed Resident #1 "...ambulates in hallways with wheelchair, walks short distances in room ..." Record review of Resident #1's Psychiatric Progress Note dated 06/28/12 revealed the following assessment: "...therapist met with client who was up in her W/C (wheelchair) alert anxious with delusional thought content noted. Client exhibited perseveration (uncontrolled repetition) in her speech. Client was focused on getting to her mail box which staff states she does not have anymore. She was sitting outside in the sun near the road. She did not respond to redirection by completely changing the subject. Therapist notified the BOM (Business Office Manager) regarding concern the client might pose a flight risk at some point in time. It must be noted that this is where client is from and her memory is coming back regarding the area. As time passes without some intervention client will attempt to leave facility grounds ..." Record review of Resident #1's Nurse's Notes dated 06/30/12 revealed a neighbor to the facility called to notify them a resident was wheeling down the street in their wheelchair. Resident #1 was located one block from the facility (Elopement #1). Record review of Resident #1's Incident Report dated 06/30/12 revealed a neighbor notified the facility Resident #1 was rolling down the street in her wheel chair. Resident #1 was found one block away from the facility. Resident #1's comment noted in the incident report was "...I was going to the post office ..." The facility's intervention to the elopement was to place a wander guard on her wheelchair. Record review of Resident #1's Nurse's Notes dated 07/02/12 revealed she went outside the facility at 2:30 p.m. She was followed by facility staff. A wander guard was placed on her wheelchair at 11:30 p.m. On 07/03/12 Resident #1's Nurse's Notes document she was seen pushing and kicking on the back door trying to get out. In an interview on 10/25/12 at 3:07 p.m. the Director of Nursing (DON) stated Resident #1 did not have a wander guard in place prior to the elopement on 06/30/12 and attempted elopement on 07/02/12. Record review of Resident #1's Nurse's Notes dated 08/03/12 revealed she was extremely agitated and yelling out. She was attempting to leave the facility. Record review of Resident #1's Nurse's Notes dated 08/05/12 revealed at 1:00 p.m. she asked a housekeeper if she could go outside. At 2:50 p.m. she was seen standing outside the front door. She had gotten out of her wheelchair and went outside. She was "coaxed" back into the facility by nurse and CNA. Record review of Resident #1's Nurse's Notes dated 08/06/12 revealed she had gotten out of her wheelchair and walked out the front door and sat on the front steps. Unnamed staff asked Resident #1 was she was outside unsupervised. Resident #1 stated she could walk a short distance. No documentation of any new interventions placed by the facility was available for review. Record review of Resident #1's Psychiatric Progress Note dated 08/13/12 revealed "...therapist met with client who exhibited a significant increase in her level of anger and anxiety. Client states she does not need a walker any longer and does not know why she is here. She exhibit delusional thought content and has a significant history of psychotic behaviors ..." Record review of Resident #1's Nurse's Notes dated 09/07/12 revealed she went outside with a Certified Nurse's Aide (CNA) and got "severely agitated screaming" when it was time to go back inside the facility. Record review of Resident #1's Nurse's Notes dated 09/17/12 revealed she left the facility without the supervision of any staff member. Resident #1 was located and returned to the facility (Elopement #2). A wander guard was placed on her left ankle. Record review of Resident #1's Provider Investigation Report dated 09/18/12 revealed a community member telephoned the facility on 09/17/12 at approximately 2:42 p.m. to report Resident #1 was seen walking down the street in the community. The Director of Nurses (DON), the Business Office Manager (BOM), and LVN A left the facility to look for Resident #1. Resident #1 was located approximately eight blocks from the facility. Record review of walking directions of Resident #1's route obtained at <http://mapq.st/YiLGAW> revealed the walking distance of 0.48 miles (2535 feet) to take approximately 11 minutes. Record review of walking directions of the nearest major four lane highway located by the facility revealed the walking distance of 0.08 miles (450 feet). Record review of Resident #1's Nurse's Notes dated 09/18/12 revealed she was observed at 10:00 a.m. sitting in the lobby without the wander guard in place. At 2:00 p.m. a new wander guard was placed on her right wrist. Resident #1 was observed attempting to cut the wander guard off with a knife. Record review of a faxed correspondence between the facility and Resident #1's Primary Care Physician dated 09/18/12 revealed a new order for Risperdal Consta (an injectable, long acting, antipsychotic medication used to treat Schizophrenia). Record review of Resident #1's treatment sheets revealed no documentation of placement check for the presence of a wander guard for May 2012 or June 2012. The July 2012 Treatment Sheet documented the wander guard to wheel chair placement check was done on 07/02/12 only. The September 2012 Treatment Sheet revealed monitor to left ankle initiated on 09/17/12. Monitor placement check discovered it was removed on 09/18/12 and a new monitor was placed on the right wrist. Record review of Resident #1's Nurse's Notes dated 09/19/12 revealed the DON questioned her about the wander guard that was not attached to her wrist. Resident #1 hit the DON and walked out the front door. Facility staff stayed with Resident #1 until she was calm and escorted her back into the building. It was documented to be the second time the resident has removed the wander guard. Record review of Resident #1's Nurse's Notes dated 09/22/12 revealed at 3:30 p.m. the facility cook reported to the Charge Nurse that Resident #1 was walking down the street. Resident #1 was picked up 3 blocks from the facility in the personal vehicle of the CNA on duty. Resident #1 was "...belligerent after coming into the building, hitting, kicking, cussing and threating staff..." (Elopement #3). In an interview on 10/24/12 at 12:06 p.m. CNA A stated she knew Resident #1. She explained Resident #1 lived on the back hall and she normally worked on the front hall. CNA A said she had heard Resident #1 had attempted to leave the building several times and would cut off her wander guard. CNA A said everyone kept an eye on Resident #1. CNA A said she had recently received training for residents with exit seeking behaviors. In an interview on 10/24/12 at 12:53 p.m. CNA B said she worked on the back hall and had taken care of Resident #1. She said Resident #1 often refused care. She said Resident #1 would have "outbursts" and sometimes get upset. CNA B said Resident #1 was able to dress independently and often wore long pants and long sleeved shirts. She said Resident #1 did not like to be touched and was often unable to check placement of the wander guard. CNA B said Resident #1 would sit in the front of the facility in the dining room and watch television most days. CNA B said all the staff watched Resident #1. In an interview on 10/24/12 at 1:10 p.m. CNA C said she provided care for Resident #1. CNA C described Resident #1 as fine when she first came to live in the facility but then she "got mean" . CNA C explained Resident #1 being mean by yelling at staff and other residents. CNA C said Resident #1 used to walk all over town when she lived in the community. CNA C said at first Resident #1 would just sit outside. She said Resident #1 did not start walking off until later, that was when the wander guard was placed. CNA C said the nurses check the wander guards to see if they are in place. CNA C said the staff working in the front would keep an eye on Resident #1 when she was sitting in the dining room watching television. CNA C said the DON and the Skin Nurse would watch out the front windows for Resident #1. In an interview on 10/25/12 at 1:35 p.m. CNA D said she was unaware of Resident #1's elopement on 09/17/12 until after it occurred. CNA D said it was everyone's responsibility to ensure the wander guards were in place. She said on the day Resident #1 eloped (09/17/12) she was looking for her to assist with showering and overheard the DON telling other staff about the incident. In an interview on 10/25/12 at 2:24 p.m. LVN A said she always worked on the front hall and did not take care of Resident #1. She said she often saw Resident #1 sitting in the dining room watching television. She said everyone kept an eye on Resident #1 when she was in the dining room. LVN A said she went with the DON and the BOM to retrieve Resident #1 on 09/17/12. She said Resident #1 was found about seven blocks from the facility. LVN A said it was a team effort to ensure wander guards were in place. In an interview on 10/25/12 at 11:45 a.m. the Administrator stated he immediately provided in-services to the staff working on 09/17/12 for the 2:00 p.m. to 10:00 p.m. shift upon the return of Resident #1 to the facility. He stated the staff were to monitor her closely for repeated attempts to elope. He stated the facility staff provided 1:1 observation for Resident #1 immediately following her elopement on 09/17/12. He said she would wander all over the building, but once she went to bed she stayed in her room and did not present an elopement risk. He said, he in-serviced each shift as they reported for duty on 09/18/12. He provided his time sheet that documented his clock out time as 8:45 p.m. on 09/19/12 and 8:15 p.m. on 09/20/12 were he provided the 1:1 observations of Resident #1. The Administrator said the Interdisciplinary Care Team met to review Resident #1's needs. He explained the team consisted of the DON, the ADON, and himself. He said the Maintenance Supervisor checked the wander guard system weekly to ensure it was working properly. The Administrator said once the facility was aware Resident #1 was repeatedly removing the wander guard device and continuing to attempt to elope, it was determined by the Interdisciplinary Care Team the facility was not able to provide the level of care required to keep Resident #1 safe. The Administrator stated 1:1 observation was provided for Resident #1 until her discharge on 09/24/12. In an interview on 10/25/12 at 2:47 p.m. Resident #1's Primary Care Physician stated he had been her doctor for several years. He stated Resident #1 was not able to walk independently until recently. He stated she started to refuse all of her medications and then started to experience behaviors. He said she became very impulsive, with goal seeking behaviors. He explained, when Resident #1 lived in the community she would walk all over town. He said without the help of her medication, Resident #1 began to exhibit the desire to repeat this behavior. Resident #1's Primary Care Physician said she would not be able to make safe decisions. He said she would probably not know to not step into the street into traffic. In an interview on 10/25/12 at 3:07 p.m. the Director of Nursing (DON) stated Resident #1 was wheelchair dependent until sometime in August 2012. She said the facility placed a wander guard on her wheelchair after the 06/30/12 elopement. The DON said the facility did not place the wander guard on Resident #1 until after the elopement on 09/17/12. The DON said after Resident #1 removed the wander guard twice and continued to exhibit exit seeking behaviors. She said the Interdisciplinary Care Team determined the facility could not provide the necessary care to keep her safe. She explained Resident #1 needed to be in a more secure environment where she could safely go outside. She said that was not feesable in their facility. The DON said she attempted to contact Resident #1's family to discuss the need to move her to a more secure facility, but got no response. The DON said she began looking for more secure placement for Resident #1 after the resident removed the third placement of the wander guard and attempted to elope on 09/19/12. She said she called numerous facilities, contacted Mental Health/Mental Retardation (MH/MR), and even spoke to the county judge for help to find placement for Resident #1. The DON stated only one other resident in the facility had a wonder guard in use. She said he was an elopement risk at the time the wander guard was placed on his wheelchair, but no longer exhibited exit seeking behaviors. The DON said he was not ambulatory without his wheelchair. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 9/17/12 until 9/24/12. On 10/25/12 at 5:20 p.m. the Administrator was informed that there was an immediate jeopardy. The facility took the following action to correct the non-compliance prior to the survey. 1. All facility staff were in-serviced on Residents At Risk for Elopement, Policy for Missing Residents, and Residents with Wander Guards. 2. An Interdisciplinary Care Team met on 09/19/12 to address this incident and corrective measures. According to the administrator currently there were no residents who resided in the facility at risk for elopement or exhibiting exit seeking behaviors.