Every finding on record at Avir at Pilot Point

Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #4) reviewed for comprehensive care plans. The facility failed to ensure Resident #4's comprehensive care plan addressed the resident's diagnosis of dementia and included appropriate interventions to meet the resident's identified needs. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: Record review of Resident #4's, face sheet dated 07/29/2026, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, severe, with other behavioral disturbance (severe dementia causing significant memory and thinking impairment with associated behavioral symptoms). Record review of Resident # 4's admission MDS, dated [DATE] reflected her BIMS score was coded as 00 out of 15, which indicated she was unable to complete the BIMS interview due to severe cognitive impairment. Record review of Resident #4's initial care plan, dated 07/03/2026, did not address the resident's dementia diagnosis. Record review of Resident #4's hospital discharge paperwork, dated 07/02/2026, reflected a diagnosis of severe dementia. Observation and interview on 07/28/2026 at 10:00AM with Resident #4, revealed she was lying in bed holding a baby doll. She was unable to provide meaningful responses to questions. The resident's' answers were not relevant to the questions asked and did not demonstrate an understanding of the interview. During an interview on 07/29/2026 at 12:03 PM with the MDS Nurse, she reported she completed resident's' initial and comprehensive care plans. She reported she used information from resident's' hospital records, transfer orders, nurse's' notes, and observations to complete resident care plans. She confirmed Resident # 4's comprehensive care plan did not address her diagnosis of dementia. She stated it should have been added to the plan and was an oversight. During an interview with DON on 07/30/2026 at 10:15 AM, she reported Resident #4's dementia should have been addressed in the resident's comprehensive care plan. She further explained if the care plan was incorrect, a resident may not receive accurate services, or an order may not be followed or missed. Record review of facility policy titled 'Dementia - Clinical Protocol,' dated November 2018, stated in part: For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (North Hall) out of 3 hallways and two of five residents (Resident #10 and Resident #34) reviewed for accidents and hazards. The facility failed to ensure two pairs of scissors and two nail clippers were not on Resident #10's bedside table on 07/28/2026.The facility failed to ensure a pair of scissors was not on Resident #34's bedside table on 07/28/2026.The facility failed to ensure that the mechanical lift on the North Hall was stored and locked in a secure manner. These failures could place residents at risk of falls and/or injuries and could place residents at risk of avoidable accidents.Findings included: 1.) Record review of Resident #10's Face Sheet, dated 07/29/2026, reflected an [AGE] year-old female, readmitted on [DATE]. The resident was diagnosed with Type 2 Diabetes (a chronic condition where the body cannot use insulin properly and sugar builds up in the blood), lack of coordination, and generalized muscle weakness. Record review of Resident #10's Quarterly MDS Assessment, dated 07/06/2026, reflected a BIMS score of 14 indicating cognitive function is intact and diagnosis of macular degeneration (a common eye disease that damages the macula, causing blurriness or loss in your sharp, central vision). Record review of Resident #10's Care Plan, dated 02/24/2026, reflected she had an ADL self-care performance deficit related to activity intolerance, fatigue and impaired balance and required the assistance of at least one staff member for ADLs such as transfers, repositioning, dressing, bathing/showering, and other personal hygiene activities. Resident #10 was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia (a medical condition where blood sugar (glucose) drops below normal levels), physical impairment/ skin desensitized to pain or pressure, slow healing process R/T DX of Diabetes Mellitus. During an observation on 07/28/2026 at 11:10 AM, Resident #10 was in her room, sitting in wheelchair and watching television. Her room was clean and homelike. It was observed that on top of her bedside table were 2 pairs of scissors and 2 nail clippers unattended and within reach. During an interview on 07/28/2026 at 11:10 AM, Resident #10 stated the scissors, and nail clippers were her own and she used them when she wanted to cut things and trim her nails. During an interview on 07/28/2026 at 11:15 AM, RN A stated she was not aware Resident #10 had scissors and nail clippers in her room. RN A stated that Resident #10 was diabetic and should not clip her own fingernails due to risk of injury and infection. RN A removed the items for safe storage. 2.) Record review of Resident #34's Face Sheet, dated 07/29/2026, reflected an [AGE] year-old female, readmitted on [DATE]. The resident was diagnosed with Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and Anxiety Disorder ( a mental health condition involving excessive, ongoing fear and worry that make it hard to do everyday tasks). Record review of Resident #34's Quarterly MDS Assessment, dated 04/30/2026, reflected a BIMS score of 08 indicating moderate cognitive impairment and diagnosis of macular degeneration (a common eye disease that damages the macula, causing blurriness or loss in your sharp, central vision). Record review of Resident #34's Care Plan, dated 12/29/2022, reflected she had an ADL self-care performance deficit and required the assistance of at least one staff member for ADLs such as dressing, bathing/showering, and other personal hygiene activities. During an observation and interview on 07/28/2026 at 11:50 AM, Resident #34 was in her room, sitting in her wheelchair and watching television. Her room was clean and homelike. It was observed that on top of her bedside table were a pair of scissors unattended and within reach. Resident #34 stated the scissors belonged to her and she used them to cut things. During an interview on 07/28/2026 at 11:51 AM, the ADON stated she was not aware Resident #34 had scissors in her room. The ADON stated the item should not be inside Resident #34's room because it could cause harm or injury to Resident #34. The ADON witnessed the scissors at Resident #34's bedside table and removed the item for secured storage. During an interview on 07/30/2026 at 10:00 AM, CNA A stated no residents were allowed to have sharp objects in their room due to risk of cutting or harming themselves. CNA A stated she was not aware Residents #10 and #34 had scissors and nail clipper their rooms. CNA A stated those items should have been removed and kept in a safe place. During an interview on 07/28/2026 at 11:00 AM, the DON stated Resident #10 was resistive to staff removing her personal belongings including the scissors and fingernail clippers. She stated her expectation was that staff removed sharp and dangerous items from resident rooms and stored them for supervised use. The DON stated the risk to residents could be danger to themselves. 3.) Observation on 07/30/26 at 9:25 AM of North hall revealed an unlocked and unsecured mechanical lift parked in a resident's room where 2 residents were observed in their beds. During an interview on 07/30/26 at 9:30 AM with LVN A revealed he was the LVN working on North Hall. He stated that mechanical lifts should be stored away from high traffic areas where residents could access them and get hurt. He stated he had been in-serviced on mechanical lifts to include storage. LVN A removed the mechanical lift from the room. During an interview on 07/30/26 at 9:38 AM with RN B, she stated that mechanical lifts should always be locked in the common areas, such as the hallways when they are not being used. RN B stated that mechanical lifts are stored at the end of the hall away from residents. She stated failure to lock mechanical lifts could cause accidents to include that someone could break a body part, such as an arm or leg when a mechanical lift is unlocked. During an interview on 07/30/26 at 10:00 AM with CNA A, she stated she left the mechanical lift in the residents' room. She stated she got called away for patient care. She stated she should not have left it in the room as it could have caused an accident. She stated one of the residents could have tripped over it or rolled into it. She stated she has been in- serviced on mechanical lifts to include storage. During an interview on 07/30/26 at 12:15 PM with the DON, she stated that her expectation was that all mechanical lifts were to be locked when they are not being used. The DON stated that all staff have been educated and trained in the proper usage and safety of mechanical lifts. She stated that she will re-educate staff with In-Service training on Mechanical Lifts and Mechanical Lift Storage and Safety. She stated that there was a risk to residents if attempted to pull themselves up using an unlocked and unsecured mechanical lift, which could cause injuries. A request to the administrator for the facility's Mechanical/Lift policy was requested on 07/30/2026 at 10:28 AM and was not received by the time of exit. Record review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, policy statement stated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.The policy did not address residents' possession of sharp and dangerous objects.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were properly stored in the dry food pantry. These failures could place residents at risk for food-borne illnesses.Findings included: During an observation of the facility's dry food pantry on 07/28/2026 at 09:26 AM revealed a 16-ounce jar of powder beef base was not labeled with a best by date, shipping label or expiration date. During an interview with the Dietary Manager on 07/30/2026 at 09:50 AM, she stated the expectation for the dietary staff was to make sure all items are properly labeled and they must have missed that one. She further stated that residents were at risk for food-borne illnesses if food is not stored properly, however in this instance she did not think there was a risk for the residents because they go through a jar a week and it would be used before the best by date. A record review of the facility's Food Receiving and Storage policy, revised November2022, the policy statement stated, Foods shall be received and stored in a manner that complies with safe food handling practices.

Based on observation, interview, and record review the facility failed to establish and maintain 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 for one (Resident #1) of five residents reviewed for infection control. The facility failed to ensure Resident #1's catheter tubing remained off the floor. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Review of Resident #1's Face Sheet, dated 03/03/26, reflected she was a [AGE] year-old female who most recently admitted to the facility on [DATE], with diagnoses including retention of urine (the inability to completely or partially empty the bladder). Review of Resident #1's MDS Assessment, dated 02/21/26, reflected she was identified as having an indwelling urinary catheter. Review of Resident #1's Care Plan, dated 11/24/25, reflected Resident #1 was identified as having an indwelling urinary catheter. An intervention included, .ensure privacy bag and leg strap or anchor are in place. Review of Resident #1's Physician's Orders, dated 03/03/26, reflected she had active orders including: .Check Foley catheter tubing secure device placement every shift. Every shift. May use leg strap to secure Foley in place. Observation of Resident #1 on 03/03/26 at 10:00 AM revealed she was sitting in her wheelchair in the hallway. Resident #1 had a catheter in place; the catheter tubing was observed touching the floor. During an interview with LVN A on 03/03/26 at 10:15 AM, he confirmed Resident #1's catheter tubing was touching the floor. He stated the catheter tubing should have been attached to a clip under Resident #1's wheelchair, which would prevent it from touching the floor. LVN A attempted to locate the clip under Resident #1's wheelchair but was unable to do so. He stated he did not know why the clip was not present. LVN A stated the risk of catheter tubing being on the floor included potential infection control issues. During an interview with the Director of Nursing on 03/03/26 at 12:26 PM, she stated she had been made aware, by LVN A, that Resident #1's catheter tubing was touching the floor. She said the catheter tubing should have been attached to a clip under Resident #1's wheelchair, which would prevent it from touching the floor. The Director of Nursing stated the risk of catheter tubing being on the floor included potential infection control issues. Review of the facility's Catheter Care, Urinary policy, dated 07/2024, reflected, Infection Control. b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for respiratory care.The facility failed to ensure Resident #1's breathing mask (used to receive medication by breathing in mist through the nose and mouth) was not on the nightstand unbagged on 01/06/2026.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure) and COPD (lung condition that makes it difficult to breathe).Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 12/24/2025, reflected moderately impaired cognition with a BIMS (tool used to measure cognitive status) score of 10. Section I (Active Diagnoses) reflected the resident was treated for COPD. Record review of Resident #1's Baseline Care Plan, dated 12/18/2025, reflected the resident was treated for COPD. Interventions included Monitor and report signs of respiratory distress.monitor oxygen saturation as ordered.administer medications per order. Record review of Resident #1's Physician's Orders reflected Ipratropium-Albuterol 0.5 mg - 2.5 mg/ml. 1 vial every 8 hours for wheezing x 2 days. Start date 01/01/2026. End date 01/02/2026. Record review of Resident #1's Medical Administration Record revealed the last breathing treatment was administered on 01/02/2026. During an observation and interview on 01/06/2026 at 10:18 AM, Resident #1 was lying in bed awake. The bed was placed against the wall, and the foot of the bed was near the door. The nightstand was placed parallel to the bed, approximately three feet from the head of the bed. The side of the nightstand was visible upon entering the room. The nebulizer machine was on top of the nightstand. The mask and tubing were connected to the nebulizer and hung from the side of the nightstand. It was not in a bag. Resident #1 stated she did not remember when she had the last breathing treatment. During an observation and interview on 01/06/2026 at 10:23 AM, LVN B went to Resident #1's room. He stated it looked like someone had given a breathing treatment and did not put the nebulizer mask in a bag. He stated he had not provided a breathing treatment to Resident #1 and had not noticed it on her nightstand. LVN B stated it should be bagged up when not in use to prevention respiratory infection. LVN B stated he would remove the nebulizer mask and tubing and discard it. During an interview on 01/06/2026 at 12:13 PM, the Administrator stated all respiratory items should be bagged when not in use. She stated it was for infection control. During an interview on 01/06/2026 at 1:08 PM, the DON stated a nebulizer mask should be stored in a bag and dated when not in use. The DON opened her tablet and stated the resident had an order to receive a breathing treatment every eight hours for two days. She stated the order ended 01/02/2026. She stated the nurse who gave the breathing treatment was primarily responsible for ensuring the mask was placed in a bag after the treatment was completed. The DON stated the nebulizer mask should not have been left on Resident #1's nightstand unbagged. She stated it was important for staff to monitor those items to ensure they were stored properly. She stated it was important to prevent respiratory infection.The facility did not have a policy specifically related to storing breathing masks and tubing.

Based on observations, interviews, and record review, the facility failed to ensure personal privacy was provided for treatment and confidential records for seven (Resident #3, Resident #17, Resident #27, Resident #29, Resident #43, Resident #54, and Resident #100) of sixteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure LVN B would not check Resident #17's blood sugar and administer her insulin in the hallway on 06/04/2025. 2. The facility failed to ensure LVN A secured Residents #3, #27, #29, #43, #54, and #100's medical information when he left his cart unattended on 06/04/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #17's Face Sheet, dated 06/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #17's Comprehensive MDS Assessment, dated 04/21/2025, reflected the resident had a severe impairment (required significant assistance and support in daily life) in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin in the last seven day. Record review of Resident #17's Care Plan, dated 05/20/2025, reflected the resident had diabetes mellitus and the interventions were to administer medication and check the blood sugar as ordered. Record review of Resident #17's Physician Order, dated 02/13/2025, reflected Insulin Regular Human Injection Solution Pen-injector 100 UNIT/ML (Insulin Regular (Human)) Inject subcutaneously (administer under the skin) with meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Observation and interview on 06/04/2025 at 6:31 AM, LVN B stated he was going to check Resident #17's blood sugar and would administer her insulin afterwards. He prepared his alcohol wipes, a push button lancet, test strip, and a glucometer. He inserted the test strip into the glucometer and then approached the resident, bringing with him the things he prepared. Resident #17 was in her wheelchair in the hallway. He pricked the residents left pointing finger, scooped the blood with the test strip, and said the blood sugar was 179. He said he would be giving the resident 2 units of insulin as per sliding scale. He then prepared the insulin and went back to the resident who was still in the hallway. He pulled the resident's shirt up, exposed the resident's abdomen and injected the insulin on the left lower quadrant of the resident's abdomen. Observation on 06/04/2025 at 6:37 AM revealed the ADON was coming out of her office and saw LVN B administering insulin to Resident #17. She told LVN B that he should have taken the resident back to her room to administer the insulin or went inside the ADON's office, which was approximately six steps away from where the resident was, to do the treatment. In an interview on 06/04/2025 at 6:42 AM, LVN B stated he should have done the treatment inside the Resident #17 room to provide privacy. He said every treatment should be done inside resident's room or somewhere where others would not see the treatment being done for the resident. He said he would not do it again. 2. Record review of Resident #3's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with urinary incontinence (loss of bladder control). Record review of Resident #3's Progress Notes, dated 06/02/2025, reflected Res refused x 2 on final round resident allowed CNA to change linens clothes and brief. Record review of Resident #27's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #27's Blood Sugar, dated 06/04/2025 at 3:37 AM, reflected the value of the resident's blood sugar was 271.0 mg/dL. Record review of Resident #29's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus and schizoaffective disorder (a mood disorder). Record review of Resident #43's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with abnormalities of gait and mobility. Record review of Resident #43's Progress Notes, 05/27/2025, reflected partial report from hospital. Patient will be admitted for fracture (a break in the continuity of the bones) of left humerus (long bone of the upper arm). Record review of Resident #54's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pain. Record review of Resident #54's Physician Order, dated 05/08/2025, reflected Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth three times a day for pain. Record review of Resident #100's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and neuromuscular dysfunction of the bladder (the normal bladder function is disrupted due to nerve damage). Observation on 06/04/2025 at 7:29 AM revealed a piece of paper was on top of nurse's cart parked in the hallway. The piece of paper indicated that Resident #3 was checked and changed, Resident #27 had diabetes mellitus 1 and with a blood sugar of 271, Resident #29 had diabetes mellitus 2 and was exhibiting restlessness, Resident #43 was on Medicare and had a fracture to the left humerus, Resident #54 refused Norco, and Resident #100 was on oxygen and had a catheter. It was observed that nobody was attending the cart, and the cart was facing the hallway. Several staff and residents were passing by the cart. In an interview on 06/04/2025 at 7:35 AM, LVN A stated he should have made sure that the shift report form was not facing up when he left the cart to administer medication. He said on the shift report form was medical information about the residents and should be confidential. LVN A stated he should have flipped the paper when he left the cart or placed it under his laptop because the information could be exposed and be seen by unauthorized individuals. LVN A said he would be mindful that no information about the residents would be left on top of the cart. In an interview on 06/05/2025 at 6:19 AM, the ADON stated all the care and treatments done for the residents should be completed in the privacy of their rooms. She said she saw LVN B administered the insulin in the hallway and corrected the staff right there and then because it was not proper to administer the insulin in the hallway. She also said that personal and medical information about a resident should be confidential and protected. She said the staff should have secured the paper before leaving the cart unattended. She said the expectations was for the staff be mindful and perform the treatment inside the room and that any information about the residents were not left on top of the cart for everyone to see. She said she would coordinate with the DON too do an in-service pertaining to privacy and confidentiality. In an interview on 06/05/2025 at 7:13 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care or treatment to prevent embarrassment and no information was left on top of the cart unsecured. She said the expectation was for the staff to do all the treatment provided inside the room and that no paper with the residents' medical information left on top of the cart. She said she would coordinate with the DON to do an in-service about providing privacy and confidentiality. In an interview on 06/05/2025 at 8:09 AM, the DON stated providing treatment in the hallway was unacceptable. She said being late was not an excuse to check the blood sugar and administer insulin in the hallway. She said he should have ushered the resident to her room or went to the office which is near to where the resident was. She said the residents should be provided privacy at all times. She said the shift report should not had been left unattended with all the medical information about some residents were written. She said it was a HIPPA violation. She said the expectation were that the residents were provided privacy, and that the medical information of the residents were secured. She said she would do an in-service about privacy during and confidentiality of the residents' medical information. Record review of the facility's policy, Dignity 2001 MED-PASS, Inc. revised February 2021 revealed Policy Statement: Each resident shall be cared for in a manner that promotes . self-esteem . Policy Interpretation and Implementation . 10. Staff protect confidential clinical information . 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Record review of the facility's policy, Resident Rights 2001 MED-PASS, Inc. revised February 2021 revealed Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . Policy Interpretation and Implementation . t. privacy and confidentiality. Record review of the facility's policy, Confidentiality of Information and Personal Privacy 2001 MED - PASS, Inc. revised October 2017 revealed Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . Policy Interpretation and Implementation . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 2. The facility will strive to protect the resident's privacy regarding his or her . b. medical treatment.

Based on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for five (Residents #3 #5, #21, #29, and #50) of twelve residents reviewed for Care Plans Revision. The facility failed to complete a quarterly care plan for Residents #3, #5, #21, #29, and #50. This failure could place the residents at risk of care and needs not being met. Findings included: Resident #3 Record review of Resident #3's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #3's Comprehensive Care Plan on 06/04/2025 reflected the last quarterly care plan completed for the resident was on 09/06/2024. Record review of Resident #3's Comprehensive MDS Assessment on 06/04/2025 reflected the last MDS was done on 05/14/2025. Resident #5 Record review of Resident #5's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #5's Comprehensive Care Plan on 06/04/2025 reflected the last quarterly care plan completed for the resident was on 01/12/2025. Record review of Resident #5's Comprehensive MDS Assessment on 06/04/2025 reflected the last MDS was done on 04/15/2025. Resident #21 Record review of Resident #21's Face Sheet, dated 06/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #21's Comprehensive Care Plan on 06/04/2025 reflected the last quarterly care plan completed for the resident was on 01/29/2025. Record review of Resident #21's Comprehensive MDS Assessment on 06/04/2025 reflected the last MDS was done on 03/31/2025. Resident #29 Record review of Resident #29's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #29's Comprehensive Care Plan on 06/04/2025 reflected the last quarterly care plan completed for the resident was on 01/22/2025. Record review of Resident #29's Comprehensive MDS Assessment on 06/04/2025 reflected the last MDS was done on 03/26/2025. Resident #50 Record review of Resident #50's Face Sheet, dated 06/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #50's Comprehensive Care Plan on 06/04/2025 reflected the last quarterly care plan completed for the resident was on 12/27/2024. Record review of Resident #50's Comprehensive MDS Assessment on 06/04/2025 reflected the last MDS was done on 05/23/2025. Observation and interview on 06/05/2025 at 7:13 AM, the Administrator stated all the residents should be care planned accordingly and timely to make sure all the current care needed by the residents were provided. She said without the care plan, the staff would not know and understand what kind of care to provide. The Administrator checked on Resident #21's care plan and saw that the last care plan done was dated 01/29/2025. She said the DON was the one doing the care plan and she would reach out to her to let her know about the issue. She said the expectation was for all the residents were care planned accordingly and that the care plans were updated quarterly and when needed. She also said she would coordinate with the DON to make sure the care plans were current. Observation and interview on 06/05/2025 at 8:09 AM, the DON stated she was responsible for doing the care plan. She said every resident needed a thorough care plan to ensure the residents received the care proper to their needs. She said the care plan should be in place so the staff providing care would be on the same page. She added, without the care plan, there could be confusion with the care of the residents. She said the care plan should be done quarterly to monitor if there were new interventions or to assess if the goals were not being met. She said the care plan could also be updated if there was a change in condition. She said if the care plan was not updated, as if they were not doing their due diligence in terms of assessing the residents. She turned on her laptop and logged in. She went to Resident #21's profile and saw the date of the last care plan. She did the same for Resident #3, #5, #29, and #50. She said it was an oversight on her side because she was the one responsible in making the care plans. She said she would audit the care plans of the residents and plan to finish the audit in the coming week. In an interview on 06/05/2025 at 10:42 AM, the MDS Coordinator stated the care plans were done upon admission and quarterly afterwards. She said the care plans were also updated if there was a change in condition. She said all the care plans should be reflected on the residents' profile so the staff could have access on them. She said after every care conference, the care plan should be placed on the residents' profile. She said she was doing the MDS and the DON was the one doing the care plans. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered 2001 MED - PASS revised March 2022 revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives . to meet the resident's . needs is developed and implemented for each resident . Policy Interpretation and Implementation . 12. The interdisciplinary team reviews and updates the care plan . d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food being served to residents was covered. This failure could place residents at risk for cross contamination and other air-borne illness. Findings included: Observation on 06/05/25 at 12:30 PM of three test trays presented to the Health & Human Services investigators, reflected: Observation of the lunch test tray containing the regular diet, included the dish of food was covered with a cloche (a dome shaped cover used in food service to keep food warm); however, the desert dish containing a slice of cake with frosting was uncovered. Observation of the lunch test tray containing the mechanical soft diet, included the dish of food was covered with a cloche; however, the desert dish containing a slice of cake with frosting was uncovered. Observation on 06/05/25 at 12:02 PM of an opened meal tray cart on the South Hall, reflected: Observation of the trays in the cart contained the dishes of food were covered with cloches and the drinks were covered with saran wrap; however, the desert dishes containing slices of cake with frosting, were uncovered. The cart remained open for approximately two minutes, as C.N.A. D passed trays to residents in their rooms. In an interview on 06/05/25 at 12:18 AM with the Dietary Manager, she stated they cover the foods before sending the trays out, to prevent cross contamination. She stated the deserts were not covered because they didn't have to be, because they were going straight to the cart from the kitchen, so they were not being exposed to possible cross contamination. She stated staff are supposed to keep the carts closed after pulling each tray, to prevent cross contamination. In an interview on 06/05/25 at 12:27 PM with the Administrator and DON, revealed the Administrator stated food is supposed to be covered to prevent anything in the air from getting to the food. The DON agreed with the Administrator's statement. In an interview on 06/05/25 at 1:00 PM with C.N.A. F, she stated food has to be covered to keep the temperature of the food warm and to protect the food from germs and flies. She stated staff are to close the carts after pulling each tray to keep the food warm and to reduce chances of anything getting to the food. In an interview on 06/05/25 at 1:18 PM with C.N.A. D, she stated the dishes and drinks are covered in the kitchen and are either immediately delivered to the residents in the dining room or placed immediately on the carts. She stated staff are supposed to keep the cart door closed because it keeps food warm and prevents cross contamination. In an interview on 06/05/25 at 2:30 PM with Dietary Aide G, she stated all food should be covered before leaving the kitchen and while not being closed in the kitchen. She stated it is important to cover the food, to protect it from whatever is in the air. Record Review of the facility's policy on Food Preparation and Service dated November 2022, revealed 4. 'Food Distribution' means the processes involved in getting food to the resident .When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart.

Based on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #12) of eight residents reviewed for Dignity. The facility failed to treat Resident #12 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his catheter bag (collects urine from the urinary bladder) on 06/03/2025. This failure could place residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life. Findings included: Record review of Resident #12's Face Sheet, dated 06/03/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed malignant (conditions that are dangerous to health) neoplasm (abnormal growth of tissue in the body) of the bladder. Record review of Resident #12's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 04/23/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS (screening tool used to assess cognitive status) score of 11. The Comprehensive MDS Assessment indicated the resident had an ostomy (surgical procedure that creates an opening to the body). Record review of Resident #12's Comprehensive Care Plan, dated 03/17/2025, reflected the resident had a urostomy (surgical procedure that creates an opening in the abdominal wall to bypass the urinary bladder) related to bladder CA and one of the interventions was to perform urostomy care. Record review of Resident #12's Physician Order, dated 10/16/2022, reflected Urostomy Care every shift. Observation and interview on 06/03/2025 at 9:23 AM revealed Resident #12 was in his bed, awake. It was observed that the resident had a catheter bag hanging on the side frame of the bed. The catheter bag did not have a privacy bag and could be seen from the hallway. The resident stated the catheter bag was for his urostomy and he had it since almost three years. He said, if he was not mistaken, his catheter bag did not have a privacy bag since the day prior. He said it would be better if no one would see his urine when the door was open. Observation on 06/03/2025 at 10:26 AM, Resident #12's catheter still does not have a privacy bag and still could be seen from the hallway. In an interview on 06/03/2025 at 10:44 AM, LVN A stated, by right, Resident #12's catheter bag should be inside a privacy bag to avoid embarrassment in case a visitor would come or would pass by. He said he did not notice that the catheter bag was exposed when he did his morning round. He said he would get a privacy and would put the resident's catheter bag inside. In an interview on 06/04/2025 at 6:18 AM, LVN C stated she did not notice that Resident #12's catheter bag was exposed when she did her last round the day prior. She said it should be inside a privacy bag to prevent the resident being humiliated because of his condition. She added that it did not matter if the resident was embarrassed or not, the catheter should be inside a privacy bag. She said it was also her responsibility to put the catheter bag inside the privacy bag. In an interview on 06/05/2025 at 6:19 AM, the ADON stated a catheter bag must have a privacy bag to avoid incidents that could lead to embarrassment. The purpose of the privacy bag was to provide dignity for residents with urinary catheters. The ADON said they have catheter bags that had a leaf on them, and a privacy bag was not needed. But for the kind of catheter bag that Resident #12 was using, it should be inside a privacy bag to prevent exposure of its content. The ADON said the expectation was for the staff to make sure the catheter bags had privacy bags when the residents were inside their rooms or outside their rooms. She said she would continually remind the staff the importance of providing dignity and would coordinate with the DON for an in-service about dignity. In an interview on 06/05/2025 at 7:13 AM, the Administrator stated a catheter bag should be inside a privacy bag to prevent any dignity issue. She said all the staff were responsible in providing dignity to all residents. She said staff must do their due diligence in ensuring the residents had a dignified existence while in the facility. The Administrator said he would coordinate with the DON to monitor that the catheter bags were not exposed. In an interview on 06/05/2025 at 8:09 AM, the DON stated catheter bags should be inside a privacy bag to maintain the resident's dignity. She said the expectation was for all the staff to ensure that the residents were provided dignity, not just providing a privacy bag but also treating them with respect. She said she start an in-service pertaining to providing dignity. Record review of the facility's policy, Dignity 2001 MED-PASS, Inc. revised February 2021 revealed Quality of Life - Dignity & Privacy Operational Policy and Procedure Manual for Long-Term Care revised August 2009 revealed Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or sense of well-being . self-esteem .Policy Interpretation and Implementation . 1. Residents are treated with dignity . at all times . 12. Demeaning practices and standards of care that compromise dignity are prohibited . a. Helping the resident to keep urinary catheter bags covered

Based on observations, interviews, and record review, the facility failed to ensure that the residents were provided medications and/or biologicals and pharmaceutical services to meet their needs for one (Resident #25) of eight residents reviewed for Pharmaceutical Services. The facility failed to ensure that Resident #25's medications were not left inside the resident's room and that the resident had a physician order for TUMS (antacid used for heartburn and indigestion). These failures could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Review of Resident #25's Face Sheet, dated 06/03/2025, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach) and schizoaffective disorder (a mental condition characterized by abnormal though processes and unstable mood). Review of Resident #25's Quarterly MDS Assessment, dated 05/12/2025, reflected resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated Resident #25 had gastro-esophageal reflux disease and schizoaffective disorder. Review of Resident #25's Comprehensive Care Plan, dated 04/29/2024, reflected the resident had schizoaffective disorder and one of the interventions were to administer medications and monitor for any side effects. The Comprehensive Care Plan did not indicate that the resident could self-administer his medications. Review of Resident #25's Assessment on 06/03/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage his own medications. Review of Resident #25's Physician Order on 06/03/2025 reflected the resident did not have any order for TUMS. Observation and interview on 06/03/2025 at 9:40 AM revealed Resident #25 was in his bed, awake. It was observed that a small plastic cup with two pills inside was on top of the resident's right side-table. According to the resident, his night nurse left it with him, and the pills were for his heartburn. He said he would take them in a little bit. In an interview with LVN A on 06/03/2025 at 10:44 AM, LVN A stated he did not give the Resident #25 anything for heartburn and he did not notice the small cup with pills when he gave the resident his morning medications. He said from the size of the medications, it looks like they were TUMS. He checked the resident's physician order and said the resident did not have an order for TUMS. He said if the resident was taking the medication, there should be an order for it because an order was needed for everything done for the residents. He said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. He said he would check if the pills were still inside the resident's room. In an interview on 06/04/2025 6:18 AM, LVN C said that she works from 10 PM to 6 AM the day before. She said the ADON asked her if she gave Resident #25 the pills and she said she did not. She said the only medications that she gave for the resident were his routine medications. She said medications should not be left with the residents to ensure that the resident took them and that if the resident was taking TUMS, there should be an order for it. In an interview on 06/05/2025 at 6:19 AM, the ADON stated medications should not be left with the residents and staff should stay with the resident until the resident was done taking the medications. She said the resident might not take them or someone else might, like another resident or a visitor. She said she asked the night nurse and the night nurse said she did not give Resident #25 anything for heartburn. She said she would coordinate with the DON to do an in-service about not leaving any medications with the residents. In an interview on 06/05/2025 at 7:13 AM, the Administrator stated staff should not leave medications unattended because of the risk of the resident not taking them or the pills not taken on time. She said another risk would be the resident might choke and nobody was there to assist the resident. She said she would coordinate with the DON about the matter and the expectation was no medications would be left with the resident unless the resident had a self-medication assessment. In an interview on 06/05/2025 at 8:09 AM, the DON stated staff should never leave the medications at the bedside for the resident to take later. She said the staff should ensure that the residents took their medications before leaving the room. She said many could go wrong like a resident could hide the pills and take them altogether or the resident might not take them at all. She said the expectation was no medication left inside the room and she would do an in-service pertaining to not leaving the medications with a resident. She also said that she already put the order for TUMS on the Resident #25's profile because every medication administered should have an order. she said she would also do an in-service about physician orders. Record review of the facility's policy, Administering Medications 2001 MED-PASS, Inc. revised April 2019 revealed Policy heading: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . 4. Medications are administered in accordance with prescriber orders . Record review of the facility's policy, Physician Orders 2001 MED-PASS, Inc. (undated) revealed Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services . Supervision by a Physician . 2. Physicians' orders must be signed electronically or in wet ink and dated.

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments for one cart (nurse's cart) of three carts reviewed for Storage of Drugs and Biologicals. The facility failed to ensure that LVN A locked his nurse's cart on 06/04/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications and not receiving the full benefit of the medication. Findings included: Observation on 06/04/2025 at 1:10 PM revealed a cart was parked in front of the nurses' station. The cart was not locked because the centralized, metal, round lock, located on the upper right corner of the cart, was protruding and the metal lock needed to be pushed to lock the drawers of the cart. The cart was facing the hallway, and the drawers could easily be opened. The drawers of the cart contained various over-the-counter medications, blister packs of medications, and insulins. Several staff and residents were passing by the unlocked cart. LVN A arrived and locked the cart. In an interview on 06/05/2025 at 6:19 AM, the ADON stated the carts should never be left unlocked to prevent unauthorized individuals from gaining access to it. She said residents might be able to open it and take some medications and ingest them or hide them. She said, aside from the residents, staff or visitors could open it and get some medications from it. She said the expectation was for the staff to lock the carts before leaving them. She said she would coordinate with the DON to do an in-service pertaining to locking the cart when left unattended. In an interview on 06/05/2025 at 7:13 AM, the Administrator stated the carts should always be locked so residents, other staff, and visitors could not open them and have access to the medications. She said it could result in accidental ingestion and overdose. she said the expectation was no carts were left unlocked. She said she would coordinate with DON to do an in-service about locking the carts. In an interview on 06/05/2025 at 8:09 AM, the DON stated carts should not be left unlocked, and the drawers facing the hallways. Unauthorized individuals should not be able to open it and gain access to the drawers. She said resident might open it, took some medications, hide it, and took them later. She said the resident might be allergic to the medication or could choke on them. She said even though the staff was called because of an incident, it should be automatic for them to lack the carts before attending to the incident. She said she would do an in-service about the importance of locking the carts. In an interview on 06/05/2025 at 8:36 AM, LVN A stated he was not aware that he left his cart unlocked because he was in a hurry due to an incident. He said it was not an excuse because it should be automatic for him to lock the cart. He said the cart should be locked every time it was left unattended because anybody, residents, staff, and visitors, could open it and could get anything from the cart. He said residents could open it and accidentally ingest medications that they were allergic to or choke on some medication. He said he would be mindful next time to always lock the cart every time he would leave his cart. Record review of facility policy Administering Medications 2001 MED-PASS, lnc. revised April 2019 revealed Policy heading: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed . and all outward sides must be inaccessible to residents or others passing by.

Based observation, interview, and record review the facility failed to establish and maintain 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 for two (Resident #5 and Resident #21) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA D would not place Resident #5's catheter bag (collects urine from the urinary bladder) on the floor while transferring the resident on 06/04/2025. 2. The facility failed to ensure CNA D performed hand hygiene while providing incontinent care to Resident #21 and would not put the gloves that she would use for incontinent care inside her pocket on 06/04/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #5's Face Sheet, dated 06/04/2025, reflected the resident was a [AGE] year-old female admitted on the facility on 03/26/2018. The resident was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #5's Comprehensive MDS Assessment, dated 04/15/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (device that drains urine from the urinary bladder). Review of Resident #5's Comprehensive Care Plan, dated 01/12/2025, reflected the resident had an indwelling catheter and one of the interventions was indwelling catheter care every shift. Record review of Resident #5's Physician Order, dated 02/08/2025, reflected Foley cath (catheter) care q shift and PRN. Observation on 06/04/2025 at 7:51 AM revealed CNA D was about to transfer Resident #5 from wheelchair to bed because the resident said she wanted to go back to her bed. It was observed that the resident had a catheter bag hanging at the side of the wheelchair. Before transferring the resident, CNA D placed the catheter bag on the floor and then transferred the resident using the stand and pivot technique. CNA D laid down the resident, pulled the blanket up, and then hung the catheter bag on the railing at the side of the bed. The catheter bag had a privacy bag but when it was on the floor, the catheter bag was outside the privacy bag. In an interview on 06/04/2025 at 8:18 AM, CNA D stated she transferred Resident #5 to her bed because the resident wanted to take a nap. She said she should not have placed the catheter bag on the floor because the floor was dirty and whatever was on the floor would transfer to the bag and could possibly travel towards the resident's bladder. She said she was just trying to hurry up and was not aware of outcome of her actions. She said she would be mindful next time she transfer the resident to hang the catheter first before the transfer. 2. Record review of Resident #21's Face Sheet, dated 06/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #21's Comprehensive MDS Assessment, dated 03/31/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #21's Quarterly Care Plan, dated 01/29/2025, reflected the resident had bowel and bladder incontinence and one of the interventions was to provide pericare (cleaning the private parts of an individual) after each incontinent episode. Observation on 06/04/2025 at 1:45 PM revealed CNA D and CNA E were about to provide incontinent care to Resident #21. Both CNAs sanitized their hands and put on a pair of gloves. CNA E went to right side of the resident while CNA D went to left side. CNA D placed a brief on the resident's side table, pulled the resident's hospital gown up, unfastened the brief, and pushed it between the resident's thighs. She pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. She did it five times. After cleaning the perineal area, she instructed the resident to roll towards the right side. Both CNA's assisted the resident to turn. CNA D started to clean the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it on the trash can. After throwing the soiled brief, she pulled a pair of gloves from her pocket, and put them on. She did not sanitize her hands before putting on a new pair of gloves that she pulled from her pocket. She took the brief from the side table, placed it under the resident, and fixed it. Both CNAs assisted the resident to roll back and fastened the brief on both sides. After fixing the brief, both CNAs washed their hands. In an interview on 06/04/2025 at 1:59 PM, CNA D stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she did hand hygiene before and after Resident #21's incontinent care and did change her gloves after cleaning the resident's bottom. She said when she changed her gloves, she did not sanitize her hands before putting on a new pair of gloves. She said she should have taken the box of gloves at bedside instead of placing some into her pocket to make sure that the gloves that she would be using were clean because her pocket might be dirty. She said she would be mindful the next time she does incontinent care to do hand hygiene in between changing of gloves and not to put the gloves inside her pocket. In an interview on 06/05/2025 at 6:19 AM, the ADON stated the catheter bag should not be placed on the floor because the floor was dirty. She said the staff should have hung it first before transferring the resident instead of placing it on the floor. She said she would check Resident #21's catheter if it needed to be changed. She said the catheter should be off the floor to prevent cross contamination and possible infection. She said staff must sanitize their hands before putting on a new pair of gloves and not put their gloves on their pockets for the same reason. She said she would coordinate with the DON to do an in-service about not placing the catheter on the floor, hand hygiene, and infection control. In an interview on 06/05/2025 at 7:13 AM, the Administrator stated catheter should be off the floor, hands should be sanitized in between changing of gloves, and gloves should not be placed inside the pockets to prevent spread of germs and development of infection. She said the staff should always make sure that they were aware that their actions could cause harm to the residents. She said she would coordinate with the DON to do an in-service about infection control. In an interview on 06/05/2025 at 8:09 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection and included in hand hygiene was sanitizing the hands before putting on a pair of gloves. She said gloves should not be placed on the staff's pockets because there was no assurance that their pockets were clean. She said, basically, the gloves from the pockets were deemed dirty. She said catheter bags should not be placed on the floor because the floor was dirty. She said not sanitizing the hands before donning a pair of gloves, putting gloves on the pocket, and putting the catheter bag on the floor could cause probable infections. she said the expectation was for the staff to be mindful with what they were doing to protect the residents from infection. She said she would do an in-service pertaining to infection control focusing on hand hygiene, no gloves on the pockets, and not placing the catheter bag on the floor. she said she was responsible in training the staff pertaining to infection control. Record review of the facility's policy, Catheter Care, Urinary 2001 MED-PASS, Inc. updated July 2024 revealed Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control . 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag . b. Be sure the catheter tubing and drainage bag are kept off the floor. Record review of the facility's policy, Perineal Care 2001 MED-PASS, Inc. (undated) revealed Purpose: The purpose of this procedure is to provide cleanliness . to prevent infections . Steps in the Procedure . 4. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens/adult brief. Record review of the facility's policy, Handwashing-Hand Hygiene Policy and Procedures 2001 MED-PASS, Inc. (undated) revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections . Policy Interpretation and Implementation . Indications for Hand Hygiene . c. after contact with blood, body fluids, or contaminated surfaces, d. after touching a resident, e. after touching the resident's environment, f. before moving from work on a soiled body site to a clean body site on the same resident, g. immediately after glove removal.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #5 and Resident #9) of two residents reviewed for respiratory care. The facility failed to ensure Resident #5's nasal cannula was changed weekly as per order. The facility failed to ensure Resident #9's nebulizer was changed weekly as per order. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #5 Review of Resident #5's Face Sheet dated 05/02/2024 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dyspnea (a lung disease that damages the air sacs in the lung causing shortness of breath). Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected resident had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment also indicated Resident #5's primary medical condition was chronic obstructive pulmonary disease. Review of Resident 5's Comprehensive Care Plan dated 04/05/2024 reflected resident experienced wheezing and coughing and interventions were oxygen at 2 to 5 liters per minute and change oxygen tubing every week. Review of Resident 5's Physician Order on dated 08/25/2022 reflected O2 via nasal cannula. May titrate between 2-5 LPM as needed every shift for shortness of breath and to keep PAO2 > 90%. as needed related to DYSPNEA, UNSPECIFIED. Every shift as needed. Review of Resident 5's Physician Order on dated 08/25/2022 reflected Change oxygen and nebulizer tubing q week on Sunday. Observation and interview with Resident #5 on 04/30/2024 at 10:09 AM, revealed Resident #5 was on her bed awake. Resident #5 was on oxygen at 3 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. Resident #5 said she was on oxygen because she had respiratory issues. She said she was not aware if the nurses were changing her nasal cannula. Resident #9 Review of Resident #9's Face Sheet dated 05/02/2024 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #9's Quarterly MDS assessment dated [DATE] reflected that Resident #9 was cognitively intact with a BIMS score of 14. The Quarterly MDS also indicated that the resident had COPD and respiratory failure. Review of Resident #9's Comprehensive Care Plan dated 02/09/2024 reflected resident was at risk of respiratory infection/distress, hypoxia, SOB, and cough related to diagnosis of COPD and one of the interventions was to administer oxygen as ordered. Review of Resident #9's Physician Order dated 06/03/2022 reflected, O2 via nasal cannula every shift PRN. May titrate between 2-5 LPM for shortness of breath and to keep pulse oximetry > 90%. as needed for SOB and to maintain pulse oximetry > 90% every shift as needed. Review of Resident #9's Physician Order dated 06/03/2022 reflected, Change oxygen concentrator humidification bottle weekly or more frequently if needed. Every night shift every Sun. Observation on 04/30/2024 at 10:59 AM, revealed Resident #9 was on her recliner sleeping. It was noted that Resident #9 had an oxygen concentrator behind her recliner. The concentrator had a humidifier with water in it. The humidifier bottle was dated 02/24/24. In an interview with Resident #9 on 04/30/2024 at 1:43 PM, Resident #9 stated only used her oxygen when she needed it. She said she was not sure when was the last time she had it on. Observation and interview with the ADON on 04/30/2024 at 02:05 PM, the ADON confirmed that Resident #9's humidifier bottle was dated 02/24/24. She also acknowledged the humidifier had water in it. The ADON said the humidifier bottle was supposed to be changed weekly. The ADON disconnected the humidifier as well as the nasal cannula connected to it and said she would change everything. The ADON then went to Resident #5's room and checked if the tubing of the nasal cannula was dated. The ADON found the date at the end of the tube connected to the oxygen concentrator. She said Resident #5's nasal cannula was dated 04/12/2024. She said she would also change the nasal cannula for Resident #5. She said the purpose of changing the humidifier and nasal cannula was to prevent infection and not to compromise the resident's breathing pattern. She said the expectation was for the staff to change the humidifier weekly and to put a date on it. In an interview with RN A on 05/01/2024 at 11:44 AM, RN A stated the humidifiers and nasal cannulas should be changed every week to prevent infection and worsening of. She said if the humidifier and the nasal cannula were not changed as ordered, the respiratory system of the resident would be compromised more. She said the order for both was to change them every Sunday. In an interview with the Administrator on 05/02/24 at 07:52 AM, the Administrator stated she was made aware by the ADON regarding the humidifier and the nasal cannula not being changed. She said as per order, the humidifier and the nasal cannula should be changed every week. She said if the resident was not always using the oxygen, the staff should still change the humidifier weekly and not leave with standing water for more than two months. The Administrator continued that there would be a possibility that microorganism and algae could grow and could compromise the lungs of the residents. She said the expectation was for the staff to change the humidifier and the nasal cannula weekly. She said on top of checking if the nasal cannula and the breathing masks were bagged, they would also include checking if they were changed accordingly by checking the date. She concluded that they already did an in-services about changing the tubing and humidifier. In an interview with the DON on 05/02/24 at 08:25 AM, the DON stated the humidifier and the nasal cannula should be changed weekly because bacterial growth could occur that could eventually cause contamination and infection. She added the order specified to change them Sunday night. She added that all the staff were equally responsible in checking if the humidifier and the nasal cannula were changed. She said the expectation was for the staff to change them weekly. She said they already did an in-service about changing the humidifier and nasal cannula on a weekly basis. She concluded that they would also check every day, especially on Mondays, if the nasal cannula and the humidifier were changed and dated. Record review of facility's policy, Oxygen Administration implemented 03/2022 revealed Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice . Policy Explanation and Compliance Guidelines: . Other infection control measures include: . b. Change oxygen tubing and mask/cannula . c. Change humidifier bottle .

Based observation, interview, and record review, the facility failed to maintain 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 for 2 (Resident #4 and Resident #38) of 6 residents observed for infection control. 1. The facility failed to ensure that LVN B changed his gloves and performed hand hygiene while providing colostomy care to Resident #4. 2. The facility failed to ensure CNA C and CNA D sanitized the mechanical lift either before or after use with Resident #38 These failures could place the residents at risk of cross-contamination and the development of infection. Findings included: Resident #4: Review of Resident #4's recent change of condition/re-admission Minimum Data Set (MDS) assessment, dated 04/11/2024, revealed she was a [AGE] year-old female readmitted to the facility on [DATE]. She was assessed as severely cognitively impaired via the Brief Interview of Mental Status (BIMS) score of 06. Resident #4 was assessed as dependent upon staff on self-care, toileting, and needed substantial/maximal assistance for showering/bathing. She was incontinent of bladder and had an ostomy for her bowel elimination. Her active diagnoses included cancer, coronary artery disease (blood vessels to the heart are narrowed), heart failure (progressive heart disease that affects the pumping action of the heart muscle), diabetes (group of diseases that affects how the body uses blood sugar), respiratory failure (lung condition resulting in lack of oxygen and too much carbon dioxide in the body), and dementia (group of symptoms that affects memory, thinking, and social abilities), Review of Resident #4's Comprehensive Care Plan, dated 04/04/2024, revealed Resident #4 had an Activities of Daily Living (ADL) self-care deficit related to dementia and required extensive assistance with all or most ADLs. Resident #4 required the use of a colostomy and was at risk for infection and excoriation with interventions that included to change wafer/colostomy bag as ordered, and colostomy care per day and as needed. Additionally, the facility had identified Resident #4 as having a Multi-Drug resistant organism (MDRO) related to colostomy and that staff must use Enhanced Barrier Precautions (EBP) by the use of gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Review of Resident #4's physician orders revealed: Change colostomy bag . and as needed with a start date of 02/08/2024. Colostomy care every shift and as needed with a start date of 02/08/2024. EPB: Staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff . with a start date of 04/17/2024. In observation on 04/30/2024 at 10:08 AM, LVN B provided colostomy care to Resident #4. LVN P entered room, performed hand hygiene, and donned a gown and pair of clean gloves. LVN P removed Resident #4's current soiled colostomy bag, and cleaned around the stoma site and applied a cream to the skin around the stoma site. LVN P then removed his gloves and donned a new pair of clean gloves. LVN P then applied a new colostomy bag to Resident #4's abdomen. LVN P failed to perform hand hygiene between glove changes and going from a dirty to a clean area. LVN P then doffed his gown and gloves, performed hand hygiene in Resident #4's sink, and exited the room. In interview with LVN P on 04/30/2024 at 10:24 AM, he stated he removed his gloves and donned new gloves after removing Resident #4's colostomy bag and cleaning her stoma site. He stated he did not perform hand hygiene but did not state why. He stated it was important to perform hand hygiene between glove changes and when moving from a contaminated to clean area to avoid any infection to spread. In interview with the DON on 05/02/2024 at 10:33 AM, she stated her expectations would be for staff to perform hand hygiene between glove changes because it was basic infection control . In interview with the Administrator on 05/02/2024 at 10:48 AM, she stated her expectations would be for staff to perform hand hygiene between glove changes for infection control purposes. In interview with the Administrator and DON on 05/02/2024 at 12:00 PM, they revised their earlier statements by stating that Resident #4's colostomy bag change was a clean procedure and not a sterile procedure and they did not expect LVN P to change gloves nor perform hand hygiene after Resident #4's colostomy bag was removed and prior to the new bag being applied. DON stated the facility's skills checkoff, Validation Checklist Ostomy Care, did not state to perform a glove change and/or hand hygiene at this time in the procedure. Review of facility skills check off document, Validation Checklist Ostomy Care, dated 2023, revealed no evidence that staff should complete glove changes and/or hand hygiene between removal and cleaning of the stoma and stoma bag and the application of the new bag. The document stated: 6. Perform hand hygiene and don appropriate personal protective equipment. 7. Empty pouch. 8. Remove pouch. 9. Clean skin around stoma . Steps 10-16 state to clean around the stoma, to measure and size the stoma appropriately, and to apply the new bag to resident's stoma site. 17. Discard items appropriately. Remove gloves and wash hands. Review of facility reference material, How to Change Your Ostomy Pouch, dated 02/13/2018 revealed no specific directive to change gloves and/or perform hand hygiene going from cleaning the stoma and then the application of the new colostomy bag. Resident #38 Review of Resident #38's Admission MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE]. She was assessed as severely cognitively impaired via BIMS score of 06. Resident #38 was assessed as needing some help with self-care, and dependent upon staff for toileting and showering/bathing. She was incontinent of bowel and bladder. Her active diagnoses included diabetes (group of diseases that affects how the body uses blood sugar) and cerebrovascular accident (CVA) (medical term for stroke, where blood flow is blocked.) Review of Resident #38's Comprehensive Care Plan, dated 04/10/2024, revealed Resident #38 had impaired physical mobility related to CVA effects, right side. Resident #38 prefers to be . transferred with hoyer lift . Additionally, the facility identified Resident #38 needing EBP, and stated Staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDRO's to hands and clothing of staff. Review of Resident #38's physician orders revealed: EPB: Staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff . with a start date of 04/17/2024. In an observation of CNA C and CNA D on 04/30/2024 between 10:29 AM and 10:37 AM, they transferred Resident #38 from bed to her wheelchair using a mechanical lift LVN C obtained the mechanical lift from the hallway and entered Resident #38's room. CNA C and CNA D then performed hand hygiene, donned appropriate personal protective equipment for EPB precautions, and safely performed the transfer of Resident #38. On 04/30/2024 at 10:36 AM, CNA D exited the resident's room with the mechanical lift and plugged in the mechanical lift's electrical cord into the wall located in the hallway between rooms [ROOM NUMBERS]. Both CNA C and CNA D were observed exiting the hallway to other areas of the facility at 04/30/2024 at 10:37 AM. CNA C failed to sanitize the mechanical lift prior to resident use. CNA D failed to sanitize the mechanical lift after resident use. In interview with CNA C on 04/30/2024 at 10:41 AM, she stated she did not sanitize the mechanical lift prior to use with Resident #38 because she wasn't thinking about it. She stated it was important to sanitize shared use equipment for infection control purposes . In interview with CNA D on 04/30/2024 at 10:49 AM, she stated she did not sanitize the mechanical lift after use with Resident #38 because she forgot and was not thinking about it. She stated it was important to sanitize shared use equipment to prevent the spread of germs . In interview with ADON on 05/02/2024 at 10:25 AM, stated she expected any shared use equipment to be sanitized either before and/or after use with residents. She stated the mechanical lift should have been sanitized by CNA C prior to use with Resident #38, and CNA D should have sanitized the equipment after use with Resident #38. She stated this was important for infection control purposes as it prevented the spread of bacteria. In interview with the DON on 05/02/2024 at 10:33 AM, she stated shared use equipment should be sanitized between resident use to prevent the spread of disease. Record review of facility policy, Infection Prevention and Control, dated 2023, revealed 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Review of facility policy Cleaning and Disinfection of Resident-Care Equipment, dated 2023 revealed Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection . 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #8, #11) of five residents reviewed for infection control. LVN A failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #8 and Resident #11. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Review of Resident #8's Face Sheet, not dated, reflected she was a [AGE] year-old-female with a diagnosis of hypotension (low blood pressure). Review of Resident #8's Physician Orders dated March 2023, reflected she took Midodrine (treats low blood pressure) 10 milligrams three times a day. 2. Review of Resident #11's Face Sheet, not dated, reflected he was a [AGE] year-old male with a diagnosis of hypertension (high blood pressure). Review of Resident #11's Physician Orders dated March 2023, reflected he took Coreg (blood pressure medication) 3.125 milligrams two times a day. An observation of medication administration with LVN A on 03/09/23 at 8:40 AM revealed he was wearing a wrist blood pressure cuff on his left wrist. LVN A removed the blood pressure cuff from his wrist, he did not sanitize the blood pressure cuff, and placed it on Resident #8's right wrist. He took the resident's blood pressure, removed the blood pressure cuff from Resident #8 and placed it back on his left wrist. LVN A sanitized his hands but did not sanitize the blood pressure cuff. LVN A then went to Resident #11's room, removed the blood pressure cuff from his wrist, he did not sanitize the blood pressure cuff, and placed it on Resident #11's right wrist. He took the resident's blood pressure, removed the blood pressure cuff from Resident #11 and placed it back on his left wrist. An interview on 03/09/23 at 9:00 AM with LVN A revealed staff did not need to sanitize the blood pressure cuff between residents. He said he had not received training to clean the blood pressure cuff. He did say failure to sanitize the blood pressure cuff between uses could spread germs. An interview on 03/09/23 at 11:57 AM with LVN B revealed it was not necessary to sanitize the blood pressure between resident uses. An interview on 03/09/23 at 11:05 AM with the DON revealed it was not necessary for staff to sanitize the blood pressure cuff between uses. She said if a resident was on contact precautions, then they would use a disposable blood pressure cuff. She said she had not read anything that said failure to sanitize a blood pressure cuff could cause infection. An interview on 03/09/23 2:20 PM with the Administrator revealed she provided the facility policy which reflected that blood pressure cuffs were supposed to be sanitized between uses. Review of website: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html on 03/09/23 reflected: Disinfection of Healthcare Equipment Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Surface Disinfection Medical equipment surfaces (e.g., blood pressure cuffs, stethoscopes, hemodialysis machines, and X-ray machines) can become contaminated with infectious agents and contribute to the spread of health-care-associated infections . For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low- or intermediate-level disinfectant. Review of website: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/recommendations.html#rec5g on 03/09/23 reflected: Recommendations for Disinfection and Sterilization in Healthcare Facilities Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions . Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient . Record review of the facility policy and procedure , Cleaning and Disinfection of Resident-Care Equipment, dated March 2023, reflected: Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include .blood pressure cuffs . d. Multiple-resident use equipment shall be clean and disinfected after each use .

Based on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (Resident #205) of 5 residents reviewed for food preferences. The facility failed to provide Resident #205 with her preferred diet to address her diabetes. This failure could place residents at risk for malnutrition and poor quality of life. Findings included: 1. Review of Resident #205's MDS assessment, dated 02/15/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included diabetes. Review of Resident #205's Order Summary Report for March 2023 reflected: 1. Regular Diet 2. Lantus Subcutaneous Solution100 UNIT/Milliliter (Insulin Glargine) Inject 10 units at bedtime. 3. Novolin R Injection Solution100 UNIT/Milliliter (Insulin Regular) Inject as per sliding scale 4. Tradjenta tablet 5 mg daily. 5. Metformin 500 mg two times a day. 6. Registered Dietitian to evaluate and treat. Review of Resident #205's lab work on admit, dated 11/11/22, reflected: HGB A1C (lab that shows average blood sugar level over the last 2-3 months) 8.0 High (normal range 4.5-5.7) Review of Resident #205's lab work after being in the facility, dated 02/07/23 reflected: HGB A1C 12.2 Very High (normal range 4.5-5.7) Review of Resident #205's Nurse Note, dated 03/02/23 at 2:12 PM, reflected: LVN B Resident with increased anxiety. Resident verbally c/o anxiety and body language appears anxious. Resident states I can't live like this, the blood sugars and insulin. Attempt to give reassurance resident inconsolable. Resident husband at bedside. Resident refused to eat lunch d/t sugars. New order for Klonopin 0.5mg BID routine. Xanax 0.25mg x 1 now. Resident then states good maybe it will let me sleep through the rest of my life. Review of Resident #205's Nurse Note, dated 03/03/23 at 2:09 PM, reflected: LVN C . Remains shakey. States she is not eating for only a few days to bring blood sugar down. Explained need to eat but resident refuses. Review of Physician Progress Note for Resident #205 by FNP, dated 03/03/23 reflected: She is also concerned about her blood sugar--explained about cortisol release and stress. She is not optimized on oral medications yet, as she had medications discontinued in hospital. She is now fixated on her blood sugars and is refusing blood sugar sticks and insulin. Instead, she states she will not eat. Informed resident that this would weaken her and she would lose all progress she had made in physical therapy and would be too weak to go home but she is still refusing to eat and states she has an extreme needle phobia. She is taking Lantus and Tradjenta. 4. Noncompliance Resident noncompliant with care and refuses to eat or allow blood sugar sticks. Encourage resident to comply so that we can manage glucose levels. Review of Nutrition/Dietary Note for Resident #205, dated 03/07/23 at 11:04 AM, reflected: Dietician Nutrition Note: Met with resident to discuss healthy eating for diabetes. Diet education provided; resident reported she does not want to eat any carbs. Discussed importance of carbohydrates and how to incorporate carbohydrates in diet for glucose control. Will continue to monitor education needs. Review of Resident #205's Current Comprehensive Care Plans revealed no care plan for diabetes or diet until Surveyor intervention. An observation and interview on 03/08/23 at 12:26 PM with Resident #25 revealed she was in her room, awake, tired, and oriented. She said she had concerns about nutrition because she was diabetic, and the facility did not serve her a diabetic diet. The resident had her lunch tray in front of her. It contained apple turnovers, a yeast roll, and cottage cheese with canned peaches. She said the only thing she could eat was the cottage cheese. An interview with Resident #205 on 03/10/23 at 10:56 AM revealed she was upset. She said her blood sugar was 237 and she was required to take insulin. She said she did not eat what the kitchen served unless it did not contain carbohydrates. She said she only ate scrambled eggs and bacon for breakfast. She said the Dietician spoke to her and said she had to eat. She said she told them she needed a diabetic diet. She said she always received cookies and cake with icing that she should not eat. An interview with Resident #205 on 03/10/23 at 12:41 PM revealed she was happy with her lunch of nachos without the chips. She said staff would offer her alternative meals when she did not want to eat what was served, but they were always full of carbohydrates. She said the alternatives offered were, cottage cheese with canned fruit, loaded with sugar, or a grilled cheese with tomato soup, also full of sugar. An interview with the LVN B on 03/10/23 at 2:11 PM regarding the nurse note she wrote for Resident #205 on 03/02/23 at 2:12 PM revealed the resident was very anxious and did not want to eat lunch. LVN B said she could not remember what was served to the resident, but the resident told her she was not going to eat for a couple of days to bring her blood sugar down. She said the family would bring in food, but she did not know what was in the containers. An interview on 03/10/23 at 2:16 PM with LVN C regarding her nurse note for Resident #205 on 03/03/23 at 2:09 PM revealed the resident was afraid to eat. LVN C said she explained to the resident that she needed to eat. LVN C said the resident would be offered what was served and she did not eat it. LVN C said the resident did not request anything different to eat. And interview on 03/10/23 at 12:51 PM with the FNP revealed on admit the resident's HGBA1C was lower than after being in the facility because the resident took steroids. (Resident was not currently on steroids.) She said when the resident admitted her diabetes was controlled with diet and metformin. She said the increased HGBA1C occurred because the resident had taken steroids and was non-compliant with her diet. She said the resident would eat food brought in by the resident's spouse. The FNP said she was having to use insulin to control the resident's blood sugars and that the resident had stopped eating. She said the resident was needle-phobic. She said she did not know why the resident was not on a diabetic diet even though the resident requested one, but that the Dietician spoke with the resident. An interview on 03/10/23 at 1:36 PM with the Dietician revealed Resident #205 was on a regular diet and the facility did not offer a diabetic diet. The Dietician said the meals served were well-balanced and usually contained 3-4 carbohydrate servings. She said the resident had requested a no carbohydrate diet. She said she did not change the resident's diet order because the facility only offered a regular, liberalized diet. An interview with the DON on 03/10/23 at 11:05 AM for Resident #205 revealed to address her diabetes the resident was followed by the FNP, had sliding scale insulin, and diet management. The DON said the resident's diet was a regular diet and that her family would bring food and she had alternate meals available to her. She said the facility did not offer a diabetic diet or a low concentrated sweets diet. She said the only diet served in the facility was a liberated, regular diet. An interview on 03/10/23 at 11:19 AM with the Administrator for Resident #205 revealed the FNP was seeing the resident and mentioned the resident was not eating. The Administrator said the Dietician spoke to the resident and that the facility offered a liberalized diet, which were good, balanced diets. The Administrator said the facility did not have a diabetic or a low concentrated sweets diet, but the resident could get a sugar substitute, sweet and low. The Administrator said every resident had the same liberated, regular diet. Review of the Facility Policy, Liberalized Diets dated 2022, reflected: It is the policy of this facility to incorporate individualized, liberated diets for residents in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' specific goals, needs, and preferences . 2. Diet consideration is determined with the resident and in accordance with their informed choices, goals and preferences, rather than exclusively by diagnosis.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #205) of 5 residents reviewed for care plans. The facility failed to provide Resident #205 with a diabetic care plan. This failure could place residents at risk for not receiving care based on their care plans. Findings included: 1. Review of Resident #205's MDS assessment, dated 02/15/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included diabetes . Review of Resident #205's Order Summary Report for March 2023 reflected: 1. Regular Diet 2. Lantus Subcutaneous Solution100 UNIT/ML (Insulin Glargine) Inject 10 units at bedtime. 3. Novolin R Injection Solution100 UNIT/ML (Insulin Regular) Inject as per sliding scale 4. Tradjenta tablet 5 mg daily. 5. Metformin 500 mg two times a day. 6. Registered Dietitian to evaluate and treat. Review of Nutrition/Dietary Note for Resident #205, dated 03/07/23 at 11:04 AM, reflected: Dietician Nutrition Note: Met with resident to discuss healthy eating for diabetes. Diet education provided; resident reported she does not want to eat any carbs. Discussed importance of carbohydrates and how to incorporate carbohydrates in diet for glucose control. Will continue to monitor education needs. Review of Resident #205's Current Comprehensive Care Plans revealed no care plan for diabetes or diet until Surveyor intervention. An observation and interview on 03/08/23 at 12:26 PM with Resident #25 revealed she was in her room, awake, tired, and oriented. She said she had concerns about nutrition because she was diabetic, and the facility did not serve her a diabetic diet. The resident had her lunch tray in front of her. It contained apple turnovers, a yeast roll, and cottage cheese with canned peaches. She said the only thing she could eat was the cottage cheese. An interview with Resident #205 on 03/10/23 at 10:56 AM revealed she was upset. She said her blood sugar was 237 and she was required to take insulin. She said she did not eat what the kitchen served unless it did not contain carbohydrates. She said she only ate scrambled eggs and bacon for breakfast. She said the Dietician spoke to her and said she had to eat. She said she told them she needed a diabetic diet. She said she always received cookies and cake with icing that she should not eat. An interview with Resident #205 on 03/10/23 at 12:41 PM revealed she was happy with her lunch of nachos without the chips. She said staff would offer her alternative meals when she did not want to eat what was served, but they were always full of carbohydrates. She said the alternatives offered were, cottage cheese with canned fruit, loaded with sugar, or a grilled cheese with tomato soup, also full of sugar. An interview on 03/10/23 at 12:48 PM with MDS Nurse revealed Resident #205 did not have a care plan for diabetes. She said the DON was supposed to do the initial care plan. The MDS Nurse said she was responsible for care plans. She said she did not think the resident's health would be affected due to a lack of care plan . An interview on 03/10/23 at 1:36 PM with the Dietician revealed Resident #205 was on a regular diet and the facility did not offer a diabetic diet. The Dietician said the meals served were well-balanced and usually contained 3-4 carbohydrate servings. She said the resident had requested a no carbohydrate diet. She said she did not change the resident's diet order because the facility only offered a regular, liberalized diet. An interview on 03/10/23 at 1:16 PM with the DON for Resident #205 revealed she put in a care plan for diabetes after Surveyor intervention. She said the MDS Nurse was responsible for care plans and she did not know why one was not entered. She said she did not think there was a risk to the resident if she did not have the care plan . Review of the Facility Policy, Care Plans dated 2022, reflected: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .

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 timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 2 (Resident #1, Resident #2) of 5 residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #1's bladder and bowel needs, nicotine dependence, ADL dependence, and advanced directives. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #2's active diagnoses, wound care, ADL dependence, mobility status, and advance directive. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident #1's face sheet dated 11/10/22, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Disease of Central Nervous System, Nicotine Dependence, Major Depressive Disorder, Hypertension (high blood pressure), and colostomy status. Code Status: Full Code. Review of Resident #1's Smoking assessment dated [DATE], revealed he was an active smoker who required supervision while smoking. Review of Resident #1's MDS dated [DATE], revealed the following: -Active diagnoses: cancer, hypertension, arthritis, and depression. -Bladder and bowel status: Ostomy. -Functional Status: Supervision (Locomotion on unit, Eating), Limited assistance (Bed Mobility, Locomotion off unit), and extensive assistive (Transfer, Dressing, Toilet Use, Personal Hygiene) -Mobility Devices: Wheelchair Review of Resident #1's Care Plan dated 11/10/22, revealed no care areas, focus, or interventions listed for active diagnoses, functional status, smoking, ostomy care or advance directive. Review of Resident #1's Order Summary Report dated 11/10/22, revealed the following: - Colostomy care q shift and PRN, date started 09/07/22 and was provided day, evening, and night. - Full Code Status, dated 09/06/22, verbal order. Review of Resident #2's face sheet dated 11/10/22, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Type II Diabetes, Schizoaffective Disorder, Bipolar, Hyperlipidemia (high cholesterol), Dementia, Open Wound of Abdominal Wall. Code Status: Full Code. Review of Resident #2's MDS dated [DATE], revealed the following: -Active diagnoses: hypertension, Diabetes Mellitus, Non-Alzheimer's Dementia, Anxiety Disorder, Bipolar disorder. -Bladder and bowel status: Ostomy. -Functional Status: Supervision (Locomotion on unit, Eating, Bed Mobility, Locomotion off unit, Transfer, Dressing, Toilet Use, Personal Hygiene). -Mobility Devices: Wheelchair, [NAME] -Skin Conditions: Surgical wound, surgical wound care, application of nonsurgical dressing Review of Resident #2's Care Plan dated 11/10/22, revealed no care areas, focus, or interventions listed for active diagnoses, wound care, functional status, or advance directive. Review of Resident #2's Order Summary Report dated 11/10/22, revealed the following: -Full Code Status, dated 10/20/22, verbal order. -Abdominal wound: Cleanse with NS, pat dry, apply skin prep around wound, apply collagen, cover with dry dressing daily and PRN soiled or dislodged. Every day shift for wound care. -HumuLIN R Solution (insulin), inject as per sliding scale subcutaneously before meals and at bedtime, prescriber written, dated 10/20/22. Observation of Resident #2 on 11/10/22 at 10:25 AM revealed he had a bandage on his abdomen dated 11/10/22, he stated he was being provided wound care daily by the facility. Interview with the DON and the MDS LVN on 11/10/22 at 1:43 pm revealed the MDS LVN had been employed at the facility for about 2 years. The MDS LVN stated she was responsible for all comprehensive care plans; however, the DON assisted her a needed. MDS LVN stated she was familiar with Resident #1 and #2; however, if there were behaviors, she would rely on the DON to inform her of the specifics. MDS LVN stated she was not aware their care plans were not completed. MDS LVN stated, if a care plan was not completed, it was because she must have forgot to finish it. The DON stated she had been employed at the facility for about 1 year. The DON stated she was not responsible for completing comprehensive care plans but might complete the initial the baseline care plan if needed. The DON stated she assisted the MDS LVN as needed. The DON stated the facility rarely had care plan meetings to discuss specific resident focus areas. The DON stated care plans were updated as needed but the baseline care plan should be completed by the MDS LVN in 14 days. The DON stated if a care plan was not updated or accurate, staff would not know how to care for the resident. She stated it could cause a safety issue to a resident as the care plan would not address a resident's specific needs. The DON stated she was familiar with Resident #1 and Resident #2 and did not know why the care plan was not updated with their preferences and diagnoses. The MDS LVN was asked what the risk was to not update a care plan with individual needs. The MDS LVN stated, it was the same as what the DON said. Interview with the Administrator on 11/10/22 at 2:09 PM revealed she did not complete care plans because it was the responsibility of the MDS LVN. The Administrator stated she would attend a care plan meeting if there was a specific concern but not as a rule. The Administrator stated every day in the morning meeting her staff (DON, ADON and MDS LVN) go over the 24-hour report and discussed recent incidents, diagnoses, behaviors, and concerns. The Administrator stated when items were discussed in this meeting, it was her expectation, the care plans were updated to reflect the information. The Administrator stated although she was ultimately responsible for the entire facility, she did not follow behind the DON or MDS LVN to ensure the care plans were updated, she trusted the care plans were updated accurately and timely. The Administrator stated if the care plans were not updated the residents were at risk to not receive individualized, specific care. Review of facility policy titled; Comprehensive Care Plans, undated revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will be also be addressed in the plan of care. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. d. The resident's goals for admission, desired outcomes, and preference for future discharge .

Based on interview, and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for one, (Cook A), of five employees reviewed for abuse and neglect. The facility did not ensure Cook A was disqualified from working in the facility when her criminal history record indicated a criminal conviction (from 7/25/18) barring employment in a nursing facility for five years. Cook A had worked in the facility from 12/03/21 through 08/18/22. This failure placed the residents at risk for possible abuse, neglect or exploitation. Findings included: Record review of Cook A's personnel file indicated she was hired on 12/03/21. In addition, this record included her criminal history report, dated 12/01/21, indicating she had an arrest offense dated 07/25/18 for an offense under section Chapter 31, Penal Code (theft), that is punishable as a felony. This report indicated the level and degree prosecuted as Felony - state jail felony with a conviction date of 07/25/18. An interview was attempted with Cook A on 10/19/22 at 12:55 PM. The interview was unsuccessful because Cook A hung up on the Surveyor. An interview on 10/19/22 at 1:25 PM the HR Manager revealed she was in charge of hiring. She said she obtained background checks and would review them along with the Administrator. She said she did not know how she missed the bar to employment for Cook A. She said going forward she would make sure she reviewed the background checks with the Administrator. An interview with the Administrator on 10/19/22 at 12:40 PM revealed Cook A should not have been hired and she was not sure how the conviction was missed during review. She said she usually reviews the background checks after the HR Director but did not know if she had reviewed the background check for Cook A. She said going forward she would make sure she reviewed the background checks. Record review of Appendix I, Criminal Convictions Barring Employment with Revision 11-1, Effective September 1, 2011 indicated (b) A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of .(3) an offense under Chapter 31, Penal Code (theft), that is punishable as a felony specifically (7) an offense under Section 22.041. Record review of facility's Abuse, Neglect, Exploitation Policy, not dated, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.

Based on observation, interview and record review, the facility failed to establish and maintain an infection control policy and procedure designated to provide a safe, sanitary and comfortable environment and to help prevent the development and transmissions of disease and infection for two (Housekeeper A and Housekeeper B) of two housekeepers observed for infection control. The facility failed to ensure Housekeepers A and B utilized proper infection control practices when cleaning residents' rooms. This failure placed residents at risk of communicable diseases, hospitalization and even death. Findings included: Observation on 07/07/22 from 2:30 PM to 2:40 PM of Housekeeper A revealed Housekeeper A walked out of one resident's room with gloves on her hands, carried covered toilet paper to another resident's room, opened the bathroom door and placed the toilet paper in the bathroom, closed the door, and exited the room. Housekeeper A went two doors down to the room she came from. At no time did Housekeeper A remove her gloves or perform hand hygiene. Observations on 07/11/22 from 9:35 AM to 9:50 AM revealed Housekeeper B walked out of resident room [ROOM NUMBER]. Housekeeper B was observed wearing gloves, carrying out clothes hangers and a soiled coffee cup. Housekeeper B went to the dining room to drop off the coffee cup. Housekeeper B then went outside to laundry. Housekeeper B was observed coming back inside, with gloves on through a staff door. Housekeeper B then went back to room [ROOM NUMBER] and continued to clean. When she finished cleaning room [ROOM NUMBER], she moved the housekeeping cart, placed wet floor signs, and mopped a small portion of the hallway before entering resident room [ROOM NUMBER]. Housekeeper B was not observed changing her gloves or performing hand hygiene at any point. During this time, Housekeeper A was at the other end hallway. Housekeeper A was observed walking from resident room [ROOM NUMBER]. Housekeeper A had gloves on and was carrying a bag of soiled linen in a trash bag. Housekeeper A opened the door to soiled utility room, dropped off soiled linen, shut the door, and went back to room [ROOM NUMBER]. Housekeeper A did not remove her glove nor perform hand hygiene. Housekeeper A then picked up a roll of clean, unused trash bags, unrolled a couple of bags, placed the unused roll of trash bags on her housekeeping cart, and went back in to finish room [ROOM NUMBER]. Housekeeper A then stepped out of the room, removed her gloves, went to the nurse's cart, grabbed a clear plastic cup, took it back to room [ROOM NUMBER], stopped at the housekeeping cart, and grabbed a fresh pair of gloves. Housekeeper A did not perform hand hygiene. Director of Nursing spoke with Housekeeper A, and Housekeeper A walked down the hallway, with gloves on, and into room [ROOM NUMBER] to speak with Housekeeper B. Housekeeper A then walked back down the hall to room [ROOM NUMBER] with gloves on. Interview on 07/11/22 at 9:09 AM with Receptionist revealed she was the former Housekeeping Supervisor. She was also acting as Housekeeping Supervisor on 07/11/22 due to Housekeeping Supervisor being on vacation. She stated the housekeepers were trained to perform hand hygiene after each room they were in, anytime they touched anything contaminated, before and after glove changes, and in between rooms. She stated the housekeepers should not be wearing gloves in the hallway. Gloves were to be changed between each resident rooms Interview with the Director of Nursing (DON) on 07/11/22 at 10:07 AM revealed hand hygiene should be performed before and after care, when hands were visibly soiled, in between patient contact, when going from one resident room to another resident room and before and after removing gloves. Gloves should not be worn in the hallway. Not changing gloves or performing hand hygiene could cause further spread of infection. The DON stated she would begin an education with the housekeeping staff. Interview with Housekeeper A on 07/11/22 at 10:35 AM revealed hand hygiene should be performed when she changed her gloves, when she came out of a patient's room and went to another room. She stated when she dropped off soiled linen, she should perform hand hygiene before putting gloves back on. When asked what could happen if gloves were not changed and hand hygiene was not performed, she stated she could contaminate other resident's rooms. Interview with Housekeeper B on 07/11/22 at 10:35 AM revealed she cleaned resident's rooms with her gloves on. Housekeeper B stated she had to wash or sanitize her hands after she used the bathroom and after she ate. She stated she was worried about not having enough gloves. She stated she did not always wash her hands but would use hand sanitizer. Housekeeper B was asked if she changed gloves after leaving a patient room, she stated she was confused on protocols. When asked what could happen if she did not change her gloves or perform hand hygiene she stated she could contaminate another room or spread infection. Interview with Administrator on 07/11/12 at 11:08 AM revealed hand hygiene should be performed often. She stated before entering a resident's room, before performing care, when performing care and change from dirty to clean, and then when finishing in a resident room. Hands should be washed or hand sanitizer should be used. Gloves should not be worn between resident rooms. Hand hygiene should be performed in between taking off gloves and putting on a new pair of gloves. Administrator stated she would expect the housekeepers to follow the same procedures to decrease the chance to spread infection. Review of the Hand Hygiene policy, dated 02/2022, reflected POLICY It is the policy of this organization that hand hygiene will be performed consistent with accepted standards of practice to prevent the spread of infection .PERFORMING HAND HYGIENE - Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .After contact with a patient or with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Immediately after glove removal .Steps for Glove Use .5. Do not wear the same pair of gloves for the care of more than one patient. 6. Always clean your hands immediately after removing gloves, each time you remove a pair of gloves

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #11) of four residents reviewed for pain management. The facility failed to provide adequate pain management for Resident #11, who admitted with severe pain and continued to experience unrelieved pain for nine days. The facility failed to notify Resident #11 ' s physician of the resident ' s adverse reaction to Tylenol #4, and failed to obtain alternative pain medication. LVNC failed to ensure Resident #1 received a pain medication prior to the Wound Care Physician assessing and measuring his wounds (necrotic areas) on his toes and feet, which resulted in severe pain. As a result, Resident #11 wished he had not admitted to the facility. The facility failed to complete a pain assessment upon Resident #11 ' s readmission on 4/01/16 and when he experienced severe pain during the WCP ' s assessment and measurement of the wounds on his toes and feet. An Immediate Jeopardy (IJ) was identified on 04/04/16. While the IJ was removed on 04/16/16 the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal. These failures placed 29 residents, who were on a pain management plan, at risk of delayed intervention, unrelieved severe pain and a decline in their quality of life. Findings included: Resident #11's face sheet, dated 04/05/16, revealed he admitted to the facility on [DATE] at the age of 55, with [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, [MEDICAL CONDITION] was the spread [MEDICAL CONDITION] to other parts of the body. Necrosis was death of living tissue, specifically; death of a portion of tissue differentially affected by local injury (as loss of blood supply, corrosion, burning or the local lesion of a disease). The website was https://www.nlm.nih.gov/medlineplus/. Resident #11's clinical record included an EMR Medication Print Pass, dated 03/21/16, which included orders for the following pain medications: [REDACTED]. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, [MEDICATION NAME] is an opiate pain medication used to treat severe pain. [MEDICATION NAME] is a strong pain medication. The website was https://www.nlm.nih.gov/medlineplus/. Resident #11's Initial Pain Assessment, dated 03/29/16 and completed by LVN Q, revealed his pain to be at a 10 of 10. The assessment reflected he told the admitting nurse that he was dying and had three months to live. It reflected he verbalizes pain, describes pain as aching, heavy, tender, tiring, exhausting, throbbing, shooting, stabbing, sharp, cramping, hot/burning in three different sites. The assessment indicated pain was relieved by medication, and listed nonverbal signs of pain, and observed body actions /behaviors including; grimacing, clenched jaw/teeth frowning/scowling, tightly shut lips, wrinkle brow, turned down mouth, tearing, irritability, clenched fists, and wringing hands. Areas checked under Activities of Daily Living (due to pain he had these changes) were: changes in daily activities or habits [MEDICAL CONDITION], loss of appetite/weight loss, incontinence, decreased ability to concentrate, withdrawal from activities, decreased ability to concentrate changes in mood. Pain management intervention is necessary, refer to resident care plan. Resident #11's record provided no evidence of an initial plan of care. Resident #11's Nurse's Note revealed the following: --On 3/29/16, for the 2 to 10 shift and completed by LVN Q, Resident #11 verbally requested pain medication shortly after admission. (Note: The Initial Pain Assessment had reflected his pain was at the highest level (10).) --On 03/30/16, for the 6 to 2 shift, at noon, and completed by LVN O, Resident #11 complained of pain and swelling of lower abdomen. At 1:40 PM, he was being transferred to hospital for evaluation. The March 2016 MAR for Resident #11 listed no pain medications. Nurse's Note, dated 04/01/16, revealed Resident #11 readmitted to facility. Resident #11's Physician order [REDACTED].#4 three times a day and every 6 hours, and [MEDICATION NAME] 300 mg every evening (HS). According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, Tylenol #4 is a combination drug that contains [MEDICATION NAME], which is used to treat mild to moderate pain. The website was <https://www.nlm.nih.gov/medlineplus/> An observation with the ADON on 04/05/16 at 8:20 AM revealed Resident #11 in bed with his eyes closed, bright red urine in nephrostomy tubes. At that time, ADON stated Resident #11 was non-ambulatory, had terminal diagnoses, had foot ulcers that were gangrenous, [MEDICAL CONDITION] and was on pain management. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, gangrenous is affected by/characterized by gangrene. Gangrene is the local death of soft tissues due to loss of blood supply. The website was https://www.nlm.nih.gov/medlineplus/. An observation and interview of the WCP's assessment measurements of Resident #11's necrotic toes with LVN C on 04/06/16 at 2:15 PM revealed the resident grimaced with his teeth clenched, eyes squeezed shut, made sucking sounds through his teeth with inhalation, and his hands gripped the bed rails. He lifted his body off the bed during measurements of the necrotic toes. When asked about pain medication, LVN C stated he received Tylenol #4 routinely three times a day and had a dose at 1:00 PM. LVN C did not ask Resident #11 about his pain, nor did the WCP during the assessment. During an interview with LVN C on 04/06/16 at 3:15 p.m., when ask about Resident #11's pain during the WCP's visit, she stated the NP could only order the Tylenol #4. She added that Resident #11 could not stand any amount of pressure touch to his feet. She stated that was why when Resident #11 was out of bed, they put him in a geri-chair instead of a wheelchair, to help prevent any bumping to his feet. LVN C stated they had been talking with him about hospice and I finally got him to agree. She revealed hospice could help with better pain medicine. During an interview with Resident #11 on 4/6/16 at 4:00 PM, he revealed he had not received Tylenol #4 or any other pain medication prior to or after the WCP's visit. That same day at 4:15 PM, Resident #11 stated he had not been taking Tylenol #4 due to being allergic. He stated it made him sick at his stomach every time he took it. He stated he had reported that he could not take Tylenol #4. Resident #11's April 2016 MAR indicated [REDACTED]. Resident #11's History and Physical Exam by the NP, dated 04/05/16, revealed .Positive for significant pain .Stage 4 [MEDICAL CONDITION] with metastasis .Bilateral toes/feet necrotic .Right nephrostomy changed 3/31 .discussed with him, hospice care, he is agreeable, tells me he has about three months to live .currently not a surgery candidate .Necrotic toes and feet, needs better pain control .consulting Hospice. During an interview with Resident #11 on 04/07/16 at 8:20 AM, when asked how he felt, he stated, If I had known I would not have anything for pain, I would have stayed at (name of prior facility) and not come here. He revealed his pain was always at 8 to 9 on a scale of 1 to 10 (1 with no pain and 10 with near unbearable pain). He stated pain in the bladder was usually the worst. He verified he had received no pain medication or other methods to control pain. An interview with MA E on 04/07/16 at 8:35 AM revealed that when Resident #11 began to refuse his Tylenol #4 due to allergic and nauseated on 4/4/16, she reported it to LVN O and then reported it to LVN C the following day. She then stated Resident #11 was alert, oriented and thought he was the best one to know about him. An interview with LVN C on 04/07/16 at 8:45 AM revealed she had no knowledge of Resident #11's refusal to take Tylenol #4 for the past four days. She also revealed she had not notified the MD or NP regarding Resident #11 having continued pain. When questioned regarding if she had documented an assessment of his pain, she said she had but was uncertain where she had documented it. Interview with the NP on 04/07/16 at 9:05 AM revealed she had ordered Tylenol #4 due to the physician being unavailable at the time and wrote to consult for hospice in order to obtain better pain control. She stated she had not been informed Resident #11 was not taking the Tylenol #4 due to nausea and the belief he was allergic to the medication. She stated she was not aware that he was not yet on hospice services. She stated that if she had known, she would have contacted the physician. An interview with the ADON conducted on 04/07/16 at 11:50 AM revealed there were several places the Pain Assessments might be depending on when and who completed it. They would be in the Nurses Notes, on the MAR, behind the MAR indicated [REDACTED]. He admitted that was one of the things they had been working on to clarify. In an interview with LVN C, charge nurse on 04/07/16 at 12:00 PM, when asked who was responsible for completing the pain assessment form, she stated, I am not sure. She stated if she saw the assessment was late, she would complete one. She stated, I think the previous ADON completed them, but since we have changed up staff I am not sure who is responsible for making sure they are completed. An interview with the DON on 04/07/16 at 12:15 PM, revealed the admitting Nurse was responsible for performing the initial pain assessment. The MDS Nurses were responsible for completing the quarterly pain assessments, but if the Charge Nurse saw a change, then they were to complete a new pain assessment at that time. The DON stated she was not informed of Resident #11's refusal of Tylenol due to allergy and nausea. She added that she had not read the medication information received from the prior facility that was in Resident #11's chart. No pain assessments for Resident #11 were provided by the facility to the surveyors prior to exit on 04/16/16. Review of Resident #11's telephone orders, dated 04/07/16, revealed the following: --On 04/07/16, an order was received for [MEDICATION NAME] Patch 2.5 mcg every 72 hours [MEDICATION NAME]. --On 04/08/16, an order was received for [MEDICATION NAME] 0.25 mg as needed. Resident #11's April 2016 MAR indicated [REDACTED]. An interview conducted with ADON, LVN C and LVN P conducted on 04/15/16 at 5:00 PM, revealed that none of them had reassessed Resident #11 for pain nor contacted the DON, MD or NP to notify them of Resident #11's Tylenol refusal or notation of medication history of having stronger medicine for effective pain control, or not being on hospice services until 04/08/16. An interview with Resident #11 on 04/14/16 at 2:30 PM, revealed when was asked how his pain management was, he stated much better and hospice had been in to see him. An interview with CNA R on 4/14/16 at 12:55 PM revealed she worked the 6-2 shift. She stated Resident #11 was more relaxed since starting the [MEDICATION NAME] Patches. She added that previously he would flinch if you touched him especially his legs and feet, saying watch me feet . At times, during incontinent care or transfer he would clench his teeth and make sucking noise. She described Resident #11's meal intake as picking at food and preferring to take meals in his room. She said he would hold his breath during transfers to the geri-chair and they would stop for him to take rest periods with deep breathing a few moments then complete the task. An interview with CNA S on 4/14/16 at 2:15 PM revealed she worked the 10-6 shift. She stated Resident #11 was sleeping better with the new [MEDICATION NAME]es. She stated previously during incontinent care he moaned and grimaced when he moved. She stated he had told her he could not even stand a sheet on his toes or feet. During an interview on 4/14/16 at 5:00 PM with the ADON, he stated he did not see any admission paperwork for Resident #11, he had a bag which contained bottles [MEDICAL CONDITION]. Review of the Policy on Pain Assessment, undated under section: Procedure: 1. Complete all aspects of pain assessment form on admit, quarterly, and significant change in condition. 2. Record pain assessment findings on the MDS 3. Include interventions in the resident's Comprehensive Plan of Care .5. Implement appropriate Monthly Pain Management Flow Sheet for MA/Nurse to record PRN pain medication usage .Notify MD of frequent PRN use for possible new orders. 6. Residents on routine pain medications should be assessed daily for pain rating for the first week, then weekly thereafter ( weekly pain rating can be documented on MAR) .Notify MD and family of changes in level of pain not being controlled by routine medication ordered. Pain should be controlled to the level acceptable to the resident (as pain is very subjective.) An IJ was identified on 04/14/16. On 04/14/14 at 12:30 PM the Administrator was notified of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 04/16/16 at 10:30 AM and included the following: --The DON and ADON completed an assessment for all residents on 04/14/16 for appropriate medications and pain management. All residents were receiving appropriate medications. --04/14/16, the residents identified as receiving pain medications were reviewed by DON and ADON. All were determined to demonstrate no change, either increasing or decreasing in pain occurrence or management, as evidence by the stability of the medication provided. --On 04/14/16, the following staff members were verbally counseled by the DON, (with written documentation) on pain management, documentation, communication and follow up of pain. --All nursing staff, nurses and MAs were in-serviced on 04/14/16 and 04/15/16 by the DON concerning pain management, pain control, pain medication, hospice, pain assessment, documentation and communication. Evidence of competency was determined using a check off. --The Nurse Practitioner will provide an in-depth in-service on pain management and pain control 04/19/16 for all nursing staff, nurses and MAs. --DON and ADON have implemented upon admission residents would be more thoroughly evaluated based on the report provided from resident's previous residence. During report from the discharging facility every effort will be made to be informed of current pain condition, pain medications and options for medication based on allergies and tolerances. --Effective 04/16/16, the DON and ADON will test current and future employees for compliance in the issue of pain assessment, pain monitoring, relieving pain, charting, communicating the effectiveness of residents' pain medication, notifying appropriate personnel when residents refuse medications, and reviewing pain medication upon admission training would be completed by 04/16/16 midnight. --Effective 04/16/16, the facility will implement a Pain Management Committee comprised of the Administrator, DON, Therapy Director, MDS Coordinators, and the BOM. The committee will monitor compliance and assess the ongoing need for pain management for residents. The committee will meet weekly and continue indefinitely or until evidence of proper and appropriate pain management for residents. Pain management committee will perform spot checks and retraining to assure compliance. --Effective 04/16/16, the DON, ADON or Administrator will continue to approve content, monitor staff participation, and implementation and effectiveness of pain management training. Training will be provided to all nursing staff on hire and as needed for continued coverage of pain management skills. This will initially be on a daily basis and will continue until all staff demonstrated adequate knowledge of the pain management criteria. --Effective 04/16/16, the facility's Quality Assurance Meetings will conduct weekly meetings for six months and quarterly thereafter, and will ensure evidence of proper and appropriate control and assessment of residents for pain management needs. --Effective 04/16/16, pain medication and documentation will be addressed by nurses during report after shifts, new pain medications and effectiveness will be recorded on the 24 hour communication board, documented in nurse notes and on the MARs. This with be implemented and monitored by the Administrator, DON and the ADON. To verify the facility's implementation of the facility's Plan of Removal the following was conducted: --In an interview on 04/15/16 at 10:30 AM, the DON she stated she had provided in-services on 04/14/16 and 04/15/16 concerning pain assessments, documentation, monitoring, effectively communication concerns of pain, who to notify for pain medication, action to take if resident refuses pain medication, resident orders and completion of admission pain assessment. --On 04/15/16, seven nurses and two med aides, representing staff from all three shifts and weekday/weekend staff, were interviewed regarding the training they received. They were each able to explain what actions to take if a resident refused pain medication, who to notify for pain medications, completion of pain assessments, documentation and monitoring. The staffs were ADON/LVN, MDS B (LVN), LVN C, LVN D, LVN Q, LVN S, LVN T, MA P, and MA U. --On 04/16/16, review of the in-service records and the check offs revealed the entire full time staff had be in serviced. In addition, interviews with Resident #11 on 04/15/16 revealed at 8:30 AM he said he was resting better, and at 10:00 AM, he said his pain was less with the Fentaynl patch. The IJ was removed on 04/16/16. The Administrator was informed of the IJ removal on 04/16/16 at 10:30 AM. While the IJ was removed on 04/16/16, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. The Resident Census and Condition of Residents Form, CMS 672, signed and dated by MDS A on 04/05/16, reflected 29 residents on a pain management program.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable mental and physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #11) of four residents reviewed for pain management. The facility failed to provide adequate pain management for Resident #11, who admitted with severe pain and continued to experience unrelieved pain for nine days. The facility failed to notify Resident #11 ' s physician of the resident ' s adverse reaction to Tylenol #4, and failed to obtain alternative pain medication. LVN C failed to ensure Resident #1 received a pain medication prior to the Wound Care Physician assessing and measuring his wounds (necrotic areas) on his toes and feet, which resulted in severe pain. As a result, Resident #11 wished he had not admitted to the facility. The facility failed to complete a pain assessment upon Resident #11 ' s readmission on 4/01/16 and when he experienced severe pain during the WCP ' s assessment and measurement of the wounds on his toes and feet. An Immediate Jeopardy (IJ) was identified on 04/14/16. While the IJ was removed on 04/16/16 the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal. These failures placed 29 residents, who were on a pain management plan, at risk of delayed intervention, unrelieved severe pain and a decline in their quality of life. Findings included: Resident #11's face sheet, dated 04/05/16, revealed he admitted to the facility on [DATE] at the age of 55, with [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, [MEDICAL CONDITION] was the spread [MEDICAL CONDITION] to other parts of the body. Necrosis was death of living tissue, specifically; death of a portion of tissue differentially affected by local injury (as loss of blood supply, corrosion, burning or the local lesion of a disease). The website was https://www.nlm.nih.gov/medlineplus/. Resident #11's clinical record included an EMR Medication Print Pass, dated 03/21/16, which included orders for the following pain medications: [REDACTED]. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, [MEDICATION NAME] is an opiate pain medication used to treat severe pain. [MEDICATION NAME] is a strong pain medication. The website was https://www.nlm.nih.gov/medlineplus/. Resident #11's Initial Pain Assessment, dated 03/29/16 and completed by LVN Q, revealed his pain to be at a 10 of 10. The assessment reflected he told the admitting nurse that he was dying and had three months to live. It reflected he verbalizes pain, describes pain as aching, heavy, tender, tiring, exhausting, throbbing, shooting, stabbing, sharp, cramping, hot/burning in three different sites. The assessment indicated pain was relieved by medication, and listed nonverbal signs of pain, and observed body actions /behaviors including; grimacing, clenched jaw/teeth frowning/scowling, tightly shut lips, wrinkle brow, turned down mouth, tearing, irritability, clenched fists, and wringing hands. Areas checked under Activities of Daily Living (due to pain he had these changes) were: changes in daily activities or habits [MEDICAL CONDITION], loss of appetite/weight loss, incontinence, decreased ability to concentrate, withdrawal from activities, decreased ability to concentrate changes in mood. Pain management intervention is necessary, refer to resident care plan. Resident #11's record provided no evidence of an initial plan of care. Resident #11's Nurse's Note revealed the following: --On 3/29/16, for the 2 to 10 shift and completed by LVN Q, Resident #11 verbally requested pain medication shortly after admission. (Note: The Initial Pain Assessment had reflected his pain was at the highest level (10).) --On 03/30/16, for the 6 to 2 shift, at noon, and completed by LVN O, Resident #11 complained of pain and swelling of lower abdomen. At 1:40 PM, he was being transferred to hospital for evaluation. The March 2016 MAR for Resident #11 listed no pain medications. Nurse's Note, dated 04/01/16, revealed Resident #11 readmitted to facility. Resident #11's Physician order [REDACTED].#4 three times a day and every 6 hours, and [MEDICATION NAME] 300 mg every evening (HS). According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, Tylenol #4 is a combination drug that contains [MEDICATION NAME], which is used to treat mild to moderate pain. The website was <https://www.nlm.nih.gov/medlineplus/> An observation with the ADON on 04/05/16 at 8:20 AM revealed Resident #11 in bed with his eyes closed, bright red urine in nephrostomy tubes. At that time, ADON stated Resident #11 was non-ambulatory, had terminal diagnoses, had foot ulcers that were gangrenous, [MEDICAL CONDITION] and was on pain management. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, gangrenous is affected by/characterized by gangrene. Gangrene is the local death of soft tissues due to loss of blood supply. The website was https://www.nlm.nih.gov/medlineplus/. An observation and interview of the WCP's assessment measurements of Resident #11's necrotic toes with LVN C on 04/06/16 at 2:15 PM revealed the resident grimaced with his teeth clenched, eyes squeezed shut, made sucking sounds through his teeth with inhalation, and his hands gripped the bed rails. He lifted his body off the bed during measurements of the necrotic toes. When asked about pain medication, LVN C stated he received Tylenol #4 routinely three times a day and had a dose at 1:00 PM. LVN C did not ask Resident #11 about his pain, nor did the WCP during the assessment. During an interview with LVN C on 04/06/16 at 3:15 p.m., when ask about Resident #11's pain during the WCP's visit, she stated the NP could only order the Tylenol #4. She added that Resident #11 could not stand any amount of pressure touch to his feet. She stated that was why when Resident #11 was out of bed, they put him in a geri-chair instead of a wheelchair, to help prevent any bumping to his feet. LVN C stated they had been talking with him about hospice and I finally got him to agree. She revealed hospice could help with better pain medicine. During an interview with Resident #11 on 4/6/16 at 4:00 PM, he revealed he had not received Tylenol #4 or any other pain medication prior to or after the WCP's visit. That same day at 4:15 PM, Resident #11 stated he had not been taking Tylenol #4 due to being allergic. He stated it made him sick at his stomach every time he took it. He stated he had reported that he could not take Tylenol #4. Resident #11's April 2016 MAR indicated [REDACTED]. Resident #11's History and Physical Exam by the NP, dated 04/05/16, revealed .Positive for significant pain .Stage 4 [MEDICAL CONDITION] with metastasis .Bilateral toes/feet necrotic .Right nephrostomy changed 3/31 .discussed with him, hospice care, he is agreeable, tells me he has about three months to live .currently not a surgery candidate .Necrotic toes and feet, needs better pain control .consulting Hospice. During an interview with Resident #11 on 04/07/16 at 8:20 AM, when asked how he felt, he stated, If I had known I would not have anything for pain, I would have stayed at (name of prior facility) and not come here. He revealed his pain was always at 8 to 9 on a scale of 1 to 10 (1 with no pain and 10 with near unbearable pain). He stated pain in the bladder was usually the worst. He verified he had received no pain medication or other methods to control pain. An interview with MA E on 04/07/16 at 8:35 AM revealed that when Resident #11 began to refuse his Tylenol #4 due to allergic and nauseated on 4/4/16, she reported it to LVN O and then reported it to LVN C the following day. She then stated Resident #11 was alert, oriented and thought he was the best one to know about him. An interview with LVN C on 04/07/16 at 8:45 AM revealed she had no knowledge of Resident #11's refusal to take Tylenol #4 for the past four days. She also revealed she had not notified the MD or NP regarding Resident #11 having continued pain. When questioned regarding if she had documented an assessment of his pain, she said she had but was uncertain where she had documented it. Interview with the NP on 04/07/16 at 9:05 AM revealed she had ordered Tylenol #4 due to the physician being unavailable at the time and wrote to consult for hospice in order to obtain better pain control. She stated she had not been informed Resident #11 was not taking the Tylenol #4 due to nausea and the belief he was allergic to the medication. She stated she was not aware that he was not yet on hospice services. She stated that if she had known, she would have contacted the physician. An interview with the ADON conducted on 04/07/16 at 11:50 AM revealed there were several places the Pain Assessments might be depending on when and who completed it. They would be in the Nurses Notes, on the MAR, behind the MAR indicated [REDACTED]. He admitted that was one of the things they had been working on to clarify. In an interview with LVN C, charge nurse on 04/07/16 at 12:00 PM, when asked who was responsible for completing the pain assessment form, she stated, I am not sure. She stated if she saw the assessment was late, she would complete one. She stated, I think the previous ADON completed them, but since we have changed up staff I am not sure who is responsible for making sure they are completed. An interview with the DON on 04/07/16 at 12:15 PM, revealed the admitting Nurse was responsible for performing the initial pain assessment. The MDS Nurses were responsible for completing the quarterly pain assessments, but if the Charge Nurse saw a change, then they were to complete a new pain assessment at that time. The DON stated she was not informed of Resident #11's refusal of Tylenol due to allergy and nausea. She added that she had not read the medication information received from the prior facility that was in Resident #11's chart. No pain assessments for Resident #11 were provided by the facility to the surveyors prior to exit on 04/16/16. Review of Resident #11's telephone orders, dated 04/07/16, revealed the following: --On 04/07/16, an order was received for [MEDICATION NAME] Patch 2.5 mcg every 72 hours [MEDICATION NAME]. --On 04/08/16, an order was received for [MEDICATION NAME] 0.25 mg as needed. Resident #11's April 2016 MAR indicated [REDACTED]. An interview conducted with ADON, LVN C and LVN P conducted on 04/15/16 at 5:00 PM, revealed that none of them had reassessed Resident #11 for pain nor contacted the DON, MD or NP to notify them of Resident #11's Tylenol refusal or notation of medication history of having stronger medicine for effective pain control, or not being on hospice services until 04/08/16. An interview with Resident #11 on 04/14/16 at 2:30 PM, revealed when was asked how his pain management was, he stated much better and hospice had been in to see him. An interview with CNA R on 4/14/16 at 12:55 PM revealed she worked the 6-2 shift. She stated Resident #11 was more relaxed since starting the [MEDICATION NAME] Patches. She added that previously he would flinch if you touched him especially his legs and feet, saying watch me feet . At times, during incontinent care or transfer he would clench his teeth and make sucking noise. She described Resident #11's meal intake as picking at food and preferring to take meals in his room. She said he would hold his breath during transfers to the geri-chair and they would stop for him to take rest periods with deep breathing a few moments then complete the task. An interview with CNA S on 4/14/16 at 2:15 PM revealed she worked the 10-6 shift. She stated Resident #11 was sleeping better with the new [MEDICATION NAME]es. She stated previously during incontinent care he moaned and grimaced when he moved. She stated he had told her he could not even stand a sheet on his toes or feet. During an interview on 4/14/16 at 5:00 PM with the ADON, he stated he did not see any admission paperwork for Resident #11, he had a bag which contained bottles [MEDICAL CONDITION]. Review of the Policy on Pain Assessment, undated under section: Procedure: 1. Complete all aspects of pain assessment form on admit, quarterly, and significant change in condition. 2. Record pain assessment findings on the MDS 3. Include interventions in the resident's Comprehensive Plan of Care .5. Implement appropriate Monthly Pain Management Flow Sheet for MA/Nurse to record PRN pain medication usage .Notify MD of frequent PRN use for possible new orders. 6. Residents on routine pain medications should be assessed daily for pain rating for the first week, then weekly thereafter ( weekly pain rating can be documented on MAR) .Notify MD and family of changes in level of pain not being controlled by routine medication ordered. Pain should be controlled to the level acceptable to the resident (as pain is very subjective.) An IJ was identified on 04/14/16. On 04/14/14 at 12:30 PM the Administrator was notified of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 04/16/16 at 10:30 AM and included the following: --The DON and ADON completed an assessment for all residents on 04/14/16 for appropriate medications and pain management. All residents were receiving appropriate medications. --04/14/16, the residents identified as receiving pain medications were reviewed by DON and ADON. All were determined to demonstrate no change, either increasing or decreasing in pain occurrence or management, as evidence by the stability of the medication provided. --On 04/14/16, the following staff members were verbally counseled by the DON, (with written documentation) on pain management, documentation, communication and follow up of pain. --All nursing staff, nurses and MAs were in-serviced on 04/14/16 and 04/15/16 by the DON concerning pain management, pain control, pain medication, hospice, pain assessment, documentation and communication. Evidence of competency was determined using a check off. --The Nurse Practitioner will provide an in-depth in-service on pain management and pain control 04/19/16 for all nursing staff, nurses and MAs. --DON and ADON have implemented upon admission residents would be more thoroughly evaluated based on the report provided from resident's previous residence. During report from the discharging facility every effort will be made to be informed of current pain condition, pain medications and options for medication based on allergies and tolerances. --Effective 04/16/16, the DON and ADON will test current and future employees for compliance in the issue of pain assessment, pain monitoring, relieving pain, charting, communicating the effectiveness of residents' pain medication, notifying appropriate personnel when residents refuse medications, and reviewing pain medication upon admission training would be completed by 04/16/16 midnight. --Effective 04/16/16, the facility will implement a Pain Management Committee comprised of the Administrator, DON, Therapy Director, MDS Coordinators, and the BOM. The committee will monitor compliance and assess the ongoing need for pain management for residents. The committee will meet weekly and continue indefinitely or until evidence of proper and appropriate pain management for residents. Pain management committee will perform spot checks and retraining to assure compliance. --Effective 04/16/16, the DON, ADON or Administrator will continue to approve content, monitor staff participation, and implementation and effectiveness of pain management training. Training will be provided to all nursing staff on hire and as needed for continued coverage of pain management skills. This will initially be on a daily basis and will continue until all staff demonstrated adequate knowledge of the pain management criteria. --Effective 04/16/16, the facility's Quality Assurance Meetings will conduct weekly meetings for six months and quarterly thereafter, and will ensure evidence of proper and appropriate control and assessment of residents for pain management needs. --Effective 04/16/16, pain medication and documentation will be addressed by nurses during report after shifts, new pain medications and effectiveness will be recorded on the 24 hour communication board, documented in nurse notes and on the MARs. This with be implemented and monitored by the Administrator, DON and the ADON. To verify the facility's implementation of the facility's Plan of Removal the following was conducted: --In an interview on 04/15/16 at 10:30 AM, the DON she stated she had provided in-services on 04/14/16 and 04/15/16 concerning pain assessments, documentation, monitoring, effectively communication concerns of pain, who to notify for pain medication, action to take if resident refuses pain medication, resident orders and completion of admission pain assessment. --On 04/15/16, seven nurses and two med aides, representing staff from all three shifts and weekday/weekend staff, were interviewed regarding the training they received. They were each able to explain what actions to take if a resident refused pain medication, who to notify for pain medications, completion of pain assessments, documentation and monitoring. The staffs were ADON/LVN, MDS B (LVN), LVN C, LVN D, LVN Q, LVN S, LVN T, MA P, and MA U. --On 04/16/16, review of the in-service records and the check offs revealed the entire full time staff had be in serviced. In addition, interviews with Resident #11 on 04/15/16 revealed at 8:30 AM he said he was resting better, and at 10:00 AM, he said his pain was less with the Fentaynl patch. The IJ was removed on 04/16/16. The Administrator was informed of the IJ removal on 04/16/16 at 10:30 AM. While the IJ was removed on 04/16/16, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. The Resident Census and Condition of Residents Form, CMS 672, signed and dated by MDS A on 04/05/16, reflected 29 residents on a pain management program.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect for one (Resident #11) of 13 residents reviewed for neglect. The facility failed to provide adequate pain management for Resident #11, who admitted with severe pain and continued to experience unrelieved pain for nine days. The facility failed to notify Resident #11 ' s physician of the resident ' s adverse reaction to Tylenol #4, and failed to obtain alternative pain medication. LVN C failed to ensure Resident #1 received a pain medication prior to the Wound Care Physician assessing and measuring his wounds (necrotic areas) on his toes and feet, which resulted in severe pain. As a result, Resident #11 wished he had not admitted to the facility. The facility failed to complete a pain assessment upon Resident #11 ' s readmission on 4/01/16 and when he experienced severe pain during the WCP ' s assessment and measurement of the wounds on his toes and feet. An Immediate Jeopardy (IJ) was identified on 04/04/16. While the IJ was removed on 04/16/16 the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal. These failures placed 29 residents, who were on a pain management plan, at risk of delayed intervention, unrelieved severe pain and a decline in their quality of life. Findings included: Review of the Policy on Abuse Prevention Policy and Procedure, dated 03/31/03, reflected neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the Policy on Pain Assessment, undated under section: Procedure: 1. Complete all aspects of pain assessment form on admit, quarterly, and significant change in condition. 2. Record pain assessment findings on the MDS 3. Include interventions in the resident's Comprehensive Plan of Care .5. Implement appropriate Monthly Pain Management Flow Sheet for MA/Nurse to record PRN pain medication usage .Notify MD of frequent PRN use for possible new orders. 6. Residents on routine pain medications should be assessed daily for pain rating for the first week, then weekly thereafter ( weekly pain rating can be documented on MAR) .Notify MD and family of changes in level of pain not being controlled by routine medication ordered. Pain should be controlled to the level acceptable to the resident (as pain is very subjective). Resident #11's face sheet, dated 04/05/16, revealed he admitted to the facility on [DATE] at the age of 55, with [DIAGNOSES REDACTED]. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, [MEDICAL CONDITION] was the spread [MEDICAL CONDITION] to other parts of the body. Necrosis was death of living tissue, specifically; death of a portion of tissue differentially affected by local injury (as loss of blood supply, corrosion, burning or the local lesion of a disease.). The website was https://www.nlm.nih.gov/medlineplus/. Resident #11's clinical record included an EMR Medication Print Pass, dated 03/21/16, which included orders for the following pain medications: [REDACTED]. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, [MEDICATION NAME] is an opiate pain medication used to treat severe pain. [MEDICATION NAME] is a strong pain medication. The website was https://www.nlm.nih.gov/medlineplus/. Resident #11's Initial Pain Assessment, dated 03/29/16 and completed by LVN Q, revealed his pain to be at a 10 of 10. The assessment reflected he told the admitting nurse that he was dying and had three months to live. It reflected he verbalizes pain, describes pain as aching, heavy, tender, tiring, exhausting, throbbing, shooting, stabbing, sharp, cramping, hot/burning in three different sites. The assessment indicated pain was relieved by medication, and listed nonverbal signs of pain, and observed body actions /behaviors including; grimacing, clenched jaw/teeth frowning/scowling, tightly shut lips, wrinkle brow, turned down mouth, tearing, irritability, clenched fists, and wringing hands. Areas checked under Activities of Daily Living (due to pain he had these changes) were: changes in daily activities or habits [MEDICAL CONDITION], loss of appetite/weight loss, incontinence, decreased ability to concentrate, withdrawal from activities, decreased ability to concentrate changes in mood. Pain management intervention is necessary, refer to resident care plan. Resident #11's record provided no evidence of an initial plan of care. Resident #11's Nurse's Note revealed the following: --On 3/29/16, for the 2 to 10 shift and completed by LVN Q, Resident #11 verbally requested pain medication shortly after admission. (Note: The Initial Pain Assessment had reflected his pain was at the highest level (10).) --On 03/30/16, for the 6 to 2 shift, at noon, and completed by LVN O, Resident #11 complained of pain and swelling of lower abdomen. At 1:40 PM, he was being transferred to hospital for evaluation. The March 2016 MAR indicated [REDACTED] Nurse's Note, dated 04/01/16, revealed Resident #11 readmitted to facility. Resident #11's Physician order [REDACTED].#4 three times a day and every 6 hours, and [MEDICATION NAME] 300 mg every evening (HS). According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, Tylenol #4 is a combination drug that contains [MEDICATION NAME], which is used to treat mild to moderate pain. The website was <https://www.nlm.nih.gov/medlineplus/> An observation with the ADON on 04/05/16 at 8:20 AM revealed Resident #11 in bed with his eyes closed, bright red urine in nephrostomy tubes. At that time, ADON stated Resident #11 was non-ambulatory, had terminal diagnoses, had foot ulcers that were gangrenous, [MEDICAL CONDITION] and was on pain management. According to the U.S. National Library of Medicine's Medline Plus, accessed on 04/21/16, gangrenous is affected by/characterized by gangrene. Gangrene is the local death of soft tissues due to loss of blood supply. The website was https://www.nlm.nih.gov/medlineplus/. An observation and interview of the WCP's assessment measurements of Resident #11's necrotic toes with LVN C on 04/06/16 at 2:15 PM revealed the resident grimaced with his teeth clenched, eyes squeezed shut, made sucking sounds through his teeth with inhalation, and his hands gripped the bed rails. He lifted his body off the bed during measurements of the necrotic toes. When asked about pain medication, LVN C stated he received Tylenol #4 routinely three times a day and had a dose at 1:00 PM. LVN C did not ask Resident #11 about his pain, nor did the WCP during the assessment. During an interview with LVN C on 04/06/16 at 3:15 PM, when ask about Resident #11's pain during the WCP's visit, she stated the NP could only order the Tylenol #4. She added that Resident #11 could not stand any amount of pressure touch to his feet. She stated that was why when Resident #11 was out of bed, they put him in a geri-chair instead of a wheelchair, to help prevent any bumping to his feet. LVN C stated they had been talking with him about hospice and I finally got him to agree. She revealed hospice could help with better pain medicine. During an interview with Resident #11 on 04/06/16 at 4:00 PM, he revealed he had not received Tylenol #4 or any other pain medication prior to or after the WCP's visit. That same day at 4:15 PM, Resident #11 stated he had not been taking Tylenol #4 due to being allergic. He stated it made him sick at his stomach every time he took it. He stated he had reported that he could not take Tylenol #4. Resident #11's April 2016 MAR indicated [REDACTED]. Resident #11's History and Physical Exam by the NP, dated 04/05/16, revealed .Positive for significant pain .Stage 4 [MEDICAL CONDITION] with metastasis .Bilateral toes/feet necrotic .Right nephrostomy changed 3/31 .discussed with him, hospice care, he is agreeable, tells me he has about three months to live .currently not a surgery candidate .Necrotic toes and feet, needs better pain control .consulting hospice. During an interview with Resident #11 on 04/07/16 at 8:20 AM, when asked how he felt, he stated, If I had known I would not have anything for pain, I would have stayed at (name of prior facility) and not come here. He revealed his pain was always at 8 to 9 on a scale of 1 to 10 (1 with no pain and 10 with near unbearable pain). He stated pain in the bladder was usually the worst. He verified he had received no pain medication or other methods to control pain. An interview with MA E on 04/07/16 at 8:35 AM revealed that when Resident #11 began to refuse his Tylenol #4 due to allergic and nauseated on 04/04/16, she reported it to LVN O and then reported it to LVN C the following day. She then stated Resident #11 was alert, oriented and thought he was the best one to know about him. An interview with LVN C on 04/07/16 at 8:45 AM revealed she had no knowledge of Resident #11's refusal to take Tylenol #4 for the past four days. She also revealed she had not notified the MD or NP regarding Resident #11 having continued pain. When questioned regarding if she had documented an assessment of his pain, she said she had but was uncertain where she had documented it. Interview with the NP on 04/07/16 at 9:05 AM revealed she had ordered Tylenol #4 due to the physician being unavailable at the time and wrote to consult for hospice in order to obtain better pain control. She stated she had not been informed Resident #11 was not taking the Tylenol #4 due to nausea and the belief he was allergic to the medication. She stated she was not aware that he was not yet on hospice services. She stated that if she had known, she would have contacted the physician. An interview with the ADON conducted on 04/07/16 at 11:50 AM revealed there were several places the Pain Assessments might be depending on when and who completed it. They would be in the Nurses Notes, on the MAR, behind the MAR indicated [REDACTED]. He admitted that was one of the things they had been working on to clarify. In an interview with LVN C on 04/07/16 at 12:00 PM, when asked who was responsible for completing the pain assessment form, she stated, I am not sure. She stated if she saw the assessment was late, she would complete one. She stated, I think the previous ADON completed them, but since we have changed up staff I am not sure who is responsible for making sure they are completed. An interview with the DON on 04/07/16 at 12:15 PM, revealed the admitting Nurse was responsible for performing the initial pain assessment. The MDS Nurses were responsible for completing the quarterly pain assessments, but if the Charge Nurse saw a change, then they were to complete a new pain assessment at that time. The DON stated she was not informed of Resident #11's refusal of Tylenol due to allergy and nausea. She added that she had not read the medication information received from the prior facility that was in Resident #11's chart. Review of Resident #11's telephone orders, dated 04/07/16, revealed the following: --On 04/07/16, an order was received for [MEDICATION NAME] Patch 2.5 mcg every 72 hours [MEDICATION NAME]. --On 04/08/16, an order was received for [MEDICATION NAME] 0.25 mg as needed. Resident #11's April 2016 MAR indicated [REDACTED]. An interview conducted with ADON, LVN C and LVN P conducted on 04/15/16 at 5:00 PM, revealed that none of them had reassessed Resident #11 for pain nor contacted the DON, MD or NP to notify them of Resident #11's Tylenol refusal or notation of medication history of having stronger medicine for effective pain control, or not being on hospice services until 4/8/16. An interview with Resident #11 on 04/14/16 at 2:30 PM, revealed when was asked how his pain management was, he stated much better and hospice had been in to see him. An interview with CNA R on 04/14/16 at 12:55 PM revealed she worked the 6-2 shift. She stated Resident #11 was more relaxed since starting the [MEDICATION NAME] Patches. She added that previously he would flinch if you touched him especially his legs and feet, saying watch me feet . At times, during incontinent care or transfer he would clench his teeth and make sucking noise She described Resident #11's meal intake as picking at food and preferring to take meals in his room. She said he would hold his breath during transfers to the geri-chair and they would stop for him to take rest periods with deep breathing a few moments then complete the task. An interview with CNA S on 04/14/16 at 2:15 PM revealed she worked the 10-6 shift. She stated Resident #11 was sleeping better with the new [MEDICATION NAME]es. She stated previously during incontinent care he moaned and grimaced when he moved. She stated he had told her he could not even stand a sheet on his toes or feet. During an interview on 04/14/16 at 5:00 PM with the ADON, she stated that review of Resident #11's admission papers had revealed he had telephone orders for bottles of the pain medications. An IJ was identified on 04/14/16. On 04/14/14 at 12:30 PM the Administrator was notified of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 04/16/16 at 10:30 AM and included the following: --The DON and ADON completed an assessment for all residents on 04/14/16 for appropriate medications and pain management. All residents were receiving appropriate medications. --04/14/16, the residents identified as receiving pain medications were reviewed by DON and ADON. All were determined to demonstrate no change, either increasing or decreasing in pain occurrence or management, as evidence by the stability of the medication provided. --On 04/14/16 the following staff members were verbally counseled by the DON, (with written documentation) on pain management, documentation, communication and follow up of pain. --All nursing staff, nurses and CMAs were in-serviced on 04/14/16 and 04/15/16 by the DON concerning pain management, pain control, pain medication, hospice, pain assessment, documentation and communication. Evidence of competency was determined using a check off. --The Nurse Practitioner will provide an in-depth in-service on pain management and pain control 04/19/16 for all nursing staff, nurses and MAs. --DON and ADON have implemented upon admission residents would be more thoroughly evaluated based on the report provided from resident's previous residence. During report from the discharging facility every effort will be made to be informed of current pain condition, pain medications and options for medication based on allergies and tolerances. --Effective 04/16/16, the DON and ADON will test current and future employees for compliance in the issue of pain assessment, pain monitoring, relieving pain, charting, communicating the effectiveness of resident's pain medication, notifying appropriate personnel when residents refuse medications, and reviewing pain medication upon admission training would be completed by 04/16/16 midnight. --Effective 04/16/16, the facility will implement a Pain Management Committee comprised of the Administrator, DON, Therapy Director, MDS Coordinators, and the BOM. The committee will monitor compliance and assess the ongoing need for pain management for residents. The committee will meet weekly and continue indefinitely or until evidence of proper and appropriate pain management for residents. Pain management committee will perform spot checks and retraining to assure compliance. --Effective 04/16/16, the DON, ADON or Administrator will continue to approve content, monitor staff participation, and implementation and effectiveness of pain management training. Training will be provided to all nursing staff on hire and as needed for continued coverage of pain management skills. This will initially be on a daily bases and will continue until all staff demonstrated adequate knowledge of the pain management criteria. --Effective 04/16/16, the facility's Quality Assurance Meetings will conduct weekly meetings for 6 months and quarterly thereafter, and will ensure evidence of proper and appropriate control and assessment of residents for pain management needs. --Effective 04/16/16, pain medication and documentation will be addressed by nurses during report after shifts, new pain medications and effectiveness will be recorded on the 24 hour communication board, documented in nurse notes and on the MARs. This with be implemented and monitored by the Administrator, DON and the ADON. To verify the facility's implementation of the facility's Plan of Removal the following was conducted: --In an interview on 04/15/16 at 10:30 AM, the DON she stated she had provided in-services on 04/14/16 and 04/15/16 concerning pain assessments, documentation, monitoring, effectively communication concerns of pain, who to notify for pain medication, action to take if resident refuses pain medication, resident orders and completion of admission pain assessment. --On 04/15/16, seven nurses and two med aides, representing staff from all three shifts and weekday/weekend staff, were interviewed regarding the training they received. They were each able to explain what actions to take if a resident refused pain medication, who to notify for pain medications, completion of pain assessments, documentation and monitoring. The staffs were ADON/LVN, MDS B (LVN), LVN C, LVN D, LVN Q, LVN S, LVN T, MA P, and MA U. --On 04/16/16, review of the in-service records and the check offs revealed the entire full time staff had been in-serviced. In addition, interviews with Resident #11 on 04/15/16 revealed at 8:30 AM he said he was resting better, and at 10:00 AM, he said his pain was less with the Fentaynl patch. The IJ was removed on 04/16/16. The Administrator was informed of the IJ removal on 04/16/16 at 10:30 AM. While the IJ was removed on 04/16/16, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan of Removal. The Resident Census and Condition of Residents Form, CMS 672, signed and dated by MDS A on 04/05/16, reflected 29 residents on a pain management program.

Based on observation, interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for two (Residents #1 and #2) of seven residents reviewed for neglect. 1) The facility failed to appropriately address and put in place interventions to prevent elopements once it identified Resident #1 was a high risk for elopement. The facility also failed to provide adequate supervision following the elopement on 09/23/14, which resulted in additional incidents of elopement on 10/16/14 and 10/26/14. 2) The facility failed to appropriately address and put in place interventions to prevent elopements once it identified Resident #2 was a high risk for elopement. The facility also failed to provide adequate supervision following the elopement on 08/09/14, which resulted in additional incidents of elopement on 09/13/14 and 10/26/14. An Immediate Jeopardy (IJ) was identified on 10/28/14. While the IJ was removed on 10/31/14, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the nine residents, including Residents #1 and #2, who were identified as wanderers at risk of elopement, by placing them at risk for serious injuries and/or death. Findings included: 1) Resident #1's Face Sheet, dated 09/03/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/09/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired. His wandering behaviors occurred daily and placed him at risk of getting into a potentially dangerous place, such as outside of the facility. Resident #1 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #1 did not use any mobility devices. Resident #1's Elopement Assessment, dated 09/03/14, reflected a score of 21, which indicated he was at "high risk" of elopement. Resident #1's Patient Progress Note, dated 10/01/14, reflected Resident #1 had Dementia with behaviors. Resident #1's undated care plan reflected he required a "Wanderguard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #1's care plan did not address the high elopement risk identified at admission. Resident #1's MARs, dated September 2014 and October 2014, reflected Wanderguard was checked weekly, every Thursday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #1 on 10/28/14 at 12:05 PM, revealed he was ambulating on the hall without staff assistance and without the use of any ambulation devices. Resident #1's Daily Skilled Nurse's notes revealed the following: 09/04/14 at 8:30 AM: "...has left facility x (times) 2 this am;" 09/06/14 at 9:35 AM: "...Attempted to get out of the facility several times. Confused...;" 09/06/14 at 7:37 PM: "...went out front door. Went to the street...;" 09/22/14 at 6:30 PM: "...sitting in TV room...Attempted to leave facility with roommate...;" 09/23/14 at 4:30 PM: "Notified of (Resident #1) being gone from day room, building searched, Person not in building...Full search began...." An incident report, dated 09/23/14 at 4:30 PM, reflected: "pt (patient) was noticed not to be in lounge by TV. Building searched per protocol Pt not on premises. Admin (Administrator) + (and) DON (Director of Nursing) on site + notified. Pt was later found outside of...with a stolen vehicle. DON + staff returned Patient to facility." A statement signed by the ADM and dated 09/23/14 reflected: "...Post Assessment: Resident wears a working Wander Guard bracelet. He must have slipped out the back door, near where the truck had been left with keys. He will stay on q (every) 15 minute checks for 24 hours. The three gates at the back of the facility will be replaced with one central gate with a secure monitoring system." Interview with Investigator J, from the local law enforcement department, via telephone on 10/29/14 at 8:28 PM, revealed police received a call on 09/23/14 at 4:14 PM, of a possible intoxicated driver headed northbound on a local highway. Investigator J stated Resident #1 appeared very confused when he stopped him. The investigator revealed the resident told him he (Resident #1) was driving from another state. Investigator J stated he called for an ambulance to check Resident #1 out to ensure he was okay. He stated one of the paramedics saw the Wanderguard bracelet on Resident #1's wrist and suggested that was used in nursing homes. Investigator J revealed he called several nursing homes in the area to see if he could locate where the resident came from. He stated he received a call from a local police department regarding the missing resident, and the facility staff came to pick up the resident from his custody within an hour or so. He stated Resident #1 was stopped about 20 miles from the facility. Interview with LVN C on 10/28/14 at 1:35 PM, revealed he was the charge nurse on the South hall on 09/23/14. He stated Resident #1 was exit-seeking as he talked about looking for his truck since his admission. LVN C stated Resident #1 was easily distracted and during the daytime spent most of his time in the TV room. LVN C stated the facility played Western movies as Resident #1 enjoyed them. LVN C stated on 09/23/14, when the elopement occurred he was in the dining room and did not know how Resident #1 got out. Interview with CNA F on 10/28/14 at 3:20 PM, revealed on 09/23/14, Resident #1 was sitting in the TV room when she went to give another resident a shower. CNA F stated she was not gone for more than 15 minutes and when she returned she was asked if she knew where Resident #1 was. CNA F revealed she did not know how Resident #1 eloped on 09/23/14, but added "maybe went out the side exit door" on the South hall. Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's elopement on 09/23/14, the direct care staff were in-serviced on elopements; however, there was no documentation of the training. Following the incident, the ADM stated the facility staff ensured Resident #1's Wanderguard bracelet functioned, which it did, and the facility staff were "keeping an eye" on Resident #1. The ADM stated all staff were alerted of the elopement, she re-reminded them to monitor Resident #1 closely, re-direct as needed and she started to look for a sitter. The ADM stated she also started the process of obtaining a new fence and gate system. Resident #1's Daily Skilled Nurse's notes reflected the following: 09/26/14 at 7:30 PM: "...No attempts to leave...attempted x (times) 2 earlier;" 09/28/14 at 7:30 PM: "...trying several attempts to get out of the front door to find his truck....;" 09/29/14 at 9:00 AM: "...continuously exit seeking;" 10/07/14 at 3:30 AM: "...been up several times this shift wandering in hallway and in room. Confused to place + (and) time, became agitated when staff tried to redirect him back to room...." An incident report, dated 10/16/14 at 5:30 PM, reflected Resident #1's second elopement. The report reflected: "...received phone call from employee that had just left...was approx 400 sf (sic) down the road north of nursing home, brought back w/o (without) incident...just had finished dinner a short time before and was headed back to TV lounge to watch TV." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" was blank. (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/16/14 from 2:00 PM to 8:15 PM according to the computer generated time sheet provided by the ADM.) A statement signed by the ADM and dated 10/17/14 reflected: "This is the second time (Resident #1) has successfully left the facility without being detected. Since his Wander Guard is working properly, he must be getting out of our back gate. A new fence with key pad is being installed on our back gate. A special sitter was scheduled to work from 2 p.m. until 8 p.m. This sitter will stay with (Resident #1, Resident #2 and Resident #3). They will be in constant supervision of the sitter during the peak wandering hours." Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's second elopement attempt on 10/16/14, Housekeeping Staff D volunteered to sit with Resident #1. The ADM stated a sitter (Transportation Staff E) was hired and assigned to watch Resident #1 from 2:00 PM to 8:00 PM daily on 10/17/14, until just recently. The ADM stated on 10/10/14, 10/11/14, 10/13/14, 10/24/14 and 10/27/14, there was no sitter with Resident #1. The ADM revealed all staff had to be more attentive and aware of Resident #1 on those days. The ADM stated they identified the second shift was "most vulnerable" as this was the time Resident #1 became more active and was exit-seeking. The ADM stated the sitter was with Resident #1 until the resident went to bed. Computer-generated time sheets for Housekeeping Staff D and Transportation Staff E, provided by the ADM and identified as two sitters who supervised Resident #1, reflected the following: Housekeeping Staff D worked 4:00 PM to 8:00 PM as a sitter for Resident #1 daily from 10/02/14 to 10/09/14, and also on 10/12/14 and 10/14/14. Transportation Staff E worked 2:00 PM to 8:00 PM as a sitter daily for Resident #1 starting on 10/15/14, 10/16/14, 10/18/14 to 10/23/14, 10/25/14 and 10/26/14. Resident #1's Daily Skilled Nurse's notes revealed the following: 10/26/14 at 6:26 PM: "...He got out front door into parking lot c (with) another resident...." (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 found. Interview with Housekeeping Staff D on 10/28/14 at 3:38 PM, revealed he worked as a sitter for about a week, but could not recall the exact dates. He stated he sat with Residents #1, #2 and #3 from 4:00 PM to 8:00 PM. He denied any of the residents tried to leave the facility during that time. Interview with Transportation Staff E on 10/28/14 at 3:43 PM, revealed he worked at the facility for about two weeks and was fired because he was told he did not do his job. He stated he spent most of the time in the living room area watching movies with Residents #1 and #2. He denied the residents tried to get out of the facility while he watched them. Interview with the ADM on 10/28/14 at 10:10 AM, revealed Transportation Staff E was assigned to watch Residents #1, #2 and #3. The ADM stated he was fired because he was not watching them. Interview with the DON on 10/28/14 at 2:02 PM, revealed following admission Resident #1 talked about wanting to go to get his truck. The DON stated it was really bad the first month and they re-directed him continuously. The DON stated they provided games and movies as a distraction. Observation of the facility on 10/28/14 at 9:50 AM, was conducted during the initial round of the facility with the assistance of the Maintenance Director. Observation revealed the Wanderguard system was on the main entrance doors identified as Main entrance South and Main entrance North. Observation revealed Main entrance South had a chime which also sounded at the South nurse's station when the door was opened. Observation revealed three other doors (side exit on South hall, exit by the Dining room and back West exit) all had a chime system on the doors, which alerted when the doors were opened. Interview with the Maintenance Director on 10/28/14 at 9:52 AM, revealed the facility had the Wanderguard alarming system on two front entrance doors, identified as South and North entrances. He explained if a resident, who was wearing a Wanderguard bracelet, exited the door the alarm sounded. He stated a staff had to put in a code for the alarm to stop and the system to be reset. He stated the facility recently purchased a new system to replace the existing system. He stated it was the responsibility of the nurses to test the Wanderguard system weekly. Observation on 10/28/14 at 11:48 AM, revealed the facility staff were using the back West exit, next to the Dining Room, to exit the building and access the patio smoking area, located in the back of the building. Observation revealed a chime sounded when the doors opened; however, no staff were observed to respond when the chime sounded. Resident #1 and #2's room was located on the South hall. Observation on 10/28/14 at 11:50 AM, revealed the side exit door on South hall, located next to Resident #1 and #2's room, did not sound when the surveyor entered the building from the outside and then exited the building. The side exit door led to the patio area, used by some residents and staff, which had open access to the outside. Observation revealed the back of the facility was fenced in; however, the gate did not have a lock system in place at that time and the gate was only secured with a latch. Observation revealed the back gate opened and provided access to the back alley behind the facility. Interview with the Maintenance Director on 10/28/14 at 11:54 AM, revealed he examined the chime system on side exit door on the South hall. He stated he replaced the batteries and the chime worked. Observation on 10/28/14 at 1:06 PM, revealed the side exit door on the South hall did not sound when the surveyor exited the building. Interview with CNA B on 10/28/14 at 1:25 PM, revealed she used the side exit door on the South hall to exit the building when she went on her smoke break. CNA B also stated laundry staff used the same exit to deliver clean laundry. Interview with LVN H on 10/28/14 at 4:35 PM, revealed the side exit door on the South hall had a chime on it. LVN H stated staff used the doors to exit the facility for breaks. Interview with the Maintenance Director on 10/28/14 at 1:10 PM, revealed the side exit door now worked as he had to move the receiver box from the nurse's station closer to the door, which made the chime sound when the door was opened. He stated the chime system was already there when he started working there in January 2014. He did not know how long the chime system did not work properly on the side exit door on the South hall. Interview with LVN C on 10/28/14 at 1:35 PM, revealed when he was on the South hall nurse's station he was not always able to hear the door chimes due to a hearing disability; however, he always watched the doors. LVN C stated the Wanderguard bracelets were checked every shift and documented on the residents' MAR. LVN C stated the Wanderguard system was checked weekly to ensure it functioned properly. LVN C stated this was also documented on the residents' MARs. Interview with CNA G on 10/28/14 at 4:19 PM, revealed she was unable to hear the chime from the side exit door on the South hall unless she was at the front of the building. 2) Resident #2's Face Sheet, dated 07/17/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's comprehensive MDS assessment, dated 07/29/14, reflected his [DIAGNOSES REDACTED]. Resident #2's cognitive skills were severely impaired. His wandering behaviors occurred daily and placed him at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #2 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #2 did not use any mobility devices. Resident #2's physician order, dated 08/01/14, reflected "Wanderguard" related to elopement risk, and to check the function every week and visual check every shift for placement. Resident #2's Elopement Assessment, dated 07/17/14, reflected a score of 21, which indicated he was at "high risk" for elopement. A re-assessment completed on 10/20/14 indicated a score of 16, which indicated he was at "moderate risk" for elopement. Resident #2's undated care plan reflected he required a "wander guard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #2's care plan did not address his high elopement risk identified at admission, or his moderate risk identified on the re-assessment. Resident #2's MAR, dated September 2014, reflected Wanderguard was checked weekly, every Wednesday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #2 on 10/28/14 at 9:36 AM, revealed he was in the TV room sitting on the couch. Observation on 10/28/14 at 11:15 AM revealed Resident #2 was ambulating up and down the hall without any staff assistance and without the use of any assistive devices. Resident #2 walked over to the back exit door on the South hall and turned around. Resident #2's Daily Skilled Nurse's Notes reflected the following: 07/23/14 at 3:00 AM: "...exited door in lobby immediately re-entered facility;" 08/09/14 at 6:45 PM: "...got out of the building. He exited through North end door. He was 2 houses down...." Incident report, dated 08/09/14 at 6:45 PM, reflected Resident #2 went out the North end door, walked down the street and was brought back to the facility by staff. Attached to the report was a statement by LVN A, "...asked me whether residents are allowed to take walks alone because he saw (Resident #2) walking alone two blocks down from the facility...found the resident standing at someone's driveway. He told me he was looking for a bed to sleep. I brought him back through the south door his wonder (sic) guard did not go off...." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "New alarm placed on resident re-checked & (and) working." There was no documentation of a full investigation conducted. Interview with LVN A was attempted on 10/29/14 at 10:30 AM, via telephone with no success. The telephone did not accept voice mail messages. Resident #2's Daily Skilled Nurse's Notes reflected the following: 08/22/14 at 3:00 AM: "...tried to open South exit door and alarm went off;" 08/31/14 at 4:00 AM: "...Res (Resident) has been awake off and on...ambulating up and down South side, and @ (at) 3 AM...was observed @ (at) doorway on south urinating on side walk and when staff tried to redirect him to use bathroom inside the building...stated angrily 'I'll pee where I want to'...." 09/13/14 at 8:47 AM: "...got out North Side door...walked down the street about 6 blocks. He was stopped by (city name) code enforcement. Ambulance + (and) Fire Department were called prior to staff locating res. Res was brought back to facility, 0 (zero) injuries noted." Incident report, dated 09/13/14 at 8:45 AM, revealed Resident #2 "exited out North End door. He walked about 6 blocks before turning around. Staff re-directed res (resident) back to building." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "Counseling c (with) nurse who did not check door when alarm went off." A statement, dated 09/13/14, from LVN I was attached and reflected: "Res exited out North End Door. He walked about 6 blocks up the street, then turned around. Res was re-directed back to the building by nurse + (and) CNA. 0 (zero) injuries noted." There was no documentation of a full investigation conducted. Interview with LVN I on 10/29/14 at 9:14 AM, revealed Resident #2 eloped on 09/13/14, through the North exit doors. LVN I stated the alarm was going off, but she could not hear the alarm from the South hall. LVN I stated a local code enforcement officer saw Resident #2 walking and notified the local fire department; however, she was out looking for Resident #2 already. LVN I stated Resident #2 was not outside even 15 minutes. She stated LVN A, who was on the North hall, stated the alarm was going off, but they could not see anyone outside when they checked. A post-survey follow-up interview on 11/12/14 at 11:52 AM with LVN I revealed when the Wanderguard alarm went off, she was alerted to this by LVN A and she immediately started the missing resident protocol, which was to get a head count. LVN I stated they discovered within two minutes it was Resident #2 who could not be located and she started the search outside of the building. LVN I stated this was when she located Resident #2 down the street and returned him to the facility. Resident #2's Daily Skilled Nurse's Notes, dated 10/26/14 at 4:15 PM, reflected: "...attempted to walk to (a store) c (with) another resident. Both residents made it out the front door into parking lot...." (Note: Transportation Staff E worked as a sitter for Resident #2 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 at 4:15 PM. Interview with LVN I on 10/29/14 at 9:14 AM revealed Resident #1 told Resident #2 that he would give him a ride in his truck to the store on 10/26/14. LVN I stated the two residents exited the facility into the parking lot when they were re-directed back into the facility. LVN I stated the Wanderguard alarm sounded and that was how they discovered the two residents in the parking lot. Review of the facility's undated Abuse Policy, provided by the ADM as current, reflected the following: "Wandering and/or missing residents:...All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wandered...When a resident is believed to be missing...This search should not take longer than 15 minutes. If resident is not found within 15 minutes, then the administrator, director of nurses, DADS and the local police will be notified. DADS procedure will be followed regarding a missing resident...The charge nurse, director of nursing, or administrator will notify the family of the situation, what is being done and encourage their assistance. When the resident is located, the charge nurse will notify all previously contacted persons...." The facility's undated Elopement Alerting Devices policy, provided by the ADM as current, reflected the following: "...To alert staff of exit seeking behavior of resident...A visual check by a licensed nurse to be done q (every) shift to verify placement of elopement alerting device...functional check of the elopement alerting device to be performed by designated staff member...." An IJ was identified on 10/28/14. On 10/28/14 at 4:46 PM, the ADM was notified of the IJ and a Plan of Removal was requested at that time. Interview with the ADM on 10/31/14 at 2:40 PM, revealed when queried how the IJ occurred, the ADM replied, "Because he (Resident #1) got out a second time." The ADM stated she thought the facility did things they could and put things in place to ensure resident's safety prior to the IJ. The ADM stated she had sitters, requested that a new system and a fence are installed. The ADM stated she had asked the previous owners for a new gate "five years ago, then three years ago," and then "gave up" when she received no response. Interview with the DON on 10/31/14 at 2:20 PM, revealed when queried how the IJ occurred, the DON replied she understood why the IJ was identified and called. The DON stated she understood the severity of the situation as they placed the residents at risk of harm. The DON stated she did not know what else she could say about the situation. During a confidential interview on 10/30/14, the surveyor was notified Resident #4 eloped out of the facility on 10/29/14. Resident #4's Face Sheet, dated 09/29/14, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's Admission Resident Data Collection, dated 09/29/14, reflected she was full weight-bearing, required one person's assistance with transfers and two persons' assistance with ambulation. Resident #4's clinical record revealed documentation from a psychiatric admission, dated 09/15/14, which reflected: "...patient is (Non- English) only...was oriented only to herself. Difficult to redirect. Mildly agitated. Insight and judgment poor. She is uncooperative with mental status exam." Resident #4's Elopement Assessment, dated 09/29/14, reflected a score of 11, which indicated she was at "moderate risk" for elopement. It reflected a "star" next to the score as there were six questions that were not answered, as evident by "UTA (Unable to Answer)." Resident #4's physician's orders [REDACTED]. Resident #4's comprehensive MDS assessment, dated 10/06/14, reflected her [DIAGNOSES REDACTED]. Resident #4's cognitive skills were severely impaired. Her wandering behaviors occurred one to three days out of the seven days evaluated; however, the wandering did not place her at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #4 required two persons' physical assistance with bed mobility, transfers and toilet use. She used a wheelchair. Resident #4's preferred language was blank. Resident #4's undated care plan did not address her moderate risk for elopement identified on admission. It reflected Resident #4 had a communication problem related to language barrier and the approaches were to anticipate, meet need and to be conscious of resident's position when in groups. Resident #4's Daily Skilled Nurse's Notes reflected the following: 10/07/14 at 6:45 PM: "...up + (and) mobile w/o (without) asst. (assist). Attempts (sic) to leave facility x (times) 3 Frequent redirections..." 10/27/14 at 6:40 PM: "...getting up + walking all over...." Incident report, dated 10/29/14 at 6:45 PM, reflected: "...A staff member was leaving had went out the door & (and) resident got out of wheelchair & ran after her. Out the front door to the car park at the door." Interview with the DON on 10/30/14 at 1:20 PM, revealed Resident #4 got out the door around 6:30 PM, following her when she left the facility and got into her car. The DON stated Resident #4 "runs," and the facility was looking for an alternate placement due to repeated behaviors. Interview with the DON on 10/31/14 at 9:05 AM, revealed Residents #3 and #4 were on line of sight supervision. The DON stated if the residents were sleeping the staff were required to check on them every 15 minutes. Resident #4's Nurse's Notes reflected Resident #4 was checked on every 15 minutes starting on 10/30/14 at 2:00 PM, as documented. On 10/31/14 at 9:05 AM, the DON provided documentation that new elopement assessments were completed on all residents in the facility on 10/30/14. The new assessment for Resident #4 reflected a score of 18, and Resident #3's elopement score was 17. No other residents were identified as exit-seeking. Observation on 10/31/14 at 10:05 AM, revealed Medical Records Director was in the hall with Resident #3. Resident #4 was observed in her room, in bed, sleeping. Observation on 10/31/14 at 10:13 AM, revealed Medical Records Director went into Resident #4's room and checked on the resident. The Plan of Removal was accepted on 10/31/14 at 1:43 PM. The facility implemented the following interventions following the IJ identification: "Resident #1 was discharged on [DATE]." "Resident #2 was discharged on [DATE] at 1:15 PM." "Gate Watch: Starting on 10/28/2014 at approximately 6:00 pm there is a 24hr (24 hour) watch restricting egress from the single rear service fence that will remain in place until final construction of new fence with NFPA (National Fire Protection Association) compliant latching system is in place, tested ." "Line of Sight (LOS) watch for exit seekers: 24 hr watch to maintain LOS with exit seekers identified. Thorough and conservative assessment of all residents has resulted in the identification of two other possible exit seekers (Resident #3) on 10/28/2014, and (Resident #4) on 10/29/2014. (Resident #3) has not eloped; he is being monitored based only on the recent thorough assessment of potential exit seeking residents. (Resident #4) recently showed exit seeking behavior and has been identified as a high risk for elopement on 10/29/2014." "Exit doors leading to rear courtyard and fence are now identified as emergency exits only with the exception of one door. This will be to minimize door chimes to prevent "alarm fatigue" for staff. Training for staff conducted by DON and ADON on 10/28/2014 and signage put in place to alert staff and non-staff of changes. Implemented on 10/28/2014 at approximately 2:00 pm as shown on attached training records." "All staff was made aware of all wanders and exit risk residents during the training session conducted by DON on 10/31/2014." Observation of the side exit door on South hall on 10/29/14 at 8:15 AM, revealed a posted sign on the door, which read "Fire Exit Only, Do not Open." Observation of Residents #1 and #2 on 10/29/14 at 8:15 AM, revealed they were in their beds. LVN K was observed sitting outside of the room. LVN K stated she was assigned to do line of sight supervision for the residents. Observation on 10/29/14 at 10:35 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation on 10/29/14 at 11:41 AM, revealed Wanderguard alarm sounded on the North front exit; however, the door was not opened. Staff responded and re-directed Resident #5 from the door. Observation of Resident #1 and Resident #2 on 10/29/14 at 12:25 PM, revealed they were in their room, in bed, sleeping. LVN H was sitting in front of Resident #1 and Resident #2's room door. LVN H stated she was assigned to do line of sight supervision for Resident #1 and Resident #2. Observation on 10/29/14 at 1:25 PM, revealed Resident #1 was not in his room, and Resident #2 was in his room. LVN H stated Resident #1 was discharged from the facility. LVN H stated Resident #1 was taken to another facility by the ADON and SW "about 10 minutes ago." Observation of the gate on 10/29/14 at 4:05 PM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 8:00 AM, revealed he was in his room asleep. CNA L stated she was assigned to do line of sight supervision for Resident #2. Observation of the gate on 10/30/14 at 8:04 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 11:45 AM, revealed Resident #2 was ambulating in the hall with CNA L. Resident #2 was discharged from the facility on 10/30/14 at 1:15 PM. per interview with the ADM. Observation on 10/30/14 at 3:00 PM, revealed the surveyor activated the Wanderguard system on the North side door. Staff responded within a few seconds. Observation on 10/31/14 at 8:40 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation also revealed another staff used the designated door to exit the facility and gain access to the patio area. Observation on 10/31/14 at 10:05 AM, r

Based on interview and record review, the facility failed to ensure an allegation of neglect was immediately reported to the State survey and certification agency and failed to have evidence of thorough investigation for two (Residents #1 and #2) of seven residents for neglect. 1. The facility failed to report to the State survey and certification agency when Resident #1 eloped on 09/23/14 and 10/16/14. 2. The facility failed to report to the State survey and certification agency when Resident #2 eloped on 08/09/13 and 09/13/14. 3. The facility failed to have evidence of a thorough investigation for Resident #1's and #2's elopements. An Immediate Jeopardy (IJ) was identified on 10/28/14. While the IJ was removed on 10/31/14, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern," due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the nine residents, including Residents #1 and #2, who were at risk for elopement, by placing them at risk for serious injuries and/or death. Findings included: 1) Resident #1's Face Sheet, dated 09/03/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/09/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired. His wandering behaviors occurred daily and placed him at risk of getting into a potentially dangerous place, such as outside of the facility. Resident #1 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #1 did not use any mobility devices. Resident #1's Elopement Assessment, dated 09/03/14, reflected a score of 21, which indicated he was at "high risk" of elopement. Resident #1's Patient Progress Note, dated 10/01/14, reflected Resident #1 had Dementia with behaviors. Resident #1's undated care plan reflected he required a "Wanderguard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #1's care plan did not address the high elopement risk identified at admission. Resident #1's MARs, dated September 2014 and October 2014, reflected Wanderguard was checked weekly, every Thursday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #1 on 10/28/14 at 12:05 PM, revealed he was ambulating on the hall without staff assistance and without the use of any ambulation devices. Resident #1's Daily Skilled Nurse's notes revealed the following: 09/04/14 at 8:30 AM: "...has left facility x (times) 2 this am;" 09/06/14 at 9:35 AM: "...Attempted to get out of the facility several times. Confused...;" 09/06/14 at 7:37 PM: "...went out front door. Went to the street...;" 09/22/14 at 6:30 PM: "...sitting in TV room...Attempted to leave facility with roommate...;" 09/23/14 at 4:30 PM: "Notified of (Resident #1) being gone from day room, building searched, Person not in building...Full search began...." An incident report, dated 09/23/14 at 4:30 PM, reflected: "pt (patient) was noticed not to be in lounge by TV. Building searched per protocol Pt not on premises. Admin (Administrator) + (and) DON (Director of Nursing) on site + notified. Pt was later found outside of...with a stolen vehicle. DON + staff returned Patient to facility." A statement signed by the ADM and dated 09/23/14 reflected: "...Post Assessment: Resident wears a working Wander Guard bracelet. He must have slipped out the back door, near where the truck had been left with keys. He will stay on q (every) 15 minute checks for 24 hours. The three gates at the back of the facility will be replaced with one central gate with a secure monitoring system." Interview with Investigator J, from the local law enforcement department, via telephone on 10/29/14 at 8:28 PM, revealed police received a call on 09/23/14 at 4:14 PM, of a possible intoxicated driver headed northbound on a local highway. Investigator J stated Resident #1 appeared very confused when he stopped him. The investigator revealed the resident told him he (Resident #1) was driving from another state. Investigator J stated he called for an ambulance to check Resident #1 out to ensure he was okay. He stated one of the paramedics saw the Wanderguard bracelet on Resident #1's wrist and suggested that was used in nursing homes. Investigator J revealed he called several nursing homes in the area to see if he could locate where the resident came from. He stated he received a call from a local police department regarding the missing resident, and the facility staff came to pick up the resident from his custody within an hour or so. He stated Resident #1 was stopped about 20 miles from the facility. Interview with LVN C on 10/28/14 at 1:35 PM, revealed he was the charge nurse on the South hall on 09/23/14. He stated Resident #1 was exit-seeking as he talked about looking for his truck since his admission. LVN C stated Resident #1 was easily distracted and during the daytime spent most of his time in the TV room. LVN C stated the facility played Western movies as Resident #1 enjoyed them. LVN C stated on 09/23/14, when the elopement occurred he was in the dining room and did not know how Resident #1 got out. Interview with CNA F on 10/28/14 at 3:20 PM, revealed on 09/23/14, Resident #1 was sitting in the TV room when she went to give another resident a shower. CNA F stated she was not gone for more than 15 minutes and when she returned she was asked if she knew where Resident #1 was. CNA F revealed she did not know how Resident #1 eloped on 09/23/14, but added "maybe went out the side exit door" on the South hall. Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's elopement on 09/23/14, the direct care staff were in-serviced on elopements; however, there was no documentation of the training. Following the incident, the ADM stated the facility staff ensured Resident #1's Wanderguard bracelet functioned, which it did, and the facility staff were "keeping an eye" on Resident #1. The ADM stated all staff were alerted of the elopement, she re-reminded them to monitor Resident #1 closely, re-direct as needed and she started to look for a sitter. The ADM stated she also started the process of obtaining a new fence and gate system. Resident #1's Daily Skilled Nurse's notes reflected the following: 09/26/14 at 7:30 PM: "...No attempts to leave...attempted x (times) 2 earlier;" 09/28/14 at 7:30 PM: "...trying several attempts to get out of the front door to find his truck....;" 09/29/14 at 9:00 AM: "...continuously exit seeking;" 10/07/14 at 3:30 AM: "...been up several times this shift wandering in hallway and in room. Confused to place + (and) time, became agitated when staff tried to redirect him back to room...." An incident report, dated 10/16/14 at 5:30 PM, reflected Resident #1's second elopement. The report reflected: "...received phone call from employee that had just left...was approx 400 sf (sic) down the road north of nursing home, brought back w/o (without) incident...just had finished dinner a short time before and was headed back to TV lounge to watch TV." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" was blank. (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/16/14 from 2:00 PM to 8:15 PM according to the computer generated time sheet provided by the ADM.) A statement signed by the ADM and dated 10/17/14 reflected: "This is the second time (Resident #1) has successfully left the facility without being detected. Since his Wander Guard is working properly, he must be getting out of our back gate. A new fence with key pad is being installed on our back gate. A special sitter was scheduled to work from 2 p.m. until 8 p.m. This sitter will stay with (Resident #1, Resident #2 and Resident #3). They will be in constant supervision of the sitter during the peak wandering hours." Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's second elopement attempt on 10/16/14, Housekeeping Staff D volunteered to sit with Resident #1. The ADM stated a sitter (Transportation Staff E) was hired and assigned to watch Resident #1 from 2:00 PM to 8:00 PM daily on 10/17/14, until just recently. The ADM stated on 10/10/14, 10/11/14, 10/13/14, 10/24/14 and 10/27/14, there was no sitter with Resident #1. The ADM revealed all staff had to be more attentive and aware of Resident #1 on those days. The ADM stated they identified the second shift was "most vulnerable" as this was the time Resident #1 became more active and was exit-seeking. The ADM stated the sitter was with Resident #1 until the resident went to bed. Computer-generated time sheets for Housekeeping Staff D and Transportation Staff E, provided by the ADM and identified as two sitters who supervised Resident #1, reflected the following: Housekeeping Staff D worked 4:00 PM to 8:00 PM as a sitter for Resident #1 daily from 10/02/14 to 10/09/14, and also on 10/12/14 and 10/14/14. Transportation Staff E worked 2:00 PM to 8:00 PM as a sitter daily for Resident #1 starting on 10/15/14, 10/16/14, 10/18/14 to 10/23/14, 10/25/14 and 10/26/14. Resident #1's Daily Skilled Nurse's notes revealed the following: 10/26/14 at 6:26 PM: "...He got out front door into parking lot c (with) another resident...." (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 found. Interview with Housekeeping Staff D on 10/28/14 at 3:38 PM, revealed he worked as a sitter for about a week, but could not recall the exact dates. He stated he sat with Residents #1, #2 and #3 from 4:00 PM to 8:00 PM. He denied any of the residents tried to leave the facility during that time. Interview with Transportation Staff E on 10/28/14 at 3:43 PM, revealed he worked at the facility for about two weeks and was fired because he was told he did not do his job. He stated he spent most of the time in the living room area watching movies with Residents #1 and #2. He denied the residents tried to get out of the facility while he watched them. Interview with the ADM on 10/28/14 at 10:10 AM, revealed Transportation Staff E was assigned to watch Residents #1, #2 and #3. The ADM stated he was fired because he was not watching them. Interview with the DON on 10/28/14 at 2:02 PM, revealed following admission Resident #1 talked about wanting to go to get his truck. The DON stated it was really bad the first month and they re-directed him continuously. The DON stated they provided games and movies as a distraction. Observation of the facility on 10/28/14 at 9:50 AM, was conducted during the initial round of the facility with the assistance of the Maintenance Director. Observation revealed the Wanderguard system was on the main entrance doors identified as Main entrance South and Main entrance North. Observation revealed Main entrance South had a chime which also sounded at the South nurse's station when the door was opened. Observation revealed three other doors (side exit on South hall, exit by the Dining room and back West exit) all had a chime system on the doors, which alerted when the doors were opened. Interview with the Maintenance Director on 10/28/14 at 9:52 AM, revealed the facility had the Wanderguard alarming system on two front entrance doors, identified as South and North entrances. He explained if a resident, who was wearing a Wanderguard bracelet, exited the door the alarm sounded. He stated a staff had to put in a code for the alarm to stop and the system to be reset. He stated the facility recently purchased a new system to replace the existing system. He stated it was the responsibility of the nurses to test the Wanderguard system weekly. Observation on 10/28/14 at 11:48 AM, revealed the facility staff were using the back West exit, next to the Dining Room, to exit the building and access the patio smoking area, located in the back of the building. Observation revealed a chime sounded when the doors opened; however, no staff were observed to respond when the chime sounded. Resident #1 and #2's room was located on the South hall. Observation on 10/28/14 at 11:50 AM, revealed the side exit door on South hall, located next to Resident #1 and #2's room, did not sound when the surveyor entered the building from the outside and then exited the building. The side exit door led to the patio area, used by some residents and staff, which had open access to the outside. Observation revealed the back of the facility was fenced in; however, the gate did not have a lock system in place at that time and the gate was only secured with a latch. Observation revealed the back gate opened and provided access to the back alley behind the facility. Interview with the Maintenance Director on 10/28/14 at 11:54 AM, revealed he examined the chime system on side exit door on the South hall. He stated he replaced the batteries and the chime worked. Observation on 10/28/14 at 1:06 PM, revealed the side exit door on the South hall did not sound when the surveyor exited the building. Interview with CNA B on 10/28/14 at 1:25 PM, revealed she used the side exit door on the South hall to exit the building when she went on her smoke break. CNA B also stated laundry staff used the same exit to deliver clean laundry. Interview with LVN H on 10/28/14 at 4:35 PM, revealed the side exit door on the South hall had a chime on it. LVN H stated staff used the doors to exit the facility for breaks. Interview with the Maintenance Director on 10/28/14 at 1:10 PM, revealed the side exit door now worked as he had to move the receiver box from the nurse's station closer to the door, which made the chime sound when the door was opened. He stated the chime system was already there when he started working there in January 2014. He did not know how long the chime system did not work properly on the side exit door on the South hall. Interview with LVN C on 10/28/14 at 1:35 PM, revealed when he was on the South hall nurse's station he was not always able to hear the door chimes due to a hearing disability; however, he always watched the doors. LVN C stated the Wanderguard bracelets were checked every shift and documented on the residents' MAR. LVN C stated the Wanderguard system was checked weekly to ensure it functioned properly. LVN C stated this was also documented on the residents' MARs. Interview with CNA G on 10/28/14 at 4:19 PM, revealed she was unable to hear the chime from the side exit door on the South hall unless she was at the front of the building. 2) Resident #2's Face Sheet, dated 07/17/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's comprehensive MDS assessment, dated 07/29/14, reflected his [DIAGNOSES REDACTED]. Resident #2's cognitive skills were severely impaired. His wandering behaviors occurred daily and placed him at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #2 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #2 did not use any mobility devices. Resident #2's physician order, dated 08/01/14, reflected "Wanderguard" related to elopement risk, and to check the function every week and visual check every shift for placement. Resident #2's Elopement Assessment, dated 07/17/14, reflected a score of 21, which indicated he was at "high risk" for elopement. A re-assessment completed on 10/20/14 indicated a score of 16, which indicated he was at "moderate risk" for elopement. Resident #2's undated care plan reflected he required a "wander guard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #2's care plan did not address his high elopement risk identified at admission, or his moderate risk identified on the re-assessment. Resident #2's MAR, dated September 2014, reflected Wanderguard was checked weekly, every Wednesday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #2 on 10/28/14 at 9:36 AM, revealed he was in the TV room sitting on the couch. Observation on 10/28/14 at 11:15 AM revealed Resident #2 was ambulating up and down the hall without any staff assistance and without the use of any assistive devices. Resident #2 walked over to the back exit door on the South hall and turned around. Resident #2's Daily Skilled Nurse's Notes reflected the following: 07/23/14 at 3:00 AM: "...exited door in lobby immediately re-entered facility;" 08/09/14 at 6:45 PM: "...got out of the building. He exited through North end door. He was 2 houses down...." Incident report, dated 08/09/14 at 6:45 PM, reflected Resident #2 went out the North end door, walked down the street and was brought back to the facility by staff. Attached to the report was a statement by LVN A, "...asked me whether residents are allowed to take walks alone because he saw (Resident #2) walking alone two blocks down from the facility...found the resident standing at someone's driveway. He told me he was looking for a bed to sleep. I brought him back through the south door his wonder (sic) guard did not go off...." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "New alarm placed on resident re-checked & (and) working." There was no documentation of a full investigation conducted. Interview with LVN A was attempted on 10/29/14 at 10:30 AM, via telephone with no success. The telephone did not accept voice mail messages. Resident #2's Daily Skilled Nurse's Notes reflected the following: 08/22/14 at 3:00 AM: "...tried to open South exit door and alarm went off;" 08/31/14 at 4:00 AM: "...Res (Resident) has been awake off and on...ambulating up and down South side, and @ (at) 3 AM...was observed @ (at) doorway on south urinating on side walk and when staff tried to redirect him to use bathroom inside the building...stated angrily 'I'll pee where I want to'...." 09/13/14 at 8:47 AM: "...got out North Side door...walked down the street about 6 blocks. He was stopped by (city name) code enforcement. Ambulance + (and) Fire Department were called prior to staff locating res. Res was brought back to facility, 0 (zero) injuries noted." Incident report, dated 09/13/14 at 8:45 AM, revealed Resident #2 "exited out North End door. He walked about 6 blocks before turning around. Staff re-directed res (resident) back to building." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "Counseling c (with) nurse who did not check door when alarm went off." A statement, dated 09/13/14, from LVN I was attached and reflected: "Res exited out North End Door. He walked about 6 blocks up the street, then turned around. Res was re-directed back to the building by nurse + (and) CNA. 0 (zero) injuries noted." There was no documentation of a full investigation conducted. Interview with LVN I on 10/29/14 at 9:14 AM, revealed Resident #2 eloped on 09/13/14, through the North exit doors. LVN I stated the alarm was going off, but she could not hear the alarm from the South hall. LVN I stated a local code enforcement officer saw Resident #2 walking and notified the local fire department; however, she was out looking for Resident #2 already. LVN I stated Resident #2 was not outside even 15 minutes. She stated LVN A, who was on the North hall, stated the alarm was going off, but they could not see anyone outside when they checked. A post-survey follow-up interview on 11/12/14 at 11:52 AM with LVN I revealed when the Wanderguard alarm went off, she was alerted to this by LVN A and she immediately started the missing resident protocol, which was to get a head count. LVN I stated they discovered within two minutes it was Resident #2 who could not be located and she started the search outside of the building. LVN I stated this was when she located Resident #2 down the street and returned him to the facility. Resident #2's Daily Skilled Nurse's Notes, dated 10/26/14 at 4:15 PM, reflected: "...attempted to walk to (a store) c (with) another resident. Both residents made it out the front door into parking lot...." (Note: Transportation Staff E worked as a sitter for Resident #2 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 at 4:15 PM. Interview with LVN I on 10/29/14 at 9:14 AM revealed Resident #1 told Resident #2 that he would give him a ride in his truck to the store on 10/26/14. LVN I stated the two residents exited the facility into the parking lot when they were re-directed back into the facility. LVN I stated the Wanderguard alarm sounded and that was how they discovered the two residents in the parking lot. Review of the facility's undated Abuse Policy, provided by the ADM as current, reflected the following: "Wandering and/or missing residents:...All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wandered...When a resident is believed to be missing...This search should not take longer than 15 minutes. If resident is not found within 15 minutes, then the administrator, director of nurses, DADS and the local police will be notified. DADS procedure will be followed regarding a missing resident...The charge nurse, director of nursing, or administrator will notify the family of the situation, what is being done and encourage their assistance. When the resident is located, the charge nurse will notify all previously contacted persons...." The facility's undated Elopement Alerting Devices policy, provided by the ADM as current, reflected the following: "...To alert staff of exit seeking behavior of resident...A visual check by a licensed nurse to be done q (every) shift to verify placement of elopement alerting device...functional check of the elopement alerting device to be performed by designated staff member...." An IJ was identified on 10/28/14. On 10/28/14 at 4:46 PM, the ADM was notified of the IJ and a Plan of Removal was requested at that time. Interview with the ADM on 10/31/14 at 2:40 PM, revealed when queried how the IJ occurred, the ADM replied, "Because he (Resident #1) got out a second time." The ADM stated she thought the facility did things they could and put things in place to ensure resident's safety prior to the IJ. The ADM stated she had sitters, requested that a new system and a fence are installed. The ADM stated she had asked the previous owners for a new gate "five years ago, then three years ago," and then "gave up" when she received no response. Interview with the DON on 10/31/14 at 2:20 PM, revealed when queried how the IJ occurred, the DON replied she understood why the IJ was identified and called. The DON stated she understood the severity of the situation as they placed the residents at risk of harm. The DON stated she did not know what else she could say about the situation. During a confidential interview on 10/30/14, the surveyor was notified Resident #4 eloped out of the facility on 10/29/14. Resident #4's Face Sheet, dated 09/29/14, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's Admission Resident Data Collection, dated 09/29/14, reflected she was full weight-bearing, required one person's assistance with transfers and two persons' assistance with ambulation. Resident #4's clinical record revealed documentation from a psychiatric admission, dated 09/15/14, which reflected: "...patient is (Non- English) only...was oriented only to herself. Difficult to redirect. Mildly agitated. Insight and judgment poor. She is uncooperative with mental status exam." Resident #4's Elopement Assessment, dated 09/29/14, reflected a score of 11, which indicated she was at "moderate risk" for elopement. It reflected a "star" next to the score as there were six questions that were not answered, as evident by "UTA (Unable to Answer)." Resident #4's physician's orders [REDACTED]. Resident #4's comprehensive MDS assessment, dated 10/06/14, reflected her [DIAGNOSES REDACTED]. Resident #4's cognitive skills were severely impaired. Her wandering behaviors occurred one to three days out of the seven days evaluated; however, the wandering did not place her at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #4 required two persons' physical assistance with bed mobility, transfers and toilet use. She used a wheelchair. Resident #4's preferred language was blank. Resident #4's undated care plan did not address her moderate risk for elopement identified on admission. It reflected Resident #4 had a communication problem related to language barrier and the approaches were to anticipate, meet need and to be conscious of resident's position when in groups. Resident #4's Daily Skilled Nurse's Notes reflected the following: 10/07/14 at 6:45 PM: "...up + (and) mobile w/o (without) asst. (assist). Attempts (sic) to leave facility x (times) 3 Frequent redirections..." 10/27/14 at 6:40 PM: "...getting up + walking all over...." Incident report, dated 10/29/14 at 6:45 PM, reflected: "...A staff member was leaving had went out the door & (and) resident got out of wheelchair & ran after her. Out the front door to the car park at the door." Interview with the DON on 10/30/14 at 1:20 PM, revealed Resident #4 got out the door around 6:30 PM, following her when she left the facility and got into her car. The DON stated Resident #4 "runs," and the facility was looking for an alternate placement due to repeated behaviors. Interview with the DON on 10/31/14 at 9:05 AM, revealed Residents #3 and #4 were on line of sight supervision. The DON stated if the residents were sleeping the staff were required to check on them every 15 minutes. Resident #4's Nurse's Notes reflected Resident #4 was checked on every 15 minutes starting on 10/30/14 at 2:00 PM, as documented. On 10/31/14 at 9:05 AM, the DON provided documentation that new elopement assessments were completed on all residents in the facility on 10/30/14. The new assessment for Resident #4 reflected a score of 18, and Resident #3's elopement score was 17. No other residents were identified as exit-seeking. Observation on 10/31/14 at 10:05 AM, revealed Medical Records Director was in the hall with Resident #3. Resident #4 was observed in her room, in bed, sleeping. Observation on 10/31/14 at 10:13 AM, revealed Medical Records Director went into Resident #4's room and checked on the resident. The Plan of Removal was accepted on 10/31/14 at 1:43 PM. The facility implemented the following interventions following the IJ identification: "Resident #1 was discharged on [DATE]." "Resident #2 was discharged on [DATE] at 1:15 PM." "Gate Watch: Starting on 10/28/2014 at approximately 6:00 pm there is a 24hr (24 hour) watch restricting egress from the single rear service fence that will remain in place until final construction of new fence with NFPA (National Fire Protection Association) compliant latching system is in place, tested ." "Line of Sight (LOS) watch for exit seekers: 24 hr watch to maintain LOS with exit seekers identified. Thorough and conservative assessment of all residents has resulted in the identification of two other possible exit seekers (Resident #3) on 10/28/2014, and (Resident #4) on 10/29/2014. (Resident #3) has not eloped; he is being monitored based only on the recent thorough assessment of potential exit seeking residents. (Resident #4) recently showed exit seeking behavior and has been identified as a high risk for elopement on 10/29/2014." "Exit doors leading to rear courtyard and fence are now identified as emergency exits only with the exception of one door. This will be to minimize door chimes to prevent "alarm fatigue" for staff. Training for staff conducted by DON and ADON on 10/28/2014 and signage put in place to alert staff and non-staff of changes. Implemented on 10/28/2014 at approximately 2:00 pm as shown on attached training records." "All staff was made aware of all wanders and exit risk residents during the training session conducted by DON on 10/31/2014." Observation of the side exit door on South hall on 10/29/14 at 8:15 AM, revealed a posted sign on the door, which read "Fire Exit Only, Do not Open." Observation of Residents #1 and #2 on 10/29/14 at 8:15 AM, revealed they were in their beds. LVN K was observed sitting outside of the room. LVN K stated she was assigned to do line of sight supervision for the residents. Observation on 10/29/14 at 10:35 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation on 10/29/14 at 11:41 AM, revealed Wanderguard alarm sounded on the North front exit; however, the door was not opened. Staff responded and re-directed Resident #5 from the door. Observation of Resident #1 and Resident #2 on 10/29/14 at 12:25 PM, revealed they were in their room, in bed, sleeping. LVN H was sitting in front of Resident #1 and Resident #2's room door. LVN H stated she was assigned to do line of sight supervision for Resident #1 and Resident #2. Observation on 10/29/14 at 1:25 PM, revealed Resident #1 was not in his room, and Resident #2 was in his room. LVN H stated Resident #1 was discharged from the facility. LVN H stated Resident #1 was taken to another facility by the ADON and SW "about 10 minutes ago." Observation of the gate on 10/29/14 at 4:05 PM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 8:00 AM, revealed he was in his room asleep. CNA L stated she was assigned to do line of sight supervision for Resident #2. Observation of the gate on 10/30/14 at 8:04 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 11:45 AM, revealed Resident #2 was ambulating in the hall with CNA L. Resident #2 was discharged from the facility on 10/30/14 at 1:15 PM. per interview with the ADM. Observation on 10/30/14 at 3:00 PM, revealed the surveyor activated the Wanderguard system on the North side door. Staff responded within a few seconds. Observation on 10/31/14 at 8:40 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation also revealed another staff used the designated door to exit the facility and gain access to the patio area. Observation on 10/31/14 at 10:05 AM, revealed no staff used the side exit door on the South hall. The "Fire Exit Only, Do not Open" sign was posted on the door. Observation of the gate on 10/31/14 at 10:15 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation on 10/31

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for two (Residents #1 and #2) of seven residents reviewed for neglect. 1) The facility failed to appropriately address and put in place interventions to prevent elopements once it identified Resident #1 was a high risk for elopement. The facility also failed to provide adequate supervision following the elopement on 09/23/14, which resulted in additional incidents of elopement on 10/16/14 and 10/26/14. The facility failed to report the elopements to the State survey and certification agency. 2) The facility failed to appropriately address and put in place interventions to prevent elopements once it identified Resident #2 was a high risk for elopement. The facility also failed to provide adequate supervision following the elopement on 08/09/14, which resulted in additional incidents of elopement on 09/13/14 and 10/26/14. The facility failed to report the elopements to the State survey and certification agency. 3) The facility failed to have evidence of thorough investigations for Resident #1's and #2's elopements. An Immediate Jeopardy (IJ) was identified on 10/28/14. While the IJ was removed on 10/31/14, the facility remained out of compliance at a severity of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the nine residents at risk for elopement including Residents #1 and #2, by placing them at risk for serious injuries and/or death. Findings included: Review of the facility's undated Abuse Policy, provided by the ADM as current, reflected the following: "Wandering and/or missing residents:...All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wandered...When a resident is believed to be missing...This search should not take longer than 15 minutes. If resident is not found within 15 minutes, then the administrator, director of nurses, DADS and the local police will be notified. DADS procedure will be followed regarding a missing resident...The charge nurse, director of nursing, or administrator will notify the family of the situation, what is being done and encourage their assistance. When the resident is located, the charge nurse will notify all previously contacted persons...." 1) Resident #1's Face Sheet, dated 09/03/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/09/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired. His wandering behaviors occurred daily and placed him at risk of getting into a potentially dangerous place, such as outside of the facility. Resident #1 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #1 did not use any mobility devices. Resident #1's Elopement Assessment, dated 09/03/14, reflected a score of 21, which indicated he was at "high risk" of elopement. Resident #1's Patient Progress Note, dated 10/01/14, reflected Resident #1 had Dementia with behaviors. Resident #1's undated care plan reflected he required a "Wanderguard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #1's care plan did not address the high elopement risk identified at admission. Resident #1's MARs, dated September 2014 and October 2014, reflected Wanderguard was checked weekly, every Thursday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #1 on 10/28/14 at 12:05 PM, revealed he was ambulating on the hall without staff assistance and without the use of any ambulation devices. Resident #1's Daily Skilled Nurse's notes revealed the following: 09/04/14 at 8:30 AM: "...has left facility x (times) 2 this am;" 09/06/14 at 9:35 AM: "...Attempted to get out of the facility several times. Confused...;" 09/06/14 at 7:37 PM: "...went out front door. Went to the street...;" 09/22/14 at 6:30 PM: "...sitting in TV room...Attempted to leave facility with roommate...;" 09/23/14 at 4:30 PM: "Notified of (Resident #1) being gone from day room, building searched, Person not in building...Full search began...." An incident report, dated 09/23/14 at 4:30 PM, reflected: "pt (patient) was noticed not to be in lounge by TV. Building searched per protocol Pt not on premises. Admin (Administrator) + (and) DON (Director of Nursing) on site + notified. Pt was later found outside of...with a stolen vehicle. DON + staff returned Patient to facility." A statement signed by the ADM and dated 09/23/14 reflected: "...Post Assessment: Resident wears a working Wander Guard bracelet. He must have slipped out the back door, near where the truck had been left with keys. He will stay on q (every) 15 minute checks for 24 hours. The three gates at the back of the facility will be replaced with one central gate with a secure monitoring system." Interview with Investigator J, from the local law enforcement department, via telephone on 10/29/14 at 8:28 PM, revealed police received a call on 09/23/14 at 4:14 PM, of a possible intoxicated driver headed northbound on a local highway. Investigator J stated Resident #1 appeared very confused when he stopped him. The investigator revealed the resident told him he (Resident #1) was driving from another state. Investigator J stated he called for an ambulance to check Resident #1 out to ensure he was okay. He stated one of the paramedics saw the Wanderguard bracelet on Resident #1's wrist and suggested that was used in nursing homes. Investigator J revealed he called several nursing homes in the area to see if he could locate where the resident came from. He stated he received a call from a local police department regarding the missing resident, and the facility staff came to pick up the resident from his custody within an hour or so. He stated Resident #1 was stopped about 20 miles from the facility. Interview with LVN C on 10/28/14 at 1:35 PM, revealed he was the charge nurse on the South hall on 09/23/14. He stated Resident #1 was exit-seeking as he talked about looking for his truck since his admission. LVN C stated Resident #1 was easily distracted and during the daytime spent most of his time in the TV room. LVN C stated the facility played Western movies as Resident #1 enjoyed them. LVN C stated on 09/23/14, when the elopement occurred he was in the dining room and did not know how Resident #1 got out. Interview with CNA F on 10/28/14 at 3:20 PM, revealed on 09/23/14, Resident #1 was sitting in the TV room when she went to give another resident a shower. CNA F stated she was not gone for more than 15 minutes and when she returned she was asked if she knew where Resident #1 was. CNA F revealed she did not know how Resident #1 eloped on 09/23/14, but added "maybe went out the side exit door" on the South hall. Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's elopement on 09/23/14, the direct care staff were in-serviced on elopements; however, there was no documentation of the training. Following the incident, the ADM stated the facility staff ensured Resident #1's Wanderguard bracelet functioned, which it did, and the facility staff were "keeping an eye" on Resident #1. The ADM stated all staff were alerted of the elopement, she re-reminded them to monitor Resident #1 closely, re-direct as needed and she started to look for a sitter. The ADM stated she also started the process of obtaining a new fence and gate system. Resident #1's Daily Skilled Nurse's notes reflected the following: 09/26/14 at 7:30 PM: "...No attempts to leave...attempted x (times) 2 earlier;" 09/28/14 at 7:30 PM: "...trying several attempts to get out of the front door to find his truck....;" 09/29/14 at 9:00 AM: "...continuously exit seeking;" 10/07/14 at 3:30 AM: "...been up several times this shift wandering in hallway and in room. Confused to place + (and) time, became agitated when staff tried to redirect him back to room...." An incident report, dated 10/16/14 at 5:30 PM, reflected Resident #1's second elopement. The report reflected: "...received phone call from employee that had just left...was approx 400 sf (sic) down the road north of nursing home, brought back w/o (without) incident...just had finished dinner a short time before and was headed back to TV lounge to watch TV." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" was blank. (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/16/14 from 2:00 PM to 8:15 PM according to the computer generated time sheet provided by the ADM.) A statement signed by the ADM and dated 10/17/14 reflected: "This is the second time (Resident #1) has successfully left the facility without being detected. Since his Wander Guard is working properly, he must be getting out of our back gate. A new fence with key pad is being installed on our back gate. A special sitter was scheduled to work from 2 p.m. until 8 p.m. This sitter will stay with (Resident #1, Resident #2 and Resident #3). They will be in constant supervision of the sitter during the peak wandering hours." Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's second elopement attempt on 10/16/14, Housekeeping Staff D volunteered to sit with Resident #1. The ADM stated a sitter (Transportation Staff E) was hired and assigned to watch Resident #1 from 2:00 PM to 8:00 PM daily on 10/17/14, until just recently. The ADM stated on 10/10/14, 10/11/14, 10/13/14, 10/24/14 and 10/27/14, there was no sitter with Resident #1. The ADM revealed all staff had to be more attentive and aware of Resident #1 on those days. The ADM stated they identified the second shift was "most vulnerable" as this was the time Resident #1 became more active and was exit-seeking. The ADM stated the sitter was with Resident #1 until the resident went to bed. Computer-generated time sheets for Housekeeping Staff D and Transportation Staff E, provided by the ADM and identified as two sitters who supervised Resident #1, reflected the following: Housekeeping Staff D worked 4:00 PM to 8:00 PM as a sitter for Resident #1 daily from 10/02/14 to 10/09/14, and also on 10/12/14 and 10/14/14. Transportation Staff E worked 2:00 PM to 8:00 PM as a sitter daily for Resident #1 starting on 10/15/14, 10/16/14, 10/18/14 to 10/23/14, 10/25/14 and 10/26/14. Resident #1's Daily Skilled Nurse's notes revealed the following: 10/26/14 at 6:26 PM: "...He got out front door into parking lot c (with) another resident...." (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 found. Interview with Housekeeping Staff D on 10/28/14 at 3:38 PM, revealed he worked as a sitter for about a week, but could not recall the exact dates. He stated he sat with Residents #1, #2 and #3 from 4:00 PM to 8:00 PM. He denied any of the residents tried to leave the facility during that time. Interview with Transportation Staff E on 10/28/14 at 3:43 PM, revealed he worked at the facility for about two weeks and was fired because he was told he did not do his job. He stated he spent most of the time in the living room area watching movies with Residents #1 and #2. He denied the residents tried to get out of the facility while he watched them. Interview with the ADM on 10/28/14 at 10:10 AM, revealed Transportation Staff E was assigned to watch Residents #1, #2 and #3. The ADM stated he was fired because he was not watching them. Interview with the DON on 10/28/14 at 2:02 PM, revealed following admission Resident #1 talked about wanting to go to get his truck. The DON stated it was really bad the first month and they re-directed him continuously. The DON stated they provided games and movies as a distraction. Observation of the facility on 10/28/14 at 9:50 AM, was conducted during the initial round of the facility with the assistance of the Maintenance Director. Observation revealed the Wanderguard system was on the main entrance doors identified as Main entrance South and Main entrance North. Observation revealed Main entrance South had a chime which also sounded at the South nurse's station when the door was opened. Observation revealed three other doors (side exit on South hall, exit by the Dining room and back West exit) all had a chime system on the doors, which alerted when the doors were opened. Interview with the Maintenance Director on 10/28/14 at 9:52 AM, revealed the facility had the Wanderguard alarming system on two front entrance doors, identified as South and North entrances. He explained if a resident, who was wearing a Wanderguard bracelet, exited the door the alarm sounded. He stated a staff had to put in a code for the alarm to stop and the system to be reset. He stated the facility recently purchased a new system to replace the existing system. He stated it was the responsibility of the nurses to test the Wanderguard system weekly. Observation on 10/28/14 at 11:48 AM, revealed the facility staff were using the back West exit, next to the Dining Room, to exit the building and access the patio smoking area, located in the back of the building. Observation revealed a chime sounded when the doors opened; however, no staff were observed to respond when the chime sounded. Resident #1 and #2's room was located on the South hall. Observation on 10/28/14 at 11:50 AM, revealed the side exit door on South hall, located next to Resident #1 and #2's room, did not sound when the surveyor entered the building from the outside and then exited the building. The side exit door led to the patio area, used by some residents and staff, which had open access to the outside. Observation revealed the back of the facility was fenced in; however, the gate did not have a lock system in place at that time and the gate was only secured with a latch. Observation revealed the back gate opened and provided access to the back alley behind the facility. Interview with the Maintenance Director on 10/28/14 at 11:54 AM, revealed he examined the chime system on side exit door on the South hall. He stated he replaced the batteries and the chime worked. Observation on 10/28/14 at 1:06 PM, revealed the side exit door on the South hall did not sound when the surveyor exited the building. Interview with CNA B on 10/28/14 at 1:25 PM, revealed she used the side exit door on the South hall to exit the building when she went on her smoke break. CNA B also stated laundry staff used the same exit to deliver clean laundry. Interview with LVN H on 10/28/14 at 4:35 PM, revealed the side exit door on the South hall had a chime on it. LVN H stated staff used the doors to exit the facility for breaks. Interview with the Maintenance Director on 10/28/14 at 1:10 PM, revealed the side exit door now worked as he had to move the receiver box from the nurse's station closer to the door, which made the chime sound when the door was opened. He stated the chime system was already there when he started working there in January 2014. He did not know how long the chime system did not work properly on the side exit door on the South hall. Interview with LVN C on 10/28/14 at 1:35 PM, revealed when he was on the South hall nurse's station he was not always able to hear the door chimes due to a hearing disability; however, he always watched the doors. LVN C stated the Wanderguard bracelets were checked every shift and documented on the residents' MAR. LVN C stated the Wanderguard system was checked weekly to ensure it functioned properly. LVN C stated this was also documented on the residents' MARs. Interview with CNA G on 10/28/14 at 4:19 PM, revealed she was unable to hear the chime from the side exit door on the South hall unless she was at the front of the building. 2) Resident #2's Face Sheet, dated 07/17/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's comprehensive MDS assessment, dated 07/29/14, reflected his [DIAGNOSES REDACTED]. Resident #2's cognitive skills were severely impaired. His wandering behaviors occurred daily and placed him at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #2 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #2 did not use any mobility devices. Resident #2's physician order, dated 08/01/14, reflected "Wanderguard" related to elopement risk, and to check the function every week and visual check every shift for placement. Resident #2's Elopement Assessment, dated 07/17/14, reflected a score of 21, which indicated he was at "high risk" for elopement. A re-assessment completed on 10/20/14 indicated a score of 16, which indicated he was at "moderate risk" for elopement. Resident #2's undated care plan reflected he required a "wander guard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #2's care plan did not address his high elopement risk identified at admission, or his moderate risk identified on the re-assessment. Resident #2's MAR, dated September 2014, reflected Wanderguard was checked weekly, every Wednesday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #2 on 10/28/14 at 9:36 AM, revealed he was in the TV room sitting on the couch. Observation on 10/28/14 at 11:15 AM revealed Resident #2 was ambulating up and down the hall without any staff assistance and without the use of any assistive devices. Resident #2 walked over to the back exit door on the South hall and turned around. Resident #2's Daily Skilled Nurse's Notes reflected the following: 07/23/14 at 3:00 AM: "...exited door in lobby immediately re-entered facility;" 08/09/14 at 6:45 PM: "...got out of the building. He exited through North end door. He was 2 houses down...." Incident report, dated 08/09/14 at 6:45 PM, reflected Resident #2 went out the North end door, walked down the street and was brought back to the facility by staff. Attached to the report was a statement by LVN A, "...asked me whether residents are allowed to take walks alone because he saw (Resident #2) walking alone two blocks down from the facility...found the resident standing at someone's driveway. He told me he was looking for a bed to sleep. I brought him back through the south door his wonder (sic) guard did not go off...." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "New alarm placed on resident re-checked & (and) working." There was no documentation of a full investigation conducted. Interview with LVN A was attempted on 10/29/14 at 10:30 AM, via telephone with no success. The telephone did not accept voice mail messages. Resident #2's Daily Skilled Nurse's Notes reflected the following: 08/22/14 at 3:00 AM: "...tried to open South exit door and alarm went off;" 08/31/14 at 4:00 AM: "...Res (Resident) has been awake off and on...ambulating up and down South side, and @ (at) 3 AM...was observed @ (at) doorway on south urinating on side walk and when staff tried to redirect him to use bathroom inside the building...stated angrily 'I'll pee where I want to'...." 09/13/14 at 8:47 AM: "...got out North Side door...walked down the street about 6 blocks. He was stopped by (city name) code enforcement. Ambulance + (and) Fire Department were called prior to staff locating res. Res was brought back to facility, 0 (zero) injuries noted." Incident report, dated 09/13/14 at 8:45 AM, revealed Resident #2 "exited out North End door. He walked about 6 blocks before turning around. Staff re-directed res (resident) back to building." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "Counseling c (with) nurse who did not check door when alarm went off." A statement, dated 09/13/14, from LVN I was attached and reflected: "Res exited out North End Door. He walked about 6 blocks up the street, then turned around. Res was re-directed back to the building by nurse + (and) CNA. 0 (zero) injuries noted." There was no documentation of a full investigation conducted. Interview with LVN I on 10/29/14 at 9:14 AM, revealed Resident #2 eloped on 09/13/14, through the North exit doors. LVN I stated the alarm was going off, but she could not hear the alarm from the South hall. LVN I stated a local code enforcement officer saw Resident #2 walking and notified the local fire department; however, she was out looking for Resident #2 already. LVN I stated Resident #2 was not outside even 15 minutes. She stated LVN A, who was on the North hall, stated the alarm was going off, but they could not see anyone outside when they checked. A post-survey follow-up interview on 11/12/14 at 11:52 AM with LVN I revealed when the Wanderguard alarm went off, she was alerted to this by LVN A and she immediately started the missing resident protocol, which was to get a head count. LVN I stated they discovered within two minutes it was Resident #2 who could not be located and she started the search outside of the building. LVN I stated this was when she located Resident #2 down the street and returned him to the facility. Resident #2's Daily Skilled Nurse's Notes, dated 10/26/14 at 4:15 PM, reflected: "...attempted to walk to (a store) c (with) another resident. Both residents made it out the front door into parking lot...." (Note: Transportation Staff E worked as a sitter for Resident #2 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 at 4:15 PM. Interview with LVN I on 10/29/14 at 9:14 AM revealed Resident #1 told Resident #2 that he would give him a ride in his truck to the store on 10/26/14. LVN I stated the two residents exited the facility into the parking lot when they were re-directed back into the facility. LVN I stated the Wanderguard alarm sounded and that was how they discovered the two residents in the parking lot. The facility's undated Elopement Alerting Devices policy, provided by the ADM as current, reflected the following: "...To alert staff of exit seeking behavior of resident...A visual check by a licensed nurse to be done q (every) shift to verify placement of elopement alerting device...functional check of the elopement alerting device to be performed by designated staff member...." An IJ was identified on 10/28/14. On 10/28/14 at 4:46 PM, the ADM was notified of the IJ and a Plan of Removal was requested at that time. Interview with the ADM on 10/31/14 at 2:40 PM, revealed when queried how the IJ occurred, the ADM replied, "Because he (Resident #1) got out a second time." The ADM stated she thought the facility did things they could and put things in place to ensure resident's safety prior to the IJ. The ADM stated she had sitters, requested that a new system and a fence are installed. The ADM stated she had asked the previous owners for a new gate "five years ago, then three years ago," and then "gave up" when she received no response. Interview with the DON on 10/31/14 at 2:20 PM, revealed when queried how the IJ occurred, the DON replied she understood why the IJ was identified and called. The DON stated she understood the severity of the situation as they placed the residents at risk of harm. The DON stated she did not know what else she could say about the situation. During a confidential interview on 10/30/14, the surveyor was notified Resident #4 eloped out of the facility on 10/29/14. Resident #4's Face Sheet, dated 09/29/14, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's Admission Resident Data Collection, dated 09/29/14, reflected she was full weight-bearing, required one person's assistance with transfers and two persons' assistance with ambulation. Resident #4's clinical record revealed documentation from a psychiatric admission, dated 09/15/14, which reflected: "...patient is (Non- English) only...was oriented only to herself. Difficult to redirect. Mildly agitated. Insight and judgment poor. She is uncooperative with mental status exam." Resident #4's Elopement Assessment, dated 09/29/14, reflected a score of 11, which indicated she was at "moderate risk" for elopement. It reflected a "star" next to the score as there were six questions that were not answered, as evident by "UTA (Unable to Answer)." Resident #4's physician's orders [REDACTED]. Resident #4's comprehensive MDS assessment, dated 10/06/14, reflected her [DIAGNOSES REDACTED]. Resident #4's cognitive skills were severely impaired. Her wandering behaviors occurred one to three days out of the seven days evaluated; however, the wandering did not place her at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #4 required two persons' physical assistance with bed mobility, transfers and toilet use. She used a wheelchair. Resident #4's preferred language was blank. Resident #4's undated care plan did not address her moderate risk for elopement identified on admission. It reflected Resident #4 had a communication problem related to language barrier and the approaches were to anticipate, meet need and to be conscious of resident's position when in groups. Resident #4's Daily Skilled Nurse's Notes reflected the following: 10/07/14 at 6:45 PM: "...up + (and) mobile w/o (without) asst. (assist). Attempts (sic) to leave facility x (times) 3 Frequent redirections..." 10/27/14 at 6:40 PM: "...getting up + walking all over...." Incident report, dated 10/29/14 at 6:45 PM, reflected: "...A staff member was leaving had went out the door & (and) resident got out of wheelchair & ran after her. Out the front door to the car park at the door." Interview with the DON on 10/30/14 at 1:20 PM, revealed Resident #4 got out the door around 6:30 PM, following her when she left the facility and got into her car. The DON stated Resident #4 "runs," and the facility was looking for an alternate placement due to repeated behaviors. Interview with the DON on 10/31/14 at 9:05 AM, revealed Residents #3 and #4 were on line of sight supervision. The DON stated if the residents were sleeping the staff were required to check on them every 15 minutes. Resident #4's Nurse's Notes reflected Resident #4 was checked on every 15 minutes starting on 10/30/14 at 2:00 PM, as documented. On 10/31/14 at 9:05 AM, the DON provided documentation that new elopement assessments were completed on all residents in the facility on 10/30/14. The new assessment for Resident #4 reflected a score of 18, and Resident #3's elopement score was 17. No other residents were identified as exit-seeking. Observation on 10/31/14 at 10:05 AM, revealed Medical Records Director was in the hall with Resident #3. Resident #4 was observed in her room, in bed, sleeping. Observation on 10/31/14 at 10:13 AM, revealed Medical Records Director went into Resident #4's room and checked on the resident. The Plan of Removal was accepted on 10/31/14 at 1:43 PM. The facility implemented the following interventions following the IJ identification: "Resident #1 was discharged on [DATE]." "Resident #2 was discharged on [DATE] at 1:15 PM." "Gate Watch: Starting on 10/28/2014 at approximately 6:00 pm there is a 24hr (24 hour) watch restricting egress from the single rear service fence that will remain in place until final construction of new fence with NFPA (National Fire Protection Association) compliant latching system is in place, tested ." "Line of Sight (LOS) watch for exit seekers: 24 hr watch to maintain LOS with exit seekers identified. Thorough and conservative assessment of all residents has resulted in the identification of two other possible exit seekers (Resident #3) on 10/28/2014, and (Resident #4) on 10/29/2014. (Resident #3) has not eloped; he is being monitored based only on the recent thorough assessment of potential exit seeking residents. (Resident #4) recently showed exit seeking behavior and has been identified as a high risk for elopement on 10/29/2014." "Exit doors leading to rear courtyard and fence are now identified as emergency exits only with the exception of one door. This will be to minimize door chimes to prevent "alarm fatigue" for staff. Training for staff conducted by DON and ADON on 10/28/2014 and signage put in place to alert staff and non-staff of changes. Implemented on 10/28/2014 at approximately 2:00 pm as shown on attached training records." "All staff was made aware of all wanders and exit risk residents during the training session conducted by DON on 10/31/2014." Observation of the side exit door on South hall on 10/29/14 at 8:15 AM, revealed a posted sign on the door, which read "Fire Exit Only, Do not Open." Observation of Residents #1 and #2 on 10/29/14 at 8:15 AM, revealed they were in their beds. LVN K was observed sitting outside of the room. LVN K stated she was assigned to do line of sight supervision for the residents. Observation on 10/29/14 at 10:35 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation on 10/29/14 at 11:41 AM, revealed Wanderguard alarm sounded on the North front exit; however, the door was not opened. Staff responded and re-directed Resident #5 from the door. Observation of Resident #1 and Resident #2 on 10/29/14 at 12:25 PM, revealed they were in their room, in bed, sleeping. LVN H was sitting in front of Resident #1 and Resident #2's room door. LVN H stated she was assigned to do line of sight supervision for Resident #1 and Resident #2. Observation on 10/29/14 at 1:25 PM, revealed Resident #1 was not in his room, and Resident #2 was in his room. LVN H stated Resident #1 was discharged from the facility. LVN H stated Resident #1 was taken to another facility by the ADON and SW "about 10 minutes ago." Observation of the gate on 10/29/14 at 4:05 PM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 8:00 AM, revealed he was in his room asleep. CNA L stated she was assigned to do line of sight supervision for Resident #2. Observation of the gate on 10/30/14 at 8:04 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 11:45 AM, revealed Resident #2 was ambulating in the hall with CNA L. Resident #2 was discharged from the facility on 10/30/14 at 1:15 PM. per interview with the ADM. Observation on 10/30/14 at 3:00 PM, revealed the surveyor activated the Wanderguard system on the North side door. Staff responded within a few seconds. Observatio

Based on observation, interview and record review, it was determined the facility failed to ensure two (Residents #1, and #2) of seven residents reviewed for elopement risk received adequate supervision to prevent elopement and accidents. 1) The facility failed to appropriately address and put in place interventions to prevent elopements once it identified Resident #1 was a high risk for elopement. The facility also failed to provide adequate supervision following the elopement on 09/23/14, which resulted in additional incidents of elopement on 10/16/14 and 10/26/14. 2) The facility failed to appropriately address and put in place interventions to prevent elopements once it identified Resident #2 was a high risk for elopement. The facility also failed to provide adequate supervision following the elopement on 08/09/14, which resulted in additional incidents of elopement on 09/13/14 and 10/26/14. An Immediate Jeopardy (IJ) was identified on 10/28/14. While the IJ was removed on 10/31/14, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the nine residents, which included Residents #1 and #2, who were identified as wanderers at risk of leaving the facility without being seen by staff in situations that might lead to a serious injury and/or death. Findings included: 1) Resident #1's Face Sheet, dated 09/03/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/09/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired. His wandering behaviors occurred daily and placed him at risk of getting into a potentially dangerous place, such as outside of the facility. Resident #1 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #1 did not use any mobility devices. Resident #1's Elopement Assessment, dated 09/03/14, reflected a score of 21, which indicated he was at "high risk" of elopement. Resident #1's Patient Progress Note, dated 10/01/14, reflected Resident #1 had Dementia with behaviors. Resident #1's undated care plan reflected he required a "Wanderguard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #1's care plan did not address the high elopement risk identified at admission. Resident #1's MARs, dated September 2014 and October 2014, reflected Wanderguard was checked weekly, every Thursday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #1 on 10/28/14 at 12:05 PM, revealed he was ambulating on the hall without staff assistance and without the use of any ambulation devices. Resident #1's Daily Skilled Nurse's notes revealed the following: 09/04/14 at 8:30 AM: "...has left facility x (times) 2 this am;" 09/06/14 at 9:35 AM: "...Attempted to get out of the facility several times. Confused...;" 09/06/14 at 7:37 PM: "...went out front door. Went to the street...;" 09/22/14 at 6:30 PM: "...sitting in TV room...Attempted to leave facility with roommate...;" 09/23/14 at 4:30 PM: "Notified of (Resident #1) being gone from day room, building searched, Person not in building...Full search began...." An incident report, dated 09/23/14 at 4:30 PM, reflected: "pt (patient) was noticed not to be in lounge by TV. Building searched per protocol Pt not on premises. Admin (Administrator) + (and) DON (Director of Nursing) on site + notified. Pt was later found outside of...with a stolen vehicle. DON + staff returned Patient to facility." A statement signed by the ADM and dated 09/23/14 reflected: "...Post Assessment: Resident wears a working Wander Guard bracelet. He must have slipped out the back door, near where the truck had been left with keys. He will stay on q (every) 15 minute checks for 24 hours. The three gates at the back of the facility will be replaced with one central gate with a secure monitoring system." Interview with Investigator J, from the local law enforcement department, via telephone on 10/29/14 at 8:28 PM, revealed police received a call on 09/23/14 at 4:14 PM, of a possible intoxicated driver headed northbound on a local highway. Investigator J stated Resident #1 appeared very confused when he stopped him. The investigator revealed the resident told him he (Resident #1) was driving from another state. Investigator J stated he called for an ambulance to check Resident #1 out to ensure he was okay. He stated one of the paramedics saw the Wanderguard bracelet on Resident #1's wrist and suggested that was used in nursing homes. Investigator J revealed he called several nursing homes in the area to see if he could locate where the resident came from. He stated he received a call from a local police department regarding the missing resident, and the facility staff came to pick up the resident from his custody within an hour or so. He stated Resident #1 was stopped about 20 miles from the facility. Interview with LVN C on 10/28/14 at 1:35 PM, revealed he was the charge nurse on the South hall on 09/23/14. He stated Resident #1 was exit-seeking as he talked about looking for his truck since his admission. LVN C stated Resident #1 was easily distracted and during the daytime spent most of his time in the TV room. LVN C stated the facility played Western movies as Resident #1 enjoyed them. LVN C stated on 09/23/14, when the elopement occurred he was in the dining room and did not know how Resident #1 got out. Interview with CNA F on 10/28/14 at 3:20 PM, revealed on 09/23/14, Resident #1 was sitting in the TV room when she went to give another resident a shower. CNA F stated she was not gone for more than 15 minutes and when she returned she was asked if she knew where Resident #1 was. CNA F revealed she did not know how Resident #1 eloped on 09/23/14, but added "maybe went out the side exit door" on the South hall. Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's elopement on 09/23/14, the direct care staff were in-serviced on elopements; however, there was no documentation of the training. Following the incident, the ADM stated the facility staff ensured Resident #1's Wanderguard bracelet functioned, which it did, and the facility staff were "keeping an eye" on Resident #1. The ADM stated all staff were alerted of the elopement, she re-reminded them to monitor Resident #1 closely, re-direct as needed and she started to look for a sitter. The ADM stated she also started the process of obtaining a new fence and gate system. Resident #1's Daily Skilled Nurse's notes reflected the following: 09/26/14 at 7:30 PM: "...No attempts to leave...attempted x (times) 2 earlier;" 09/28/14 at 7:30 PM: "...trying several attempts to get out of the front door to find his truck....;" 09/29/14 at 9:00 AM: "...continuously exit seeking;" 10/07/14 at 3:30 AM: "...been up several times this shift wandering in hallway and in room. Confused to place + (and) time, became agitated when staff tried to redirect him back to room...." An incident report, dated 10/16/14 at 5:30 PM, reflected Resident #1's second elopement. The report reflected: "...received phone call from employee that had just left...was approx 400 sf (sic) down the road north of nursing home, brought back w/o (without) incident...just had finished dinner a short time before and was headed back to TV lounge to watch TV." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" was blank. (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/16/14 from 2:00 PM to 8:15 PM according to the computer generated time sheet provided by the ADM.) A statement signed by the ADM and dated 10/17/14 reflected: "This is the second time (Resident #1) has successfully left the facility without being detected. Since his Wander Guard is working properly, he must be getting out of our back gate. A new fence with key pad is being installed on our back gate. A special sitter was scheduled to work from 2 p.m. until 8 p.m. This sitter will stay with (Resident #1, Resident #2 and Resident #3). They will be in constant supervision of the sitter during the peak wandering hours." Interview with the ADM on 10/28/14 at 2:35 PM, revealed following Resident #1's second elopement attempt on 10/16/14, Housekeeping Staff D volunteered to sit with Resident #1. The ADM stated a sitter (Transportation Staff E) was hired and assigned to watch Resident #1 from 2:00 PM to 8:00 PM daily on 10/17/14, until just recently. The ADM stated on 10/10/14, 10/11/14, 10/13/14, 10/24/14 and 10/27/14, there was no sitter with Resident #1. The ADM revealed all staff had to be more attentive and aware of Resident #1 on those days. The ADM stated they identified the second shift was "most vulnerable" as this was the time Resident #1 became more active and was exit-seeking. The ADM stated the sitter was with Resident #1 until the resident went to bed. Computer-generated time sheets for Housekeeping Staff D and Transportation Staff E, provided by the ADM and identified as two sitters who supervised Resident #1, reflected the following: Housekeeping Staff D worked 4:00 PM to 8:00 PM as a sitter for Resident #1 daily from 10/02/14 to 10/09/14, and also on 10/12/14 and 10/14/14. Transportation Staff E worked 2:00 PM to 8:00 PM as a sitter daily for Resident #1 starting on 10/15/14, 10/16/14, 10/18/14 to 10/23/14, 10/25/14 and 10/26/14. Resident #1's Daily Skilled Nurse's notes revealed the following: 10/26/14 at 6:26 PM: "...He got out front door into parking lot c (with) another resident...." (Note: Transportation Staff E worked as a sitter for Resident #1 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 found. Interview with Housekeeping Staff D on 10/28/14 at 3:38 PM, revealed he worked as a sitter for about a week, but could not recall the exact dates. He stated he sat with Residents #1, #2 and #3 from 4:00 PM to 8:00 PM. He denied any of the residents tried to leave the facility during that time. Interview with Transportation Staff E on 10/28/14 at 3:43 PM, revealed he worked at the facility for about two weeks and was fired because he was told he did not do his job. He stated he spent most of the time in the living room area watching movies with Residents #1 and #2. He denied the residents tried to get out of the facility while he watched them. Interview with the ADM on 10/28/14 at 10:10 AM, revealed Transportation Staff E was assigned to watch Residents #1, #2 and #3. The ADM stated he was fired because he was not watching them. Interview with the DON on 10/28/14 at 2:02 PM, revealed following admission Resident #1 talked about wanting to go to get his truck. The DON stated it was really bad the first month and they re-directed him continuously. The DON stated they provided games and movies as a distraction. Observation of the facility on 10/28/14 at 9:50 AM, was conducted during the initial round of the facility with the assistance of the Maintenance Director. Observation revealed the Wanderguard system was on the main entrance doors identified as Main entrance South and Main entrance North. Observation revealed Main entrance South had a chime which also sounded at the South nurse's station when the door was opened. Observation revealed three other doors (side exit on South hall, exit by the Dining room and back West exit) all had a chime system on the doors, which alerted when the doors were opened. Interview with the Maintenance Director on 10/28/14 at 9:52 AM, revealed the facility had the Wanderguard alarming system on two front entrance doors, identified as South and North entrances. He explained if a resident, who was wearing a Wanderguard bracelet, exited the door the alarm sounded. He stated a staff had to put in a code for the alarm to stop and the system to be reset. He stated the facility recently purchased a new system to replace the existing system. He stated it was the responsibility of the nurses to test the Wanderguard system weekly. Observation on 10/28/14 at 11:48 AM, revealed the facility staff were using the back West exit, next to the Dining Room, to exit the building and access the patio smoking area, located in the back of the building. Observation revealed a chime sounded when the doors opened; however, no staff were observed to respond when the chime sounded. Resident #1 and #2's room was located on the South hall. Observation on 10/28/14 at 11:50 AM, revealed the side exit door on South hall, located next to Resident #1 and #2's room, did not sound when the surveyor entered the building from the outside and then exited the building. The side exit door led to the patio area, used by some residents and staff, which had open access to the outside. Observation revealed the back of the facility was fenced in; however, the gate did not have a lock system in place at that time and the gate was only secured with a latch. Observation revealed the back gate opened and provided access to the back alley behind the facility. Interview with the Maintenance Director on 10/28/14 at 11:54 AM, revealed he examined the chime system on side exit door on the South hall. He stated he replaced the batteries and the chime worked. Observation on 10/28/14 at 1:06 PM, revealed the side exit door on the South hall did not sound when the surveyor exited the building. Interview with CNA B on 10/28/14 at 1:25 PM, revealed she used the side exit door on the South hall to exit the building when she went on her smoke break. CNA B also stated laundry staff used the same exit to deliver clean laundry. Interview with LVN H on 10/28/14 at 4:35 PM, revealed the side exit door on the South hall had a chime on it. LVN H stated staff used the doors to exit the facility for breaks. Interview with the Maintenance Director on 10/28/14 at 1:10 PM, revealed the side exit door now worked as he had to move the receiver box from the nurse's station closer to the door, which made the chime sound when the door was opened. He stated the chime system was already there when he started working there in January 2014. He did not know how long the chime system did not work properly on the side exit door on the South hall. Interview with LVN C on 10/28/14 at 1:35 PM, revealed when he was on the South hall nurse's station he was not always able to hear the door chimes due to a hearing disability; however, he always watched the doors. LVN C stated the Wanderguard bracelets were checked every shift and documented on the residents' MAR. LVN C stated the Wanderguard system was checked weekly to ensure it functioned properly. LVN C stated this was also documented on the residents' MARs. Interview with CNA G on 10/28/14 at 4:19 PM, revealed she was unable to hear the chime from the side exit door on the South hall unless she was at the front of the building. 2) Resident #2's Face Sheet, dated 07/17/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's comprehensive MDS assessment, dated 07/29/14, reflected his [DIAGNOSES REDACTED]. Resident #2's cognitive skills were severely impaired. His wandering behaviors occurred daily and placed him at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #2 required one person's physical assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and hygiene. Resident #2 did not use any mobility devices. Resident #2's physician order, dated 08/01/14, reflected "Wanderguard" related to elopement risk, and to check the function every week and visual check every shift for placement. Resident #2's Elopement Assessment, dated 07/17/14, reflected a score of 21, which indicated he was at "high risk" for elopement. A re-assessment completed on 10/20/14 indicated a score of 16, which indicated he was at "moderate risk" for elopement. Resident #2's undated care plan reflected he required a "wander guard bracelet" and was at risk for injury from wandering in an unsafe environment. The approaches were to monitor for placement every shift, monitor for proper functioning every week and to involve the resident in social functioning and activities as tolerated. Resident #2's care plan did not address his high elopement risk identified at admission, or his moderate risk identified on the re-assessment. Resident #2's MAR, dated September 2014, reflected Wanderguard was checked weekly, every Wednesday, for functionality. It further reflected Wanderguard was checked visually every shift for placement. Observation of Resident #2 on 10/28/14 at 9:36 AM, revealed he was in the TV room sitting on the couch. Observation on 10/28/14 at 11:15 AM revealed Resident #2 was ambulating up and down the hall without any staff assistance and without the use of any assistive devices. Resident #2 walked over to the back exit door on the South hall and turned around. Resident #2's Daily Skilled Nurse's Notes reflected the following: 07/23/14 at 3:00 AM: "...exited door in lobby immediately re-entered facility;" 08/09/14 at 6:45 PM: "...got out of the building. He exited through North end door. He was 2 houses down...." Incident report, dated 08/09/14 at 6:45 PM, reflected Resident #2 went out the North end door, walked down the street and was brought back to the facility by staff. Attached to the report was a statement by LVN A, "...asked me whether residents are allowed to take walks alone because he saw (Resident #2) walking alone two blocks down from the facility...found the resident standing at someone's driveway. He told me he was looking for a bed to sleep. I brought him back through the south door his wonder (sic) guard did not go off...." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "New alarm placed on resident re-checked & (and) working." There was no documentation of a full investigation conducted. Interview with LVN A was attempted on 10/29/14 at 10:30 AM, via telephone with no success. The telephone did not accept voice mail messages. Resident #2's Daily Skilled Nurse's Notes reflected the following: 08/22/14 at 3:00 AM: "...tried to open South exit door and alarm went off;" 08/31/14 at 4:00 AM: "...Res (Resident) has been awake off and on...ambulating up and down South side, and @ (at) 3 AM...was observed @ (at) doorway on south urinating on side walk and when staff tried to redirect him to use bathroom inside the building...stated angrily 'I'll pee where I want to'...." 09/13/14 at 8:47 AM: "...got out North Side door...walked down the street about 6 blocks. He was stopped by (city name) code enforcement. Ambulance + (and) Fire Department were called prior to staff locating res. Res was brought back to facility, 0 (zero) injuries noted." Incident report, dated 09/13/14 at 8:45 AM, revealed Resident #2 "exited out North End door. He walked about 6 blocks before turning around. Staff re-directed res (resident) back to building." The section on the form titled "Additional comments and/or steps taken to prevent recurrence" reflected "Counseling c (with) nurse who did not check door when alarm went off." A statement, dated 09/13/14, from LVN I was attached and reflected: "Res exited out North End Door. He walked about 6 blocks up the street, then turned around. Res was re-directed back to the building by nurse + (and) CNA. 0 (zero) injuries noted." There was no documentation of a full investigation conducted. Interview with LVN I on 10/29/14 at 9:14 AM, revealed Resident #2 eloped on 09/13/14, through the North exit doors. LVN I stated the alarm was going off, but she could not hear the alarm from the South hall. LVN I stated a local code enforcement officer saw Resident #2 walking and notified the local fire department; however, she was out looking for Resident #2 already. LVN I stated Resident #2 was not outside even 15 minutes. She stated LVN A, who was on the North hall, stated the alarm was going off, but they could not see anyone outside when they checked. A post-survey follow-up interview on 11/12/14 at 11:52 AM with LVN I revealed when the Wanderguard alarm went off, she was alerted to this by LVN A and she immediately started the missing resident protocol, which was to get a head count. LVN I stated they discovered within two minutes it was Resident #2 who could not be located and she started the search outside of the building. LVN I stated this was when she located Resident #2 down the street and returned him to the facility. Resident #2's Daily Skilled Nurse's Notes, dated 10/26/14 at 4:15 PM, reflected: "...attempted to walk to (a store) c (with) another resident. Both residents made it out the front door into parking lot...." (Note: Transportation Staff E worked as a sitter for Resident #2 on 10/26/14 from 2:00 PM to 8:00 PM according to the computer generated time sheet provided by the ADM.) There was no documented incident report dated 10/26/14 at 4:15 PM. Interview with LVN I on 10/29/14 at 9:14 AM revealed Resident #1 told Resident #2 that he would give him a ride in his truck to the store on 10/26/14. LVN I stated the two residents exited the facility into the parking lot when they were re-directed back into the facility. LVN I stated the Wanderguard alarm sounded and that was how they discovered the two residents in the parking lot. Review of the facility's undated Abuse Policy, provided by the ADM as current, reflected the following: "Wandering and/or missing residents:...All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wandered...When a resident is believed to be missing...This search should not take longer than 15 minutes. If resident is not found within 15 minutes, then the administrator, director of nurses, DADS and the local police will be notified. DADS procedure will be followed regarding a missing resident...The charge nurse, director of nursing, or administrator will notify the family of the situation, what is being done and encourage their assistance. When the resident is located, the charge nurse will notify all previously contacted persons...." The facility's undated Elopement Alerting Devices policy, provided by the ADM as current, reflected the following: "...To alert staff of exit seeking behavior of resident...A visual check by a licensed nurse to be done q (every) shift to verify placement of elopement alerting device...functional check of the elopement alerting device to be performed by designated staff member...." An IJ was identified on 10/28/14. On 10/28/14 at 4:46 PM, the ADM was notified of the IJ and a Plan of Removal was requested at that time. Interview with the ADM on 10/31/14 at 2:40 PM, revealed when queried how the IJ occurred, the ADM replied, "Because he (Resident #1) got out a second time." The ADM stated she thought the facility did things they could and put things in place to ensure resident's safety prior to the IJ. The ADM stated she had sitters, requested that a new system and a fence are installed. The ADM stated she had asked the previous owners for a new gate "five years ago, then three years ago," and then "gave up" when she received no response. Interview with the DON on 10/31/14 at 2:20 PM, revealed when queried how the IJ occurred, the DON replied she understood why the IJ was identified and called. The DON stated she understood the severity of the situation as they placed the residents at risk of harm. The DON stated she did not know what else she could say about the situation. During a confidential interview on 10/30/14, the surveyor was notified Resident #4 eloped out of the facility on 10/29/14. Resident #4's Face Sheet, dated 09/29/14, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's Admission Resident Data Collection, dated 09/29/14, reflected she was full weight-bearing, required one person's assistance with transfers and two persons' assistance with ambulation. Resident #4's clinical record revealed documentation from a psychiatric admission, dated 09/15/14, which reflected: "...patient is (Non- English) only...was oriented only to herself. Difficult to redirect. Mildly agitated. Insight and judgment poor. She is uncooperative with mental status exam." Resident #4's Elopement Assessment, dated 09/29/14, reflected a score of 11, which indicated she was at "moderate risk" for elopement. It reflected a "star" next to the score as there were six questions that were not answered, as evident by "UTA (Unable to Answer)." Resident #4's physician's orders [REDACTED]. Resident #4's comprehensive MDS assessment, dated 10/06/14, reflected her [DIAGNOSES REDACTED]. Resident #4's cognitive skills were severely impaired. Her wandering behaviors occurred one to three days out of the seven days evaluated; however, the wandering did not place her at risk for getting into a potentially dangerous place, such as outside of the facility. Resident #4 required two persons' physical assistance with bed mobility, transfers and toilet use. She used a wheelchair. Resident #4's preferred language was blank. Resident #4's undated care plan did not address her moderate risk for elopement identified on admission. It reflected Resident #4 had a communication problem related to language barrier and the approaches were to anticipate, meet need and to be conscious of resident's position when in groups. Resident #4's Daily Skilled Nurse's Notes reflected the following: 10/07/14 at 6:45 PM: "...up + (and) mobile w/o (without) asst. (assist). Attempts (sic) to leave facility x (times) 3 Frequent redirections..." 10/27/14 at 6:40 PM: "...getting up + walking all over...." Incident report, dated 10/29/14 at 6:45 PM, reflected: "...A staff member was leaving had went out the door & (and) resident got out of wheelchair & ran after her. Out the front door to the car park at the door." Interview with the DON on 10/30/14 at 1:20 PM, revealed Resident #4 got out the door around 6:30 PM, following her when she left the facility and got into her car. The DON stated Resident #4 "runs," and the facility was looking for an alternate placement due to repeated behaviors. Interview with the DON on 10/31/14 at 9:05 AM, revealed Residents #3 and #4 were on line of sight supervision. The DON stated if the residents were sleeping the staff were required to check on them every 15 minutes. Resident #4's Nurse's Notes reflected Resident #4 was checked on every 15 minutes starting on 10/30/14 at 2:00 PM, as documented. On 10/31/14 at 9:05 AM, the DON provided documentation that new elopement assessments were completed on all residents in the facility on 10/30/14. The new assessment for Resident #4 reflected a score of 18, and Resident #3's elopement score was 17. No other residents were identified as exit-seeking. Observation on 10/31/14 at 10:05 AM, revealed Medical Records Director was in the hall with Resident #3. Resident #4 was observed in her room, in bed, sleeping. Observation on 10/31/14 at 10:13 AM, revealed Medical Records Director went into Resident #4's room and checked on the resident. The Plan of Removal was accepted on 10/31/14 at 1:43 PM. The facility implemented the following interventions following the IJ identification: "Resident #1 was discharged on [DATE]." "Resident #2 was discharged on [DATE] at 1:15 PM." "Gate Watch: Starting on 10/28/2014 at approximately 6:00 pm there is a 24hr (24 hour) watch restricting egress from the single rear service fence that will remain in place until final construction of new fence with NFPA (National Fire Protection Association) compliant latching system is in place, tested ." "Line of Sight (LOS) watch for exit seekers: 24 hr watch to maintain LOS with exit seekers identified. Thorough and conservative assessment of all residents has resulted in the identification of two other possible exit seekers (Resident #3) on 10/28/2014, and (Resident #4) on 10/29/2014. (Resident #3) has not eloped; he is being monitored based only on the recent thorough assessment of potential exit seeking residents. (Resident #4) recently showed exit seeking behavior and has been identified as a high risk for elopement on 10/29/2014." "Exit doors leading to rear courtyard and fence are now identified as emergency exits only with the exception of one door. This will be to minimize door chimes to prevent "alarm fatigue" for staff. Training for staff conducted by DON and ADON on 10/28/2014 and signage put in place to alert staff and non-staff of changes. Implemented on 10/28/2014 at approximately 2:00 pm as shown on attached training records." "All staff was made aware of all wanders and exit risk residents during the training session conducted by DON on 10/31/2014." Observation of the side exit door on South hall on 10/29/14 at 8:15 AM, revealed a posted sign on the door, which read "Fire Exit Only, Do not Open." Observation of Residents #1 and #2 on 10/29/14 at 8:15 AM, revealed they were in their beds. LVN K was observed sitting outside of the room. LVN K stated she was assigned to do line of sight supervision for the residents. Observation on 10/29/14 at 10:35 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation on 10/29/14 at 11:41 AM, revealed Wanderguard alarm sounded on the North front exit; however, the door was not opened. Staff responded and re-directed Resident #5 from the door. Observation of Resident #1 and Resident #2 on 10/29/14 at 12:25 PM, revealed they were in their room, in bed, sleeping. LVN H was sitting in front of Resident #1 and Resident #2's room door. LVN H stated she was assigned to do line of sight supervision for Resident #1 and Resident #2. Observation on 10/29/14 at 1:25 PM, revealed Resident #1 was not in his room, and Resident #2 was in his room. LVN H stated Resident #1 was discharged from the facility. LVN H stated Resident #1 was taken to another facility by the ADON and SW "about 10 minutes ago." Observation of the gate on 10/29/14 at 4:05 PM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 8:00 AM, revealed he was in his room asleep. CNA L stated she was assigned to do line of sight supervision for Resident #2. Observation of the gate on 10/30/14 at 8:04 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation of Resident #2 on 10/30/14 at 11:45 AM, revealed Resident #2 was ambulating in the hall with CNA L. Resident #2 was discharged from the facility on 10/30/14 at 1:15 PM. per interview with the ADM. Observation on 10/30/14 at 3:00 PM, revealed the surveyor activated the Wanderguard system on the North side door. Staff responded within a few seconds. Observation on 10/31/14 at 8:40 AM, revealed a staff member was sitting next to the back gate and was monitoring. Observation also revealed another staff used the designated door to exit the facility and gain