Every finding on record at Bedford Springs Health and Rehabilitation

Based on observation, interview, record review and review of the facility policy it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety. On 11/05/19, during initial tour, one (1) of four (4) refrigerator's temperatures were not within a safe range for food storage, the cooler temperature was fifty-eight (58) degrees Fahrenheit. The findings include: Review of the facility Census and Condition, dated 11/05/19, reveal forty-four (44) of out forty-four (44) residents received meals from the kitchen. Review of the facility policy, titled Record of Refrigeration Temperature, revised 08/08/19, revealed the refrigerator must be clean and temperature must be 41 degree Fahrenheit or less. Per the Food Code, a one (1)-two (2) degree variance are allow for accuracy. Review of the facility policy, tilted Food Storage, revised 09/14/18, revealed all frozen egg entrees and processed egg products should be stored according to manufacturer's instructions. These products are pasteurized. Thaw in refrigerator at 41 degrees Fahrenheit or less for eight (8) to ten (10) hours. Refrigerated items should be safe as long as power was out no more than four hours. Keep doors closed as much as possible. Discard any perishable foods such as meat, poultry, fish, eggs, and leftover have been greater than 41 degrees Fahrenheit for two (2) hours or more. On 11/05/2019 at 9:54 AM, the Director of Dietary (DOD) provided a tour of the kitchen, which included the food prep area, dry storage, and refrigerated storage. Observation revealed the walk-in cooler temperature was fifty-eight (58) degrees Fahrenheit. Continued observation of the kitchen, revealed one (1) and half (½) cases of liquid egg products, two (2) sleeves of American cheese, two (2) cream cheese, two (2) shredded lettuce, two (2) packages lunch meat/sliced ham. In addition one (1) bag shredded cheese, three-quarter case of sour cream packets, one (1) pimento cheese, one (1) margarine, and three (3) boxes pound cake. Second observation of the kitchen, on 11/06/19 at 3:05 PM, revealed the walk-in refrigerator cooler temperature was being worked on by the vendor. Review of the facility, titled Record of the Refrigeration Temperatures, on 11/06/19 at 11:30AM, revealed the walk-in cooler temperature reached 42 degrees at 7:20 AM. Review of the vendor report on 11/06/19 at 3:30 PM, revealed the vendor had been called to the facility on [DATE] at 11:20 AM. The vendor report stated the refrigerant on the cylinder was low, there was a leak on the thermal expansion value and the vendor tightened fitting pressure tested system. The vendor also vacuum and changed the refrigeration system and replaced the low-pressure switch. Further observation on 11/06/19 at 3:05 PM, revealed the walk-in cooler continued to store one (1) and half (½) cases of liquid egg products. Interview with Dietary Aide (DA) #1, on 11/05/19 at 10:35 AM, revealed she checked the facility refrigerators around 6:00 AM and recorded temperatures on the log. DA #1 states the temperatures were checked once daily and walk-in cooler temperature was 40 degrees Fahrenheit on 11/05/19. She stated she had not realize the walk-in cooler was above a safe temperature or was at 58 degrees Fahrenheit) until the DOD brought it to the dietary staff's attention on 11/05/19 around 11:00 AM. DA #1 stated once she pulled all her ingredients for breakfast from the walk-in cooler and placed in the prep cooler, she did not go back into the walk-in cooler unless she forgot something or it was lunch time. Further, interview with the Dietary Aide #1, revealed she witnessed the Dietitian and the Director of Dietary throwing away food which was not holding the correct temperature. She reported she was unsure what foods where kept and what was thrown away. The DA #1 state she did not use the food in the walk-in cooler. She stated if the food from the walk-in cooler was served by mistake, residents could become sick. Interview with Dietitian, on 11/05/19 at 2:11 PM, revealed she had only been employed with the facility for about a month. She stated she did not monitor the temperatures of the refrigerators or complete audits. Interview with Dietary Aide (DA) #2, on 11/07/19 at 8:52 AM, revealed the walk-in cooler temperature was at 50 degrees on 11/05/19, so the Director of Dietary (DOD) was contacted around 8:00 AM. She stated the DOD and Dietitian had checked temperatures on the food in the walk-in cooler and threw out some foods. She revealed none of the food was used for resident's consumption; however, she could not guarantee this. DA stated she anticipated another kitchen staff would stop anyone from using the foods from the walk-in cooler. She stated it was important to have correct temperatures for the walk-in cooler to prevent food-borne illness to the residents. Interview with Director of Dietary (DOD) on 11/06/19 at 3:05 PM, revealed she was not aware the walk-in cooler was not holding the correct temperature until the walk through. She stated she did not complete formal audits with documentation expect for the temperature logs, however, she expected her staff to let her know when there were issues with any of the kitchen equipment. Continued interview revealed, the DOD stated she did not know how the liquid egg products re-appeared in the walk-in cooler because she had thrown them away yesterday. She revealed consuming spoiled liquid egg products could cause illness to resident, which could result in hospitalization and emotional distress. Interview with Administrator on 11/08/19 at 4:29 PM, revealed she was not aware of the recent concerns of the high temperature in the walk-in cooler. The Administrator stated the Director of Dietary notified the maintenance department to repair any issues concerning the kitchen equipment. Continued interview with the Administrator, revealed while the repairs were being conducted, the DOD would contact her and they would determine the next action in the process. The Administrator stated she would have to look at policy to find out what foods would need to be removed from the walk-in cooler for resident safety. Furthermore, the Administrator reported her responsibility as an Administrator was to provide a safe environment and provide care to resident's needs.

Based on observation, interview, record review and review of the facility policy it was determined the facility failed to ensure one (1) of one (1) refrigerated scheduled medication boxes were affixed to the medication refrigerator located on the East Hall. In addition, the facility failed to ensure the pharmacy emergency scheduled medication kit was secured within an affixed box or area in the medication refrigerator. The findings include: Review of policy titled Medication Ordering and Receiving From Pharmacy Provider/ Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 2007, revealed emergency medications and supplies were provided by the pharmacy in compliance with applicable state and federal regulations. The policy further revealed that Schedule II medications were a part of the emergency medication supply and must be double locked and shall be stored in a locked cabinet or locked drawer separate from the non-controlled medications. Review of policy titled Emergency Pharmacy Service and Emergency Kits (E-KITS) policy, dated 05/16, revealed the emergency kit, along with the list of contents posted on the outside of the kit, is maintained at a designated, locked area that was easily accessible in an emergency. Emergency medications were secured, checked periodically for integrity and dating, and stored in accordance with the State Board of Pharmacy and federal regulations. Schedule II medications in the emergency medication supply must be double locked and shall be stored in a locked cabinet or locked drawer separate from non-controlled medication. Observation of facility medication storage room, on 11/06/19 at 9:52, revealed a two-lock, metal storage box that contained resident-specific medication was not affixed to the medication refrigerator. The refrigerated, narcotic emergency kit (E-Kit) was located in the top, right corner of the refrigerator. The E-Kit was in a plastic, latched container that was sealed with two (2), plastic, zip cable ties and was not affixed to the medication refrigerator. Both narcotic boxes were stored in a refrigerator that contained non-narcotic medications. Observation of the medication refrigerator on, 11/07/19 at 9:49 AM, revealed the resident-specific, refrigerated narcotic storage box was affixed to the medication refrigerator with a long, thick chain. The refrigerated E-Kit remained unaffixed, in a plastic box sealed with two (2), plastic, zip cable ties. Interview with Licensed Practical Nurse (LPN) #1, on 11/07/19 at 9:49 AM, revealed the facility affixed the refrigerated narcotic box to the refrigerator yesterday with a chain. Review of the Pharmacy's monthly Med Station Review form, for (MONTH) 2019, revealed the Emergency Medication Services' Controlled EDK storage was in compliance. Review list did not note what it considered in compliance. Interview with the Consultant Pharmacist #1, on 11/08/19 at 11:59 AM, revealed she checked the resident narcotic box to make sure it was affixed during her monthly visits and did not recall the resident narcotic storage box not being affixed to the medication refrigerator. Interview with LPN #1, on 11/06/19 at 12:15 PM, revealed only the medication nurses with keys to each medication cart can get into the medication room and then into the medication refrigerator. She stated the residents' refrigerated narcotics box contained two locks with two separate keys that were needed to open the box. Each nurse had one key and an extra key was hanging on a hook in the medication room, next to the medication refrigerator. Interview with LPN #1, on 11/07/19 at 9:49 AM, revealed she was unsure if there was a log to document the unaffixed, refrigerated narcotic E-Kit was checked to see if it was both there and sealed. She stated she did not sign off on anything during her shift and that maybe 3rd shift does it. She revealed that when she opened the medication refrigerator to remove resident medication, she did not check to see if the narcotic E-Kit was there and sealed. Interview with Registered Nurse (RN) #2, on 11/08/19 at 10:38 AM, revealed the narcotic boxes were not affixed in the refrigator and the boxes could be taken out of the medication room. She stated nursing was instructed yesterday to start documenting that the narcotic boxes were present, affixed and locked to ensure they did not get misplaced, removed from the refrigerator or diverted. She stated if the narcotics were diverted, misplaced or not available in event of emergency, it could impact patient safety and their lives. Interview with the Director of Nursing, on 10/07/19 at 11:33 AM, revealed the facility did not document the monitoring of the narcotic boxes or the E-Kit, nor did they check for their presence, or if the E-box was sealed. She stated she believed the narcotic box in the refrigerator had a chain, but she had to confirm that. She stated that she had asked pharmacy to provide a log sheet so the facility could begin documenting their auditing of the narcotic boxes. The DON revealed it was important to verify the presence of the narcotic storage boxes and acknowledge there was always a percentage of a chance that it could go missing. She stated that the resident would not be able to get the medication they need, if either of the narcotic boxes were missing. Interview with the Administrator, on 11/07/19 at 2:39 PM, revealed she was unaware of how the refrigerated narcotics were stored and would have to review the policy of narcotic storage. She stated you have to be a nurse to go into the medication room and knew that the narcotic E-Kit was in the medication room. She revealed that you have to have a physician's order to remove anything from the narcotic E-Kit and a nurse had to contact pharmacy to obtain an access code to be able to pull medication from E-Kit. She stated the access code just has to be written down and was more for paper work and was not needed to physically open the box. She revealed she did not know if there was an actual lock on the narcotic E-Kit and stated narcotics could go missing, if not properly stored. She denied any impact to the residents, if emergency narcotics were found unavailable because the facility would be able to order stat medications if something were found missing. The DON stated the nurses were busy 24-7 and were in and out of the medication room and would know if it the narcotic E-Kit was not there. She stated the facility would know immediately and be able to correct it timely. She was unaware of any documentation of nursing auditing the narcotic E-Kit. When this surveyor asked if there was a potential for staff to divert narcotics or if residents could be affected, the Administrator stated she did not feel comfortable answering that question until she spoke with her regional support.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were permitted to remain at the facility and not discharged for one (1) out of twenty-eight (28) sampled residents, Resident #341. Interview with Resident #341's son, on 11/08/19 at 11:30 AM, revealed Resident #341 was confused and could not make decisions while he/she was in the long term care facility. The son stated Resident #341 thought he/she was in Florida and sometimes did not recognize him on the phone. He further stated the resident did not act like this in the past and he found out from the hospital physician the resident had [MEDICAL CONDITION] because of the anesthesia administered during surgery. He also stated he told the facility he did not want the resident to leave the facility; however the facility discharged the resident because he/she wanted to go to the hospital. Interview with the Acute Care Hospital Social Worker, at 10:30 AM on 12/09/19, revealed Resident #341 was transported back to the hospital emergency roiagnom on [DATE], where the resident had surgery a few days prior. He/she stated after re-admission Resident #341 exhibited behaviors of yelling at staff and impatience; however, did not threaten to harm him/herself or others. The Hospital Social Worker stated the resident had mental health issues and was confused as a result of the surgery. Further interview revealed he/she did not feel the long-term care facility staff provided enough and/or appropriate interventions to deal with the resident's behaviors prior to transferring the resident back to the hospital. He/she stated if you gave the resident attention, he/she would calm down and would not exhibit those behaviors. In addition, review of Resident #341's long term care record revealed there was no documented evidence the transfer/discharge to the acute care facility was necessary or the facility attempted to find an appropriate discharge setting to meet the resident's needs. The findings include: Review of the facility's Admission Criteria Policy, last reviewed date 07/30/18, revealed the facility would admit residents who could adequately and safely be cared for and whose medical and psychological needs could be met. Review of the facility's policy titled, Transfer/Discharge Notice, last revised date 09/05/18, revealed residents would be transferred and discharged according to resident's medical and psychological needs. Transfer and discharge provisions significantly restrict a facility's ability to transfer or discharge a resident once that resident had been admitted to the facility. The facility may not transfer or discharge a resident once that resident had been admitted to the facility unless: the transfer or discharge was necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility; the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility; the safety of the individuals in the facility was endangered; the health of individuals in the facility would otherwise be endangered; the resident had failed, after reasonable and appropriate notice, to pay for a stay at the facility; or the facility ceased to operate. To demonstrate that for any of the events listed above, the facility would document in the resident's medical record. Review of the facility's policy titled, Discharge without Physician Approval, last revised date 06/28/18, revealed that discharges against medical advice of the attending physician would require a signed statement from the resident or responsible party to release the facility from responsibility for discharge. The order for an approved discharge would be signed and dated by a physician and recorded in the resident's medical record. If the resident or responsible party insisted upon being discharged without the approval of the attending physician/nurse practitioner/physician assistant, the resident and/or responsible party would sign a Release of Responsibility for Discharge against Medical Advice form. Should either party refuse to sign the release, such refusal would be documented it the resident's medical record and witnessed by two staff members. The administrator and director of nursing would be notified of the resident/responsible party discharge without an order from the attending physician/nurse practitioner/physician assistant. The director of nursing or charge nurse would inform the resident and/or responsible party of the potential risks involved in the early discharge of the resident. A copy of the statement would be filed in the medical record. Review of the facility's Discharge Planning Process Policy, last revised 07/29/19, revealed the facility would ensure a discharge planning process was in place to address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involve the resident, if applicable, the resident representative, and the interdisciplinary team in developing the discharge plan. Further review revealed if the resident chooses to be discharged to a setting which does not appear to meet the post-discharge needs or appears unsafe, the situation would be treated as a refusal of care and the facility would discuss with the resident and representative the implications and risks of the discharge to the location and attempt to determine why the destination was chosen; provide more suitable options to meet the resident's needs; document if the resident refused the offered option of an appropriate discharge setting and determine if a referral to Adult Protective Services or other state entity was necessary; and if so the referral should be made at the time of discharge. Record review revealed Resident #341 was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Interview on 11/08/19 at 3:25 PM with the Administrator, revealed the surveyor requested a copy of Resident #341's baseline care plan; however, he/she stated copies of all of the requested documents had been provided to the survey team. Review of all documents provided revealed no baseline care plan for Resident #341. Review of the Hospital Discharge Summary, dated 04/05/19, revealed Resident #341 presented to the hospital on [DATE] for an open wound to the left lower extremity below-knee that was complicated by [MEDICAL CONDITION] and a recent surgery with dehiscence. The resident underwent [REDACTED]. The resident developed [MEDICAL CONDITION] which was attributed to toxic metabolic dysfunction with [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the Patient Transfer Form, dated 04/05/19, revealed Resident #341 was assessed by the hospital nurse to be oriented times two (2) with disruptive behavior as well as confused and forgetful. Review of Admission Nurse's Note, dated 04/05/19 at 8:40 PM, revealed the facility assessed the resident to be oriented person, place and time. Resident #341 had frequent complaints of pain to hip and legs, had verbal behaviors upon arriving to the facility such as calling out and yelling repeatedly. Continued review revealed the staff were unable to redirect for very long. Review of a Nurse's Note, dated 04/06/19 at 5:51 PM, revealed Resident #341 had been unpleasant that shift by yelling out often and disrupting other residents. Continued review revealed the resident would yell for assistance and lash out at staff if demands were not met immediately. Resident #341 yelled and cursed at the nurse, and the nurse's attempts to redirect the resident were not successful. Additional review revealed Resident #341 stated that he/she was going home. Review of a Nurse's Note, dated 04/07/19 at 3:27 PM, revealed Resident #341 was alert and oriented with confusion. In addition, the resident was very demanding with staff and yelled for hours on multiple occasions. Staff attempted to redirect the resident by offering drink, snack, toileting and conversation. Continued review revealed Resident #341 rested in bed after staff provided incontinence care. Review of a Daily Skilled Nurse's Note, dated 04/08/19 at 11:55 PM, revealed Resident #341 was assessed to have long term memory problems, memory/recall problems, unable to recall staff names and faces; exhibited signs/symptoms of [MEDICAL CONDITION], inattention and disorganized thinking; verbal behaviors; and mood problems, little interest/pleasure in doing things and trouble falling/staying asleep/sleeping too much. Continued review of the nurse comments/concerns revealed the resident screamed and yelled profanities; the nurse and certified nurse aide (CNA) offered water, and repositioned him in bed multiple times. Resident #341 fell asleep after pain medication was administered. Review of a Psychiatric Initial Evaluation, dated 04/09/19, revealed Resident #341 was assessed as having a Mini-Mental Status Examination (MMSE) score of twenty (20) indicating the resident had moderate cognitive impairment and poor insight and poor judgement. Continued review revealed the treatment plan was to increase [MEDICATION NAME] 25 milligrams (MG) every morning (QAM) and 100 mg every four (4) hours if needed (PRN) for anxiety disorder. Review of a Nurse's Note, dated 04/09/19 at 9:00 AM, revealed Resident #341 was very demanding and yelling out into the hallway constantly, even after his/her needs were met. Further review revealed that if staff could not meet his/her needs immediately, he/she would curse and yell at staff. Review of a Nurse's Note, dated 04/09/19 at 10:30 AM, revealed Resident #341 continued with demanding and verbal behaviors, cursed at staff and yelled into the hallway inappropriate comments about staff. Further review revealed he/she stated that the resident wanted to go home and go to the hospital and that they should not have brought him/her here. Review of the Activity's Director (AD) note, dated 04/09/19 at 11:48 AM, revealed Resident #341 was observed by the nurse's station yelling and demanding to go to hospital. Resident #341 agreed to watch a movie in the activities room then demanded to talk to the Social Services Director (SSD) so he/she could get an update on how to discharge to the hospital. The AD took the resident to the SSD's office as the resident requested. Review of the Social Services Director (SSD) note, dated 04/09/19 at 11:49 AM, revealed Resident #341 was brought to his/her office for one to one support because he/she would yell and curse at staff. Further review revealed Resident #341 demanded to go home and the SSD explained that his/her home was torn down and his/her son could not take care of him. The SSD tried to call son for two days in a row, with no return call. However, there was no documented evidence the Resident was offered other options other than return to the acute care hospital that could meet the resident's needs. Review of a Nurse's Note, dated 04/09/19 at 1:36 PM, revealed Resident #341 was out in the hallway and continued to yell all shift. Review of the SSD note, dated 04/09/19 at 1:10 PM, revealed Resident #341 continued to demand to go home or to the hospital. Review of a SSD note, dated 04/09/19 at 1:44 PM, revealed Resident #341 asked for pain medication from the nurse but it was not given due to not due at the time. The SSD offered interventions but unable to keep him focused on tasks and continued to stated he/she wants to go home or to the hospital. Review of a Nurse's Note, dated 04/09/19 at 2:37 PM, revealed Resident #341 stated that he/she wanted to go back to the hospital and demanded that staff send him there and he/she was being held there against his/her will. Continued review revealed the nurse informed the resident that it would be against medical advice to leave the facility. Resident #341 stated he/she understood what it means to sign out against medical advice and what the repercussions were to sign out against medical advice. Resident gave verbal consent to sign out against medical advice with the nurse and the Social Services Director, as witness. Review of a Nurse's Note, dated 04/09/19 at 4:15 PM, revealed Resident #341 would yell that he/she wanted to leave and go back to the hospital. Continued review revealed Resident #341 cursed and yelled at staff and could not be redirected. Review of a Nurse's Note, dated 04/09/19 at 6:36 PM, revealed Emergency Medical Services (EMS) arrived at the facility and Resident #341 yelled at EMS staff as they transported him/her on the stretcher. Resident #341's son called the facility and he was informed that his/her father gave verbal consent for leave against medical advice (AMA) so the resident was transported to the hospital. The nurse told the son of Resident #341 the he/she was discharged to the hospital because he/she continually yelled stating that he/she wanted to leave. Review of the Emergency Medical Services (EMS) Transfer Report, dated 04/09/19, revealed EMS dispatched and responded to a non-emergent call to the facility for patient needing transport to hospital per the patient's request. The patient and nursing home were advised there were closer appropriate facilities but the facility agreed to cover the expenses of the transport. Continued review revealed the patient was transported by ambulance due to confined to bed and unable to sit in an upright position due to extreme pain. The patient was moved from the ambulance to the emergency room (ER) via stretcher. Review of the Resident Transfer or Discharge Notice, dated 04/09/19, revealed Resident #341 was discharged to the hospital because the safety of individuals in the facility was endangered by the resident being here. In addition, there was no documented evidence of a signed Against Medical Advice (AMA) Form. Review of the Hospital Social Services Worker note, dated 04/16/19, revealed the facility admitted Resident #341 on 04/05/19 with known behaviors and care needs from the Emergency Medical Services (EMS) transport. The long term care facility informed the hospital social worker that the resident wanted to leave the facility and return to the hospital against medical advice. Continued review revealed the facility dropped off the resident on 04/09/19 in the hospital's emergency department with nowhere to go. However, the hospital was attempting to find placement at another nursing facility because the long term care facility refused to readmit the resident. Review of the long term care SSD's note on 04/10/19, revealed the acute care hospital social worker contacted him/her to ask how Resident #341 ended back at that hospital since it was not medically necessary. The social worker informed the SSD that the resident was dropped off at the hospital's emergency room by ambulance and he/she was trying to find placement for the resident. Interview with Social Services Director (SSD) on 11/08/19 at 10:16 AM, revealed Resident #341 was his/her own person and was not cognitively impaired. The SSD stated Resident #341 demanded that he/she wanted to leave and go to the hospital on [DATE]. The SSD stated the resident was offered television shows to watch, sensory activities to help with anxiety, and reassured his/her feelings but the interventions did not work. Further interview revealed the SSD did not provide more interventions because the resident wanted to go home. The SSD stated the facility had to send him/her back to the hospital because that was what the resident wanted. Further interview revealed that on 04/09/19 the SSD signed the discharge against medical advice form on behalf of the resident. However, the SSD did not offer more suitable discharge options to meet the resident's needs. Interview with the Resident #341's son, on 11/08/19 at 11:30 AM, revealed Resident #341 was confused and could not make decisions while he/she was in the facility. The son stated Resident #341 thought he was in Florida and sometimes did not recognize him on the phone. Further interview revealed the resident called him all hours of the night because he/she did not know what he/she was doing. He further stated that the resident did not act like this in the past and he found out from the hospital physician that the resident had [MEDICAL CONDITION] because of the anesthesia administered to him during surgery. He also stated that he told the facility that he did not want the resident to leave the facility but they stated the resident was leaving against medical advice. Post survey interview with the Acute Care Hospital Social Worker, at 10:30 AM on 12/09/19, revealed Resident #341 was transported to the emergency room of the hospital where the resident had a surgery in April 2019. He/she stated that Resident #341 exhibited behaviors of yelling at staff and impatience; however, he did not threaten to harm himself or others. He/she stated the resident had mental health issues but was confused as a result of the surgery. Further interview revealed he/she did not feel the facility staff provided enough and appropriate interventions to deal with the resident's behaviors. He/she stated if you gave the resident attention, he would calm down and would not exhibit those behaviors. Interview with Licensed Practical Nurse (LPN) #4, on 11/08/19 at 11:46 AM, revealed Resident #341 was upset and demanded to go home and to the hospital. He/she stated the resident was lucid and responded appropriately, and the resident was not confused during the time she provided his/her care. Further interview revealed he/she provided redirection, pain medication, referred to the psychiatrist, but the facility could not keep the resident there against his/her will. However, he/she did not explain to Resident #341 that the facility could find an appropriate discharge setting to meet the resident's needs rather than the hospital. Interview with the Director of Nursing (DON), on 11/08/19 at 10:34 AM, revealed the DON was sent a referral for Resident #341 on 04/03/19 and the hospital's nurse's notes revealed the resident was confused, anxious, and agitated at times. The hospital staff reported to the facility nursing staff that the resident had behaviors of yelling out, cursing, noncompliance, anxiety and agitation. He/she stated the resident had inappropriate behaviors upon admission and throughout his/her stay on 04/09/19; however, did not harm himself or others. Continued interview revealed that multiple interventions were put in place such as redirection, one on one activities, and pain management; however, none of the interventions were successful. Further interview revealed the staff could have done more for the resident's behaviors but he/she might have refused it. Interview with the Administrator on 11/08/19 at 3:25 PM, revealed the facility provided care for residents that had dementia and psychiatric [DIAGNOSES REDACTED]. Residents were admitted based on the acuity and [DIAGNOSES REDACTED].#341's needs but he/she did not want to be there. She further stated that Resident #341 was oriented enough to make his/her own decisions. Further interview revealed she trusted her staff to make discharge/transfer decisions and they followed the discharge/transfer policies.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was implemented for one (1) of thirteen (13) sampled residents, Resident #45, related to diabetic foot care. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed the care plan focused on how the facility would assist residents to meet their goals. The care plan was designed to identify problems, reflect treatment goals, and to identify measureable outcomes. The care plan was an aide to prevent and or reduce decline in residents' status and promote optimal functioning. Review of Resident #45's clinical record revealed the facility readmitted the resident on 10/21/16, with the [DIAGNOSES REDACTED]. Review of Physician Orders, dated 07/10/18 and 07/24/18, revealed Resident #45 was to have Diabetic Shoes. Review of the Care Plan for Resident #45, dated 02/24/17, revealed the resident was at risk for complications associated with Diabetes. Interventions included diabetic shoes when available, dated 08/28/18. Observation, on 09/11/18 at 10:41 AM, revealed Resident #45 wearing black, worn, leather type shoes to both feet. The shoes were stretched where the foot entered the shoe and visibly worn on the outside and under-sole of both shoes. Interview with Resident #45, on 09/11/18 at 10:41 AM, revealed the facility evaluated the resident's eligibility for diabetic shoes several months ago. The resident stated the shoes, which he/she currently wore, were regular sneakers. The resident further stated he/she did not know why the facility had not provided the diabetic shoes. Interview with the Social Services Director (SSD), on 09/13/18 at 3:55 PM, revealed she and the Director of Nursing (DON) identified diabetic residents who needed and were eligible for diabetic shoes and Resident #45 was identified as eligible. She stated the medical company notified her of the required documentation to get the shoes and the DON worked on obtaining the documentation. The SSD stated the facility was waiting for the physician to make facility rounds in order to obtain the required documents, and the physician made rounds once a month. She stated Resident #45 had not received diabetic shoes as of 09/13/18. Interview with the DON, on 09/13/18 at 4:55 PM, revealed in early (MONTH) (YEAR), she and the SSD compiled a list of diabetic residents who would benefit from diabetic shoes and identified Resident #45 eligible for shoes. She stated when she attempted to order the shoes she was informed of documentation required by the medical company. She stated the facility was waiting on the medical provider to make monthly rounds to obtain required documentation and had not made progress in obtaining Resident #45's diabetic shoes. Continued record review revealed a Report of Consultation, dated 08/30/18, from the Podiatrist for Resident #45's wound care to the right toes. The Podiatrist recommendation/order was to clean the right foot ulcers with saline, dry well, apply a thin layer of Santyl cream, apply a saline moist gauze, and a dry dressing. Review of a Physician Order, dated 08/30/18, revealed staff was to cleanse the right foot ulceration with normal saline, pat dry, apply Santyl to the wound bed, cover with a moist gauze, secure with a dry dressing, and change daily. Review of the Care Plan, dated 08/28/18, revealed Resident #45 had diabetic ulcers to the right great toe, second toe, and ball of the foot, with interventions to provide treatments as ordered. Review of Resident #45's electronic Medication Administration Record [REDACTED]. The order on the MAR indicated [REDACTED]. Observation, on 09/13/18 at 8:20 AM, revealed Registered Nurse (RN) #1 completed wound care to Resident #45's right foot. The RN removed the soiled dressing, cleaned the toe with normal saline, and patted the area dry. She placed Santyl to the wound bed followed by a dry dressing. RN #1 completed wound care to the other areas on the foot with the same procedure. The nurse did not place a moist saline dressing on top of the Santyl as ordered. Interview with RN #1, on 09/13/18 at 8:56 AM, revealed prior to completing wound care she reviewed the treatment orders on the MAR. She stated she washed Resident #45's wound, applied the medicated cream, and placed a dry dressing proceeded by another dry dressing to hold the smaller dressing in place. She stated she did not check the wound care order on the MAR indicated [REDACTED]. Continued interview with the DON, on 09/13/18 at 4:55 PM, revealed she was responsible to ensure all orders were correct on the electronic MAR. She stated physician orders [REDACTED]. Interview with Certified Nursing Assistant (CNA) #1, on 09/13/18 at 2:30 PM, revealed the care plan included how to care for the residents. She stated if the residents had specialty shoes, they would be included on the care plan. She stated she reviewed care plans weekly for changes and either the nurses or the Assistant Director of Nursing (ADON) updated the care plans. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed resident care plans gave staff a guide on how to properly care for residents and were to be followed as written. She stated she did not review care plans daily and was notified about changes to care plans during report. She further stated if staff did not follow resident care plans, the residents' conditions could worsen. Interview with LPN #4, on 09/13/18 at 2:40 PM, revealed care plans told a story as to how to care for the resident. She stated nurses and CNAs were to follow the resident care plan and if not, then harm could occur to the resident. Interview with the Minimum Data Set (MDS) Coordinator, on 09/13/18 3:00 PM, revealed all staff was responsible to follow resident care plans. She stated she placed new orders/treatments on care plans during the Interdisciplinary Team (IDT) meeting every morning. She stated when diabetic shoes were requested; the facility added 'as available' on the care plan until the shoes were acquired. She stated the facility was to acquire the shoes in a timely manner and if the shoes were not available, or if treatment orders were done incorrectly, the care plan was not followed and could result in a negative outcome. Interview with the ADON, on 09/13/18 at 4:20 PM, revealed the IDT reviewed orders every morning and the MDS Coordinator placed new orders on the resident care plans and staff was verbally informed of changes to the care plans. She stated care plans helped care for residents and were not followed if staff did not have specialty equipment available or did not complete treatments correctly, which could affect resident outcomes. She stated she did not audit care plan implementation. Further interview with the DON, on 09/13/18 at 4:55 PM, revealed staff was to start care plans when new orders were obtained and the IDT reviewed the plans to ensure they were complete, and added other essential needs to existing care plans. She stated the IDT reviewed the entire resident care plan during the MDS quarterly review of the resident. She further stated staff was to follow care plans and if not, the residents' conditions could decline. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed staff was to provide good customer service and quality care to the residents. He stated the nursing administration had not presented issues with staff not following care plans. He further stated nursing administration made daily rounds to observe resident care, which would include care plan implementation. He stated if staff was not implementing the care plan, the DON and ADON would address the issue immediately.

Based on observation, interview, and review of facility's maintenance log, it was determined the facility failed to maintain a hazard free environment for one (1) of thirteen (13) sampled residents, Resident #18. Observation revealed Resident #18's footboard was wobbly on the resident's bed. Interview revealed he/she used the footboard to steady his/her balance when standing and his/her hand slipped off when it became unstable and he/she almost fell . The findings include: The facility did not provide a Maintenance Repair policy. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/14/17, with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required extensive assistance of one (1) staff with transfers. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) and determined the resident not interviewable. Review of Resident #18's Care Plan, dated 12/28/17, revealed the resident had an unsteady gait and fluctuated with the level of assistance due to disease. Observation, on 09/11/18 at 8:42 AM, 09/12/18 11:10 AM, and 09/13/18 at 11:00 AM, revealed Resident #18's footboard on the bed was wobbly. Interview with Resident #18, on 09/12/18 at 11:10 AM and 3:07 PM, revealed he/she reported the wobbly footboard to staff multiple times, but maintenance staff had not evaluated the footboard. The resident stated he/she used the footboard to steady himself/herself with transfers and while transferring, his/her hand slipped off and he/she almost fell . He/she further stated the loose footboard was disturbing when repositioning in the bed. Interview with Resident #18's Roommate, on 09/12/18 at 3:07 PM, whom the facility assessed with [REDACTED].#18 reported to staff about the wobbly footboard. He/she stated staff said they would notify maintenance but maintenance staff had not evaluated or addressed the footboard. Interview with Certified Nursing Assistant (CNA) #1, on 09/13/18 at 2:30 PM, revealed staff placed maintenance needs in the maintenance log and any staff could place a repair need in the log. She stated she had not noted any issues with bed boards being loose, but a loose board could hurt a resident. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed maintenance staff was notified of repairs by staff writing the issue in the maintenance log. She stated maintenance staff reviewed the log twice a day, initialed, and marked through when it was completed. The LPN stated nursing staff was not required to evaluate bed equipment for resident safety; however, residents often used their beds for balance assistance with transfers. She stated a resident could get hurt if the bed frame was not intact. Interview with the Maintenance Director, on 09/12/18 on 3:45 PM, revealed the facility relied on the electronic system for routine maintenance. He stated the system prompted maintenance to check resident beds once a month; however, the head and footboards of the bed were not included on the routine bed maintenance. He stated he had prior awareness of Resident #18's loose footboard, but could not fix it because it required the bed to be removed from the resident's room to complete. He stated the resident could get hurt with the wobbly footboard. Review of the electronic Maintenance Log revealed the system prompted maintenance staff to test bed controls, bed hand controllers, and bed cords for correct operation on a monthly bases. Review of the electronic Maintenance Log, for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed there was not an entry to repair Resident #18's footboard. Interview with the Regional Plant Operation Director, on 09/13/18 at 3:39 PM, revealed the electronic system prompted the maintenance department to check resident beds monthly. He stated the Maintenance Director should have requested nursing staff move another bed into the room as soon as he became aware of the safety issue. He further stated any equipment, directly related to the residents, that needed repair was to be repaired or removed from service immediately. Interview with the Assistant Director of Nursing (ADON), on 09/13/18 at 4:20 PM, revealed all staff was to place repair needs in the maintenance log and the director checked the log twice a day. She stated staff had been educated on how to fill out the repair form, and safety education was included in orientation and yearly in-services to check beds, lights, call bells, toilets, and equipment used daily for the care of residents. She stated it was a resident safety issue if the footboard was loose. Interview with the Director of Nursing (DON), on 09/13/18 at 4:55 PM, revealed staff was to place repair needs in the maintenance log. She stated she was not aware of any current repair needs that might affect resident safety. The DON stated staff was educated on the proper way to report maintenance needs and a wobbly footboard could be a safety hazard. She further stated it was the facility's responsibility to keep residents safe. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed safety was everyone's concern. He stated the Maintenance Director was new and still learning. He stated he was not made aware of safety issues with residents' beds and he was responsible to ensure the facility followed regulations to provide proper care and services to the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to follow the physician order [REDACTED]. The findings include: Review of the facility's policy, Resident with Diabetes, dated 09/17/15, revealed medications were to be administered as ordered. Review of the facility's policy, Change of Condition, revealed the facility entered orders for treatments or medications into the Electronic Medical Record (EMR). Review of Resident #45's clinical record revealed the facility readmitted the resident on 10/21/16, with multiple diagnoses, which included Diabetes. Review of a Report of Consultation, dated 08/30/18, revealed the Podiatrist ordered to clean the right foot ulcers with saline, dry well, apply a thin layer of Santyl, apply a saline moist gauze, and a dry dressing. Review of a Physician Order, dated 08/30/18, revealed staff was to cleanse the right foot ulceration with normal saline, pat dry, apply Santyl to the wound bed, cover with a moist gauze, secure with a dry dressing, and change daily. However, review of Resident #45's electronic Medication Administration Record [REDACTED]. The order on the MAR indicated [REDACTED]. Observation of Resident #45's wound care, on 09/13/18 at 8:20 AM, revealed Registered Nurse (RN) #1 removed the soiled dressing from the right toe, cleaned the toe with normal saline, and patted the area dry. RN #1 placed the Santyl cream to the wound bed followed by a dry dressing. The RN completed other areas to the foot with the same procedure. The nurse did not place a moist saline gauze on top of the Santyl cream before applying the dry dressing, per the physician order. Interview with RN #1, on 09/13/18 at 8:56 AM, revealed prior to completing wound care she reviewed the treatment orders in the EMR and gathered the supplies needed to complete the treatment. She stated she washed Resident #45's wound, applied the medicated cream, and placed a dry dressing proceeded by another dry dressing to hold the smaller dressing in place. She stated the nurses' station had a reference book for current treatment orders; however, she did not review the book because she knew the resident's treatment had not changed, as she had completed the treatments frequently. She further stated she did not check the wound care order in the EMR to the original order in the paper chart because the Assistant Director of Nursing (ADON) and Director of Nursing (DON) did that in the morning meeting after the order was written to ensure it was transcribed correctly. Interview with the DON, on 09/13/18 at 1:00 PM, revealed the facility reviewed new orders during the morning meetings the day after orders were received. She stated the orders were checked for transcription accuracy and to ensure all elements of an order were completed. She stated nurses did not do chart checks in the facility. She stated she accompanied staff weekly for wound assessments, measurements, and condition of the wounds and did not review accuracy of treatment orders during the weekly wound audits. She stated the pharmacy changed the treatment order for Resident #45 in the EMR on 09/04/18, because the pharmacy said the length of the order would not fit on the medication label and therefore shortened the order. The DON stated staff did not identify the inaccurate order when the medicated cream box arrived or when reviewing the order in the EMR prior to treatment. She stated the nurses were not following the physician order [REDACTED]. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed nurses transcribed orders into the EMR and the DON checked to ensure the orders were transcribed correctly the next day in the morning meeting. She stated it was important to complete treatments as ordered or the wound could worsen or be delayed in healing. She further stated she did not review the original written order against the treatment order in the EMR with weekly wound assessments. She stated the facility did not instruct nurses to review the accuracy of the orders, except with the monthly print out of orders signed by the ADON or DON, and physician. Interview with the Minimum Data Set (MDS) Coordinator, on 09/13/18 at 3:00 PM, revealed she attended the morning meetings and she, the DON, and other staff present reviewed orders entered into the EMR to ensure staff transcribed the orders as written. She stated staff and administration did not review treatment orders weekly to ensure the order remained correct in the EMR. The Coordinator stated orders were written to care for the resident's condition and if the orders were not followed as written, the nurses were not following the physician order. She stated the resident's condition could be impacted and could change. Interview with the ADON, on 09/13/18 at 4:20 PM, revealed orders were reviewed during the morning meeting the day after the orders were written. One staff read the order from the chart to another staff that verified the order was transcribed correctly in the EMR. She stated the facility did not review treatment orders weekly during weekly wound assessments to ensure accuracy of the order. She stated if staff did not complete the correct treatment order, then staff did not follow physician order. She further stated the resident could be affected by prolonged wound healing and poor outcome. Continued interview with the DON, on 09/13/18 at 4:55 PM, revealed she was responsible to ensure all orders were correct in the EMR. She stated the physician orders [REDACTED]. She stated incorrect treatment could cause slow or no progress in wound healing. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed staff should provide good customer service and quality care to residents. He stated nursing administration had not identified issues with incorrect treatment orders. He further stated he expected staff to resolve issues that could affect the condition of a resident.

Based on observation, interview, record review, and review of the facility's guidelines, it was determined the facility failed to provide diabetic shoes per physician order [REDACTED]. The findings include: The facility did not provide a policy on Diabetic Foot Care. Review of the facility's Resident with Diabetes Guideline Steps, dated 09/17/15, revealed to provide diet as ordered and monitor intake, administer medications and lab work as ordered, monitor for signs and symptoms for [DIAGNOSES REDACTED] and [MEDICAL CONDITION], monitor skin for redness or circulatory problems, monitor and ensure position changes, and encourage activity and exercise attendance. Review of Resident #45's clinical record revealed the facility readmitted the resident on 10/21/16, with multiple diagnoses, which included Diabetes. Review of Resident #45's Physician Orders, dated 07/10/18, revealed an order for [REDACTED].>Review of Physician Orders, dated 07/24/18, revealed an order for [REDACTED].>Review of the Care Plan for Resident #45, dated 02/24/17, revealed the resident was at risk for complications associated with Diabetes. Interventions included diabetic shoes when available, dated 08/28/18. Review of a letter from the Billing Specialist, dated 08/15/18, revealed the facility was notified of the required documentation in order to obtain diabetic shoes for residents. Observation, on 09/11/18 at 10:41 AM, revealed Resident #45 had on worn black leather type shoes to both feet. The shoes were stretched where the foot entered the shoe and visibly worn on the outside and under-sole. Interview with Resident #45, on 09/11/18 at 10:41 AM, revealed the facility evaluated the resident's eligibility for diabetic shoes several months ago, but had not provided the shoes for him/her. The resident stated he/she walked on the outer edge of his/her feet and his/her shoes were regular sneakers and uncomfortable because they were old and worn. The resident further stated the facility did not inform him/her as to why the diabetic shoes were not provided. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed diabetic shoes were ordered by Social Services, as staff nurses did not evaluate for the need of diabetic shoes. She stated the facility did not train or instruct staff to evaluate for the need of diabetic shoes; however, she evaluated diabetic residents for good health and skin condition of the feet. She stated she would notify the Director of Nursing (DON) or Social Services if the resident requested diabetic shoes or felt the resident needed shoes. She further stated she had not previously identified Resident #45 as needing shoes nor did the resident request to her the need for shoes. Interview with the Minimum Data Set (MDS) Coordinator, on 09/13/18 at 3:00 PM, revealed the provider ordered diabetic shoes, and the Social Service Director (SSD) and DON worked on obtaining the documentation to order the shoes. The MDS Coordinator stated the Interdisciplinary Team (IDT) ensured the order was taken off and placed into the electronic medical record in the morning meetings. After the initial review, she was not sure how the shoes were tracked to ensure the residents received them. She stated if the orders were not followed and completed, the resident's condition could worsen. She further stated she did not follow-up during quarterly MDS reviews to check if residents received requested devices. Interview with the SSD, on 09/13/18 at 3:55 PM, revealed residents were not physically evaluated for diabetic shoes; however, she and the DON compiled a list of diabetic residents and reviewed who were eligible or would benefit from diabetic shoes. She stated Resident #45 was identified as eligible and the DON obtained an order for [REDACTED]. She stated Resident #45 had not received diabetic shoes as of 09/13/18. Interview with the Assistant Director of Nursing (ADON), on 04/13/18 at 4:20 PM, revealed diabetic shoes were ordered through a pharmacy. The resident required a foot exam by the medical provider and a detailed progress note and then the facility submission occurred with the resident's insurance. The pharmacy would send out a technician who measured the resident's foot for a correct fit. She stated the DON called the physician for needed documentation, but he had not been to the facility. She stated she was involved in the evaluation for diabetic shoes but was not instructed to follow-up on or fax documentation to the provider's office requesting completion. She stated not following through with orders resulted in a delay in treatment. Interview with the DON, on 09/13/18 at 4:55 PM, revealed in early (MONTH) (YEAR), she and the SSD compiled a list of diabetic residents who would benefit from diabetic shoes and identified Resident #45 eligible for shoes. She stated she called the provider and obtained an order on 07/10/18 for the shoes, and on 07/24/18, the Nurse Practitioner wrote a second order for diabetic shoes. She stated when she attempted to order the shoes she was informed of the documentation required by the medical company and she called the provider to request the required documents, but had not faxed the documentation or followed up. She stated the facility was waiting on the medical provider to make monthly rounds and had not made progress in obtaining Resident #45's diabetic shoes. She stated she did not document communication or progress related to the shoes. She further stated the facility had not followed the physician order [REDACTED].>Attempted phone interviews with the physician were unsuccessful. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed he was to ensure residents received proper care and services to maintain their optimal level of health. He stated nursing administration had not notified him of difficulties in obtaining shoes for Resident #45.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program for two (2) of thirteen (13) sampled residents, Resident #4 and #45. Observation revealed staff failed to wash hands and remove Personal Protective Equipment (PPE) before leaving Resident #45's contact isolation room. Further observation revealed while providing wound care, staff removed contaminated supply stickers from the biohazard wastebasket and placed them on the dresser, then took them out of the isolation room to the nurses' station. In addition, Resident #4 was in isolation and observation revealed a biohazard waste receptacle was not available in the room. The findings include: Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions, revised (MONTH) 2012, revealed standard contact precautions were to be utilized for residents with known infections which could be transmitted by direct contact. Staff and visitors were to wear gloves and gowns when entering a room for contact precautions and wash their hands after removal of gown and gloves and immediately leave the room. Masks were to be removed by the elastic bands prior to leaving the room and hands were to be washed. Review of the facility's Guideline Steps to Donning and Removing Personal Protective Equipment (PPE), dated 06/01/15, revealed removed PPE articles were to be placed in a waste or linen receptacle and immediately perform hand hygiene after removing PPE. 1. Observation, on 09/11/18 at 9:10 AM, revealed a cart with PPE at the entry of Resident #4's room. A sign on the door said see nurse before entering the room. Resident #4 was under contact isolation precautions for what was described by the Director of Nursing (DON) as a stomach bug. Continued observation revealed there was no biohazard waste receptacle in the room for staff disposal of PPE before exiting the room. Interview, on 09/13/18 at 11:25 AM, with Certified Nursing Assistant (CNA) #2 revealed before leaving a contact isolation room, staff, and/or visitors must deposit the worn PPE in a biohazard waste hamper and she had not seen any isolation rooms without a red bag waste hamper. CNA #2 stated a red bag waste hamper should always be in the room when the resident was under isolation precautions. The CNA stated if a red bag waste hamper was not in a resident's room, staff should place the worn PPE in a regular disposable waste container bag because PPE must not be worn outside of the resident's room. Interview with CNA #1, on 09/13/18 2:30 PM, revealed staff should place PPE in yellow or red biohazard bins in resident rooms. She stated the bins were placed in the rooms when the resident started on isolation precautions and the CNAs changed out the bags once a day. Interview, on 09/13/18 at 2:22 PM, with Licensed Practical Nurse (LPN) #1 revealed when a resident was under isolation precautions, a hamper with a red bag liner should be in the resident's room for deposit of biohazardous waste such as used PPE. She stated the room should also have a hamper with a yellow bag for the resident's soiled laundry. After removing PPE, the LPN stated staff or visitors should dispose of it in the red lined hamper and not in the regular trash. LPN #1 stated disposal of PPE in the proper waste container minimized cross-contamination throughout the facility. Interview, on 09/13/18 2:52 PM, with the DON revealed the biohazard (red bag) waste hamper was not in Resident #4's room on the morning of 09/11/18, because staff had not yet retrieved a hamper from storage outside of the main building. She stated there was not much storage space in the main building so some supplies had to be stored elsewhere. The DON stated she monitored staff for proper process with use of and disposal of PPE, but she did not have written records of her monitoring. 2. Record review revealed Resident #45 was placed in contact isolation on 09/07/18, due to the resident's wound culture resulted in [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) and [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) (contagious infections). Observation, on 09/11/18 at 10:06 AM, revealed the Chaplain was donned in PPE including a mask in Resident #45's room. The Chaplain removed his gown and gloves, left the isolation room with the mask on, and did not wash his hands. The Chaplain walked around the facility with the mask on physically touching countertops, side rails, and residents. Interview with the Chaplain, on 09/11/18 at 10:35 AM, revealed he was educated on isolation precautions and knew he was to remove all PPE and wash hands before leaving the room. He stated if the steps were not followed, he could spread germs to other residents, and they could get sick. Interview with LPN #3, on 09/13/18 at 1:50 PM, revealed staff was to remove all PPE and wash hands before leaving the room. She stated if PPE was not removed and hands not washed, staff could spread infection around the facility. She further stated residents could become sick if staff did not follow proper infection control practices. Observation of Resident #45's wound care, on 09/13/18 at 8:20 AM, revealed Registered Nurse (RN) #1 did not clean the bedside table prior to placing a barrier and sterile dressing supplies for the resident's foot on top of the table. LPN #1 assisted with wound care and retrieved discarded outer wound packaging from the red biohazard bag, which contained the soiled dressings. The LPN removed the charge stickers from the packaging and placed them on top of the resident's dresser. LPN #1 washed her hands, put on clean gloves, placed the removed stickers onto the gloved fingers, left the isolation room, and placed the stickers on the resident's charge paper at the nurses' station. Further observation revealed RN #1 did not date or time the resident's dressing. Interview with RN #1, on 09/13/18 at 8:56 AM, revealed all surfaces were to be cleaned prior to placing sterile wound supplies on top and she did not complete this step during wound care. She stated cross contamination could occur and the wound could worsen or be delayed in healing. She stated staff was not to remove articles from the red biohazard bag because once items were placed into the biohazard bag, they were considered contaminated. RN #1 stated items were not to be removed from an isolation room because that was a cross contamination issue and could cause residents to become ill. Interview with LPN #1, on 09/13/18 at 10:45 AM, revealed she assisted RN #1 during Resident #45's wound care and retrieved supply stickers from the biohazard bag and placed the stickers on the resident's dresser. She stated she left with the stickers and placed them on the resident's page in the charge book. LPN #1 stated the facility educated her annually on infection control and audited her infection control techniques. She did know how else to ensure the resident was charged for the supplies if the stickers were in the biohazard bag. Interview with the Assistant Director of Nursing (ADON), on 09/13/18 at 4:20 PM, revealed she assisted the staff educator and audited staff handwashing techniques and observed staff on the floor daily. She stated she completed one on one training when she identified errors in technique. She stated once items were thrown into the red disposable biohazard bag, the items were not to be removed. Interview with the DON, on 09/13/18 at 4:55 PM, revealed she audited staff on infection control with visual observations and completed immediate re-education when breaks in techniques were identified. She stated staff development and the ADON monitored staff compliance with infection control. She stated staff received education during orientation, annually, and as needed for proper infection control. She further stated staff was not to wear PPE out in the hallway and hands were to be washed before leaving the room. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed he was to ensure staff followed regulations to ensure residents received proper care. He stated staff had not reported identified issues with infection control.

Based on observation, interview, and facility policy review, it was determined the facility failed to prepare and distribute food in a safe and sanitary manner. Observations revealed kitchen staff did not have hair fully contained in hairnets and did not wash hands during meal service after touching uncleaned surfaces. In addition, stored food in the refrigerator was not dated and clean baking trays were placed on metal shelving that had a black sticky substance on the surface. The findings include: Review of the facility's policy, Food Storage, dated 07/17/17, revealed all food stored in the refrigerator was to be dated in order to determine whether to be discarded. Review of the facility's policy, Hand Washing and Glove Use, dated 02/01/14, revealed hands must be washed after contact with any unsanitary surface. Review of the facility's policy, Personal Hygiene, revised 04/20/16, revealed staff was to have hair completely restrained and covered. A policy for scheduled kitchen cleaning was not provided. Observation of the kitchen, on 07/25/17 at 8:32 AM, revealed the refrigerator contained an undated opened plastic container labeled sour cream, an undated opened jar labeled mayonnaise, and an undated opened gallon container labeled milk. Observation of the kitchen, on 07/25/17 at 12:50 PM, revealed the Dietary Manager had hair uncovered above both ears and uncovered hair on the back of the head. Further observation revealed Dietary Cook #1 and #2 with hair uncovered on the both sides and the back of their heads. Observation of the kitchen, on 07/26/17 at 11:16 AM, revealed the Dietary Manager with hair on the back of her head uncovered. Further observation revealed a black sticky substance on the metal shelf under the steamer unit with clean metal pans on top of the sticky black matter. Observation at 11:43 AM, revealed staff placed four (4) metal food covers, with food substance stuck to the sides and water beaded on the surface, on the top of clean baking pans. Further observation at 11:51 AM, revealed Dietary Aide #2 walked to the refrigerator, opened the door with her bare hands, and without washing her hands, returned to plating food for residents. Observation at 12:09 PM, revealed the tray cart had a zippered plastic cover with crusted white substance on two (2) of three (3) sides. Interview with Dietary Aide #2, on 07/27/17 at 1:00 PM, revealed she was trained to have hair completely covered with a hairnet. She stated staff was to wash hands when entering the kitchen, after going to the bathroom, between cooking, handling raw foods, and after touching surfaces. Dietary Aide #2 stated she was not sure about the cleaning schedule for the kitchen. Interview with Dietary Cook #2, on 07/27/17 at 1:30 PM, revealed the facility followed a cleaning schedule daily, weekly and monthly. She stated the plastic covered tray carts were to be cleaned after every meal service, and taken out weekly and washed. She stated hair should completely covered with hairnets. She stated staff was to wash hands when entering the kitchen and anytime hands came in contact with surfaces or food. She further stated food could become contaminated with bacteria and cause the residents to become sick if hands were not washed after opening the refrigerator door. Interview with the Dietary Manager, on 07/26/17 at 8:49 AM, revealed staff was to wear hairnets to cover the entire head of hair. The Dietary Manager stated hairnets provided sanitation for meals and preparing food. She revealed it could be unappetizing for residents to find hair in their food. She further stated she was responsible for ensuring staff wore hairnets properly. The Dietary Manager stated the kitchen followed a cleaning schedule and shelves were to be cleaned weekly, and the plastic covers were wiped down at the end of the day and washed outside weekly. She further stated staff was to date and label food to ensure the food was discarded before bacteria could grow and cause illness if served to the residents. Interview with Administrator, on 07/27/17 at 2:20 PM, revealed he did random audits of the kitchen. He further stated the Dietary Manager was responsible for education and oversite of proper hand washing, placement of hairnets, and cleaning. He revealed it was important for all staff in the kitchen to maintain the best practices concerning hygiene and cleaning to prevent illness within the facility.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an accurate and complete record of controlled medications for two (2) of two (2) medication carts as evidenced by the absence of signatures on the controlled medication count forms. The findings include: Review of the facility's policy, Medication Administration Controlled Substances, dated May 2016, revealed at shift change, a physical inventory of controlled medications was to be conducted by two (2) licensed clinicians and documented on the audit record. Review of the facility's Controlled Substance Accountability Count form, dated January 2013, revealed the form was used to verify the controlled drugs on hand had been counted and each medication count was in agreement with the quantity stated on controlled drug records. There were areas on the form for staff to record the date, shift, and signature of the on-coming and off-going nurse. Review of Bluegrass Estates' Controlled Substance Accountability Count, dated 05/20/17 to 07/05/17, revealed absent signatures for the on-coming nurse on 05/26/17 at 7:00 AM, 06/02/17 at 7:00 AM, 06/18/17 at 7:00 AM and 7:00 PM, and 07/03/17 at 11:00 PM. There were absent signatures for the off-going nurse on 05/20/17 at 7:00 AM, 05/26/17 at 4:00 PM, and 06/19/17 at 7:00 AM. Review of Memory Lane's Controlled Substance Accountability Count, dated 05/07/17 to 07/01/17, revealed absent signatures for the on-coming nurse on 06/05/17 at 11:00 PM and 06/27/17 at 7:00 AM. There were absent signatures for the off-going nurse on 05/07/17 at 7:00 AM, 05/13/17 at 7:00 PM, 05/24/17 at 7:00 AM, 05/26/17 at 7:00 AM, 05/27/17 at 7:00 AM, 06/06/17 at 7:00 AM, 06/25/17 at 7:00 PM, and 06/27/17 at 7:00 PM. Interview with Licensed Practical Nurse (LPN) #2, on 07/27/17 at 8:35 AM, revealed the controlled medications were counted on each medication cart at shift change to ensure accurate count and then the on-coming and off-going nurse signed the count form stating that reconciliation had been done and was correct. The LPN also stated the on-coming nurse who signed the form was also responsible for the keys to the controlled medication box and the contents. Interview with the Director of Nursing (DON), on 07/27/17 at 10:55 AM, revealed a narcotic count was to be done at every shift change with the off-going nurse and the on-coming nurse and each would sign that the count was correct. The DON stated the process ensured the controlled medication count was accurate and any unreconciled count would be addressed immediately. She further stated the facility did not monitor the process. Interview with the Administrator, on 07/27/17 at 3:00 PM , revealed each licensed staff person who participated in the narcotic count at shift change was to sign off that they accepted the count to prevent possible theft of the medications, and to ensure residents received their medications as ordered. The Administrator stated the on-coming nurse, once the narcotics have been counted, accepted responsibility for that count and the medication cart until the end of the shift. He stated the matter of absent signatures was concerning to him as he would question if the counts were completed.

Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) User Manual, Version 3.0, it was determined the facility failed to complete a significant change on the Minimum Data Set (MDS) for one (1) of fifteen (15) sampled residents, Resident #2. The facility failed to complete a significant change MDS when Resident #2 showed an improvement in his/her health status in more than one (1) area. The findings include: Review of the facility's policy, Resident Assessment, revised June 2017, revealed a Significant Change in Status Comprehensive Assessment would be completed within fourteen (14) days after the determination of a significant change. Review of the RAI User Manual, Version 3.0, Chapter 2, revealed a significant change was a decline or improvement in a resident's status that would not normally resolve itself without intervention, impacted more than one (1) area of the resident's health status, and required interdisciplinary review and/or revision of the care plan. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 03/10/17, following hospitalization for Septic Shock related to a Urinary Tract Infection and a new [DIAGNOSES REDACTED]. Observation of Resident #2, on 07/25/17 at 11:10 AM, revealed the resident got up from lying on the bed to a sitting position on the side of the bed, without assistance. Further observation at 2:30 PM, revealed the resident ambulated with a walker onto the outdoor patio and sat in a rocking chair. Observation of Resident #2, on 07/26/17 at 8:30 AM, revealed the resident ambulated in the hallway with a rolling walker without staff assistance. Review of Resident #2's admission MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance for Activities of Daily Living (ADL) including transfers, ambulating in the room and corridor, locomotion on and off the unit, dressing, personal hygiene and toilet use. He/she required limited assistance with bed mobility and supervision with eating. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15). Further review of the clinical record revealed Resident #2 received Physical Therapy (PT) from 03/12/17 until 03/24/17, as well as Occupational Therapy (OT) from 03/13/17 until 03/20/17. Review of Resident #2's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of thirteen (13) out of fifteen (15), an improvement from the admission MDS assessment score of ten (10.) The facility assessed the resident had improved to supervision for the performance of bed mobility, transfer, ambulation in room and in the corridor, locomotion on and off the unit, toilet use and personal hygiene. Resident #2 was independent with eating and dressing and required set-up only. Review of Resident #2's Comprehensive Care Plan, dated 03/23/17, revealed the facility assessed the resident was at risk for falls and interventions were dated 03/23/17, except one (1) dated 04/19/17, which revealed non-skid socks were to be worn at all times. The resident was assessed to have ADL and self-care deficits on 03/23/17, with all interventions dated 03/23/17, except one (1) dated 06/28/17, which stated labs as ordered. Interview with the MDS Coordinator, on 07/27/17 at 9:15 AM, revealed she did see that Resident #2 had improved in the ADL's on the 06/24/17 MDS assessment when compared to the 03/17/17 admission MDS assessment. She also stated she had not performed a significant change assessment on 06/24/17, and instead performed a quarterly assessment. The MDS Coordinator stated because the assessment demonstrated improvement in more than one (1) area, a significant change assessment should have been conducted. She further stated a significant change assessment would have ensured the review/revision of the care plan. Interview with the Administrator, on 07/27/17 at 2:00 PM, revealed he had a basic knowledge of the MDS assessment process. He further stated a significant change assessment was completed when a resident had either a decline or improvement in their status. Further interview with the Administrator revealed it was necessary to revise the plan of care to meet the needs of the resident.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop a care plan for one (1) of the fifteen (15) sampled residents, Resident #6. The facility assessed Resident #6 was at risk for pressure ulcer formation; however, a care plan was not developed. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed each resident's comprehensive care plan was designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. Care plan interventions were implemented after consideration of the resident's problem areas and their causes. Interventions were to address the underlying sources of the problem areas rather than addressing only symptoms or triggers. Observation of Resident #6, on 07/25/17 at 10:32 AM, revealed him/her outside smoking in a wheelchair. Observations at 11:30 AM, 12:55 AM, 2:15 PM, revealed the resident in a wheelchair in the activities room. Observation at 3:03 PM, revealed the resident in a wheelchair outside smoking. Observation at 4:00 PM, revealed Resident #6 in a wheelchair at the nurses' station. Review of Resident #6's clinical record revealed the facility admitted the resident on 01/20/16, with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident was at risk for developing pressure ulcers, and the treatment section revealed a pressure reducing device was used for the bed. Resident #6 was frequently incontinent of bowel and bladder. The resident weighed three hundred seventy-four pounds (374) and was sixty-four (64) inches tall. Review of Resident #6's Braden Scale, dated 07/22/17, revealed the facility assessed the resident was at risk for developing pressure ulcers and preventative measures should be immediately implemented and documented on the care plan. However, review of the Comprehensive Care Plan, revealed the facility did not develop a care plan for pressure ulcer risk until 07/27/17, the last day of survey. Interview with the MDS Coordinator, on 07/27/17 at 10:50 AM, revealed Resident #6 was at risk for pressure ulcer formation and the comprehensive care plan should contain a care plan for being at risk. However, after reviewing the care plan, the MDS Coordinator revealed she had failed to implement a risk for pressure ulcer care plan. She stated Resident #6 was at risk for pressure ulcer formation due to the conditions of obesity, incontinence, Diabetes, [MEDICAL CONDITION], and other medical conditions. Interview with Licensed Practical Nurse #1, on 07/26/17 at 9:20 AM, revealed Resident #6 was at risk for pressure ulcer formation. Factors that affected risks for Resident #6 included obesity, Diabetes, non-compliance with off-loading, non-compliance with incontinent care, incontinence, non-compliance with treatments, and elevated glucose levels. Interview with the Director of Nursing (DON), on 07/26/17 at 10:00 AM, revealed Resident #6 was at risk for pressure ulcer formation because he/she was incontinent, obese, diabetic, refused care, was non-compliant with his/her diet, and sat in the wheelchair for prolonged periods of time. The DON reviewed the comprehensive care plan and revealed the risk for pressure ulcer care plan was not included in the comprehensive care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of fifteen (15) sampled residents, Resident #1. Staff failed to notify the physician of a change in Resident #1's skin status. The findings include: Review of facility's policy, Care Plans-Comprehensive, undated, revealed the care plan was used to identify or reduce declines in the resident's status. Care plan interventions were to be implemented after consideration of the resident's problem areas and their causes. The policy further revealed interventions were to address the underlying sources of the problem areas rather than addressing only symptoms or triggers. Review of the facility's policy, Change of Condition, undated, revealed the facility was to notify the physician of a change in a resident's health and document actions. Review of Resident #1's clinical record revealed the facility readmitted the resident on 06/02/17, with [DIAGNOSES REDACTED]. Review of Resident #1's significant change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required extensive assistance for bed mobility, and extensive assistance with cleaning self after elimination and was totally dependent for showers or bed baths. The facility assessed the resident was always incontinent of urine and stool. The resident's weight was eighty-nine (89) pounds and he/she was sixty-three (63) inches tall. The facility determined the resident had one (1) Stage 2 pressure ulcer and was at risk for developing pressure ulcers. Review of Resident #1 Braden Scale, dated 07/18/17, revealed the facility assessed the resident was a high risk for developing pressure ulcers. Review of Resident #1's Comprehensive Care Plan, dated 05/18/17, revealed the resident was at risk for developing skin breakdown due to needed assist with bed mobility, bladder and bowel incontinence, and weight loss. Staff was to report skin status changes, including new areas, to the physician. Review of plan for pressure ulcer, dated 07/11/17, revealed changes in skin status, including new areas, were to be reported to the physician. Review of Resident #1's Weekly Skin Assessments, dated 05/22/17 to 07/26/17, revealed staff identified one (1) pressure ulcer on the resident's sacrum on 07/11/17. Observation of Resident #1's wound care to the sacrum, on 07/26/17 at 4:20 PM, with Licensed Practical Nurse (LPN) #1, revealed a small open red area with white matter on the left side of the sacrum ulcer. Interview with LPN #1, on 07/26/17 at 4:30 PM during the wound care, revealed she was not sure if the small area was a new area. Continued interview with LPN #1, on 07/27/17 at 8:36 AM, revealed the second opened skin ulceration to Resident #1 was a new finding and a change in skin status. She stated she did not notify the physician of the change in skin status on 07/26/17, because she was flustered and forgot. She further stated a delay in treatment could cause the skin ulceration to worsen, get bigger, or get infected. Further interview at 4:10 PM, revealed Resident #1's care plan included notifying the physician of any newly developed open skin areas. Interview with the Director of Nursing (DON), on 07/27/17 at 2:48 PM, revealed the facility was to notify the physician of Resident #1's identified skin status change. She further stated all nurses were responsible for reviewing resident care plans and updating care plans with new findings. She stated newly identified skin ulcerations were reviewed in the daily meeting and followed in the monthly Quality Assurance (QA) meetings concerning progress or decline of wound statuses. Interview with the Administrator, on 07/17/17 at 2:20 PM, revealed wound treatments, improvements, and/or decline were discussed in the QA and Performance Improvement (PI) meetings that were conducted monthly with the Medical Director. He stated the DON was to ensure nursing staff followed and updated all care plans.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assess and obtain prompt treatment for [REDACTED].#1 and #6. Resident #1 developed a new pressure area identified by staff and did not notify the physician for treatment orders. Resident #6 was not care planned to prevent pressure ulcers yet had been identified as a high risk for pressure ulcer development. The findings include: 1. Review of the facility's policy, Change of Condition, undated, revealed the facility was to evaluate and document changes in a resident's health, relay the evaluation to the physician, and transcribe orders if received. Review of the facility's policy, Pressure Ulcer Treatment, undated, revealed the facility was to document and report any change in a resident's condition to the physician. Review of the facility's policy, Pressure Ulcer Management Resource, dated 06/01/15, revealed the assessment was always the starting point for ulcer treatment, and the wound was measured and documented. The physician would be notified of new pressure ulcers to obtain and initiate treatment. Review of Resident #1's clinical record revealed the facility readmitted the resident on 06/02/17, with [DIAGNOSES REDACTED]. Review of Resident #1's significant change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required extensive assistance for bed mobility and with cleaning self after elimination, and was totally dependent for showers or bed baths. The facility assessed the resident was always incontinent of urine and stool. The resident's weight was eighty-nine (89) pounds and he/she was sixty-three (63) inches tall. The facility determined the resident had one (1) Stage 2 pressure ulcer and was at risk for developing pressure ulcers. Review of Resident #1's Braden Scale, dated 07/18/17, revealed the facility assessed the resident was a high risk for developing pressure ulcers. Review of Resident #1's Weekly Skin Assessment, dated 07/11/17, revealed one (1) open area on the sacrum that was not present on admission. Review of Resident #1's Comprehensive Care Plan, dated 05/18/17, revealed the resident was at risk for developing skin breakdown due to needed assistance with bed mobility, bladder and bowel incontinence, and weight loss. Staff was to report skin status changes, including new areas, to the physician. In addition, there was a plan for pressure ulcer to the coccyx, dated 07/11/17, with an intervention to report changes in skin status, including new areas, to the physician. Observation of Resident #1's wound care to the sacrum, on 07/26/17 at 4:20 PM, with Licensed Practical Nurse (LPN) #1, revealed a small open red area with white matter on the left side of the sacrum ulcer. Interview with LPN #1, on 07/26/17 at 4:20 PM during wound care, revealed she was not sure if the small red area was a new area. LPN #1 stated she would review the resident's record and see if the area was new, and if it was, she would report the new finding to the physician. Continued interview with LPN #1, on 07/27/17 at 8:36 AM, revealed the small red area on Resident #1 was a new finding. She stated she did not notify the physician of the new area. Further interview at 2:45 PM, revealed a delay in treatment could worsen the wound condition and could cause it to become larger and harder to heal. Interview with LPN #3, on 07/27/17 at 8:21 AM, revealed she did not receive in report on 07/28/17, that Resident #1 had a new area to the buttocks. LPN #3 stated the wound nurse needed to be notified so an assessment and measurements could be obtained and documented. LPN #3 further stated the physician needed to be notified as soon as a new area was discovered to provide treatment and prevent further breakdown. Further interview at 11:30 AM, revealed she reported to the Director of Nursing (DON) Resident #1's condition earlier in the morning and notified the physician. Interview with the DON, on 07/27/17 at 2:28 PM, revealed when a new area of skin breakdown was noted, the physician was to be notified of the change in condition to obtain orders to prevent further breakdown of the resident's skin. The DON further stated she was responsible for assessment, measurement, and documentation of all new pressure areas. The DON stated staff was instructed to place new pressure areas on the twenty-four (24) hour report as well as report to oncoming staff who would be responsible for caring for the resident. The DON further stated the twenty-four (24) hour report was taken to the daily meeting and discussed and followed as appropriate. The DON stated a delay in treatment could cause the wound to decline or become infected. Further interview at 4:05 PM, revealed the DON had not completed an assessment of Resident #1's new skin area and would get to the assessment tomorrow or later in the day. Interview with the Administrator, on 07/27/17 at 2:20 PM, revealed the facility did not have a wound management team or wound physician to consult for the care of pressure ulcers. The Administrator further stated he expected all new wounds in the facility to be assessed, evaluated, and reported as soon as possible to prevent the condition of the wound from worsening. 2. Review of the facility's policy, Wound Sense, not dated, revealed weekly skin evaluations were to be done and if there was an open area identified, a wound evaluation was automatically triggered and would apply to non-ulcer skin condition. Review of the facility's policy, Pressure Ulcer Management, dated 06/01/15, revealed assessment was always the starting point for ulcer treatment. The pressure area was to be measured and included the size along with the length, width, depth, and appearance of surrounding skin and should be documented. The area was to be reassessed and measured weekly. Observation of Resident #6, on 07/25/17 at 10:32 AM, revealed him/her outside smoking in a wheelchair. Observations at 11:30 AM, 12:55 AM, 2:15 PM, revealed the resident in a wheelchair in the activities room. Observation at 3:03 PM, revealed the resident in a wheelchair outside smoking. Observation at 4:00 PM, revealed Resident #6 in a wheelchair at the nurses' station. Review of Resident #6's clinical record revealed the facility admitted the resident on 01/20/16, with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident was at risk for developing pressure ulcers and a pressure reducing device was used for the bed. Resident #6 was frequently incontinent of bowel and bladder. The resident weighed three hundred seventy-four pounds (374) and was sixty-four (64) inches tall. Review of Resident #6's weekly skin assessment, dated 07/09/17, revealed LPN #4 documented the right thigh had a reddened intact non-blanchable ulcer and the left thigh had an abrasion. Review of Resident #6's Braden Scale, dated 07/22/17, revealed the facility assessed the resident was at risk for developing pressure ulcers and preventative measures should be immediately implemented and documented on the care plan. However, review of the Comprehensive Care Plan, revealed a plan for at risk for pressure ulcer was not developed until 07/27/17, the last day of the survey. Review of Resident #6's Medication Administration Record, [REDACTED]. Interview with the DON, on 07/26/17 at 10:00 AM, revealed Resident #6 was at risk for pressure ulcer formation because he/she was incontinent, obese, diabetic, refused care, non-compliant with diet, and sat in the wheelchair for prolonged periods. She further revealed nurses did weekly skin assessments on the residents and if there was a change in a wound or a new skin condition noted, she would be notified, the physician would be notified, and the care plan would be updated. The DON stated she did not do the weekly skin assessments, but she was the wound nurse and took care of the pressure ulcer assessments. She stated she had not assessed Resident #6's wounds for at least two (2) weeks because she did not consider the wounds on the thighs to be pressure ulcers, but incontinence [MEDICAL CONDITION]. She revealed incontinence [MEDICAL CONDITION] could be red, could be an open area, and blanchable. Observation of Resident #6's wound care, on 07/26/17 at 3:30 PM, with LPN #1, revealed an open area to the back right lower thigh and an open area to the back of the left upper thigh. LPN #1 cleaned both areas, applied [MEDICATION NAME], and left the areas open to air (no bandage was applied). After treatment was completed, Resident #6 sat down in the wheelchair and the wounds came in direct contact with the wheelchair. Interview with LPN #1, on 07/26/17 at 3:30 PM during wound care, revealed both areas on Resident #6's thighs were open but were not pressure areas. LPN #1 revealed the areas were incontinence [MEDICAL CONDITION], friction [MEDICAL CONDITION], or abrasions. LPN #1 revealed incontinence and the rubbing of the legs on the wheelchair were factors in the development of the areas. She further stated she was not sure what the difference was between a pressure ulcer, abrasion, and [MEDICAL CONDITION]. Interview with the MDS Coordinator, on 07/27/17 at 10:50 AM, revealed Resident #6 was at risk for pressure ulcer formation and the comprehensive care plan should contain a plan for being at risk. However, after reviewing the care plan, the MDS Coordinator revealed she had failed to implement a risk for pressure ulcer care plan. She revealed Resident #6 was at risk for pressure ulcer formation due to obesity, incontinence, Diabetes, [MEDICAL CONDITION], and other medical conditions. She further revealed a pressure relief cushion should be in Resident #6's wheelchair. She stated incontinence [MEDICAL CONDITION] occurred on mainly moist areas and was widespread, not localized to one (1) area. She stated pressure ulcers usually occurred on bony prominences, but could occur anywhere there was pressure. The MDS Coordinator revealed she relied on the nurses' skin assessments and the DON's assessments to be accurate because she would not know if there had been a change in residents' skin condition. Observation of Resident #6 skin assessment, on 07/27/17 at 10:25 AM with the DON, revealed the back of the left upper thigh had an open area and measured one (1) centimeter (cm) long and six tenths (0.6) cm wide with a depth of one tenth (0.1) cm. The DON assessed the area as open with granulated tissue, macerated outside edges, and no drainage. The area on the right upper thigh was five tenths (0.5) cm long and six tenths (0.6) cm wide and less than one tenth (0.1) cm in depth. The DON assessed the open area to have a pale yellow center with visible edges. Interview with the DON, on 07/27/17 at 10:25 AM during the skin assessment, revealed she determined the open areas on Resident #6's thighs were incontinence [MEDICAL CONDITION] or friction [MEDICAL CONDITION] and not pressure. The DON revealed pressure areas were non-blanchable areas and occurred on bony prominences. She further revealed open areas were not always pressure. She stated she would have to research pressure ulcers and get back with the surveyor as to whether the two (2) open areas were pressure or [MEDICAL CONDITION]. The DON revealed she did not know when the wounds to the right and left thighs had changed from abrasions to open areas because there was no documentation of the size. The DON stated she had not been assessing the wounds of Resident #6 because she did not consider them pressure ulcers, even though the resident was at risk for pressure ulcer formation.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain their infection control program to prevent the development and transmission of disease and infection for three (3) of fifteen (15) sampled residents, Residents #1, #4, and #10. Staff failed to perform hand hygiene when providing incontinent care and peri care for Residents #1 and #10. In addition, the nurse failed to perform hand hygiene between glove changes during Resident #4's wound care. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2015, revealed all personnel shall be trained and follow handwashing/hand hygiene procedures including after direct contact with residents, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after handling used dressings, after contact with objects in the immediate vicinity of the resident, after removing gloves, and before and after handling food and assisting a resident with meals. The policy stated use of gloves did not replace handwashing/hand hygiene. Review of the facility's policy, Perineal Care for Male or Female, undated, revealed hands were to be washed and clean gloves applied before the perineal area was cleaned. After the perineal area was cleaned, gloves were to be removed, discarded, and hands were to be washed. In addition, the penis and labia were to be cleaned first avoiding the anal area. The anal area was to be cleaned last. Review of the facility's policy, Pressure Ulcer Treatment, dated 06/01/15, revealed hands were to be washed and clean gloves applied before removing a soiled dressing, soiled gloves were to be removed, placed in a plastic bag, and hands were to be washed, then clean gloves applied before cleaning the wound. After the wound was cleaned and the dressing applied, gloves were to be removed and hands were to be washed. 1. Review of Resident #4's clinical record revealed the facility admitted the resident on 02/15/17, with [DIAGNOSES REDACTED]. The record revealed the facility assessed the resident to have an open area on the sacrum with treatment obtained on 07/11/17. Observation of Resident #4's wound care, on 07/26/17 at 10:35 AM, revealed Licensed Practical Nurse (LPN) #2 performed a dressing change to the sacral wound. The nurse removed the soiled dressing and changed gloves without performing hand hygiene. LPN #2 then poured normal saline on gauze and cleaned the wound, dabbing it from the center outward, and then back into the open wound with the same gauze. Resident #4 was positioned on his/her right side and then rolled onto his/her back placing the cleaned sacral wound onto the resident's brief (the brief was used by the resident before wound treatment). The nurse did not clean the wound again. LPN #2 changed gloves without performing hand hygiene, changed Resident #4's brief, repositioned the resident, and touched the bed linens before removing gloves and washing her hands. LPN #2 took the trash bag to the soiled utility and did not perform hand hygiene after leaving the soiled utility room and walked to a treatment cart and placed charge stickers in a folder. Interview with LPN #2, on 07/26/17 at 11:30 AM, revealed when she performed the dressing change for Resident#4, she did not wash her hands between glove changes. She stated she forgot and she should have washed her hands with each glove change, with removal of the soiled dressing, and after the brief change. LPN #2 stated she was unaware she cleaned the wound, and then cleaned the surrounding skin and back into the wound bed with the same gauze. She stated she would normally clean the wound from the center outward without going back to the open wound. LPN #2 stated she was unaware Resident #4 had rolled onto his/her back after she cleaned the wound and the wound had touched the used brief. The LPN stated she recalled assisting the resident after the brief change by placing the bed linens over the resident and placing the call light within the resident's reach. She stated she should have wash her hands after she had taken the soiled trash to the soiled utility room before she touched the treatment cart to put charge stickers in a folder. 2. Review of Resident #10's clinical record revealed the facility admitted the resident on 07/03/08, with [DIAGNOSES REDACTED]. Observation of Resident #10's incontinent care/peri care, on 07/26/17 at 3:20 PM, revealed CNA #1 removed the resident's soiled brief and positioned the resident on the left side and cleaned stool from the resident's anal area with disposable wipes. CNA #1 placed the soiled wipes and brief into a plastic bag. CNA#1 repositioned the resident, touching the resident's skin with her soiled gloves. CNA #1 proceeded to clean the resident's peri area with the same gloved hands she cleaned stool from the anal area. After CNA #1 completed peri care, she removed her soiled gloves but did not wash her hands. The CNA then touched the resident's clothing and brushed the resident's hair. Interview with CNA #1, on 07/26/17 at 3:40 PM, revealed staff was supposed to wash hands after removing gloves. She stated she forgot to change gloves and washed hands after providing incontinent care and peri care to Resident #4. In addition, she stated she should have washed her hands prior to brushing the resident's hair. CNA #1 revealed the facility trained her in proper hand hygiene and she was able to access that information for review. Interview with LPN #2, on 07 27/17 at 12:37 PM, revealed the CNAs provided incontinent care to residents under her supervision and she observed incontinent care when assisting the CNAs. She stated she had instructed CNAs in the proper techniques when she observed problems with infection control issues. The LPN stated gloves were to be changed and hands washed after providing incontinent care and before providing peri care. In addition, she stated CNA #1 should have washed her hands after removing gloves and before brushing the resident's hair. Interview with the Staff Development Coordinator (SDC), on 07/27/17 at 12:48 PM, revealed all employees received education on proper hand hygiene during orientation with a return demonstration for proper technique. She stated training on proper hand hygiene was included in the yearly competency training. She stated when incontinent care and peri care were completed together, gloves were to be changed, and hands washed between cleaning the two (2) areas. She stated whenever anything dirty, including stool, was in contact with gloves, gloves were to be removed, hands washed, and clean gloves put on before completing peri care. In addition, she stated staff should remove gloves and wash hands before attending to a resident's other needs such as brushing hair. Interview with the Contract Wound Care Nurse, on 07/27/17 at 1:55 PM, revealed staff received wound care training through a computerized program online. She stated the process was presented during orientation including several glove changes with handwashing. She stated staff was to wash hands anytime gloves were changed. The Wound Care Nurse stated when staff cleaned a wound; the expectation was that cleaning proceeded from the wound center outward and that nothing was to be brought from surrounding tissue back into the wound bed. She stated the wound center was to be cleaned, and then a separate gauze with cleanser used to clean the surrounding area. In addition, she stated after cleaning the wound, gloves were to be removed, hands washed, and clean gloves donned before dressing the wound. She stated she instructed nurses to take someone with them to assist with positioning the resident to prevent the wound from touching a contaminated surface after cleaning. She also stated glove change and hand washing was expected after the dressing was placed on the resident, and hands were to be washed immediately after exiting the soiled utility room. Interview with the Director of Nursing, (DON), who was the facility's Wound Care Nurse, on 07/27/17 at 2:28 PM, revealed she had not conducted any audits of hand hygiene or wound care treatment. She revealed she had taken nurses with her when she completed wound treatments to educate the nurses on proper techniques of changing gloves, washing hands, and cleaning wound beds. She stated wound care was part of the nurses' orientation and was covered yearly and when needed. The DON stated staff should wash hands between glove changes. She revealed she had not routinely observed incontinent care for residents. She stated she wanted staff to use hand sanitizer and then wash hands after leaving the soiled utility room. The DON stated a break in infection control practice could result in infections and worsening of wounds. 3. Observation of Resident #1's wound care, on 07/26/17 at 4:20 PM, revealed CNA #3 entered the resident's room to assist LPN # 1 with turning and repositioning the resident. CNA #3 washed her hands upon entering the resident's room and donned a clean pair of gloves. CNA #3 then picked up a floor mat off the floor, folded it, and placed the mat by a wall near the resident's sink. CNA #3 did not remove her gloves, wash her hands, and don clean gloves before proceeding to assist LPN #1 with the resident. While LPN #1 was beginning to perform Resident #1's wound care, she noted the resident had stool in his/her brief and LPN #1 stopped wound care to clean the resident. During the course of cleaning the resident's anal area, CNA #3 pulled cleaning wipes, using the same gloved hands that touched the floor mat, from the packet and passed them to LPN #1. The LPN used the wipes to clean the resident. Attempted Interview with CNA #3 via telephone on 07/27/17 at 10:40 AM, was unsuccessful. Interview with CNA #2, on 07/27/17 at 11:00 AM, revealed if she moved a potentially contaminated item, such as a floor mat off a resident's floor, while wearing a pair of clean gloves, she would remove the gloves, wash her hands, and don a clean pair of gloves before providing resident care. The purpose of the hand hygiene and glove change was to prevent the spread of infection. CNA #2 stated to move an item such as a floor mat with gloved hands and then proceed to provide the resident with care/touching the resident, or touching supplies used on the resident, would be nasty and not a clean practice. Interview with the Director of Nursing, (DON), on 07/27/17 at 2:28 PM, revealed she had not conducted any audits of hand hygiene. The DON stated if staff touched a floor matt, staff should remove gloves, wash hands, and put on new gloves immediately to prevent transmission of contaminants to the resident. The DON stated a break in infection control practice could result in infections and worsening of wounds. Interview with the Administrator, on 07/2717 at 3:00 PM, revealed the facility followed rates of infection in the facility through tracking and trending of infections, and any trends/increases would be discussed in Quality Assurance (QA) meetings. He stated infection control practices were discussed in daily staff huddle meetings, which were opportunities for managers to communicate with staff and vice versa. The Administrator stated if staff broke infection control practices, or if staff needed additional training, then the Staff Development Coordinator (SDC) would be assigned to provide the infection control in-service education.

Based on interview, record review, review of the facility's policy and procedures, and the facility's investigative reports, it was determined the facility failed to have an effective system in place to ensure care plan interventions were implemented for one (1) of eight (8) sampled residents, Resident #2. The facility assessed Resident #2 as an elopement risk and a care plan was developed. Care planned approaches for reducing elopement risk for Resident #2 included providing diversional activities, redirecting the resident away from doorways, and to check proper functioning of the audible alarm system every shift and as needed. On 08/04/16 at 10:30 PM, Certified Nursing Assistant (CNA) #1 passed Resident #2 by the time clock employee door. She failed to redirect, move him/her away per the resident's plan of care, or alert the nursing staff of his/her location. Resident #2 eloped from the facility without staff knowledge. Licensed Practical Nurse (LPN) #2 heard a low-pitched buzzing and traced the buzzing to the time clock employee door, opened it, peered out and did not see the resident. She failed to test the door alarm then or at any other time during the shift. Staff did not notice the resident was missing until Unsampled Resident C alerted staff two (2) times of an alarm sounding outside the resident's window. Staff found Resident #2 in the employee parking lot at approximately 11:42 PM. (Refer to F323) The facility's failure to have an effective system in place to ensure implementation of care plan interventions for residents assessed to be at risk for elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 08/12/16 and was determined to exist on 08/04/16. The facility was notified of the Immediate Jeopardy on 08/12/16. An Acceptable Allegation of Compliance (AOC) was received on 08/16/16 alleging the removal of the IJ on 08/16/16. The State Survey Agency (SSA) validated the IJ was removed on 08/16/16 as alleged and the Scope and Severity (S/S) was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy Care Plans-Comprehensive, reviewed 06/01/15, revealed the facility considered a resident's problem areas and their causes prior to implementation of care plan interventions. Interventions addressed underlying sources of the problem area, rather than addressing only symptoms or triggers. Review of the facility's policy Elopement/Wandering, undated, revealed care plans addressed wandering as a specific problem. The facility formulated approaches, identified any patterns, and determined and addressed the causes. Review of the facility's investigation reports, dated 08/05/16 and 08/11/16, revealed on 08/04/16 at approximately 11:42 PM, nursing staff found Resident #2 sitting in his/her wheelchair about fifty (50) feet from the time clock employee door. The resident's chair alarm was positioned along the back of the wheelchair sounding an alarm. CNA #1 last observed the resident prior to elopement, at approximately 10:30 PM, seated near the time clock employee door. Between 10:30 PM and 10:50 PM, LPN #2 located the source of a low-pitched buzzing noise to the time clock employee door. The door was ajar. LPN #2 peered out the door and did not observe the resident. She then closed the door and reset the alarm. At approximately 10:50 PM, CNA #1 returned with the residents who smoked and noted Resident #2 was no longer sitting near the door. Sometime later, Unsampled Resident C informed CNA #1 on two (2) occasions that he/she heard a faint alarm sound. Remembering Resident #2 had been sitting close to the time clock employee door, CNA #1 began searching for Resident #2. At approximately 11:42 PM, CNA #1 found Resident #2 fifty (50) feet from the time clock employee door, sitting in his/her wheelchair with his/her chair alarm sounding. Resident #2 had gotten both wheels stuck in the gravel building apron, which abutted the employee parking lot. Review of the facility's clinical record for Resident #2, revealed the facility admitted Resident #2 on 06/23/09 with [DIAGNOSES REDACTED]. The facility assessed Resident #2 as at risk of elopement on 03/17/16. Review of the facility's Comprehensive Care Plan for Resident #2, dated 03/25/16, revealed the facility developed the care plan related to exit seeking behaviors. Approaches for this problem area included staff monitoring for signs of exit seeking behaviors, using verbal or physical cues to redirect the resident, using diversional activities when the resident displayed exit seeking behaviors, using an audible monitoring system to alert staff of exit seeking behaviors, and checking the audible alarm system every shift and as needed. On 04/11/16, the facility developed a care plan to address wandering behaviors with interventions that included staff keeping the resident away from doors. Review of the facility's CNA care plan for Resident #2, dated 08/01/16, revealed the resident was at risk for elopement and was not to leave the building without staff or family. The CNA care plan did not include the facility interventions of staff providing diversional activities, redirection of the resident away from doors, or audible alarm checks each shift. Interview with CNA #1, on 08/11/16 at 3:15 PM, revealed she cared for Resident #2 the night he/she eloped from the facility. She stated Resident #2 displayed prior exit seeking behavior. The CNA stated a few weeks prior the resident had pushed on the front door, and that he/she often tailgated at the front door. CNA #1 reported she did not redirect or move the client away from the time clock employee door on 08/04/16, per the resident's plan of care, nor did she alert the nursing staff of the resident's location. CNA #1 stated she was unaware of checking an audible alarm system every shift per the care plan. Interview with LPN #2, on 08/11/16 at 2:35 PM, revealed she was the nurse for Resident #2 on 08/04/16. She remembered the evening of the elopement Resident #2 discussed needing to leave the facility to paint. LPN #2 did not place the resident on additional monitoring at that time. LPN #2 indicated it was her responsibility to monitor the residents' care and stated Resident #2 did not receive care per the care plan. She stated staff failed to follow Resident #2's care plan interventions when they left the resident near a door. In addition, LPN #2 was not aware staff was supposed to check the audible alarm system per the resident's elopement care plan and did not know where this would be documented. Interview with the Director of Nursing (DON), on 08/12/16 at 2:40 PM, revealed the facility trained nursing staff during orientation to follow the residents' care plans, as this was a standard of nursing practice and the facility's policy. She further stated the staff nurses were to help ensure the CNAs followed residents' care plans. The DON stated Resident #2's care plan interventions failed as staff did not effectively implement them, specifically removing Resident #2 from the door. Additionally, she stated she was unaware that checking the audible alarm system was on the resident's care plan and did not know who should do it or where it would be documented. Interview with the Administrator, on 08/12/16 at 3:30 PM, revealed she was responsible for all care given to the residents in the facility. She stated the DON was responsible to ensure nursing staff adhered to facility policies. The Administrator stated her investigation of the elopement did not show any breakdown in communication regarding care plan implementation. The facility implemented the following actions to remove the Immediate Jeopardy: 1. A head to toe assessment was completed by LPN #2 upon the resident's return to the facility. Resident #2 was immediately placed on one (1) to one (1) supervision until 08/05/16 at 6:30 PM when he/she was placed on fifteen (15) minute checks. 2. The time clock employee door was manned from 2:40 AM until 2:29 PM by the Administrator in Training (AIT), Regional Plant Operations and Housekeeping staff. On 08/05/16 at 12:47 PM hourly checks of all seven (7) doors were implemented until 5:03 PM by AIT. On 08/07/16, the facility began four (4) hour door checks on all seven (7) doors. Charge Nurses, Administrator, AIT, Director of Nursing (DON), and Assistant Director of Nursing (ADON), Business Office Manager, Medical Records, Housekeeping, Chaplain, Activities Director, Dining Services Director, Social Service Director, and Regional Plant Operations documented these checks on the Exit Door Monitor Form through 08/18/16. 3. A 100% door audit was completed on 08/05/16 at 4:00 AM by the AIT and the Regional Plant Operations . The Regional Plant Operations determined the Door Prop Alarm on the time clock employee door was not working properly. Contract Company #1 arrived on 08/05/16 at approximately 6:00 AM replaced the alarm, added a redundant alarm, and tested the electronic locking equipment, which was operational. Following the audit, on 08/08/16 Contract Company #2 also upgraded keypads on the Patio and Therapy doors. On 08/09/16, Contract Company #2, replaced the Patio door alarm with a louder alarm. Finally, on 08/10/16 the time clock employee and Patio door alarms were tied to the nursing station. 4. On 08/05/16 the Regional Plant Operations contacted the recently retired Plant Operations Director concerning any past work orders related to the time clock employee door. He stated he did not receive any work orders concerning the time clock employee door. On 08/12/16, the Administrator reviewed work orders from August, July, and June of 2016 and did not find any for the time clock employee door. The Plant Operation Director will check the work order folder twice daily, every day. The Administrator will review, validate completion, and sign all work orders. 5. On 08/05/16, the DON, ADON the Charge Nurses re-evaluated 100% of all in-house residents for Elopement risk and the Elopement Binder reviewed for accuracy, no corrections were necessary. The DON updated Resident #2's CNA care plan to reflect he/she was an Elopement Risk following her review of his/her care plans. All care plans with Elopement Risk identified will be audited daily by the Interdisciplinary Team (IDT), the Dining Services Director, Social Service Director, ADON, DON, Activities Director and the Administrator and documented in the Stand Up meeting minutes. 6. On 08/06/16 100% of residents identified as being at risk for elopement were placed on fifteen (15) minute checks until the Quality Assurance and Performance Improvement Team (QAPI) determines the monitoring can be discontinued. Any resident who exhibits exit-seeking behaviors will be immediately placed on one (1) to one (1) care/observation. All new or readmitted residents will be assessed with [REDACTED]. She will also notify the DON or the On-Call nurse and immediately review interventions for appropriateness. The IDT team will audit new Elopement/Wandering interventions for both the nursing and CNA care plans, the following day. 7. The AIT conducted a facility-wide Elopement Drill on 08/07/16 at 11:00 AM. 8. A member of the Administrative Management Team will be present in the facility twenty four (24) hours a day, seven (7) days a week; with a member of the Regional Team daily, seven (7) days a week. Continued Administrative oversight will be discussed and determined by the QAPI committee including but not limited to Dietary Manager, Social Service Directors, ADON, DON, Activities Director, and Administrator. 9. The Administrator-In-Training, DON, ADON, Business Office Manager, Social Services Director, Dining Services Director and Activities Director were educated on the facility Policies and Procedure of elopement, missing resident, care of the wandering resident and Code Green on 08/05/16 by the Nurse Consultant. On 08/05/16, 08/08/16, 08/09/16, 08/15/16 and 08/16/16, all seventy one (71) staff were educated on Elopement and Missing Resident Policy and Procedures, Care of the Wandering Resident, Routine and fifteen (15) minute checks, Code Green, Behavioral Assessment, Door Alarm Systems, Work Orders, Elopement Risk Evaluations and Care Planning and Work Orders. Post education tests were completed by all seventy one (71) staff on the Elopement and Wandering resident education. No staff has been allowed to return to work without receiving the mandated education from Manager on Duty (Director of Nursing, Assistant Director of Nursing, Administrator, Administrator in Training, Social Service Director, Quality of Life Director, Business Office Manager, Human Relations Director, Housekeeping Director, and or the Chaplin. The DON, ADON, and the Administrator kept a log tracking all completed education. The Manager on Duty staffed the time clock employee door at each shift change until 08/12/16 checking individuals in to ensure they completed the required education prior to working. Any employee currently on vacation or FMLA will receive the mandated training prior to their next scheduled shift. All new employees will be educated during orientation by the Assistant Director of Nursing. 10. An Ad Hoc Quality Assurance (QA) Meeting was held on 08/05/16 with the AIT, DON, Regional Vice President, and the Medical Director to discuss the elopement and the plan of correction. Another Ad Hoc Quality Assurance (QA) on 08/12/16 was held with the Administrator, DON, AIT, and the Medical Director to discuss the Immediate Jeopardy (IJ) related to the 08/05/16 elopement and the plan to remove the IJ. The SSA validated removal of the IJ as follows: 1. Review of nursing notes and a skin assessment, dated 08/05/16, confirmed Resident #2 had an assessment upon return to the facility. Review of Resident #2's Safety Logs revealed he/she was placed on one one (1) to one (1) visual supervision from midnight on 08/05/16 until 6:30 PM when he/she was placed on fifteen (15) minute visual supervision, which continued through 08/18/16. Telephone interview with LPN #2 on 08/11/16 at 2:35 PM revealed she did a head to toe assessment of Resident #2 when he/she returned to the building and discovered an abrasion to his right pinkie finger. She further stated she put Resident #2 on one (1) to one (1) visual supervision following the elopement. 2. Observation of door alarm checks on 08/11/16 at 1:00 PM and 08/18/16 at 1:00 PM revealed all seven (7) door alarms were functioning properly and staff responded to the alarms timely. Review of the time clock employee Exit Door Monitoring form, dated 08/05/16 through 08/18/06 revealed the time clock employee door was observed from 2:40 AM until 2:29 PM. At noon, staff began hourly alarm checks of all seven (7) doors began. Further review revealed the door alarm monitoring decreased at 5:00 PM to four (4) hours. The four (4) hour checks were documented on the Exit Door Monitor Form through 08/18/16. Review of the undated staffing schedule revealed the Administrator had assigned a supervisor to do four (4) hour checks twenty-four (24) hours a day from 08/08/16 through 08/14/16. Interview with AIT on 08/18/16 at 4:00 PM revealed he was part of the original response team as the Administrator was out of town at the time of the elopement. He explained he arrived on 08/05/16 around 2:20 AM and secured the time clock employee door. He went on to state; he and Housekeeping maintained one (1) to one (1) observation of the door for twelve (12) hours. He reported he implemented an hourly check of all seven (7) doors on 08/05/16 at Noon and that decreased to every four (4) hours on 08/07/16 and continued through today. An interview with Regional Plant Operations on 08/10/16 at 2:45 PM revealed he had also been part of the original response team. He stated he had secured the door with the Administrator in Training shortly after the elopement and had done countless door function checks since that time. Telephone interview with Door Technician on 08/12/16 at 10:40 AM revealed he had assisted with the testing of the door functionality from 08/05/16 through 08/11/16. Interview with DON on 08/18/16 at 4:10 PM revealed she had assisted with the door checks both day and all through the night since the elopement. Interview with Dining Services Director on 08/18/16 at 3:55 PM revealed she had frequently done door checks and responded to alarms since 08/05/16. Interview with Social Services Director on 08/11/16 at 4:20 PM revealed she had participated with the door checks. 3. Observation of door alarm checks on 08/11/16 at 1:00 PM and 08/18/16 at 1:00 PM revealed all seven (7) door alarms were functioning properly and staff responded to the alarms. Observation of the time clock employee door on 08/18/16 at 4:30 PM revealed the Regional Plant Operations and Door Technician had replaced the actual door and the doorframe. Review of a letter from Contract Company #1, dated 08/05/16, stated they had examined the parking lot door, replaced a faulty alarm device and added a redundant alarm at the hallway junction on 08/05/16 at 6:00 AM. Interview with Regional Plant Operations, on 08/10/16 at 2:45 PM revealed he notified the Contract Company #2 on 08/07/16 and their door technician came the same day, inspected the time clock employee door and updated hardware. Telephone interview with Door Technician on 08/12/16 at 10:40 AM revealed 08/07/16, he had adjusted the door frame so the door would close more easily, changed out the keypad and replaced the magnetic lock switch which enables the egress alarm. He relayed the wiring from the time clock employee door to the nursing station panel was faulty and he set up a wireless system. He stated from 08/05/16 through 08/11/16 he assisted with the testing of the doors, upgraded keypads on the Patio and Therapy doors and replaced the Patio door alarm with a louder alarm. Further interview revealed he was confident that all the facility doors alarmed appropriately but the time clock employee door frame needed to be replaced and it was his understanding the facility had ordered it. Another interview with the door technician, on 08/18/16 at 1:30 PM revealed he assisted with the time clock employee doorframe replacement on 08/18/16 and the entire door had been replaced in the course of the week. 4. Review of the facility work orders from June 2016 through August 2016 revealed no mention of the time clock employee clock door. Review of the facility confidential statements acquired by the facility during their investigation of the elopement revealed the AIT called the previous Maintenance Director on 08/05/16, and he reported not having received any work order forms for the time clock employee door. Continued review revealed the Administrator and Signature Clinical Consultant (SCC) stated they called the previous Maintenance Director on 08/05/16 at 11:00 AM and he reported he had not ever received any work order forms. Interview with Regional Plant Operations on 08/10/16 at 2:45 PM revealed, per his review of the daily door checks and work orders, the facility had not received any work orders regarding the doors. Interview with the Administrator on 08/12/16 at 3:35 PM revealed, she was unaware of any issues with doors prior to the elopement, or work orders requesting repair of the time clock employee door. She stated she had reviewed June, July and August work orders. 5. Observation, on 08/12/16 at 9:30 AM, revealed the Elopement Book at the nursing station. Review of the facility Elopement Book, compared to a list of residents at risk of elopement, found the books to be correct on 08/12/16 and 08/18/16. Review of Resident #2's Nursing and CNA care plans, both dated 08/05/16, revealed notations he/she was at risk for elopement. Review of the Stand Up Meeting minutes for 08/15/16 through 08/18/16 revealed the IDT reviewed all the care plans for residents identified as at risk for Elopement on each day. Interview with Social Services Director on 08/18/16 at 5:50 PM revealed she had reviewed the Elopement Book for accuracy, participated in IDT meetings daily, when present in the facility and had taken part in the review of the care plans for the residents at risk for elopement. Interview with DON on 08/18/16 at 4:10 PM revealed she had updated Resident #2's Nursing and CNA care plans and had led the effort to ensure all residents at risk for elopement had been identified and their care plans were up to date. She further explained the care plans were being reviewed daily in the IDT. 6. Review of Safety Check Forms revealed 100% of residents at risk for elopement, verified by Elopement Book, were visually monitored every fifteen (15) minutes from 08/06/16 through 08/18/16. An elopement assessment was present on the facility record for the one (1) new admission they received 08/05/16 through 08/18/16, he/she was not identified as an elopement risk. Interview with Social Services on 08/18/16 at 5:50 PM revealed she had completed the Elopement Risk Evaluation form on the new resident on 08/05/16. She stated he/she had not been determined to be at risk if he/she had been at risk she would have informed the Charge Nurse and the DON know so the fifteen (15) minute safety checks could begin. Interview with the DON on 08/18/16 at 4:10 PM revealed new residents who are at risk for elopement will have an Elopement/Wandering Care Plan and either she DON or the On-Call Nurse would be called to review the care plan for efficacy. She went on to explain the following day the IDT team would review the Elopement/Wandering care plan interventions for both nursing and CNA care plans. 7. Review of facility records revealed completed in-service sign in sheets for two (2) facility-wide Elopement Drills, on 08/07/16 and 08/15/16. An interview with the AIT revealed he had conducted both drills and intended to do them once a week through August and then monthly, thereafter. An interview with the Business Office Manager on 08/18/16 at 3:10 PM revealed she had worked on 08/15/16 and participated in the Elopement Drill on 08/15/16. An interview with LPN #2 on 08/18/16 revealed she had been present for and participated in the Elopement Drill on 08/15/16. An interview with CNA #9 on 08/18/16 at 5:55 PM revealed she was in the building for the 08/07/16 Elopement Drill but had been on her lunch break. An interview with CNA #6 on 08/18/16 at 5:55 PM revealed she participated in an Elopement Drill following Resident #2's elopement but could not remember the date. 8. Review of the undated staffing schedule revealed the Administrator had assigned a supervisor to be in the facility twenty-four (24) hours a day from 08/08/16 through 08/14/16. Interview with the Business Office Manager on 08/18/16 at 3:10 PM revealed she was part of the team that was staffing the facility around the clock. She stated she had been participating since 08/08/16. Interview with the ADON on 08/18/16 at 5:50 PM revealed she had taken day and evening shifts to ensure there was a supervisor in the building twenty-four (24) hours a day. Interview with the DON on 08/18/16 at 4:10 PM revealed she had been working long hours since the elopement and had been part of the team scheduled to cover the building twenty-four (24) hours a day. Interview with the AIT on 08/18/16 at 6:00 PM revealed he was participating in the twenty-four hour coverage. 9. A review of a sign in sheets for education held on 08/05/16 revealed the AIT, DON, ADON, Business Office Manager, Social Services Director, Dining Services Director and Activities Director were educated on facility Policies and Procedure of Elopement, Missing residents, Care of the Wandering resident and Code Green by the Nurse Consultant. Interview with the Director of Dining Services on 08/18/16 at 3:55 PM revealed she had attended the education and review of Elopement policies 08/05/16. She also stated she assisted in educating staff on Elopement and Missing Resident Policy and Procedures, Code Green, Door Alarm Systems and Work Orders. Interview with the Business Office Manager at 3:10 PM on 08/18/16 revealed she received the Elopement policy re-education on 08/05/16 from the SCC. She went on to state she taught others about Work Orders, Elopement, Code Green, Behavioral Assessment and Monitoring. Interview with the ADON on 08/18/16 at 5:50 PM revealed she was present for the Elopement education that the SCC did the day after the elopement. She added she educated many staff including doing the phone education of the six (6) staff that couldn't make it in to the building before 08/15/16. She reported she educated staff on Elopement and Missing Resident Policy and Procedures, Care of the Wandering Resident, Routine and fifteen (15) minute checks, Code Green, Behavioral Assessment, Door Alarm Systems, Work Orders, Elopement Risk Evaluations and Care Planning and Work Orders. Interview with the AIT on 08/18/16 at 6:00 PM revealed he attended the Elopement education on 08/05/16. He stated he had taught some staff and assisted in standing at the time clock employee door checking to ensure staff did not clock in until they were educated. Review of the sign-in sheets for re-education on Care of the Wandering Resident and Elopement/Missing Resident policies and Code Green and associated post re-education competency tests revealed seventy-one (71) total staff total were re-educated beginning on 08/05/16 and ending on 08/16/16. Review of the sign in sheets for two (2) hour and fifteen (15) minute resident checks, Behavioral Assessment, and Work Orders education revealed seventy-one (71) total staff were re-educated beginning on 08/12/16 and ending on 08/16/16. Comparison of payroll records with sign-in sheets revealed no staff have been allowed to return to work without receiving the mandated education from the Manager on Duty, six (6) staff received the education by phone, two staff persons, both on Family Medical Leave, were sent certified letters indicating they could not return to work without receiving their education. A review of the Administrator's Log tracking all completed education revealed current and accurate account of staff education. An interview with a Dietary Aide, a new hire, on 08/18/16 at 4:45 PM revealed she had met with the Administrator on 08/17/16, her first day, and learned about how to search for and return residents who escape and Code Green. Interview with the Nurse Consultant, on 08/18/16 at 5:00 PM, revealed she had reviewed and re-trained most of the Administrative staff on Elopement Policy on 08/05/16 and updated the Administrator on Policy review on 08/08/16, when the Administrator returned from vacation. Interviews on 08/18/16 with CNA # 3 at 3:30 PM, CNA # 6 at 6:00 PM, LPN #3 at 4:00 PM, RN # 2 at 5:00 PM, the Business Office Manager at 5:55 PM, the Social Services Director at 5:50 PM, the ADON at 6:30 PM and the DON at 4:10 PM revealed all had been re-educated, on the Care of the Wandering Resident, Elopement/Missing Resident policies, Code Green, Work Orders and Behavior Monitoring. 10. Review of sign-in sheets and minutes for ad hoc QA meetings held on 08/05/16, 08/09/16 and 08/12/16 revealed the meeting of 08/05/16 was attended by the AIT, DON, Regional Vice President, and the Medical Director joined by phone to discuss the elopement and follow up plan. Further review revealed, the ad hoc QA meeting of 08/9/16 was attended by the Administrator, AIT, Director of Clinical Operations and the Medical Director by phone to discuss to discuss Resident #2's safety plan, staff education, door repairs and monitoring. Additional review revealed the 08/12/16 ad hoc QA meeting was attended by the Administrator, DON, ADON, Chaplain, Director of Medical Records/Human Resources, Director of Dining Services, Business Office Manager, Social Services Director, SCC and Director of Housekeeping. Interview with the Business Office Manager, on 08/18/16 at 3:10 PM revealed she had attended the 08/12/16 ad hoc QA meeting and participated in the discussion of issues surrounding the elopement and resulting quality improvement opportunities. Interview with the AIT on 08/18/16 at 6:00 PM, revealed he had attended the first two ad hoc QA meetings held at the facility and was aware of the IJ situation and actions taken. Interview with the Administrator, on 08/18/16 at 3:00 PM, revealed she attended the 08/09/16 and 08/12/16 ad hoc QA meetings to discuss the elopement, staff education, IJ tags and actions taken to remove the Jeopardy. Interview with the SCC on 08/18/16 at 3:45 PM, revealed she had attended the ad hoc QA meeting on 8/12/16 and had assisted in the strategy for IJ removal.

Based on observation, interview, record review, and review of the facility's policy and procedures and investigative report, it was determined the facility failed to have an effective system in place to ensure each resident received supervision and the environment was free of hazards to prevent an incident of elopement for one (1) of eight (8) sampled residents, Resident #2. The facility assessed Resident #2 as an elopement risk and a care plan was developed with interventions which included redirecting the resident away from doorways and to check proper functioning of the audible alarm system every shift and as needed. On 08/04/16, Resident #2 eloped from the facility without staff knowledge. At 10:30 PM, Certified Nursing Assistant (CNA) #1 noted Resident #2 seated in his/her wheelchair by the time clock employee door; however, failed to redirect, move him/her away, or alert the nursing staff of the resident's location. At 11:42 PM, staff discovered Resident #2 outside approximately fifty (50) feet from the facility. Resident #2 was assessed to have a one (1) centimeter abrasion to the right hand on the outer aspect of his/her fifth phalange. Interview and record review revealed Resident #2 had exited the facility through the time clock employee exit door, which was equipped with a fifteen (15) second delayed egress, prop alarm hardware, magnetic latch/lock, keypad. The door had also historically been wired to a panel in the nursing station, which flashed red and sounded an additional alarm. Interviews revealed the door had been malfunctioning, work orders had been completed, but the door was not repaired. Review of the National Weather Service report, on 08/04/16 at 11:30 PM, revealed the weather conditions included rain and thunderstorms with a temperature of seventy-seven (77) degrees and humidity of eighty-two (82) percent. The facility's failure to have an effective system in place to ensure adequate supervision of residents and to ensure the exit doors functioned properly placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 08/12/16 and was determined to exist on 08/04/16. The facility was notified of the Immediate Jeopardy on 08/12/16. An Acceptable Allegation of Compliance (AOC) was received on 08/16/16 alleging the removal of the IJ on 08/16/16. The State Survey Agency (SSA) validated the IJ was removed on 08/16/16 as alleged and the Scope and Severity (S/S) was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Care of the Wandering Resident, undated, revealed the facility created care plans to address wandering behaviors and elopement risk. The facility formulated approaches, identified patterns, and determined and addressed the causes of wandering and elopement type behaviors. The facility identified and decreased resident stressors that triggered wandering. The facility also provided structure, repetition, consistency, and predictability in the environment and developed a therapeutic relationship with the resident. Review of Door Prop Alarm Timers Installation and Operating Instructions, dated April 2011, revealed, the central function of the door prop alarms was to prevent doors being propped open too long by sounding an alarm when the door was open for more than a predetermined amount of time. The door alarm sounded if the door was not completely closed or if the door handle was pushed for more than fifteen (15) seconds. Additionally, the instructions stated forbidden condition detection was when the door could be opened without sounding the alarm if the closed door was not latched. The instruction manual specifically stated forbidden condition detection was a security risk. According to the door instructions, once the door alarmed, the alarm would not stop until an employee re-secured the door and entered the code on the keypad. Review of the Work Order policy, dated January 2005, stated the facility completed maintenance work orders in order to establish priority of maintenance service. The policy stated the department managers or any staff members filled out a work orders and forwarded them to the Maintenance Director. Staff placed work order requests in a basket located at the nursing station where maintenance picked up the requests daily. Review of the facility's investigation reports, dated 08/05/16 and 08/11/16, revealed on 08/04/16 at approximately 11:42 PM, nursing staff found Resident #2 sitting in his/her wheelchair about fifty (50) feet from the time clock employee door. The resident's chair alarm was up along the back of the wheelchair and the chair alarm sounded. The report stated CNA #1 had observed the resident prior to elopement at approximately 10:30 PM. The resident was seated near the time clock employee door. Between 10:30 PM and 10:50 PM, LPN #2 heard and located the source of a low-pitched buzzing noise, which emitted from the open time clock employee door. The LPN peered out the door and then closed the door and reset the alarm. The report stated at approximately 10:50 PM, CNA #1 returned to the area and noted Resident #2 was no longer sitting near the door. Later, Unsampled Resident C reported to CNA #1 that he/she heard a faint alarm sound. CNA #1 started a search for Resident #2 after Unsampled Resident C had twice reported that he/she had heard an alarm sound. At approximately 11:42 PM, CNA #1 found Resident #2 approximately fifty (50) feet from the time clock employee door sitting in his/her wheelchair stuck in the gravel building apron, which abutted to the employee parking lot located in the rear of the building. The chair alarm on the wheelchair was sounding and the resident was unable to move his/her wheelchair out of the gravel building apron. CNA #1 immediately brought the resident into the facility. Resident #2 was assessed by LPN #2. The resident sustained [REDACTED]. The facility determined the resident was outside for approximately fifty (50) minutes. Observation, on 08/10/16 at 2:45 PM and on 08/18/16 at 12:10, revealed the time clock employee exit door was in a small vestibule northwest of the main hallway and not visible from the nursing station. The alarm horn was located approximately eight (8) feet away from the door and directed toward the nursing station. Observation, on 08/12/16 at 5:10 PM, revealed the facility parking lot was absent lighting. The area in front of the facility facing the roadway contained a street light. The road in front of the facility had a posted speed limit of twenty-five (25) miles per hour. The road sloped downward to a nearby, unlit, and busy two (2) lane highway with a posted speed limit of sixty-five (65) miles per hour. A large fenced area containing an electrical transformer was located behind the facility. Beyond the transformer was a densely wooded area. Review of the facility's clinical record for Resident #2, revealed the facility admitted the resident on 06/23/09 with [DIAGNOSES REDACTED]. Review of the Elopement Risk Assessment, dated 03/17/16, revealed Resident #2 was at risk for elopement based on the resident's ability to independently ambulate, the resident's impaired cognition, and his/her demonstration of wandering and exit seeking behaviors. Review of the Minimum Data Set (MDS) for Resident #2, dated 03/21/16, revealed the facility assessed the resident as independently ambulatory with a wheelchair. The facility conducted a Brief Interview for Mental Status (BIMS) examination and assessed the resident with a score of eight (8) out of fifteen (15), determining the resident was interviewable. Review of the Comprehensive Care Plan for Resident #2 dated 03/25/16, revealed the resident was an elopement risk and had followed visitors to the exit doors, sat by the exit doors, and wandered around the facility. The facility developed a care plan related to exit seeking behaviors. Approaches for this problem area included staff monitoring for signs of exit seeking behaviors, use of verbal or physical cues to redirect the resident, use of diversional activities when the resident displayed exit seeking behaviors, use of an audible monitoring system to alert staff of exit seeking behaviors, and conducting a check of the audible alarm system every shift and as needed. On 04/11/16, the facility revised the resident's Comprehensive Care Plan to address wandering behaviors with interventions that included staff keeping the resident away from doors. Interview with Resident #2, on 08/11/16 at 1:15 PM revealed he/she vaguely remembered wanting to get some fresh air and exiting the facility, and that he/she did not get very far. Resident #2 pointed to the time clock employee door and stated he/she believed that was the door he/she used to leave the building. Interview with CNA #1, on 08/11/16 at 3:15 PM, revealed she cared for Resident #2 the night he/she eloped from the facility. She stated that on 08/04/16 at 10:30 PM, she observed Resident #2 sitting alone at the time clock employee door. However, CNA #1 reported she did not redirect or move the client away from the time clock employee door on 08/04/16, nor did she alert the nursing staff of the resident's location. When she returned from the patio at 10:50 PM, Resident #2 was not sitting at the door. Later, CNA #1 reported she answered a call light for Unsampled Resident C, who informed he/she had heard a faint alarm sound. CNA #1 stated she also heard the alarm sound but thought it was another resident's radio. The CNA #1 turned down the volume of the radio and left the resident's room. CNA #1 stated sometime later Unsampled Resident C again called her to the his/her room and informed he/she still heard an alarm. CNA #1 reported she then remembered Resident #2 had been sitting close to the time clock employee door and she had not seen him/her since. CNA #1 stated she was aware Resident #2 was at risk for elopement and nursing staff often placed the resident on fifteen (15) minute checks or one (1) to one (1) monitoring due to exit seeking behaviors. She stated Resident #2 pushed on the front door and often tailgated visitors to the front door. CNA #1 stated she began searching for Resident #2 and at approximately 11:42 PM, she found the resident outside, approximately fifty (50) feet from the facility's time clock employee door. She stated the resident had gotten his/her wheelchair stuck in the gravel building apron, which abuts the employee parking lot. The resident's pad alarm had been pulled up between his/her back and the wheelchair and was sounding. CNA #1 stated Resident #2 was dry and appropriately dressed for the hot weather, she reported he/she was wearing cotton pajamas and house slippers. The resident was smiling and stating he was trying to get to his painting job. CNA #1 stated she could not remember if Resident #2 was on additional monitoring at the time of elopement. Interview with Licensed Practical Nurse (LPN) #2, on 08/11/16 at 2:35 PM, revealed she was the assigned nurse for Resident #2 on 08/04/16. She stated Resident #2 had a history of [REDACTED]. LPN #2 stated she did not place the resident on additional monitoring at that time. She explained she was charting at the nursing station when she heard a quiet alarm sound. She checked the alarm panel in the nursing station and it did not indicate any issues with the doors. LPN #2 stated the time clock employee door was not visible from the nursing station and the alarm was barely audible. LPN #2 then followed the sound to the time clock employee door, which was ajar. LPN #2 reported she peered out the door, and not seeing anybody, closed the door and set the alarm. The LPN reported she had to close the door a couple times to get the alarm to reset with the keypad. At approximately 11:42 PM, CNA #1 alerted the LPN that Resident #2 was out of the facility and in the parking lot. LPN #2 stated the resident told her he/she was trying to get to a painting job. She stated she completed a head to toe assessment and the resident sustained [REDACTED]. Interview with LPN # 1, on 08/11/16 at 2:57 PM, revealed Resident #2 was often confused, made a habit of pushing on doors, and was at risk for falls. Interview with LPN #3 on 08/12/16 at 10:15 AM, revealed she was familiar with Resident #2 and had to assist in redirecting Resident #2 from following visitors out the front in the past. Interview with Registered Nurse (RN) #3, on 08/12/16 at 11:30 AM, revealed she was aware of Resident #2's exit seeking behaviors. She stated the resident consistently pushed on doors. RN #3 stated staff should have ensured the resident was kept away from doors at all times. Further review of the facility's investigations, dated 08/05/16 and 08/11/16, revealed six (6) interviewed staff stated that the door alarm and latch did not function adequately and all had submitted work orders. The report further stated the Administrator reviewed three (3) months of work orders and found no work orders pertaining to the time clock employee door. The facility determined the malfunctioning time clock employee door caused Resident #2's elopement. Review of the facility's Logbook Documentation regarding facility door inspections, from 04/23/16 through 08/04/16, revealed the facility inspected all facility doors daily but did not identify functioning issues with any doors during this period. The facility inspected the door lock mounting and the operation and panic hardware on the egress doors, verified the code, and operation of the keypad. During fire drills, the facility also ensured any magnetically locked doors automatically unlocked during a fire alarm. The facility checked the operation of the delayed egress by pushing the door release for a fraction of a second and ensuring the door did not open and the alarm did not sound. Then the facility applied pressure to the door release for the pre-determined nuisance period setting to ensure the door alarm sounded and automatically opened in less than fifteen (15) seconds. The facility also inspected the doors and hardware for proper operation and condition. Continued interview with CNA #1, on 08/11/16 at 3:15 PM revealed the time clock employee door had been malfunctioning since the facility hired her sixteen (16) months previously. She described having difficulty with the door latch catching. She went on to state the time clock employee door alarm did not trigger the nursing station panel to flash and sound as the other doors did. Instead, when the door alarm triggered, it emitted a low buzzing sound. CNA #1 stated strong winds would trigger the door alarm. CNA #1 stated she voiced her concerns to nursing staff multiple times but did not submit a work order to maintenance to repair the door. Interview with CNA #2, on 08/12/16 at 10:00 AM, revealed she experienced maintenance issues with the time clock employee door for the previous five (5) years. CNA #2 stated the door did not automatically latch when employees used it. The door remained ajar and employees had to push or pull on the door to latch it. She described the door alarm as sounding like a hearing aid. She stated she knew the sound of the time clock employee door and responded to it when she heard it sounding. CNA #2 stated she filled out numerous work orders and the facility had worked on the door numerous times, but it continued to be an issue. Sometimes the maintenance employee put a note on the door reminding employees to shut the door all the way. CNA #2 stated the malfunctioning door latch and quiet alarm concerned her. She stated a resident could get out, roll or ambulate down the hill to the busy two (2) lane highway, and get hit by a car. Continued interview with LPN #3 on 08/12/16 at 10:15 AM, revealed the time clock employee door did not latch properly and employees vigorously pushed the door shut and latch it. She also stated the door's alarm produced only a faint beeping and did not alarm at the nursing station at all. LPN #3 stated she filled out multiple work orders about the time clock employee door but could not remember the date when she last completed a work order. She stated the broken door was a factor in Resident #2's elopement. Interview with the retired Facility Operations on 08/12/16 at Noon revealed he remembered having to come into the facility in the middle of the night, three (3) to four (4) months prior to the resident's elopement to replace a spring in the time clock employee door. Further interview revealed, there was no work order as the staff had called him directly. He went on to state he had not had any other problems with the time clock employee door. Interview with the DON, on 08/12/16 at 2:40 PM, revealed the facility had not found any work orders pertaining to the time clock employee door. She stated that during the course of the facility's investigation, staff reported that concerns with the door existed prior to Resident #2's elopement. She stated she rarely used the time clock employee entrance and was unaware of any maintenance concerns with the door prior to the investigation. Interview with the facility's contracted Door Technician with Contract Company #2, on 08/12/16 at 10:40 AM, revealed the facility called him to work on the door on 08/07/16 and he performed repairs to the time clock employee door. His repairs included adjusting the door frame to enable the door to close more easily, changing out the security keypad, and replacing the magnetic lock switch that enabled the egress alarm. The Door Technician also stated the nursing station panel had been wired to the time clock employee door but the wiring was faulty and he changed it to a wireless connection. The Door Technician further stated the facility needed to replace the door frame. Interview with the Regional Service Manager for Contract Company #2, on 08/12/16 at 10:40 AM, revealed the facility used Contract Company #2 to manage the facility's quarterly fire alarm door functioning and sounding. He stated the facility had not used their services to repair any of the doors prior to the elopement. Interview with Regional Plant Operations, on 08/10/16 at 2:45 PM, revealed the facility called him on the morning of 08/05/16 regarding the elopement of Resident #2. Upon arrival, he stated he tested the time clock employee alarm system and discovered the alarm made a barely audible low buzzing sound. He stated this was not normal and had concluded the horn speaker had worn out. The Regional Plan Operations reviewed the facility layout and stated the time clock employee exit door was located in a small vestibule northwest of the main hallway and not visible from the nursing station. He measured the distance from the time clock employee exit door to the location staff found Resident #2 following elopement at fifty-five (55) feet. He then stated he determined the distance from the resident's elopement location to the road in front of the facility at two hundred twenty-five (225) feet. The Regional Plant Operations further established the distance from the resident's elopement location to the nearby two (2) lane highway at five hundred and fifty (550) feet. He further stated two-lane highway did not have lighting and the posted speed limit was sixty-five (65) miles per hour. Additionally, he stated there was a large area containing an electrical transformer surrounded by a ten (10) foot high fence behind the facility, and beyond that was a densely wooded area. The Regional Plant Operations stated the facility contained seven (7) doors, each equipped with a fifteen (15) second delayed egress, a variably timed door prop alarm, a magnetic latch/lock, a keypad, and was wired to a panel at the nursing station. He further stated the facility based maintenance person tested all doors daily and documented results in the maintenance computer system. He also stated the facility maintained a contract with an outside agency that tested the doors quarterly. The Regional Plant Operations explained the facility had not experienced any problems with the doors prior to the elopement. He also reported the facility had not received any work orders regarding the doors. Interview with the Administrator, on 08/11/16 at 1:00 PM, revealed after the elopement of Resident #2 on 08/04/16, the facility identified the horn alarm on the time clock employee door malfunctioned. The Administrator reported she was unaware of any issues with doors prior to the elopement. She stated she was unaware of any work orders requesting repair of the time clock employee door. Continued interview with the Administrator, on 08/12/16 at 3:30 PM, revealed she was responsible for all care given to the residents in the facility. She stated the DON was responsible to ensure nursing staff adhered to facility policies. The facility implemented the following actions to remove the Immediate Jeopardy: 1. A head to toe assessment was completed by LPN #2 upon the resident's return to the facility. Resident #2 was immediately placed on one (1) to one (1) supervision until 08/05/16 at 6:30 PM when he/she was placed on fifteen (15) minute checks. 2. The time clock employee door was manned from 2:40 AM until 2:29 PM by the Administrator in Training (AIT), Regional Plant Operations and Housekeeping staff. On 08/05/16 at 12:47 PM hourly checks of all seven (7) doors were implemented until 5:03 PM by AIT. On 08/07/16, the facility began four (4) hour door checks on all seven (7) doors. Charge Nurses, Administrator, AIT, Director of Nursing (DON), and Assistant Director of Nursing (ADON), Business Office Manager, Medical Records, Housekeeping, Chaplain, Activities Director, Dining Services Director, Social Service Director, and Regional Plant Operations documented these checks on the Exit Door Monitor Form through 08/18/16. 3. A 100% door audit was completed on 08/05/16 at 4:00 AM by the AIT and the Regional Plant Operations . The Regional Plant Operations determined the Door Prop Alarm on the time clock emplyee door was not working properly. Contract Company #1 arrived on 08/05/16 at approximately 6:00 AM replaced the alarm, added a redundant alarm, and tested the electronic locking equipment, which was operational. Following the audit, on 08/08/16 Contract Company #2 also upgraded keypads on the Patio and Therapy doors. On 08/09/16, Contract Company #2, replaced the Patio door alarm with a louder alarm. Finally, on 08/10/16 the time clock employee and Patio door alarms were tied to the nursing station. 4. On 08/05/16 the Regional Plant Operations contacted the recently retired Plant Operations Director concerning any past work orders related to the time clock employee door. He stated he did not receive any work orders concerning the time clock employee door. On 08/12/16, the Administrator reviewed work orders from August, July, and June of 2016 and did not find any for the time clock employee door. The Plant Operation Director will check the work order folder twice daily, every day. The Administrator will review, validate completion, and sign all work orders. 5. On 08/05/16, the DON, ADON the Charge Nurses re-evaluated 100% of all in-house residents for Elopement risk and the Elopement Binder reviewed for accuracy, no corrections were necessary. The DON updated Resident #2's CNA care plan to reflect he/she was an Elopement Risk following her review of his/her care plans. All care plans with Elopement Risk identified will be audited daily by the Interdisciplinary Team (IDT), the Dining Services Director, Social Service Director, ADON, DON, Activities Director and the Administrator and documented in the Stand Up meeting minutes. 6. On 08/06/16 100% of residents identified as being at risk for elopement were placed on fifteen (15) minute checks until the Quality Assurance and Performance Improvement Team (QAPI) determines the monitoring can be discontinued. Any resident who exhibits exit-seeking behaviors will be immediately placed on one (1) to one (1) care/observation. All new or readmitted residents will be assessed with [REDACTED]. She will also notify the DON or the On-Call nurse and immediately review interventions for appropriateness. The IDT team will audit new Elopement/Wandering interventions for both the nursing and CNA care plans, the following day. 7. The AIT conducted a facility-wide Elopement Drill on 08/07/16 at 11:00 AM. 8. A member of the Administrative Management Team will be present in the facility twenty four (24) hours a day, seven (7) days a week; with a member of the Regional Team daily, seven (7) days a week. Continued Administrative oversight will be discussed and determined by the QAPI committee including but not limited to Dietary Manager, Social Service Directors, ADON, DON, Activities Director, and Administrator. 9. The Administrator-In-Training, DON, ADON, Business Office Manager, Social Services Director, Dining Services Director and Activities Director were educated on the facility Policies and Procedure of elopement, missing resident, care of the wandering resident and Code Green on 08/05/16 by the Nurse Consultant. On 08/05/16, 08/08/16, 08/09/16, 08/15/16 and 08/16/16, all seventy one (71) staff were educated on Elopement and Missing Resident Policy and Procedures, Care of the Wandering Resident, Routine and fifteen (15) minute checks, Code Green, Behavioral Assessment, Door Alarm Systems, Work Orders, Elopement Risk Evaluations and Care Planning and Work Orders. Post education tests were completed by all seventy one (71) staff on the Elopement and Wandering resident education. No staff has been allowed to return to work without receiving the mandated education from Manager on Duty (Director of Nursing, Assistant Director of Nursing, Administrator, Administrator in Training, Social Service Director, Quality of Life Director, Business Office Manager, Human Relations Director, Housekeeping Director, and or the Chaplin. The DON, ADON, and the Administrator kept a log tracking all completed education. The Manager on Duty staffed the time clock employee door at each shift change until 08/12/16 checking individuals in to ensure they completed the required education prior to working. Any employee currently on vacation or FMLA will receive the mandated training prior to their next scheduled shift. All new employees will be educated during orientation by the Assistant Director of Nursing. 10. An Ad Hoc Quality Assurance (QA) Meeting was held on 08/05/16 with the AIT, DON, Regional Vice President, and the Medical Director to discuss the elopement and the plan of correction. Another Ad Hoc Quality Assurance (QA) on 08/12/16 was held with the Administrator, DON, AIT, and the Medical Director to discuss the Immediate Jeopardy (IJ) related to the 08/05/16 elopement and the plan to remove the IJ. The SSA validated removal of the IJ as follows: 1. Review of nursing notes and a skin assessment, dated 08/05/16, confirmed Resident #2 had an assessment upon return to the facility. Review of Resident #2's Safety Logs revealed he/she was placed on one one (1) to one (1) visual supervision from midnight on 08/05/16 until 6:30 PM when he/she was placed on fifteen (15) minute visual supervision, which continued through 08/18/16. Telephone interview with LPN #2 on 08/11/16 at 2:35 PM revealed she did a head to toe assessment of Resident #2 when he/she returned to the building and discovered an abrasion to his right pinkie finger. She further stated she put Resident #2 on one (1) to one (1) visual supervision following the elopement. 2. Observation of door alarm checks on 08/11/16 at 1:00 PM and 08/18/16 at 1:00 PM revealed all seven (7) door alarms were functioning properly and staff responded to the alarms timely. Review of the time clock employee Exit Door Monitoring form, dated 08/05/16 through 08/18/06 revealed the time clock employee door was observed from 2:40 AM until 2:29 PM. At noon, staff began hourly alarm checks of all seven (7) doors began. Further review revealed the door alarm monitoring decreased at 5:00 PM to four (4) hours. The four (4) hour checks were documented on the Exit Door Monitor Form through 08/18/16. Review of the undated staffing schedule revealed the Administrator had assigned a supervisor to do four (4) hour checks twenty-four (24) hours a day from 08/08/16 through 08/14/16. Interview with AIT on 08/18/16 at 4:00 PM revealed he was part of the original response team as the Administrator was out of town at the time of the elopement. He explained he arrived on 08/05/16 around 2:20 AM and secured the time clock employee door. He went on to state; he and Housekeeping maintained one (1) to one (1) observation of the door for twelve (12) hours. He reported he implemented an hourly check of all seven (7) doors on 08/05/16 at Noon and that decreased to every four (4) hours on 08/07/16 and continued through today. An interview with Regional Plant Operations on 08/10/16 at 2:45 PM revealed he had also been part of the original response team. He stated he had secured the door with the Administrator in Training shortly after the elopement and had done countless door function checks since that time. Telephone interview with Door Technician on 08/12/16 at 10:40 AM revealed he had assisted with the testing of the door functionality from 08/05/16 through 08/11/16. Interview with DON on 08/18/16 at 4:10 PM revealed she had assisted with the door checks both day and all through the night since the elopement. Interview with Dining Services Director on 08/18/16 at 3:55 PM revealed she had frequently done door checks and responded to alarms since 08/05/16. Interview with Social Services Director on 08/11/16 at 4:20 PM revealed she had participated with the door checks. 3. Observation of door alarm checks on 08/11/16 at 1:00 PM and 08/18/16 at 1:00 PM revealed all seven (7) door alarms were functioning properly and staff responded to the alarms. Observation of the time clock employee door on 08/18/16 at 4:30 PM revealed the Regional Plant Operations and Door Technician had replaced the actual door and the doorframe. Review of a letter from Contract Company #1, dated 08/05/16, stated they had examined the parking lot door, replaced a faulty alarm device and added a redundant alarm at the hallway junction on 08/05/16 at 6:00 AM. Interview with Regional Plant Operations, on 08/10/16 at 2:45 PM revealed he notified the Contract Company #2 on 08/07/16 and their door technician came the same day, inspected the time clock employee door and updated hardware. Telephone interview with Door Technician on 08/12/16 at 10:40 AM revealed 08/07/16, he had adjusted the door frame so the door would close more easily, changed out the keypad and replaced the magnetic lock switch which enables the egress alarm. He relayed the wiring from the time clock employee door to the nursing station panel was faulty and he set up a wireless system. He stated from 08/05/16 through 08/11/16 he assisted with the testing of the doors, upgraded keypads on the Patio and Therapy doors and replaced the Patio door alarm with a louder alarm. Further interview revealed he was confident that all the facility doors alarmed appropriately but the time clock employee door frame needed to be replaced and it was his understanding the facility had ordered it. Another interview with the door technician, on 08/18/16 at 1:30 PM revealed he assisted with the time c

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to follow comprehensive care plan interventions for one (1) of thirteen (13) sampled residents, Resident #5. The staff failed to float Resident #5's heels off the mattress as care planned to prevent recurrence of pressure ulcers. The findings include: Review of the facility's policy regarding Care Plans, dated 06/01/15, revealed the facility would develop and maintain a comprehensive care plan for each resident that identified problem areas and their causes, and would develop interventions that were meaningful to the resident. The care plan would identify the professional services that were responsible for each element of care. Review of the clinical record for Resident #5, revealed the facility admitted the resident on 09/19/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/16, revealed the facility assessed Resident #5 with a score of three (3) of fifteen (15) on the Brief Interview for Mental Status (BIMS) and the facility determined the resident was not interviewable. The facility further assessed the resident as requiring extensive assistance of two (2) for dressing and toileting. The resident required total assistance of two (2) with transfers, and total assistance of one (1) for bathing/hygiene. The resident was incontinent of bowel and bladder and received antidepressants routinely. Review of Resident #5's Comprehensive Care Plan, dated 10/02/15, revealed the facility determined the resident was at risk for pressure ulcers and interventions included floating the resident's heels off the mattress. Observation of Resident #5, on 06/07/16 at 11:16 AM, 2:40 PM, 3:10 PM and 4:32 PM, and on 06/08/16 at 9:03 AM and 2:46 PM, revealed the resident was positioned on his/her back with the head of the bed elevated. The resident's feet were flat against the footboard and his/her knees were bent upward. The resident's heels were pressed into the footboard and not floated as instructed by the care plan. Observation of Resident #5, on 06/08/16 at 2:46 PM, with LPN #1, revealed Resident #5 was positioned on his/her back with bent knees and feet flat against the footboard of the bed. The resident's feet were not floated on a pillow per the care plan. The resident had moderately reddened intact heels with a small amount of scarring. Interview with Certified Nurse Aide (CNA) #2, on 06/08/16 at 2:50 PM, revealed she provided care for Resident #5 many times. She stated the resident slid down in bed and had his/her feet flat against the footboard frequently. According to CNA #2 she had to check the resident every two (2) hours and repositioned the resident if needed. She was trained on preventing pressure ulcers and positioning residents; however, she forgot to float the resident's heels. The nurse aide care plan instructed the staff to ensure the resident's heels were floated. She explained that not following the care plan for positioning of the resident could cause new skin breakdown and this was not wanted. Interview with LPN #1, on 06/08/16 at 3:06 PM, revealed she was responsible for overseeing the residents on the West Hall. She stated she did not notice Resident #5's feet were pressed into the footboard or that the resident's heels were not floated today. She had not checked the resident to ensure the care plan was followed. She was aware that the resident had a history of [REDACTED]. According to LPN #1 the resident had recently lost weight and was in a position to develop new skin breakdown. The resident had a past history of skin breakdown and not following the care plan to relieve pressure could result in new skin breakdown. Interview with the Interim Director of Nursing (DON), on 06/09/16 at 10:12 AM, revealed the unit nurse was responsible for ensuring residents received the appropriate care based on the care plan. The nurse should have seen this concern and resolved it. According to the DON, pressure could cause skin breakdown and this resident was assessed to be at high risk.

Based on observation, interview, record review, and review of the facility's policy for Pressure Ulcers, it was determined the facility failed to monitor one (1) of thirteen (13) sampled residents, Resident #5, to ensure pressure relief interventions were in place and to identify other risk factors. Facility staff failed to prevent Resident #5 from sliding down in bed causing the resident's feet to be pushed into the footboard on the bed. The findings include: Review of the facility's policy regarding Pressure Ulcer Assessment, not dated, revealed pressure ulcers generally formed when a resident remained in the same position for an extended period of time causing increased pressure and decreased circulation. Staff would perform routine skin inspections with daily care. Multiple factors, including pressure intensity, could cause the formation of pressure ulcers. Shearing was the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary. Review of the clinical record for Resident #5, revealed the facility admitted the resident on 09/19/13 with [DIAGNOSES REDACTED]. In addition, the resident had chronic [MEDICAL CONDITION] related to the kidney disease and received medication to raise the hemoglobin in the blood. Review of Resident #5's laboratory results, revealed the hemoglobin level was 8.8 on 04/13/16 and 9.7 on 05/11/16. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/16, revealed the facility assessed Resident #5 with a score of three (3) of fifteen (15) on the Brief Interview for Mental Status (BIMS) and the facility determined the resident was non-interviewable. The facility further assessed the resident as requiring extensive assistance with dressing and eating and total care with transfers and hygiene. The resident was incontinent of bowel and bladder. The resident had a poor appetite and a recent weight loss was now stable. The resident required oxygen continuously at two (2) liters per minuet by nasal cannula. Review of the Comprehensive Care Plan, dated 10/02/15, revealed Resident #5 had a history of [REDACTED]. The resident was incontinent of bowel and bladder and was immobile. Observations of Resident #5, on 06/07/16 at 11:16 AM, 2:40 PM, 3:10 PM, 3:45 PM and 4:32 PM and on 06/08/16 at 9:03 AM, revealed the resident was positioned in bed on his/her back with the head of the bed elevated. The resident slid down in the bed and had his/her feet and heels pressed against the footboard with the knees bent upward. There was no evidence nursing staff floated the resident's heels since the heels were directly on the mattress. Interview with Certified Nurse Aide (CNA) #1, on 06/08/15 at 11:40 AM, revealed she provided care for Resident #5 many times. She stated the resident slid down in bed frequently and needed to have the heels lifted off the mattress. She stated she forgot to elevate the resident's heels. The resident did slide down in the bed and pressed his/her feet and heels against the footboard. She had to pull the resident up in bed when she checked Resident #5 every two (2) hours. She had not discussed the sliding with a nurse and there was nothing on the care plan to prevent the sliding. She stated she received training on positioning and prevention of pressure ulcers and knew pressure ulcers could form on the resident. Interview with Licensed Practical Nurse (LPN) #1, on 06/08/16 at 12:10 PM, revealed she passed medications and took care of the residents needs. She stated she did not monitor Resident #5 to ensure the staff were following the care plan and lifting the resident's heels off the bed. She had not identified the resident frequently sliding down in bed to the extent that the feet and heels were pressed hard into the footboard. She stated she had received training on positioning and pressure prevention and knew pressure and shearing could cause the resident to develop pressure ulcers again. Interview with the Interim Director of Nursing, on 06/08/16 at 4:20 PM, revealed the nurse caring for Resident #5 was responsible to ensure the resident had pressure ulcer prevention interventions in place and to monitor the CNA. She stated she had no knowledge of the resident's positioning issues.

Based on interview, record review, and policy review, it was determined the facility failed to prevent a significant medication error for one (1) of thirteen (13) sampled residents. On 04/21/16, the facility sent Resident #1 to the Emergency Department (ED) after presenting as lethargic and unresponsive. The ED sent Resident #1 back to the facility the same day with a discharge [DIAGNOSES REDACTED]. The facility failed to investigate the medication overdose. The findings include: Review of the facility's policy statement regarding Accidents and Incidents-Investigating and Report, dated 06/01/16, revealed the facility would have investigated accidents or incidents involving residents occurring on the premises and reported the incident to the Administrator. The Nurse Supervisor/Charge Nurse and/or Department Director or Supervisor would have initiated and documented the investigation of the accident or incident. Staff would have entered the resulting data into the Event Manager. Review of the clinical record revealed the facility admitted Resident #1 on 06/23/09 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) Assessment, completed on 03/21/16, revealed the facility assessed the resident as completely dependent upon staff for transfers and dressing. Resident #1 self-propelled via wheel chair and ate independently. The facility conducted a Brief Interview for Mental Status (BIMS) exam during the assessment and assessed the resident with a score of eight (8) out of fifteen (15), and determined the resident was not interviewable. Review of the Nursing Notes, dated 04/21/16 at 7:05 AM, revealed Licensed Practical Nurse (LPN) #4 observed Resident #1 by the nurse's station in a wheelchair, leaning to the left. Staff had difficulty arousing Resident #1 and assisted him/her to bed. Nursing administered sternal rub and elicited some movement of the resident's left arm. The LPN assessed Resident #1's blood pressure at eighty-eight over fifty-two (88/52) and a pulse rate at one hundred two (102). The Advanced Practice Registered Nurse (APRN) ordered the facility to send Resident #1 to the emergency department (ED). Review of Resident #1's Resident Transfer Form, dated 04/21/16, revealed the resident was unresponsive, had low blood pressure and his/her behavior was uncooperative and suspicious. His/her mental status was confused. LPN #2 signed the form. Review of the RN's ED note, dated 04/21/16 at 2:13 PM, revealed Resident #1 was in the ED from 8:04 AM until 2:13 PM on 04/21/16. Review of the ED Physician's note, dated 04/21/16 at 8:05 AM, revealed Resident #1 presented with pinpoint pupils, an altered mental status and responded to painful stimuli. Review of the ED Physician note, dated 04/21/16 at 8:51 AM, revealed Resident #1 had two (2) medication patches on his/her body. The resident had an Estriadol patch on his/her chest and a [MEDICATION NAME] on his/her back. Review of the ED Physician note, dated 04/21/16 at 11:56 AM, revealed the hospital administered three (3) doses of [MEDICATION NAME], (an opiate antidote), for a total of four (4) milligrams (mg). After the first dose, Resident #1 was briefly alert and communicative; however, he/she remained disoriented to time, place, and situation. The hospital administered two (2) more doses of [MEDICATION NAME], after which Resident #1 had pinpoint pupils and would respond to verbal stimuli, but then immediately returned to lethargy. Review of the ED Physician note, dated 04/21/16 at 1:32 PM, revealed the hospital also completed a Computed Typography (CT) scan of the resident's head to rule out acute brain illness, and a chest X-ray. The tests did not demonstrate acute illness. The Physician discharged Resident #1 with a [DIAGNOSES REDACTED]. Review of LPN #4's Nursing Note, dated 04/21/16 at 3:56 PM, revealed Resident #1 returned from the ED with an order to discontinue the [MEDICATION NAME] and begin [MEDICATION NAME] as needed for pain. Interview with LPN #2, on 06/08/16 at 9:05 AM and on 06/09/16 at 9:40 AM, revealed she worked day shift on 04/21/16 and responded to Resident #1. She stated she was initially concerned about the resident's lethargy until she performed a sternum rub and Resident #1 yelled at her. She described Resident #1's long history of psychiatric issues and explained he/she had often played possum. Staff had some informal discussion amongst themselves about the incident; however, the administrative staff did not conduct staff interviews nor did they request any written statements. Although LPN #2 could not recall who the Assistant Director of Nursing (ADON) or Director of Nursing (DON) was at the time of the incident, she stated staff did not report the incident to management because it was not a true over dose. Review of the facility's Controlled Drug record, dated March 2016 and April 2016, revealed Resident #1's nurse would have taken off the [MEDICATION NAME] and replaced it with a new topically applied patch every seventy-two (72) hours. LPN #1 document a [MEDICATION NAME] was placed on Resident #1 on 04/20/16 at 8:00 AM. She further documented removal and destruction of the used patch. Interview with LPN #1, on 06/08/16 at 12:10 PM, revealed she heard about the incident second hand. She did not know she had applied the last patch to Resident #1 prior to the event. According to LPN #1 she was unaware of any investigation into the incident. The facility did not interview her nor ask to review her Medication Administration Record [REDACTED] Interview with LPN #3, on 06/09/16 at 10:00 AM, revealed she worked on the West Hall on 04/21/16. Resident #1 was lethargic and had low blood pressure at the time of the incident. When she further assessed the resident, she stated she found one (1) patch on the resident which she thought was a [MEDICATION NAME]. She did not remember finding additional patches on the resident and was unaware Resident #1 had an order for [REDACTED].#3 also voiced doubt regarding Resident #1's Opioid overdose stating Resident #1 often had pinpoint pupils, possibly related to his/her TBI. She independently reviewed the MAR for April 2016 to determine if there were any medication errors that could explain an Opioid Overdose [DIAGNOSES REDACTED]. Facility Administration did not interview her. Additionally, she did not document the incident in a Situation, Background, Assessment and Recommendation (SBAR) note. Interview with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (DON), on 06/08/16 at 9:00 AM, revealed they did not know about the incident involving Resident #1. They did not know if the facility investigated the incident. Neither of them were sure if they were employed with the facility on 04/21/16. The facility did not provide documentation of an investigation into the significant medication error involving Resident #1 on 04/21/16. Interview with the ADON, on 06/09/16 at 10:45 AM, revealed she was in class room orientation on 04/21/16. Staff did not inform her of the medication error until the survey. After reviewing the documentation, she reported the event should have triggered an SBAR and it was missing. She also stated she would have conducted an investigation of the medication error. She described Opioid Overdose as a serious and often fatal medical condition. Interview with the Interim DON, on 06/09/16 at 2:00 PM, revealed she started with the facility on 04/08/16 and had reviewed the documentation from the 04/21/16 medication error during the survey. She stated the facility staff did not report the medication error to her. Had she been aware she would have conducted an investigation. She would have sent reports of the investigation findings to the Administrator and the Regional Consultant.