Every finding on record at Billdora Senior Care

Based on observation, interview, record review and facility policy review the facility failed to provide sufficient pain medication prior to wound care for a resident who moaned and yelled out during wound care for one (1) of two (2) wound care observations. Resident #1Findings Include:Policy review of facility's policy Pain Management dated 2025 revealed the facility should provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being. Behavioral signs and symptoms they may suggest the presence of pain include but are not limited to facial expressions grimacing, groaning.On 04/08/2026 at 9:02 AM, during an observation of wound care being provided by Registered Nurse (RN) # 1/Treatment Nurse and was assisted by RN #2/Infection Preventionist (IP) nurse, RN #1 informed the State Agency (SA) that Resident # 1 moans out during wound care. She stated they gave her Tylenol thirty minutes prior to starting wound care. Resident #1 was turned on her side, and the soiled dressing was removed. RN #1 began to clean the wound with normal saline and Resident #1 yelled out it hurts. Resident #1 displayed facial grimaces, moaning and yelling out during the entire wound care process. RN #2 tried to console the resident by rubbing her hand and talking to her. RN#1 cleaned the wound several times, discarding gauze after each wipe. Resident #1 continued moaning and hollering out with every wipe applied to the wound. The SA asked again what time the nurse administered pain medication. RN #1 replied over 30 minutes ago and continued with the care. Each time RN #1 wiped the wound the resident moaned and yelled with facial grimaces. Record review of Resident #1's Weights and Vitals Summary dated 4/08/26 indicated a pain level of (4) and the resident was given Tylenol at 8:52 AM and wound care began at 9:02 AM.On 04/08/26 at 10:13 AM, in an interview with RN #1 she stated Resident #1 is confused and cannot verbalize pain. She stated resident was recently hospitalized and returned to the facility Sunday. She stated she did wound care on Resident #1 on Monday and Tuesday. She stated wound had declined when she came back from the hospital. She stated Resident #1 always moans and hollers doing wound care. She stated she does not think cart nurses gave resident pain medication prior to wound care for the last three months. She stated she did not give her any pain medication prior to wound care these past three months. She stated when she initially started doing resident wound care three months ago, the resident would holler out and moan. She stated she would stop and ask resident if she was in pain and Resident #1 would respond no. She stated she did not have an order for pain medication. She stated she did not contact the physician for pain medication prior to providing wound care these past three months. She confirmed that resident was moaning and yelling out in pain and she did not get an order. She stated the physician wrote an order yesterday for routine Tylenol. She stated she should have called and got an order for pain on Monday. She stated Resident was hollering out Monday and Tuesday and she did call them to get an order. She stated she asks the resident if she is in pain. She stated Resident cannot rate pain on a scale. She stated from a nurse's perspective, a resident with a stage 3 wound would need pain medication prior to receiving wound care.On 04/08/26 at 10:51 AM, during an interview Licensed Practical Nurse (LPN)#1 stated he is Resident #1's nurse today. He stated he gave Resident #1 Tylenol around 8:50 AM. He stated Resident #1 cannot verbalize needs and wants. He stated from a nurse's point of view he would give resident pain medication before providing wound care for stage 3 wound.On 04/08/26 at 10:59 AM, in an interview with RN #2/IP nurse confirmed Resident #1 was moaning and hollering out during wound care. She confirmed that a stage 3 wound or higher should have pain medications before wound care is provided every time.On 04/08/26 at 3:00 PM, during an interview the Director of Nursing (DON) confirmed she would have given pain medication due to resident interview or signs and symptoms of pain. She stated Resident #1 has declined and was admitted with a stage 3 sacrum wound. She stated based on Resident #1's assessment staff should give some type of pain medication. She stated if there was no order, the nurse should have contacted the physician for a pain medication order. She stated her expectations of nurses is to use their judgement and stop wound care treatment for pain/discomfort and then continue with wound care after treatment with pain medication.On 04/09/2026 at 9:15 AM, in an interview with Certified Nursing Assistant (CNA) #1 stated she has assisted RN #1/Treatment nurse with wound care for Resident #1. She stated Resident #1 will moan and yell out it hurts when the nurse provides wound care. She stated the nurse would stop for a few minutes and continue with wound care.On 04/09/2026 at 11:34 AM, in an interview the physician acknowledged that the wound looks bad, not healing and the wound is painful. She stated the wound is worsening and Resident #1 required more medication than Tylenol. She stated she sees the resident once a month and has seen the wound. She stated she cannot recall if she ordered any pain medication prior to the Tylenol. She stated she switched the pain medication on 4/9/26 so resident would not be in pain during wound care.On 04/09/2026 at 12:30 PM, in an interview with the DON she confirmed that the vital pain level assessments dating back to November 2025 - April 8,2026 revealed multiple dates in that time frame where the resident was documented as having experienced pain. She stated that it was documented and present and staff must not have done anything about it. She stated that the process for assigning a pain score 0-10 to the resident in this case requires the nurse to utilize a face tool such as Wong-Baker score where the nurse chooses a facial grimace severity indicating pain that corresponds with a numerical value (0-10) on the Medication Administration Record (MAR) since the resident was unable to verbalize a numeric value for pain.Record review of Resident #1 admission Record revealed an admission date of 11/26/25 with diagnoses that included pressure ulcer of sacral region stage 3. Record review of the Order Summary Report with active orders as of 4/8/26 revealed a physician order dated 4/7/26 for Stage 3 to sacrum: Cleanse with normal saline, pat dry, apply collagen pad and calcium alginate to wound bed. Apply betadine to peri wound skin. Cover with silicone border dressing qd (every day) and prn (as needed) for soilage every day shift related to Pressure Ulcer of Sacral Region Stage 3.A record review of the Order Summary Report dated November 2025 through April 8, 2026, revealed there was no pain medication ordered prior to 4/8/26.Record review of the Order Summary Report with active orders as of 4/8/26 revealed an order dated 4/8/26 for Acetaminophen Oral Tablet 500 mg (milligrams). Give 2 (two) tablets via (by way of) PEG (Percutaneous Endoscopic Gastrostomy) tube every 6 hours as needed for pain.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/24/26 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicates the interview was not completed or was unable to be completed. Section J revealed Resident #1 did not receive pain medication. Section M revealed Resident #1 had a Stage 3 pressure ulcer.A record review of the Electronic Medication Administration Record (EMAR) from November 26, 2025, to April 7, 2026, revealed no pain medications were given.Record review of the Pain Assessment dated 11/25/25 revealed Should Pain Assessment Interview be Conducted? The response was marked Yes.Record review of Resident #1's Pain Assessment dated 12/3/25, 2/16/26 and 2/24/26 revealed Should Pain Assessment Interview be Conducted? The response was marked No.Record review of Resident #1 Wound Weekly Observation Tool dated 3/31/26 revealed sacrum wound granulation tissue present beefy red. Length (L) 0.7 centimeters (cm), Width (W) 0.3 cm, Depth (D) 0.1 cm. No drainage.Record review of Resident #1 Wound Weekly Observation Tool dated 4/7/26 revealed sacrum wound granulation tissue present beefy red. L 3.8 cm, W 1.8cm, D 0.1 cm. Small amount of serosanguinous drainage.Record review of Resident #1's Weights and Vitals Summary dated 1/1/26 through 4/8/26 revealed Resident #1 complained of pain on 01/12/26 at a pain level was a five (5), on 01/14/26 pain level was a four (4), on 01/16/26 pain level was a (5),on 03/10/26 pain level was a (5), on 03/14/26, pain level was a six (6), on 03/24/26 pain level was a three (3) with no documentation in the medical record pain medication was administered.

Based on observation, interview, and record review, and facility policy review the facility failed to ensure staff followed proper hand hygiene and Enhanced Barrier Precautions (EBP) during wound care and peri care for one (1) of two (2) sampled residents reviewed for pressure ulcers. Resident #1. Findings Include:Record review of the facility policy Hand Hygiene Policy dated 2025 revealed, Policy: Staff involved direct contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors.Record review of the facility policy Enhanced Barrier Precautions undated, revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.4. High-contact resident care activities include.d. Providing hygiene.f. Changing briefs or assisting with toileting.On 04/08/2026 at 9:02 AM, during an observation of wound care, provided by Registered Nurse (RN) 1/Treatment Nurse and assisted by RN #2/ Infection Preventionist (IP) nurse. RN #2 donned (put on) a gown but did not don gloves prior to touching the feeding pump. RN #2 did not perform hand hygiene prior to applying gloves. RN #1 removed gloves, left room to retrieve a bag off the cart. She returned to the room and donned gloves and did not perform hand hygiene prior to applying gloves. After cleaning the wound she stated, I forgot to bring hand sanitizer in the room. She removed gloves and went to the cart to get hand sanitizer. The cart was parked in front of the door. She returned to the room with hand sanitizer. She applied sanitizer to hands. She opened normal saline and poured it on the gauze from the bottle into the gauze. RN #2 nurse told RN #1l to stop, you messed up you need to pour the saline in a cup on the gauze. RN #1 stopped removed gloves and went to get a cup and placed gauze and a cup and statured the gauze. She did not sanitize hands after removing gloves. She returned to the room to perform hand hygiene, donned gloves and continued to clean the wound. RN #1 finished up wound care, and they stated we need to do perineal (peri) care. RN #1 removed gowns and gloves and exited room to gather supplies for peri care. RN #1 returned to the room and started to do peri care in the buttocks area. RN #1 did not apply for a gown prior to starting peri care.On 04/08/26 at 9:38 AM, in an interview with RN #1/Treatment nurse confirmed that she had to leave the room several times due to not having all supplies needed for care. She confirmed that she did not have a gown when she provided peri care. She stated she should have had a gown on prior to peri care. She confirmed that doing care she had forgotten to sanitize her hands a couple of times. She stated she placed the resident at higher risk for infection by not wearing a gown and washing hands every time during wound and peri care. She stated the resident has an open wound and could get infected.On 04/08/26 at 10:59 AM, during an interview with RN #2/IP nurse stated she did not realize RN #1 did not wash her hands a couple of times during wound care. She confirmed she did not wash her hands after placing pump on pause. She stated Resident #1 had a higher risk of infection from RN #1 not wearing a gown during peri care. She stated she did not realize RN #1 had taken the gown off to get peri care supplies. She stated that it is a contamination issue.On 04/08/26 at 3:00 PM, during an interview with the Director of Nursing (DON), confirmed that RN #2/IP should have washed her hands before applying gloves to assist with wound care. She stated RN#1 /Treatment Nurse should have worn a gown doing peri care. She stated the proper technique is to wash or sanitize hands before applying gloves. She stated RN #1/Treatment Nurse should have donned a gown for EBP during direct care. She stated that peri care is direct care. She stated she expects staff to wear gowns when providing care to residents who are on EBP. She stated she expects staff to follow protocol standards for infection control aspects of it. Record review of Resident #1 admission Record revealed an admission date of 11/26/25 with diagnoses that included pressure ulcer of sacral region stage 3. Record review of the Order Summary Report revealed an order for treatment to a Stage 3 to the sacrum: Cleanse with normal saline, pat dry, apply collagen pad and calcium alginate to wound bed. Apply betadine to peri wound skin. Cover with silicone border dressing every day and as needed for soilage, every day shift related to pressure ulcer of sacral region stage 3.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/24/26 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the interview was not completed or was unable to be completed. Section J revealed Resident #1 did not receive pain medication. Section M revealed a stage 3 pressure ulcer.

Based on observation, interview, record review and facility policy review, the facility failed to ensure adequate supervision was provided to prevent an elopement from the facility for one (1) of four (4) sampled residents reviewed. Resident #1The facility's failure to provide adequate supervision resulted in Resident #1 leaving the facility unnoticed and unsupervised on 1/20/26. This placed Resident #1 and all other residents who are at risk for wandering in a situation that is likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 1/20/26 when Resident #1 eloped from the facility. The facility Administrator was notified of the IJ on 1/28/26 at 6:00 PM and was presented with the IJ template. The facility provided an acceptable removal plan on 1/29/26, in which they alleged all corrective actions to remove the IJ were completed on 1/20/26.The SA validated the Corrective Action Plan on 1/29/26 and based on the implementation of the corrective actions completed by the facility on 1/20/26 the SA determined the IJ and SQC to be past non-compliance (PNC) and the IJ was removed on 1/21/26 prior to the SA's entrance on 1/28/26.Findings Include:Record review of the facility policy titled, Elopements and Wandering Residents dated 2025 revealed This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Policy Explanation and Compliance Guidelines.1. The facility is equipped with door locks/alarms to help avoid elopements.3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks.4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering.c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.d. Adequate supervision will be provided to help prevent accidents or elopements.Review of the admission Record for Resident #1 revealed the facility admitted the resident on 1/19/26 with diagnoses that included dementia and delusional disorder and hallucinations.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 1/26/26 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Section E indicated Resident #1 had a history of wandering. Section GG indicated Resident #1 was able to walk independently for one hundred fifty (150) feet.Record review of the admission History and Physical for Resident #1 dated 11/24/25 revealed History of Present Illness.history of dementia with agitation and psychosis.being seen in his home and meets homebound criteria due to difficulty leaving home without assistance.Aggressive behaviors and irritability have been noted, particularly in relation to attempts to cross the street. Agitation occurs when unable to perform desired activities, such as going across the road.Safety issues discussed with daughters. Recommend getting a second lock on all doors where you need a key to exit doors to avoid patient wandering and leaving the house.Dementia.with psychotic disturbance.Record review of the admission physician orders for Resident #1 dated 1/19/26 revealed the resident had order for monitoring Wandering & elopement X (for) 14 days.Record review of the Order Summary Report dated 1/28/26 for Resident #1 revealed an active order with start date 1/19/26 for Monitor Behavior every shift for.anxious/Restless.Pacing; Other. Record review of the Progress Notes for Resident #1 dated 1/20/26 11:57 AM revealed Licensed Practical Nurse (LPN) #1 documented, At approximately 10:35-10:40 AM resident was visually observed sitting on side by this nurse. At approximately 11:30-11:40 AM staff were getting lunch ready for resident and noted that he was not in his room. Staff attempted to search in facility for resident but were unable to locate and floor nurse notified the DON (Director of Nursing). At 11:52 Code [NAME] was called overhead. Building was searched and outside areas. At 11:55 AM resident was located. At 11:57 AM resident returned to facility.On 1/29/26 at 3:39 PM, during a telephone interview the Resident Representative of Resident #1 stated that she was notified by LPN #1 on the morning of 1/20/26 that Resident #1 had exited the facility unaccompanied and unsupervised and had been located by staff and returned to the facility.On 1/28/26 at 11:15 AM, during an interview, the Administrator stated that on 1/20/26 she was notified by the DON at approximately 11:42 AM she was notified by announcement of Code [NAME] via the overhead speaker and that all staff responded appropriately according to the facility missing resident procedure. She stated that the resident was located by the Maintenance Technician 0.5 miles (half mile) from the facility and returned him to the facility. She stated that following the incident she was able to review security camera footage and observed the Dietary Aide assisting Resident #1 with the front door and Resident #1 exited the front door. She stated that she notified all appropriate agencies according to state and federal requirements and completed an investigation which revealed that the Dietary Aide confirmed that she had observed Resident #1 at the front door at approximately 11:45 AM, did not know who he was, and disengaged the lock on the front door by entering the numeric code into the wall-mounted keypad next to the front door for Resident #1 to exit unaccompanied and unsupervised. She confirmed that the facility had procedures in place that included monitoring for wandering and elopement for newly admitted residents, and staff-confidential numeric codes required to open all exit doors, which were monitored routinely by the maintenance staff. She confirmed that the facility had no two-part (resident worn monitor and corresponding door monitor) safe wandering system. On 1/28/26 at 12:00 PM, observation and interview revealed Resident #1 was resting on his bed in his room with staff present for one-on-one supervision. The resident was alert and oriented to self and able to communicate well verbally but unable to explain the 1/20/26 elopement.On 1/28/26 at 12:10 PM, during an interview, Registered Nurse (RN) #1 stated she was the assigned Unit Manager for Resident #1 on 1/20/26. She confirmed she received in-service training related to missing resident and elopements and participated in elopement drills since the 1/20/26 incident. She confirmed that she, LPN #1, the DON and the residents' primary physician had assessed and evaluated the resident upon return to the facility with no injury noted and one-on-one supervision was initiated and continued for Resident #1, as well as use of an elopement risk band placed on the resident's left wrist. She stated the weather on 1/20/26 had been clear, cool and fair and that the resident had been wearing black jeans, a plaid button-up shirt, black socks and slip-on athletic-casual loafers with a rigid sole.On 1/28/26 at 12:15 PM, during an interview LPN #1 stated that he was familiar with Resident #1 and his care and that he had been on duty and responsible for the care of Resident #1 on 1/20/26 dayshift (6:00 AM through 6:00 PM). LPN #1 explained that the resident was admitted by the facility on 1/19/26 and during the morning of 1/20/26 had been observed walking in the hallway and in his room. He stated that he had personally observed the resident sitting on the side of his bed at approximately 10:35 AM, and the resident had later walked to the nurse's station. He explained that at approximately 11:40 AM, Certified Nurses' Aide (CNA) #1 had reported that she could not locate the resident to serve his lunch. LPN #1 said that following a quick (one to two minute) search, the Director of Nurses (DON) was notified that the resident was missing and the DON announced a Code [NAME] (missing resident) via the overhead speaker, which summoned all staff to the nurses station where they were told the identity of the missing resident and provided with instructions. He stated that the Maintenance Technician located the resident 0.5 miles from the facility sitting outside on the steps of a local business and returned Resident #1 to the facility. He said that Resident #1's primary physician was at the facility and evaluated the resident, with no injury or new orders noted and RN #1 assessed the resident, including a body/skin audit and noted no injury. He stated the weather on 1/20/26 had been clear, cool and fair and that the resident had been wearing black jeans, a black and gray plaid button-up shirt, black socks and slip-on athletic-casual loafers with a rigid sole. On 1/28/26 at 1:00 PM, during an interview, the Maintenance Technician revealed that he was on duty on 1/20/26 and at approximately 11:40 AM was notified by CNA #1 that she could not find Resident #1. He said he immediately began to look for the resident inside and after reporting to the nurses' station upon hearing the missing resident announcement via the overhead speaker got into his car and drove towards town and at approximately 11:55 AM saw the resident 0.5 miles from the facility sitting on the steps outside a local business. He stated he approached the resident who asked him for a ride and got into his car without incident and he notified facility staff that he had located the resident and was returning to the facility. The Maintenance Technician stated that when Resident #1 got into his car the resident's clothes and shoes were clean and dry. He stated that he brought him straight back to the facility and assisted him inside at approximately 11:57 AM. He confirmed he then assisted with checking exit doors to confirm doors and locks were functioning correctly. He confirmed that regardless of the route taken by Resident #1 on 1/20/26, he would have had to cross two of the busiest streets in town. He confirmed the weather on 1/20/26 had been clear, cool and fair and that the resident had been wearing clean, dry black jeans, button-up shirt, black socks and slip-on athletic-casual loafers with a rigid sole. On 1/28/26 at 1:40 PM, during an interview CNA #1 revealed she was on duty on dayshift (6:00 AM to 6:00 PM) 1/20/26. At approximately 11:40 AM she was serving lunch on lower hall. She stated that she began to look for Resident #1, first in the dining room and then in therapy and then notified the nurses that Resident #1 may be missing. She stated that following a quick one-to-two-minute search to check, a Code [NAME] was announced over the overhead speaker and all staff reported to the nurses' station and were told the name of the missing resident and began to search for him inside and outside the facility. She stated that in a matter of minutes the code was cleared via overhead speaker. She stated that she obtained the resident's vital signs upon return and was assigned to one-on-one supervision of Resident #1 and confirmed that the resident remained on one-on-one supervision.On 1/29/26 at 3:24 PM, during a record review of the Personnel Action dated 1/20/26 and interview, the Dietary Aide confirmed that at approximately 11:40 AM on 1/20/26 she failed to check with nursing staff and input the numeric code into the wall-mounted keypad beside the front entrance and allowed Resident #1 to exit unaccompanied and unsupervised, which resulted in termination of her employment at the facility on 1/28/26. Record review of the local weather history according to WWW.Wunderground, copyright the Weather Channel, for the facility location for 11:53 AM, revealed the temperature was 56 degrees Fahrenheit, with zero precipitation, six to eight mile per hour winds and the weather condition was fair.Immediacy Removal Plan:Incident10:40 A.M. On 01/20/26, newly admitted resident #1 was observed by Licensed Practical Nurse (LPN) #1 sitting on the side of his bed in his room.11:40 A.M. Certified Nursing Assistant (C.N.A.) #1 was unable to locate resident #1.Immediate Action taken on 1/20/202611:40 AM CNA #1 notified LPN #2 that she could not locate the resident.11:41 AM LPN #1 notified Director of Nursing that the resident was missing.11:41 AM Code [NAME] initiated by Director of Nursing11:42 AM Administrator notified immediately by Code Adam11:43 AM Physician notified by Administrator11:43 AM Resident representative notified LPN #211: 45 AM LPN #1 head count to ensure all other residents were accounted for11:45 AM All staff began an search of the facility.11:48 AM Dietary Aide reported to Dietary Manager who reported to LPN #1 she may have mistakenly allowed the resident to exit the building.11:49 AM Search expanded outside the facility with Maintenance staff assigned to search by vehicle11:55 AM Maintenance Technician located the resident sitting outside a local business 0.5 mile from facility. Resident stated that he was on his way to the high school to a basketball game.11:57 AM Resident returned safely to the facility by Maintenance Technician.11:58 AM Physician assessed and evaluated Resident #1 with no injury noted.11:58 A.M. LPN #1 performed a full body audit with no injury.11:59 AM Pain Assessment performed by Registered Nurse (RN) #1 with no pain verbalized.12:00 Noon Resident#1 placed on 1:1 monitoring upon return.12:01 PM Resident #1 reassessed for wander and elopement risk by RN #1 scoring moderate risk for elopement12:05 PM Care plan updated by Minimum Data Set ( MDS) coordinator to include one-on-one (1:1) monitoring12:15 PM Maintenance Supervisor assured all doors where functioning properly12:15 PM Director of Nurses and MDS Coordinator and Quality Assurance Nurse performed audit on 43 residents to identify risk for wandering and elopement. Four other residents continue to be at risk for wandering and elopement1:00 PM Administrator called the Mississippi State Department of Health Hotline to report the event and reported on Attorney General Medicaid Fraud Site.1:15 PM Wonder and Elopement Binder was reviewed by Director of Nursing and Quality Assurance RN for updated risk assessment and current photo for five residents1:15 PM Updated Colored Signage signaling to check with nursing before allowing anyone out the door was completed by Staff Development Nurse.1:15 PM Dietary Aide suspended pending investigation and then terminated by AdministratorQuality Assurance Committee:Quality Assurance Performance Improvement (QAPI) conducted an emergency meeting on 1/20/2026 at 1:00 PMA Quality Assurance Performance Improvement (QAPI) Committee was held on 1/20/2026 at 1:00 PM with the following staff in attendance: Administrator, Business Office Manager, Infection Preventionist, Social Services Director, MDS Coordinator, Maintenance/Housekeeping Director, Medical Director, Certified Occupational Therapist, Director of Nursing, Activity Director, Dietary Manager, and Staff DevelopmentRoot Cause Analysis: The Dietary Aide tapped in the code to the door and allowed the resident to walk out the door without following resident-identification protocols.EducationStaff Development Nurse and Director of Nursing started on 1/20/2026 and ending on 1/21/2026. educating all staff on Elopement and Wandering Residents Policy, Code [NAME] Policy, Identifying Residents at Risk for Elopement, Resident Identification Protocols, Conducted Elopement Drills on each shift. All staff educated on the above in services prior to beginning their shift.MonitoringBeginning 1/22/26 the Staff Development Coordinator and DON will monitor the competency of education regarding wandering and wandering risk and safety awareness of staff using knowledge testing of three staff members five days weekly for two weeks, then two staff members three days weekly for two weeks, then one staff member weekly for one month, then one staff member monthly for three months.Beginning 1/22/26 the Social Services Director will monitor the Elopement Binder to ensure each resident assessed as at risk for elopement has a current photograph and up to date risk assessment in the binder daily, five times weekly.Beginning 1/22/26 the Social Services Director will monitor residents at risk of wandering and elopement for alert ban placement five times each week for one month, then once weekly for one week, then monthly for three months. Upon installation of Safe Wandering System, alert ban placement will be replaced by safe wandering system bracelet placement. Facility alleges all corrective action completed on 1/20/2026.The SA validated the Corrective Action Plan on 1/29/26 through observations, interviews, and record reviews and determined that the IJ was removed on 1/21/26, prior to SA entrance on 1/28/26 and was determined to be Past Noncompliance.

Based on facility policy review, interviews, and record review, the facility failed to provide residents with mail on Saturdays for one (1) of (17) sampled residents, Resident #25. Findings included: A record review of the facility policy Communications Within and External to the Facility revised in August 2024, revealed, The facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility. The facility will ensure the resident has the ability to .receive mail, letters, packages, and other materials delivered to the facility . On 03/04/2025 at 10:10 AM, during a resident council meeting, members stated that residents in the facility does not receive mail on weekends. On 03/04/2025 at 10:20 AM, during an interview, the facility Administrator stated that the Activities Director distributes mail during the weekdays. The Administrator further stated that the front desk receptionist, nurses, or Certified Nurse Aides (CNAs) distribute mail on weekends when it is received at the front desk. The Administrator suggested that Resident #25 be interviewed, as she consistently receives mail. On 03/04/2025 at 10:27 AM, during an interview, Resident #25 stated that she never receives mail on weekends. She stated that even if mail arrives on the weekend, it is stored in the front office, and the Activities Director delivers it to her on Mondays. Resident #25 stated that no CNA or nurse has ever brought her mail on weekends. On 03/04/2025 at 10:22 AM, during an interview, the front desk receptionist stated that she does not work on weekends. She stated that nurses and CNAs usually retrieve the mail and distribute it on weekends. On 03/04/2025 at 10:30 AM, during an interview, Licensed Practical Nurse (LPN)# 1 stated that she was unaware of who retrieves the mail on Saturdays and distributes it to residents. LPN #1 stated that she had never delivered mail on weekends and had never seen any residents receive mail on Saturdays. On 03/04/2025 at 10:35 AM, during an interview, CNA #1 stated that she did not know what happens with mail on weekends. She stated that she had never been instructed to retrieve mail from the front office or distribute it to residents on weekends. On 03/04/2025 at 10:47 AM, during an interview, the facility's Social Services Director stated that the Activities Director distributes residents' mail Monday through Friday but was unsure who distributed mail on weekends. On 03/04/2025 at 10:53 AM, during an interview, Activities Staff #1 stated that she distributes residents' mail Monday through Friday. She stated that the charge nurse is responsible for distributing mail on weekends when she is not there. However, she stated that when she arrives on Mondays, packages are often waiting in the office to be distributed. On 03/04/2025 at 11:01 AM, during an interview, Registered Nurse (RN)# 1 stated that she had never distributed mail on weekends. She further stated that, to her knowledge, if mail is delivered to the facility on the weekend, it is stored in the front office until it is distributed on Monday. On 03/04/2025 at 11:05 AM, during an interview, the Director of Nursing (DON) stated that Activities Staff #1 distributes the mail during the week. When asked who delivers mail on weekends, the DON stated that she assumed it would be distributed by social services or activities staff. The DON confirmed that nurses and CNAs do not retrieve or distribute mail on weekends. A record review of Resident #25's Admission Record revealed an admitted [DATE] with a diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. A record review of Resident #25's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on interview, record review and facility policy review the facility failed to provide prompt resolution of a grievance related to a resident's missing property for one (1) of (17) sampled residents. Resident #22. Findings included: A review of the facility's policy titled Missing Property, dated 4/17, revealed It is the policy of the facility to safeguard resident' property (to the extent possible) to assure there is no misappropriation On 03/03/25 at 12:24 PM, in an interview, Resident #22 stated that a Saints jersey was missing from her closet. She was unsure when it went missing. She reported that Social Services (SS) initially told her they would order a replacement jersey but later informed her in January 2025 that they would need to reorder it. She further stated that SS told her they would check on the status of the jersey but never followed up with her. On 03/04/25 at 1:10 PM, in an interview, SS stated that she typically completes a grievance when residents report missing items. She confirmed that Resident #22 had reported her missing jersey late in 2024, during football season. She stated she completed a grievance but acknowledged that there was no record of the grievance in the grievance book. She further stated that she discussed the issue with the Nursing Home Administrator (NHA) and that the plan was to replace the jersey. The last time she spoke with NHA about the issue was at the end of 2024. On 03/04/25 at 1:22 PM, in an interview, NHA stated she planned to contact the resident's family to verify that Resident #22 owned a Saints jersey. She stated the resident never reported the missing jersey to her directly, but that SS had informed her about it. She confirmed she had not yet contacted the family for verification but planned to order a replacement jersey in size 2XL (extra large). However, she acknowledged that she had not verified Resident #22's size before placing the order. On 03/04/25 at 2:03 PM, in a phone interview, Resident #22's Resident Representative (RR) stated she was informed by both the resident and SS about the missing jersey. She stated the incident occurred late last year and assumed the facility had already replaced it. She confirmed that SS had contacted her and that she verified the jersey was missing. She also confirmed that the jersey was not at the resident's home. On 03/06/25, in a follow-up phone interview, the RR stated that a 2XL jersey would not fit Resident #22. She expressed concern that the facility did not contact her to confirm the appropriate size before ordering the replacement. A record review of Resident #22's inventory sheet, dated 11/25/24, documented the presence of one Saints jersey with #9 and [NAME] on it. A record review of Resident #22's Admission Record revealed an admitted [DATE] with diagnoses including Major Depressive Disorder. A record review of Resident #22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.

Based on record review and staff interviews, the facility failed to provide written notification of the reason for a resident's hospital discharge to the resident and/or Resident Representative (RR) for one (1) of (1) residents reviewed for hospitalization (Resident #18). Findings include: A record review of the Admission Record revealed the facility admitted Resident #18 on 6/10/24, with diagnoses including Acute Respiratory Failure with Hypoxia and Acute Systolic Congestive Heart Failure. A record review of the transfer/discharge letter dated 1/9/25 revealed the Resident was discharged to the hospital on 1/8/25, however, the letter did not provide a reason for the transfer/discharge. On 03/04/25 at 1:07 PM, in an interview with the Social Service Director, she confirmed it was her role to mail hospital transfer/discharge letters to the family. She stated she was not aware that the letter was required to include the reason for the transfer/discharge and confirmed with the State Agency (SA) that the letter sent to the RR for Resident #18 did not include this information. On 03/04/25 at 1:22 PM, in an interview the Administrator, stated she was not aware of any regulation requiring the facility to include the written reason for the transfer/discharge in the letters sent to the Responsible Party. She stated she believed that doing so would be a violation of the Health Insurance Portability and Accountability Act (HIPAA).

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident requiring oxygen therapy had an Oxygen in Use sign placed on the resident's door as specified in the facility policy for one (1) of four (4) days of survey observations. (Resident #107). Findings Include: A record review of the facility's Oxygen Concentrator policy, revised April 2017, revealed Policy: To administer oxygen for the treatment of certain diseases or conditions. Policy Explanation and Compliance Guidelines: 1. Care of the Resident . h. Place an oxygen warning sign on the resident's door . On 03/03/25 at 11:30 AM, an observation of Resident #107 in her room, up in a wheelchair, revealed that oxygen was flowing at 3 milliliters per hour. However, there was no Oxygen in Use signage on the door. On 03/03/25 at 11:32 AM, during an interview, Licensed Practical Nurse (LPN)#1 confirmed that there was no oxygen signage on the door. She stated that an Oxygen in Use sign should have been placed on the door upon admission on 2/17/25 to alert staff and visitors not to enter with flammable materials. On 03/05/25 at 11:45 AM, during an interview, the Director of Nursing (DON) confirmed that oxygen signage should have been placed on the door. She stated that the purpose of the signage is to alert staff and visitors that oxygen is in use to prevent fire hazards. A record review of Resident #107's Admission Record revealed an admitted [DATE] with diagnoses including Dysphagia and Shortness of Breath. A record review of Resident #107's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview.

Based on staff interviews, record reviews, and facility policy reviews the facility failed to collaborate with hospice services related to a resident's continuous plan of care for one( 1) of two (2) hospice residents reviewed. Resident #30. Findings Include: Record review of the facility's policy, Hospice Care-Facility Responsibilities, with a revision date of 4/2017, revealed, It is the policy of this facility to improve quality and consistency of care between hospice and the facility in the provision of hospice care to our residents in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Policy Explanation and Compliance Guidelines: . 2. b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for terminal illness, related conditions, and other conditions to ensure quality of care for the patient and family . Record review of the Admission Record, for Resident #30, revealed the facility admitted the resident on 5/30/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Vascular Dementia, Unspecified Severity, With Mood Disturbance. Record review of Order Summary Report, with active orders as of 11/16/2023, revealed a physician order ADMIT to hospice (Proper Name)/TERMINAL DIAGNOSIS OF COPD, dated 6/13/23 Record review of the Visit Note Report written by Hospice, revealed it did not contain the most recent visits by Hospice. The last notes were dated 8/31/23. The Hospice chart was not updated with each visit. On 11/14/23 at 1:25 PM, in an interview with Social Service (SS), she revealed she coordinates hospice serviced with the family. She stated she contacts the family when the physician recommends hospice and explains hospice to the family and the resident and answers all of their questions. She stated she does not do anything after that. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23, Section O revealed Resident #30 was coded for having received hospice care. On 11/14/23 at 2:05 PM, in an interview with the Director of Nurses (DON), she stated the Hospice nurse talks to the staff nurses. She stated no one reviews the hospice notes to see if they are receiving the notes to follow up with hospice care. She stated the facility should follow up with Hospice to coordinate the resident's plan of care. On 11/14/23 at 2:17 PM, in an interview with Registered Nurse (RN) #1/Hospice Nurse, stated she comes to the facility on ce a week to see Resident #30. She stated Licensed Practical Nurse (LPN) #2 comes once a week also. She stated she usually talks to the charge nurse. She stated the hospice office prints out the weekly notes and gives them to LPN #1/Medical Records Nurse at the facility. On 11/14/23 at 2:33 PM, in an interview with LPN #1 she stated she has never received hospice notes on Resident #30 from Hospice. She revealed she has only received records from Hospice when a resident expires. On 11/14/23 at 2:46 PM, in an interview with RN#2 / Charge Nurse, she stated she talks with the Hospice nurse when they come if she is in the facility that day. The Charge Nurse revealed she does not get written reports from Hospice and does not document what hospice tells her about the resident. On 11/14/23 at 2:54 PM, in an interview with LPN #2 from Hospice, she stated she gives the Medical Records Nurse the daily report forms when Hospice prints them out. She revealed it has been several months since they have given her reports to give to the facility, as they have a new staff member that is running behind on printing the reports. LPN #2 revealed no one from the facility has called requesting the reports.

Based on observations, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1, who had severe cognitive impairment, from exiting the facility through a window on 3/14/23 at approximately 8:00 PM. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised for approximately two (2) hours and 37 minutes, until facility staff located the resident approximately 500 hundred feet away from the facility at a local business. This concern was identified for one (1) of four (4) residents reviewed for wandering behavior and risk for elopement. The State Agency (SA) conducted a Complaint Investigation (CI) at the facility from 3/21/23 through 3/23/23. During the survey, the SA investigated the facility reported incident, CI MS# 21045, related to an elopement, and determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid. The facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility. Resident #1 was last seen by the facility staff at approximately 8:00 PM, on 3/14/23. However, at approximately 9:00 PM, during an hourly observation, Resident #1 was not located. The facility initiated a facility wide search, at which time it was discovered that the window in the resident's room had been opened, with the screen knocked out behind the blinds. At approximately 9:23 PM, facility staff called 911, the Administrator, the Director of Nurses (DON), the Medical Doctor (MD), and the Resident's Representative (RR). The facility staff checked to make sure that all other residents were accounted for, and they expanded the search to include the area surrounding the facility. Resident #1 was located by facility staff at 10:37 PM, approximately 500 feet behind the facility, at a local business. Resident # 1 was transferred per ambulance to a local hospital. The hospital found no major injuries and released the resident back to the facility. The family transported the resident to the facility at 12:45 AM on 3/15/23, and one on one supervision was initiated. Resident #1 had been admitted to the facility on [DATE], and at that time, the facility's Wandering Risk Assessment revealed, that the resident was considered a moderate risk for wandering and hourly visuals had been initiated. Immediately following the elopement, the DON began an investigation of the incident and in-servicing the staff on the facility's policy for wandering and elopement. As part of the facility's corrective actions, no employees were allowed to work until they had attended the in-service on the Elopements and Wandering Residents Policy. Facility staff assessed all current residents for elopement risk and updated the Elopement Binder kept at the Nurses Station. The Maintenance Supervisor began immediately to secure facility windows with self-tapping screws the prevent the windows from opening more than three (3) inches. The facility's failure to provide supervision to prevent the elopement for Resident #1, allowed the resident to be away from the facility, unnoticed and unsupervised until found standing behind a local business, by facility staff. This situation placed Resident #1 and other residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. On 3/23/23, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which occurred on 3/14/23 and existed at 42 CFR(s): 483.25 (d)(1)(2) - Free of Accidents, Hazards/Supervision/Device (F689) - Scope/Severity J due to the facility's failure to provide adequate supervision to prevent an elopement of Resident #1. The SA notified the facility's Administrator of the Past Noncompliance (PNC) IJ and SQC on 3/23/23 at 11:15 AM, and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 3/14/23 through 3/15/23, the SA determined the IJ to be PNC and the IJ was removed on 3/15/23, prior to the SA's entrance on 3/21/23. Findings include: Review of the facility's policy, Elopements and Wandering Residents Policy, revised 9/2017, revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . 6. d. Adequate supervision will be provided to help prevent accidents or elopements . Record review of the Facility Investigation prepared by the Director of Nurses (DON) revealed Licensed Practical Nurse (LPN) #1 noted seeing Resident #1 in his room at 8:00 PM, however, he was not in his room at 9:00 PM when Certified Nurse Aide (CNA) #1 went into Resident #1's room for an hourly observation. CNA #1 immediately reported to LPN #1 that Resident #1 was not in his room and facility staff initiated a resident headcount, with only Resident #1 unaccounted for. The staff initiated a search for Resident #1 inside and outside the facility. It was noted by staff, that behind his closed window blinds, the window was opened and the window screen was knocked out. At 9:23 PM, the local police department, the Administrator, the Director of Nurses (DON), Resident #1's Responsible Representative (RR), and his primary physician (who was also the facility's Medical Director) were notified by LPN #1, that Resident #1 could not be located. Resident #1 was located behind the facility at a local business by the Quality Assurance (QA) Nurse at 10:37 PM and transported by ambulance to the local hospital emergency department (ED) for assessment. As the resident had no major injuries, he returned to the facility at 12:45 AM on 3/15/23, by family. An observation on 3/21/23 at 9:00 PM, revealed the Northwest corner of the facility property was located approximately 500 feet from the intersection of a highway and adjacent street. The property was situated on the corner lot and backed up to a densely wooded area between the facility property and the backyards of the residences and the local business, which faced the next closest parallel street to the north. There was only one car seen driving down the street in front of the local business where Resident #1 had been located. The facility property was well lit with multiple streetlights on the property. The wooded area was very dark. There was a five-foot-high chain link fence around the facility property; the gates at the Northwest and Northeast corners of the property, which served the driveway that ran behind the facility (and provided service for the kitchen and other delivery and utility vehicles) were both wide open. There were houses and buildings across the street from the facility with streetlights in their yards on the East and West sides. Observation of Resident #1's room window revealed the bottom edge of the window was four (4) feet and seven (7) inches above the ground. The parking lot on the East side of the building was well lit by the streetlight and the streetlights of neighboring properties. The grassy yard area between the building and Street on the South side of the property were well lit by streetlights. Review of the weather report during investigation, revealed that the temperature during the time of Resident #1's elopement had been approximately 55 degrees Fahrenheit with no rain noted, clear with a full moon. Weather report for 1/14/23 was obtained from https://www.timeanddate.com. On 3/21/23 at 10:00 PM, during an interview with Registered Nurse (RN) #1 she confirmed she was on duty at the facility on the 6:00 PM to 6:00 AM shift on 3/14/23. She stated that at approximately 9:00 PM, LPN #1 informed her that Resident #1 was not in his room. RN #1 confirmed that all staff members were notified of the missing resident and a search was conducted beginning inside the building and continued outside the building. She reported that LPN #1 had contacted the local police department, Resident #1's primary physician, the resident's RR, the DON, and the Administrator. RN #1 said that she was notified at approximately 10:40 PM, that Resident #1 had been located and was taken to the local hospital emergency department. She confirmed the DON conducted an In-Service on the facility's Elopements and Wandering Residents Policy, the evening of 3/14/23, for all staff present and announced that one hundred percent (100%) of all staff were required to complete the In-Service training prior to working at the facility again. RN #1 noted she had observed the Maintenance Supervisor at the facility securing windows in resident rooms on the evening of 3/14/23 and early hours of 3/15/23. The nurse confirmed Resident #1 returned to the facility from the local ED at approximately 12:45 AM on 3/15/23, and orders were received to place the resident on one-on-one monitoring. She stated she had not noted any change of behavior in Resident #1 since the incident. On 3/21/23 at 10:30 PM, in an interview the Administrator, he confirmed he was notified at approximately 9:25 PM on 3/14/23, that Resident #1 had exited the facility through the window in his room and the staff had not located him. He stated the facility admitted Resident #1 on 1/20/23. Upon admission, the resident had been assessed for wandering/elopement risk and was deemed a Moderate elopement risk and the staff had been making hourly visual observations of the resident. He stated that he confirmed LPN #1 had conducted a headcount of all residents and that Resident #1 was the only resident unaccounted for and all appropriate notifications had been made per facility policy. He stated that at approximately 10:40 PM, he was notified that the resident was located and was being taken to the local ED for assessment and treatment as needed. He confirmed that the facility immediately started in-service training for all staff regarding missing residents and elopement policy and procedures. He stated Resident #1 was changed from hourly monitoring to one-on-one monitoring and that the Maintenance Supervisor had installed window stops on all resident windows which allowed the windows to open no more than three (3) inches. He revealed he had attended a Quality Assessment and Performance Improvement (QAPI) committee meeting on 3/15/23, and that all committee members, including the facility Medical Director were in attendance. During the meeting, the Elopement and Wandering Residents policy was reviewed and the incident, including interventions to provide for residents' safety and the prevention of future elopements. On 3/22/23 at 11:40 AM, an interview with the Maintenance Supervisor revealed, that he was made aware of the elopement of Resident #1 on 3/14/23 at approximately 9:30 PM and had reported to the facility and assisted in a search for the resident. He stated he arrived at the facility approximately five (5) minutes after the Administrator notified him of the elopement. Upon his arrival, he noted he immediately went and looked at the resident's window on the outside and then walked the streets surrounding the building with a flashlight. He said he saw all Department Heads, city police, sheriff's department personnel and volunteer firefighters searching on foot or in cars. He confirmed Resident #1 was located at approximately 10:30 PM, and after he had been notified, he went to work placing self-tapping screws into the window sash on each window of each resident room in the facility, which prevented windows from opening more than three (3) inches. He said that since then he has placed self-tapping screws in all windows of all common areas as well, which included the dining room and the activity room. On 3/22/23 at 12:10 PM, during an interview with the QA Nurse, she confirmed she had been notified at approximately 9:30 PM on 3/14/23, by LPN #1 of the elopement of Resident #1. She stated she reported to the facility and participated in the search. She revealed she located him approximately five hundred (500) feet behind the facility standing at a local business. She explained that the back of the facility property backed up to the back of the business. She said Resident #1 was wearing a red flannel button up shirt, gray warm-up pants, and black diabetic shoes with Velcro closures. She stated that Resident #1 was then transferred to the local hospital ED. The QA Nurse confirmed that she had attended an in-service about missing residents, elopement and supervision after Resident #1 eloped on 3/14/23. She confirmed she had taken part in an elopement drill as well. She noted that Resident #1 remains on one-on-one monitoring since his return from the ED on 3/15/23. The QA Nurse also confirmed that she had attended a QAPI committee meeting on 3/15/23, during which the facility policy, Elopements and Wandering Residents Policy was reviewed, along with the incident, and the interventions with methods for measuring efficacy. On 3/22/23 12:17 PM, a telephone interview with the facility Ombudsman revealed he had been notified of the elopement of Resident #1 and had visited the facility on 3/15/23. He stated he had visited Resident #1 and observed that a CNA was with the resident. He confirmed the resident had no visual injuries. On 3/23/23 at 5:20 PM, an interview with LPN #1, she confirmed she was working the 6:00 PM to 6:00 AM shift at the facility on 3/14/23, and at approximately 9:00 PM, CNA #1 reported to her that Resident #1 was not in his room. At that time, LPN #1 notified all staff present that Resident #1 was missing. She stated that she had never observed Resident #1 exit seeking. LPN #1 confirmed that she had attended an in-service about missing residents, elopement, and supervision, after Resident #1 eloped on 3/14/23. She confirmed she had taken part in an elopement drill as well. She also confirmed that Resident #1 had been on one-on-one monitoring since his return from the ED on 3/15/23. On 3/23/23 at 5:35 PM, an interview with the DON revealed she was made aware of the elopement of Resident #1 on 3/14/23 at approximately 9:23 PM, and had called other nursing staff to request assistance in locating Resident #1. Upon arrival at the facility, she confirmed she had interviewed staff and confirmed the safety of the other residents. Once the resident was located, she confirmed LPN #1 had made notifications to the primary physician and RR to notify them that the resident had been located and transferred to the local hospital ED. The DON confirmed she attended a QAPI committee meeting on 3/15/23 at 2:00 PM, during which the elopement of Resident #1 was discussed, and the Elopement policy was reviewed with no changes recommended to the policy. She stated the committee reviewed the interventions and staff education efforts and discussed monitoring the efficacy of the interventions enacted to prevent further elopements. She revealed she and the MDS Nurse reviewed/reassessed the fifty (50) current residents and updated the wandering/elopement assessments and binder. She stated staff education/In-Services regarding wandering/elopement began the night of the elopement and continued until all staff had received the education prior to working at the facility. She confirmed she reported the incident to SA at approximately 5:00 PM on 3/15/23. She stated elopement drills were completed quarterly for both shifts and In-Service training was provided at least twice a year which included elopement drills. She stated the facility had scheduled elopement drills for all shifts monthly and planned to review results and determine future frequency. The DON reported the Interdisciplinary Team (IDT) reviewed the Wandering/Elopement Binder every Tuesday during the Weekly High-Risk Meeting. She confirmed that she had been involved with the MDS Nurse in the update of the Care Plan for Resident #1, on 3/14/23. Record review of the Admission Record for Resident #1 revealed, the facility admitted Resident #1 on 1/20/23. Resident #1's medical diagnoses included Vascular Dementia with Other Behavioral Disturbance and Senile Dementia of the Brain. Record review of the Wandering Risk Assessment, completed on 1/20/23, revealed Resident #1 had a moderate risk for wandering. Record review of the Care Plan for Resident #1 revealed it was updated on 3/14/23, to reflect the 3/14/23 elopement, and new interventions included one on one monitoring, a secured window, and use of the Wander ID band (red band) to his wrist. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/27/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 which reflected the resident was unable to complete the interview. The Assessment for Mental Status revealed, Resident #1 exhibited a short-term memory problem, and his Cognitive Skills for Daily Decision Making were severely impaired. Section E revealed that Resident #1 had exhibited wandering behavior one (1) to three (3) days of the seven (7) days reviewed. Record review of the QAPI committee meeting sign in sheet and Corrective Action Plan dated 3/15/23 at 2:00 PM revealed the meeting was attended by the Administration, DON, all department heads, and facility Medical Director. Review revealed the committee reviewed the facility policy titled Elopements and Wandering Residents Policy and the incident of the elopement of Resident #1 on 3/14/23 and formed a plan to ensure residents' safety and prevent elopements. The facility implemented the following Corrective Action Plan prior to the SA's entrance on 3/21/23: CORRECTIVE ACTIONS Resident #1 was last seen at approximately 8:00 PM. He was unable to be located at the 9:00 PM visual observation check. The facility interior and exterior search was conducted with the census and all other residents were accounted for. The facility search was expanded, and he was located by facility staff at approximately 10:37 p.m. at a local business near the facility. The Administrator and Director of Nurses were notified at 9:23 PM on 3/14/2023. The resident representative, his daughter, was notified at 9:29 PM on 3/14/2023. The resident's Physician was notified at 9:29 PM on 3/14/2023. Resident's care plan was updated on 3/14/2023, by the Minimum Data Set Coordinator nurse to include increased monitoring. An in-service was started on 3/14/2023, by the Director of Nursing for the staff that were available in the facility on the facility's wandering and missing resident policy, the facility search, review of the doors including codes and locks, evaluating the residents of being at risk and wandering, the one on one intervention to decrease the risk of elopement and the elopement risk binders and contents. The Staff Development Nurse is continuing this in-service, and staff will not be allowed to work until they have completed this in-service. Post event: 1. Resident # 1 was sent to the emergency room by ambulance and returned to the facility at 12:45 am on 3/15/2023. He was accompanied by his daughter. He did not have any injuries. Resident # 1 was placed on one on one observation on 3/15/2023 and continues to receive one on one observation. 2. A skin audit was completed on 3/15/2023, by the Licensed Practical Nurse # 1 and there were no injuries noted. 3. Pain monitoring was completed on 3/15/2023, after the emergency room visit by the Licensed Practical Nurse #1 and no pain was voiced by resident #1. 4. The Maintenance Director secured all resident rooms windows and ensured they only open 3-4 inches on 3/15/2023. The security company came to the facility on [DATE], to check the exit doors to ensure they were secure. 5. On 3/15/2023, the Director of Nurses and the Minimum Data Set Coordinator and the interdisciplinary team performed an audit of the 50 current residents to identify risk for wandering and elopement. 6. Six (6) residents were identified to be at risk for wandering and elopement. The wandering and elopement binder were reviewed by the Social Service Director on 3/15/2023, to ensure that the residents had current pictures with current information, updated care plans and checked bracelet placement and updated wandering risk assessments. The wandering risk assessments will be completed on new admissions, quarterly and upon significant change in status. The facility Maintenance Director is monitoring the windows weekly times four weeks which started on 3/15/2023. On 3/15/2023, the facility Quality Assurance Performance Improvement Committee conducted an emergent meeting and reviewed the facility policy on wandering and elopement. There were no changes made to the policy. The Quality Assurance Performance Improvement team reviewed the process that was done to secure the windows. The windows will open 3-4 inches. The team also reviewed the process for checking the doors which will be continued to be done weekly to ensure that they are working properly this is being done by the Maintenance Director. The residents that are identified for wandering and elopement will be observed for the presence of the alert bracelet five times weekly by the Social Service Director. The residents that are identified as being at risk will be reviewed weekly in the interdisciplinary high-risk meeting to identify any changes that need to be made to their plan of care. The attendees of the Quality Assurance Performance Improvement Committee were the Administrator, Director of Nursing, Infection Preventionist, Staff Development, Maintenance Director, and the Medical Director. Facility will increase the frequency of the Elopement drills. The facility alleged that the immediate jeopardy was removed on 3/15/2023 at 2:00 PM. VALIDATION The State Agency (SA) validated the facility's corrective action: 1. The SA validated through record review of the local hospital emergency department (ED) report dated 3/14/23 and facility Progress Notes for Resident #1, and interview that he was transferred to the ED by ambulance, with no injuries noted, and returned to the facility at 3/15/23 at 12:45 AM via family vehicle. 2. The SA validated through record review of Progress Notes for Resident #1, and interview that a skin audit was completed for Resident #1 by LPN #1 upon return to the facility on [DATE] with no injuries noted. 3. The SA validated through record review of Progress Notes for Resident #1, and interview that a pain audit was completed for Resident #1 by LPN #1 upon return to the facility on [DATE] with no complaints of pain noted. 4. The SA validated through observations and interviews that all resident room windows had been secured and opened no more than four (4) inches, and that the security company came to the facility on [DATE] and assessed exit doors. 5. The SA validated through interviews that the DON and MDS Coordinator along with the Interdisciplinary Team (IDT) audited all residents for wandering and elopement risk. 6. The SA validated through record review of assessment documentation, Elopement Binder, and interviews that six (6) residents were identified to be at risk for wandering and elopement, the Elopement Binder and Care Plans were updated, and wander bracelets were correctly placed for the six (6) identified residents by the Social Service Director on 3/15/23. The SA validated through record review and interviews that the facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance and Performance Improvement (QAPI) meeting on 3/15/23. The actions taken to ensure the provision of adequate supervision to meet Resident #1's needs were verified was evidenced by verification of the in-services, re-assessments, elopement drills, wander bracelet checks, and audit tools. The SA verified that Resident #1's Care Plan was updated on 3/14/23 to reflect elopement risk and one-on-one observation. The SA verified that the wander bracelet was applied to Resident #1's wrist and that Resident #1's was monitored constantly by one-on-one monitoring. The SA also validated through Resident #1's monitoring documentation and interview that Resident #1 was on constant one-on-one observation. The SA validated that the Social Services Director had updated the Elopement Binder. The SA validated through interviews and record review of In-Service Sign-In sheets that Elopement Drills were conducted on all shifts with employees. The SA validated through interviews and sign-in sheets that beginning 3/14/23, the DON conducted mandatory in-services with all facility staff on elopement and missing resident policy, protocol, and procedures. The SA validated that all corrective actions to remove the Immediate Jeopardy were completed as of 3/15/22, prior to entrance.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents had readily available and reasonable access to personal funds seven days a week for seven (7) of 29 sampled residents reviewed for personal funds. Resident #2, Resident #3, Resident #4, Resident #17, Resident #19, Resident #20, and Resident #22. Findings include: A record review of the facility's policy Resident Personal Funds/Personal Effect, undated, revealed A. Policies: 1. Residents have the right to manage their own financial affairs .10. Residents will have access to personal funds daily during normal business hours . On 03/21/22 at 3:14 PM, during an interview with Resident #3, she told the State Survey Agency (SSA) that she cannot get money on the weekend because there is no one at the facility to get her money. The Business Office Manager (BOM) is the only one that gives the residents their money and she is not here on the weekends. On 03/22/22 at 10:00 AM, during the Resident Council Meeting, Resident #3, who is the Resident Council President, reported the personal funds are only available Monday through Friday until 5 PM when the BOM is at the facility. She said she must ask for money either on Friday or Thursday before the weekend to assure she has money if needed. She explained no one has ever told her she could have someone call the BOM when she is not here, and she would come give her money from her personal funds. During the meeting, all residents in attendance confirmed that money is only available from the BOM and is not available on evenings or weekends. The residents reported that no one has ever told them that personal funds should be available every day. At 10:10 AM on 03/22/22, Resident #2 was present in the Resident Council meeting. She explained she was told she could not get money on weekends because nobody is available to give out the money. The BOM had told her if she needs money for the weekend, to get it on Friday. She explained she was never told to have a nurse to call the BOM to come to the facility and give them money on the weekend. On 03/22/22 at 10:15 AM, Resident #4 was in attendance in the Resident Council meeting. He reported he has a personal fund account at the facility and gets money only on weekdays because the BOM is the only one who gives out money and she is not at the facility after 5 o'clock on weekdays and not at the facility at all on the weekends. On 03/22/22 at 10:20 AM, Resident #17 attended the Resident Council meeting. During the resident council meeting, he confirmed he has a personal fund account at the facility, but can only get his money while the BOM is working. At 10:25 AM on 03/22/22, Resident #19 was present in the Resident Council meeting. She explained she has a trust fund account at the facility, but she is not able to get her money on the weekends because the business office is closed. She reported she must get any money she wants for the weekend by Friday. On 03/22/22 at 10:30 AM, during an interview with Resident #20, she explained she can get her money during the weekdays only and not on the weekends. At 10:35 AM on 03/22/22, Resident #22 explained she has always had a personal fund account at the facility and can get money when she asks for it on the weekdays. She reported the BOM is the only one who gives out money and she is not available in the evening or on weekends. On 03/23/22 at 11:05 AM, during an interview with the BOM, she reported currently she is the only staff member at the facility that residents can get personal funds from. She confirmed residents don't have access to their personal funds after 5:00 PM on the weekdays and not on weekends. But, if someone would call her, she would come to the facility and get the resident their money because she doesn't live far way. She explained she has never told any residents or nurses to call her if they needed money on a weekend. If she is off work for any reason, the Administrator or a staff member will step in and give residents their money per request. On 03/23/22 at 3:35 PM, during an interview with the Director of Nursing, she confirmed the BOM has always been the only staff member that residents get personal funds from unless she is not here. She confirmed the residents do not have any access to personal funds after 5:00 PM on weekdays and not at all on weekends. A record review of the facility's Trust Transaction History dated March 24, 2022, revealed all residents in attendance of the Resident Council meeting have personal trust fund accounts. Record review of Resident #2's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/09/2022 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Record review of Resident #3's Quarterly MDS with ARD of 03/09/2022 revealed a BIMS score of 15, which indicated the resident is cognitively intact. Record review for Resident #4's Quarterly MDS with ARD of 03/11/2022 revealed a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #17's Quarterly MDS with ARD of 01/18/2022 revealed a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #19's 5-day Prospective Payment System (PPS) MDS with an ARD of 01/17/2022 revealed a BIMS score of 15, which indicated the resident is cognitively intact. Record review of Resident #20's 5-day PPS MDS with ARD of 01/17/2022 revealed a BIMS score of 14, which indicated the resident is cognitively intact. Record review of Resident #22's 5-Day PPS MDS with ARD of 01/19/2022 revealed a BIMS score of 15 which indicated the resident is cognitively intact.

Based on observation, staff interviews, record reviews, and Resident Assessment Instrument (RAI) review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of 29 residents reviewed for MDS accuracy. Resident #43. Findings include: A record review of a typed letter presented by the facility, undated, with the facility stamp revealed For MDS assessments, we follow the instructions of the RAI (Resident Assessment Instrument) manual. A record review of Center of Medicare and Medicaid Services RAI Version 3.0 Manual dated October 2019, revealed K0300: Weight Loss . Steps for Assessment this item compares the resident's weight in the current observation period with his or her weight at two snapshots in time: At a point closest to 30-days preceding the current weight and At a point closest to 180-days preceding the current weight . For Subsequent Assessments 1. From the medical record, compare's the resident's weight in the current observation period to his or her weight in the observation period 30 days ago . Coding Instructions . Code 2, yes not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the past 180 days, and the weight was not planned and prescribed by a physician .K0510: Nutritional Approaches . definitions .feeding tube presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system. Examples include but are not limited to nasogastric tubes, gastrostomy tubes, jejunostomy tubes, and percutaneous endoscopic gastrostomy (PEG) tubes . Coding instructions for Column 2 check all nutritional approaches performed after admission/entry or reentry to the facility and within the 7-day look back period. Check all that apply . K0510B, feeding tube-nasogastric or abdominal (PEG) . K0710: Percent intake by artificial route . Steps for assessment 1. Review intake records to determine actual intake through [MEDICATION(S)] or tube feeding routes . Coding instructions select the best responses 1. 25% or less . On 03/21/22 at 10:47 AM, the State Survey Agency (SSA) observed Resident #43 sitting in a high back wheelchair, with a PEG tube tube observed protruding from underneath his shirt. The resident explained he had a stroke and came to the facility for therapy and had the feeding tube inserted after the stroke. He reported that although he can now eat, he continues to have the feeding tube and receives water flushes through the tube. At 2:26 PM on 03/21/22, during an interview with Resident #43, he explained since he was admitted to the facility in November of 2021, he has lost maybe five (5) pounds. A record review of Resident #43's Admission Record revealed the facility admitted Resident #43 on 11/22/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #43's Quarterly MDS with an Assessment Reference Date (ARD) of 02/21/2022, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated he is cognitively intact. For the question Loss of 5% or more in the last month or 10% or more in the last 6 months was checked as yes, which indicated he had significant weight loss. Feeding tube-nasogastic or abdominal (PEG) was not checked, which would indicate Resident #43 did not have a PEG tube during the seven day look back period. A record review of Resident #43's Weights and Vitals Summary revealed on 11/22/2021, Resident #43 weighed 208.0 pounds (lbs.); on 01/17/2022, he weighed 203.4 pounds which is a -2.21 % Loss; and on 12/13/2021, he weighed 204.4 lbs. On 01/17/2022, the resident weighed 203.4 pounds which is a -0.49 % Loss for a 30 day period. A record review of Resident #43's Order Summary Report with Active Orders as of : 3/24/2022 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/21/22 at 3:30 PM, during an interview with the Director of Nursing (DON), she confirmed Resident #43 does have a PEG tube, but only receives water flushes and no feedings. The DON reviewed Resident #43's most recent MDS with and ARD of 02/21/2022 Section K510 and K0710 and confirmed the feeding tube assessment by artificial route was coded incorrectly. The DON verified the assessment is a MDS discrepancy. On 03/21/22 at 3:34 PM, during an interview with the MDS Coordinator LPN #1, she explained she is new to MDS has only been working in MDS at the facility for one month. She reviewed Resident #43's quarterly MDS and confirmed the tube feeding by artificial route assessment was coded incorrectly. On 03/24/22 at 09:10 AM, during an interview with the Dietary Manager, she explained she completes the section of the MDS for nutrition which is Section K, swallowing and nutritional status. She reviewed the Quarterly MDS with an ARD of 02/21/22 for Resident #43 and confirmed she completed the assessment on 2/02/2022. The Dietary Manager first reviewed section K0300 weight loss, which was coded weight loss not on prescribed weight-loss regimen. She reviewed Resident #43's weights and reported she used the weight for 01/17/22 of 203.4 and compared to the weight of admission on 208.0 and explained that is not a 5% weight loss and the assessment was coded in error. She also reviewed section K510 and confirmed it is also coded incorrectly because the resident does have a PEG tube in his stomach and was admitted with the PEG tube. She explained she would have included the water flushes on part K710. She reported she marked all the sections in error and must had been having a bad day. She reported the assessment for Quarterly MDS is a discrepancy and does not accurately reflect the resident's status. She explained after she completes her assessments for the MDS the MDS coordinator reviews her assessments and then the DON reviews and signs off before submitting MDS, and if there are any discrepancies noted they will come back to her and ask her to make corrections. At 9:35 AM on 03/24/22, during an interview with the DON, she reported she had to train the MDS Coordinator, and she does not know everything about MDS, but both worked together to get MDS assessments completed and submitted. During training, she would review the MDS assessment for accuracy with the coordinator, but now the MDS Coordinator reviews the MDS assessments herself and then she will sign off for completion. She confirmed the assessment for Resident #43's nutrition was coded incorrectly and is a MDS discrepancy. She confirmed Resident #43 has not had a significant weight loss of 5% in a month, after reviewing the resident's weights since admission. She reported the facility uses the RAI manual for instructions on completing MDS assessments.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to secure the catheter strap and failed to use the correct technique to insert an indwelling catheter for one (1) of five (5) care observations. Resident #1. Findings include: Record review of the facility's policy, Policy: Catheterization of Female, dated 2021, revealed, Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma. Policy Explanation and Compliance Guidelines .Procedure for Catheterization of a Female .7.g. Place the catheter tray on the sterile towel (under pad) and open the lubricant container. Avoid contamination .u. For indwelling catheterization: .ii. Secure the catheter to the resident's thigh . On 3/23/22 at 9:25 AM, the State Agency (SA) observed indwelling catheter care performed by Certified Nursing Assistant #1 (CNA) and CNA #2. There was no leg strap to secure the catheter. CNA #1 stated that she always tells the nurse when the resident does not have a leg strap on. On 03/23/22 09:28 AM, in an interview with RN #2, she confirmed there was no leg strap on the catheter tubing last night or this morning. She stated she forgot to get one and put it on. She confirmed the purpose of the leg strap is to keep the catheter in place and to keep it from becoming dislodged and causing trauma or discomfort by tugging on the tubing. On 3/23/22 at 10:10 AM, the SA observed Resident # 1's indwelling catheter being inserted per physician orders, by Registered Nurse #1 (RN)/Charge Nurse. RN #1 did not open the lubricant and add it to the sterile tray. She asked CNA #1 to open the packet of lubricant. As CNA #1 held the lubricant packet in her hand, RN #1 attempted to insert the catheter tip into the lubricant packet. She allowed the sterile catheter tip to come in contact with the contaminated outer portion of the lubricant packet. RN #1 did not secure the catheter with a leg strap. On 3/23/22 at 10:40 AM, in an interview with RN #1, she stated she probably did a lot of things wrong and she knows she messed up. She confirmed she did not inflate the balloon before she inserted the catheter. She also confirmed she should have put the lubricate in the sterile tray. She stated her actions could cause the resident to get a bacterial infection. On 3/23/22 at 4:33 PM, in an interview with the Director of Nursing (DON), she stated RN #1 did not follow policy on indwelling catheter insertion. She stated RN #1 could have caused the resident to get an urinary tract infection and she confirmed the purpose of the leg strap is to keep the catheter in place and keep it from coming out. A record review of the Admission Record revealed the facility admitted Resident #1 on 10/7/2016. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Medication Review Report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/22 revealed a Brief Interview of Mental Status (BIMS) was not completed. A record review BIMS Staff Interview - dated 12/15/21, revealed a BIMS score of 99. Resident was unable to participate in the cognition interview. A record review of the facility's Inservice for the Month of January 2022 with topics including Infection Control w(with)/Universal Precautions revealed RN #1 signed the inservice on 1/20/22 which indicated she received training on infection control. A record review of the facility's Inservice for the Month of October 2021 with topics including Cath and G-tube Insertion revealed RN #1 signed the inservice on 10/7/21 which indicated she received training on catheter insertion.

Based on observation, resident interview, staff interview, and facility statement review, the facility failed to obtain approval from the Resident Counsel related to timing of meals, evening meals to morning meals, and provide a substantial snack between those meal times. Based on two (2) of four (4) days observed, and 10 Resident Counsel members interviews. Findings Include: Review of the facility statement, concerning Meal times, revealed Breakfast started at 7:00 AM and dinner started at 4:00 PM. There is a 15 hour lapse in between dinner and breakfast, unless a substantial snack was served in between. During resident group meeting, on 06/25/2019 at 10:09 AM, the members of the Resident Council complained about supper time. The council said that there's too much time between supper and breakfast. The group said supper comes out at 4:00 PM, and breakfast is at 7:00 AM. Resident #12 said he talked to the Administrator and the Director of Nursing (DON) and asked them if the facility could provide the residents a large breakfast, small lunch and a large dinner to hold the residents until breakfast the next day. Resident #41, the Resident Council President, said she has been in other facilities and she had never eaten dinner that early. The residents also stated they did not eat dinner at 4:00 PM at home. Observation, on 06/25/19 at 3:40 PM, revealed the tray line temperatures were completed and the first trays to the rooms came out at 4:03 PM. During an interview, on 06/26/19 at 2:23 PM, the Dietary Manager confirmed the evening meal comes out at 4:00 PM and breakfast starts at 7:00 AM. The Dietary manager said the resident will get a snack in between meals if they ask for one. the Dietary manager confirmed the residents that did not ask for a snack did not get one. Observation, on 06/26/2019 at 4:00 PM, confirmed the supper meals came out on the floor to be served. During an interview, on 06/30/19 at 3:35 PM, the Administrator confirmed the evening meals started at 4:00 PM and breakfast at 7:00 AM. The Administrator said the residents had never complained about not having enough food to last through the night. Members that were present at Resident Group Meeting was Resident #3, #11, #12, #19, #23, #30, #39,#41, #45, and #52.

Based on record review, staff interview, and policy interview the facility failed to accurately complete the Pre-Admission Screening and Resident Review (PASRR) on one (1) of three (3), PASRRs reviewed, Resident #29. Findings Include: Record review of the Preadmission Screening and Resident Reviews (PASSR) program/policy revealed the PASSR level II is advocacy program mandated by the federal centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness and intellectual/developmental disabilities are appropriately placed and receive necessary services to meet their needs. PASSR Level ll guidelines require that nursing homes address behavioral health needs of residents, including residents with Mental Illness (MI), Intellectual disability (ID) and conditions related to intellectual disability (referred to in regulatory language as related conditions (RC). These are the target conditions for PASSR. Behavioral health needs, when present, must be identified through a comprehensive evaluation process referred to as Preadmission Screening and Resident Review evaluations assessment: whether the individual requires the level of care provided in an institutionally based setting and if so whether an NF is the appropriate institution. Once a person with a suspected or known [DIAGNOSES REDACTED]. The term PASSR is used interchangeably with the term Level ll evaluation. The Level l is the initial screen which identifies persons who are subject to Level ll evaluations. Record Review of the Preadmission Screen and Resident Review (PASSR) for Resident #29, documented upon admission (02/08/17) revealed the resident did not have a mental illness noted upon admission. Record Review of Resident #29's Admission physician's orders [REDACTED]. Record Review of the physicians Orders Dated 06/26/19, revealed the resident was ordered [MEDICATION NAME] 25 mg twice a day and 50 mg at bedtime for [MEDICAL CONDITION]. During an interview, on 06/26/2019 at 3:30 PM, the Social Services Director confirmed The PASSR on admission was inaccurate. The Social Services Director confirmed Resident #29 was admitted with a psychiatric [DIAGNOSES REDACTED]. A review of the facility's Face Sheet revealed the facility admitted Resident #29 on 02/08/2017, with diagnoses, which included [MEDICAL CONDITION], Anxiety and [MEDICAL CONDITION] Fibrillation. A review of Resident #29's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2019, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment.

Based on record review, staff interview, and facility policy review the facility failed to notify the family in writing and notify the ombudsmen of a transfer for an acute hospitalization stay for one (1) of three (3), hospitalization s reviewed, Resident #53. Findings Include: Review of the Bed Hold/ Temporary Leave Policy revealed at the time of transfer for hospitalization or therapeutic leave, the facility will provide the resident and or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Record review of the Minimum Data Set (MDS) revealed Resident #53 was sent to the hospital with anticipation to return on 04/27/2019, 05/06/2019, and 05/31/2019. There was no documented evidence of written notification to the family and Ombudsman of the transfers for Resident #53. During an interview, on 06/26/19 at 10:33 AM, the Social Worker revealed the facility had not notified the family in writing in a language they could understand, of the transfers for Resident #53. The Ombudsmen also was not notified in writing, of the resident going to the hospital. A review of the facility's Face Sheet revealed the facility admitted Resident #53, on 04/25/2019, with diagnoses, which included Major [MEDICAL CONDITIONS] Fibrillation and Hypertension. A review of Resident #53's Quarterly MDS, with an Assessment Reference Date (ARD) of 05/31/2019, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact.

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to assess a resident for self-administration of eye drops, Resident #39, for one (1) of 24 residents observed during the initial pool process. Findings include A review of the facility policy titled, Self-Administration of Medication Policy, dated (MONTH) (YEAR), revealed the interdisciplinary team was to determine if the practice (self-administer medications) was safe and would assess the resident. The policy revealed the team would determine before the resident exercises this right. Review of the medical record revealed no assessment for Resident #39 to self-administer medications. An observation, on 6/14/19 at 11:05 AM, revealed a small green bottle of Refresh Eye Drops on Resident #39's bedside table. The bottle of eye drops did not have a label or name on it. An interview at this time with Resident #9 revealed the Refresh eye drops were hers and given to her by the eye doctor. Resident #39 said the nurse at the facility did not give the eye drops to her and the nurses don't know about it. A review of Resident #39's Admission Record revealed the facility admitted the resident on 12/05/18. A review of Physician's Orders for Resident #39 revealed an order, dated 12/05/18, for Refresh Tears solution one (1) drop both eyes every eight (8) hours as needed for [MEDICAL CONDITION]. The eye drops did not have an order to self-administer or leave at the bedside. A review of Resident #39's Baseline Care Plan, dated 12/05/18, section D, Self Administer Medications, was marked yes. The baseline care plan was signed by the Director of Nursing (DON) on 12/05/18. A review of Resident #39's comprehensive care plan revealed no mention of eye drops or the resident self-administering medications. An interview, on 06/26/19 at 3:17 PM, with the DON, revealed she was aware of Resident #39 having eye drops in her room and said the assessments would have been done by the MDS nurse. Further interview on 06/26/19 at 4:09 PM, with the DON, revealed the only assessment completed related to self-administering medications was documented on Resident #39's form Baseline Care Plan on admission. On 06/27/19 at 9:11 AM, an interview with Licensed Practical Nurse (LPN) #2 revealed she had been Resident #39's nurse for about a year. LPN #2 said she did not know the resident had eye drops in her room that she was self-administering. LPN #2 also said she did not believe the resident to be capable of administering eye drops with proper use or technique. LPN #2 said if she had seen them she would have removed the medication, notified the family, and the charge nurse. On 06/27/19 at 10:37 AM, an interview with Registered Nurse (RN) #1/MDS Nurse, revealed she started working here in (MONTH) of (YEAR) and said she was familiar with Resident #39. RN #1 said she had also completed Resident #39's last MDS assessment. She stated the resident was known to have eye drops, but the inter-disciplinary team (IDT) team did not complete an assessment and did not care plan Resident #39 using the eye drops by herself. RN #1 also stated that Resident #39 was very independent and when the staff would remove the eyedrops, the resident or her family would bring the eye drops back. RN #1 stated the care plan for Resident #39 would not address the issues of self-administering or Resident #39 continuing to bring more eye drops to her room. RN #1 then said the care plan should address Resident #39's continued self use of the eye drops and if an assessment determined that resident could self administer, there would need to be a care plan for that as well. A review of Resident #39's admission Minimum Data Set (MDS), with an Assessment Reference Date of 12/12/18, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident 39 had a moderate cognitive impairment. A review of Resident #39's MDS, with an ARD date of 06/03/19, revealed a BIMS with a score of 15, which indicated no cognitive impairment.

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to develop a care plan related to self-administered eye drops for one (1) of 22 resident care plans reviewed, Resident #39. Findings include: A review of the facility policy titled, Reviewing and Revising the Care Plan, revised 02/2017, revealed the Comprehensive Care Plan must be developed within seven (7) days after the completion of the comprehensive assessment, and that the care plan would be prepared by the inter-disciplinary team that had determined the resident's needs. A review of Resident #39's current Comprehensive Care Plan revealed no mention of eye drops, or the resident self-administering medications. A review of Resident #39's Baseline Care Plan, dated 12/05/18, section D, Self administer medications, was marked Yes. The baseline care plan was signed by the Director of Nursing (DON) on 12/05/18. An observation and interview, on 06/24/19 at 11:05 AM, revealed a small green bottle of Refresh eye drops on Resident #39's bedside table. The bottle did not have a label or name on it. Resident #39 revealed the Refresh eye drops were hers, that were given to her by her eye doctor, and the nurse at the facility did not administer the eye drops to her. A review of Physician's Orders for Resident #39 revealed an order, dated 12/05/18, for Refresh tears solution one (1) drop both eyes every eight (8) hours as needed for [MEDICAL CONDITION]. The eye drops did not have an order to self-administer or leave at bedside. In an interview, on 06/26/19 at 3:17 PM, the DON said she was aware of Resident #39 having eye drops in her room, and said the assessments would have been done by the Minimum Data Set (MDS) nurse. Upon further interview, on 06/26/19 at 4:09 PM, the DON stated the only assessment completed related to self-administering medications was documented on Resident #39's Baseline Care Plan on admission. On 06/27/19 at 10:37 AM, an interview with Registered Nurse RN #1/MDS Nurse, revealed she was familiar with Resident #39 and had completed Resident #39's last MDS assessment. She stated the resident was known to have eye drops, but the inter-disciplinary team (IDT) team did not complete an assessment and did not care plan Resident #39 using the eye drops by herself. RN #1 said the care plan should address Resident #39's continued self-use of the eye drops and if an assessment determined that resident could self- administer, there would need to be a care plan for that as well.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection while delivering ice to resident rooms for one (1) of three (3) observations for one (1) of four (4) days of survey. Findings include: Review of the facility policy titled, Ice machines and Ice Storage Chests, dated 07/17, revealed to help prevent contamination of ice machines, staff shall follow these precautions that included to keep the access doors or storage container tops closed when not in use and keep the ice scoop in a covered container when not in use. An observation, on 06/24/19 at 2:54 PM, revealed Certified Nursing Assistant (CNA) #1 was passing ice to resident rooms using an ice chest and scoop. CNA #1 opened the ice chest and reached inside the chest for the ice scoop. She scooped the ice into the cup and set the ice scoop back in the ice chest with the ice, left the ice chest open, and walked into a resident's room. CNA #1 came back to the cart and picked up the scoop out of the ice chest, placed the scoop in a bag, and closed the lid. An interview at this time with CNA #1 confirmed she left the ice chest open with the ice scoop in the ice. CNA #1 said the facility policy was to place the scoop in the bag separate from the ice when not using it. Review of the Employee Inservice Attendance Sheet for CNA #1 revealed she attended the meetings on infection control on 04/10/19, and 01/21/19. On 06/26/19 at 3:39 PM, an interview with the Director of Nursing (DON) revealed the staff have regular inservices on infection control and the ice scoop being left in the ice chest would be an infection control concern. On 06/27/19 at 9:48 AM, an interview with the Staff Development Nurse confirmed CNA #1 attended inservices when infection control education was covered.

Based on observation, record review, facility policy review, staff interview, and resident interview, the facility failed to provide a comfortable noise level for two (2) of 57 residents reviewed . Residents #25 and #43 Findings include: Review of the facility's policy titled, Resident Rights, revealed the facility will ensure that all staff members are educated on the rights of the residents, and the responsibility of the facility to properly care for it's residents. During the initial tour an observation and interview, on 09/17/18 at 11:20 AM, revealed a loud noise that shook the window and the room. Resident #25 stated the back door to the facility doesn't have a [MEDICATION NAME] to prevent the door from slamming. Resident #25 stated she has had to get used to it. During an interview, on 09/18/18 at 2:24 PM, Resident #43 revealed the door doesn't bother her in the day time as much. Resident #43 stated It bothers her mostly at night when she's asleep, and the staff goes in and out. An observation and interview, on 09/19/18 at 10:38 AM, with the Maintenance Director and the Administrator in Resident #43's room confirmed the door slammed so hard the window glass and the room shook. The Maintenance Director stated he was going to call (Name of Glass Company) to get some shocks that would slow the door down to prevent the door from slamming so hard. The Administrator confirmed the noise from the door was to loud, and would disturb the residents while sleeping. During an interview, on 09/19/18 at 2:17 PM, the Maintenance Director revealed the facility has a maintenance log at the nurses' station they look at daily. The Maintenance Director also stated he does environmental rounds weekly to check for any problems in the building. A review of the Face Sheet revealed the facility admitted Resident #25, on 05/09/2016, with the included [DIAGNOSES REDACTED]. A review of Resident # 25's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/16/2018 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A review of the Face Sheet revealed the facility admitted Resident #43, on 09/07/2017, with the included [DIAGNOSES REDACTED]. A review of Resident #43's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2018, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment.

Based on observation, record review, facility policy review and staff interview, the facility failed to follow Resident #45's Care Plan for a pureed consistency diet, for one (1) of 21 care plans reviewed. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 02/2017, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. The facility's policy also stated that the care plan was to be consistent with the resident rights, and include measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility's policy further stated qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the Care Plan for the Focus (no date) revealed: (Name of Resident) receives a NAS (No Added Salt) pureed diet with honey thick liquids and receives PEG (Percutaneous Endoscopic Gastrostomy) tube feedings ([MEDICATION NAME]) at night due to a DX. (Diagnosis) of Dysphagia, and risk of weight loss. The Interventions included: Provide diet as ordered. Further review of the Care Plan revealed personnel responsible for this intervention were the Dietary Manager (DietM), all Certified Nursing Assistants (CNA), all Licensed Practical Nurses (LPN), and all Registered Nurses (RN). The Care Plan revealed Resident #45's admitted was 08/15/18. An observation, on 09/17/2018 at 4:30 PM, revealed Resident #45 was served her supper meal in her room. The food items on the tray were pureed consistency, with the exception of the dessert. The dessert was two lemon squares, that measured a total of three (3) inches by two (2) inches. The consistency of the dessert was not pureed. During an interview, on 09/17/2018 at 4:40 PM, Certified Nursing Assistant (CNA) #1 stated she brought, and set up the supper tray into Resident #45's room. CNA #1 stated she knew it (the dessert) was not pureed like the rest of her food, and she was aware that the resident had a pureed diet order During an interview, on 09/18/2018 at 3:15 PM, the Dietary Manager (DM), revealed the resident should have been served a dessert that was of a pureed consistency due to the resident's risk for choking. Review of Resident #45's Clinical physician's orders [REDACTED]. During an interview, on 09/19/18 at 10:50 AM, Registered Nurse (RN) #2/Minimum Data Set (MDS)/Care Plan Coordinator, revealed it was her expectation that the staff was to follow the care plan interventions to meet the resident's needs. During an interview, on 09/19/2018 at 2:20 PM, the Director of Nursing (DON), confirmed the care plan had not been followed for Resident #45. The DON confirmed the resident should have been provided a meal tray in which all of the food items were a pureed consistency. The DON stated the resident is at risk for aspirating, and the care plan should have been followed. Review of the Face Sheet revealed the facility admitted Resident #45, on 08/15/2018, with [DIAGNOSES REDACTED]. The Face Sheet also revealed secondary [DIAGNOSES REDACTED]. Review of the Comprehensive Admission MDS, with an Assessment Reference Date (ARD) of 08/22/2018, revealed Resident #45 required a therapeutic and mechanically altered diet.

Based on observation, interview, and record review, the facility failed to implement a care plan to prevent the development and worsening of a pressure sore for one (1) of fifteen (15) residents reviewed (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 scored a 00. Resident #1 was severely cognitively impaired. Record review of the care plan for Resident #1 revealed a care plan for Stage 4 Decubitus Coccyx Area. The approaches included notify MD (medical doctor) of worsening and s/s (signs and symptoms) of infection, treatment as ordered, reposition Q (every) 2 hrs (hours) and prn (as needed), and air mat to bed. Resident #1's decubitus ulcer to the coccyx began as a stage II and worsened to a Stage IV. Resident #1 developed the Stage IV pressure area to the coccyx when the pressure relief mattress failed on [DATE]. Interview with Resident #1's hospice nurse on [DATE] at 10:55 a.m. revealed that Resident #1 was admitted to hospice on [DATE] and was placed on an air mattress provided by hospice. On [DATE], the hospice nurse stated she received a call from the facility saying the air mattress was not working properly and was replaced by the contracted medical supply company. Interview on [DATE] at 10:35 a.m. the Director of Nursing (DON) confirmed that the pressure ulcer was acquired "in house" following the failure of the pressure relief mattress. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:00 a.m. revealed when Resident #1 was admitted to hospice services, the mattress was changed to an air mattress which did not stay inflated properly. LPN #1 stated after a "couple of days" a Stage II was found Resident #1's coccyx. Record review of the hospice invoice for repairs to the air mattress for Resident #1, from medical supply company, dated [DATE] at 5:48 p.m., noted: " Finished. Lal (low air loss) had 1 (one) lost cpr (cardiopulmonary) plug, I exchanged lal and cleaned filters, also needs a new hepa filter " . Invoice dated [DATE] at 4:19 p.m. regarding Resident #1 ' s air mattress, noted: " Done. Exchanged lal pump, it was making a loud clicking noise. Invoice dated [DATE] at 9:49 a.m. regarding Resident #1 ' s air mattress noted: " They are still having trouble with the LAL mattress. Will not stay inflated and a light is on and has been on over night. Please send tech to check this out " .

Based on observation, staff interview, record review and policy review, the facility failed to prevent the development and worsening of a decubitus ulcer for one (1) of fifteen (15) residents reviewed as evidence by a Stage II decubitus development due to a malfunction of a pressure release mattress. (Residents #1). Findings include: Resident #1 Review of the facility's policy entitled "Pressure Sore Prevention For Residents at Risk Policy", undated, noted: "It is the policy of this facility to identify residents at risk for developing pressure sores and to implement appropriate nursing interventions. Procedure: (5). The potential to develop pressure sores will be identified on the resident's comprehensive plan of care. Interventions may include use of pressure relieving devices in the bed and in a chair, turning and repositioning schedules, ambulation programs, toileting schedules for turning and repositioning schedules, ambulation programs, toileting schedules for incontinent residents, and/or the use of skin barriers for incontinent residents. (6). All pressure sores, which develop, will be documented in the resident's clinical record." Record review revealed a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated that Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. This MDS documented the Brief Interview for Mental Status (BIMS) score of 00, which indicated that Resident #1 was unable to complete the assessment. Record review of Resident #1's weekly body audit dated [DATE] at 3:07 p.m. revealed a closed blister to crevice of buttock. Record review of "Nurses Progress Notes", dated [DATE], noted the pressure area continued to worsen to a Stage II decubitus to coccyx measuring 3.0 cm X 3.0 cm with depth undetermined. Record review of the facility's "Wound/Skin Documentation Record" for Resident #1, dated [DATE], noted: Stage III pressure ulcer to coccyx measuring 3 X (by) 3 centimeters (cm) with unreadable depth measurement. A record review of the facility's "Wound/Skin Documentation Record" for Resident # 1, dated [DATE], revealed coccyx wound had progressed to Stage IV pressure ulcer to coccyx measuring 0.5 cm X 1.0 cm with a depth of 0.5 cm with 2.0 cm tunneling at 4:00 with 100% of wound bed red and small amount serosanguinous drainage. Record review of the wound assessment by Licensed Practical Nurse (LPN) #1, dated [DATE], for Resident #1 noted: Wound care continue to Stage IV Decubitus to coccyx area measuring 0.5 cm in length and 1.0 cm in width with depth of 0.5 cm. Wound tunneling @ 1.8 cm with deepest part @ 4:00. Wound bed is 100% red. Small amount serosanguinous drainage noted. Record review of Resident #1 ' s invoice for repairs to air mattress, from medical supply company to the hospice company, dated [DATE] at 5:48 p.m., noted: " Finished. Lal (low air mattress) had 1 (one) lost cpr (cardiopulmonary) plug, I exchanged lal and cleaned filters on con, also needs a new hepa filter " . Invoice dated [DATE] at 4:19 p.m. regarding Resident #1 ' s air mattress, noted: " Done. Exchanged lal pump, it was making a loud clicking noise. Invoice dated [DATE] at 9:49 a.m. regarding Resident #1 ' s air mattress, noted: " They are still having trouble with the LAL mattress. Will not stay inflated and a light is on and has been on over night. Please send tech to check this out. (less) " . Interview on [DATE] at 10:35 a.m. with the Director of Nursing (DON) stated Resident #1 was placed on a new air mattress when she was admitted to hospice services and it (mattress) was not functioning properly causing a pressure area. A new air mattress was brought in to replace the other one. The DON confirmed the pressure ulcer did develop in house. Interview on [DATE] at 10:30 a.m. with the DON, noted the Certified Nursing Assistants (CNA's) noticed that the mattress would not stay inflated completely and it was replaced but a Stage II decubitus to the coccyx had already developed. The DON stated that is was just protocol for hospice to put all residents on an air mattress. Interview with Resident #1 ' s hospice nurse on [DATE] at 10:55 a.m. revealed Resident #1 was admitted to hospice on [DATE] and was placed on an air mattress provided by hospice. On [DATE] she received a call from the facility saying the air mattress was not working properly and was replaced by the contracted medical supply company. Observation and interview on [DATE] at 10:00 a.m. with LPN #1, Treatment Nurse, during care observation, revealed when Resident #1 was placed on hospice, the mattress was changed to an air mattress. LPN #1 stated "The one she had did not stay inflated properly and after a couple of days a stage II decubitus ulcer was found and treatments started." Interview on [DATE] at 1:20 p.m. with the facility Administrator revealed he did remember that the mattress had gone down and not inflating properly and had to be repaired. Interview by phone on [DATE] at 2:56 p.m. with Resident #1's Hospice Nurse, confirmed there was a malfunction of the resident's bed, "The CPR (cardiopulmonary resuscitation) plug was missing off the bed and made the bed deflate". The Hospice Nurse also stated that the CNA was able to see the red circles on the resident's skin and realized that the bed was not working properly. The Hospice Nurse stated that the equipment company that they lease equipment from was called on [DATE] to replace the mattress. Record review of Resident #1's care plan dated [DATE] identified "Decubitus Stage III Coccyx" and indicated date originated as [DATE]. Approaches were listed as Complete as apply, notify MD of area and changes, turn every two hours, maintain clean and dry, vitamins/meds ordered listed; Prostat AWC 30 cc twice a day, Treatment ordered by MD listed; Cleanse with normal saline, pat dry, apply Santyl to wound bed and [MEDICATION NAME] to peri-wound cover with bordered foam dressing every day and as needed until resolves. Dietary changes/supplement listed; Pre-[MEDICATION NAME] level, heel protectors every shift, Pre-[MEDICATION NAME] level and complete blood count (CBC) every six months, Hospice services, air mattress to bed, and oxygen at two (2) liters per minute. Updated on [DATE] 16 in French Foley catheter inserted and [MEDICATION NAME] 25 mcq every 72 hours for pain. Record review of Resident #1's care plan dated [DATE] identified "Stage four (4) decubitus (muscle bone and tendon involvement with resulting dead tissue-drainage may be present) Coccyx area. Approaches listed: Obtain labs as ordered. Report abnormal [MEDICATION NAME] to MD. Registered Dietician (RD) consult. Weekly assessment with measurement. Notify MD of worsening and signs and symptoms of infection. Cleanse decubitis to coccyx with normal saline, pat dry and apply Santyl to wound bed and [MEDICATION NAME] to periwound every day and as needed and cover with bordered foam dressing- this approach changed on [DATE] to cleanse decubitus to coccyx with normal saline, pat dry and apply calcium alginate rope to wound bed and cover with foam dressing daily and as needed. Prostat AWC 30 cc by mouth twice a day. Prescribed diet with supplements. Treatment as ordered. Reposition every two (2) hours and as needed. Air Mattress to bed.

Based on observation, record review, staff interview and policy review the facility failed to administer pain medications prior to decubitus care for one (1) of one (1) residents observed for decubitus care, Resident #7. Findings include: Cross Refer to F-309 for the facility's failure to provide pain medication prior to treatment for [REDACTED]. Record review on 7/25/12 revealed that Resident #7 was admitted on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Physican's Orders for treatment of [REDACTED]. Review of the Minimum Data Set with Assessment Reference Date of 7/09/12 scored the Brief Interview for Mental Status at 00, indicating severely impaired cognitive status. Record review revealed on 7/22/12, 6:00 p.m. nurses notes stated, "Tx (treatment) order to cleanse (with) NS, pat dry, apply Santyl to wound bed....Resident cont (continues with) Hospice Service. Showing some distress by moaning (and) groaning (and) by facial grimaces. (Continue) to monitor. (Responsible Party) (at) bedside (and) aware." Tylenol was administered per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There were only three (3) documentations noting Tylenol was given during the month of July, 2012 on the day of survey; July 7, 8 and 22. Interview on 7/25/12 at 10:30 a.m. with Licensed Practical Nurse #1 about Resident #7 decubitus care stated, "I already done it." When asked about pain medications LPN #1 stated, "[MEDICATION NAME] was given by (name of med nurse), then I waited 30 minutes before treatment is done." Interview on 7/25/12 at 10:35 a.m. with LPN #2 about Resident #7 pain medication given prior to decubitus care this morning who stated, "He has [MEDICATION NAME] but it ' s never been used, it was wrote by hospice for pain." Interview at 11:00 a.m. with LPN #1 about pain medications who stated, "I told her (med nurse) to give him pain meds because I was about to do his treatments and I knew he had [MEDICATION NAME] ordered." Observation on 7/25/12 at 11:00 with LPN #2 of Resident #7 MAR indicated [REDACTED]. Interview on 7/25/12 at 11:00 a.m. with LPN #2 who stated, "I gave it about 10 o'clock but I didn't mark the MAR, I can't exactly remember what time it was. I didn't think he needed the [MEDICATION NAME], I usually give Tylenol to see if it helps." Interview on 7/25/12 at 1:45 p.m. with RN #1 about pain medication not being given to Resident #7 before decubitus care, who stated, "It concerns me too, hospice writes the orders, hospice brings the medication, my nurses should have checked on it and put it on the MAR."

Based on observation, record review, staff interview and policy review the facility failed to adequately assess for pain prior to decubitus care for Resident #7, one (1) of one (1) residents observed for decubitus care. Findings Include: Resident # 7 Record review on 7/25/12 revealed that Resident #7 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Physican's Orders for treatment of [REDACTED]. The facility's Pain Management policy (no date) attached to in-service on 4/23/12 stated, "The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being." Review of the facility's " controlled drug record " for Resident #7 with a Pharmacy filled date of 6/30/12 revealed that no medication of [MEDICATION NAME] ([MEDICATION NAME]) was signed out. Record review revealed on 7/22/12, 6:00 p.m. nurses notes stated, "Tx (treatment) order to cleanse (with) NS, pat dry, apply Santyl to wound bed....Resident cont (continues with) Hospice Service. Showing some distress by moaning (and) groaning (and) by facial grimaces. (Continue) to monitor. (Responsible Party) (at) bedside (and) aware." Tylenol was administered per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There were only three (3) documentations noting Tylenol was given during the month of July, 2012 on the day of survey; July 7, 8 and 22. Record Review on 7/25/12 of the Minimum Data Set (MDS), Section J, dated 7/9/12 has Resident #7 on scheduled pain regimen. Pain Assessment documentation revealed no pain medications administrated, and no indications of pain by resident. Interview on 7/25/12 at 11:1 5a.m. with Certified Nursing Assistant (CNA) #1 about Resident #7 Activities of Daily Living (ADL), who stated, "He's been bedfast since he came back from the hospital; no, no he can't stand, he used Total Lift for about 2 years, gets bed bath by us (facility staff) and has hospice come but I don't wait for them, I will assist with his bath when they come. He is not strong enough to resist care. Depending on how much pain he is in, his arms and legs tense up. If I think he is hurting I will tell his nurse, he is so sick and sore all over I know he has to hurt." Interview on 7/26/12 at 9:00 a.m. with LPN #2 about administration of pain medications prior to treatment this morning stated, "Yes, I gave him [MEDICATION NAME] 1mg (milligram) down the tube; the order was changed to 0.5, so I gave him 0.5, I mean he gets 0.5 BID (twice a day) and PRN (as needed)." Observation on 7/26/12 at 9:30 a.m. with LPN #1 during decubitus care for Resident #7 revealed the Resident was non-verbal, and moved eyes from side to side when spoken to by other people. During decubitus care of the right elbow, the Resident guarded his right arm. During care of the left heel, Resident #7 "drew" his foot away. Interview on 7/26/12 at 9:30 a.m. with LPN #1 during decubitus care and Resident #7 trying to move foot, who stated, "I think it hurts him because he drew his leg up like to stop hurting me."

Based on observation, record review, staff interview, physician interview, and policy review, the facility failed to prevent an avoidable fracture for one (1) of three (3) residents reviewed with fractures (Resident #1). Resident #1 was transferred with a lift using only one (1) person to assist and the incorrect transfer sling/pad. Resident #1 sustained a fracture to the left hip. Findings include: Record review revealed that Resident #1 moved into the home on 9/23/99 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #1's cognitive skills were severely impaired. Resident #1 required extensive assistance of one (1) person for bed mobility. Resident #1 was not transferred from bed during the seven (7) day look back period of the MDS. Resident #1 was noted to have impairment on both upper and lower extremities. Wheelchair was identified as the primary mode of locomotion. Review of the Resident Incident Report dated 3/20/11 at 6:41 p.m., noted: "Elder noted on the floor toward right side with head and shoulders craddled by CNA (Certified Nurse Aide) hands. Nearfall with no actual contact on floor broken by CNA during transfer using total lift. Left femoral neck fracture." Review of an x-ray report dated 3/21/11 noted: "Impression: 1. Fracture of the left femoral neck along the trochanteric line as marked on the images." Review of the nurse's notes dated 3/20/11 at 6:41 p.m. noted: "Called to room per CNA. I noted resident lying on the floor toward right side with head and shoulders craddled (cradled) by CNAs hands. Near fall with no actual contact to floor broken by CNA during transfer. Elder alert and verbally responsive. Elder stated "I'm not hurt" but when I began to assess her, she began to say she's hurt." Review of the statement written by CNA #2 on 3/20/11, with no time noted, noted: "There wasn't another aid (aide) available. I pulled the lift pad up from under her (Resident #1). I strapped the top doubled on the white strap. I crossed the two straps under her legs. I put those doubled on blue. I checked them all to make sure that they were hooked right. I proceeded to lift (Resident #1). Once I got her up enough so I could remove the chair, I pulled it out. I kept (the resident's) head toward me. As we started to move over the bed, I noted that (the resident's) head part was dropping. It would let her head hit the floor, so I caught her and we hit the floor. I was on the bottom and she was in my arms. Her legs was (were) still up in the air. She landed on me. I called out for help, in the mean time I let her legs on down because I still had the remote in my hand. The aids and nurse came in to help me with (resident). Once we checked the resident out we observed two things. (1). The pad was upside down under her. (2). It was the wrong lift pad under her." Review of the facility's document entitled "Determination for Resident Lift/Transfer Assistance" revealed Resident #1 had been assessed as needing the total lift with the assistance of two (2) staff members for all transfers. Review of the "Nurse Aide's Information Sheet" indicated Resident #1 required total mechanical lift with two (2) person assist. Review of the resident's plan of care dated 1/10/11 had an intervention which noted: "Use two (2) staff to assist with transfers." The sling size to use with transfers was identified to be a medium size. Interview on 5/5/11 at 11:30 a.m. with the Director of Nursing (DON) confirmed that Resident #1 sustained a fracture to the left hip. The DON stated the CNA had attempted to transfer the resident without waiting for assistance. The DON stated it was the facility policy that all transfers using the total lift were to be provided using to staff members. The DON stated the CNA had been reprimanded and no longer worked at the facility. Interview on 5/5/11 at 5:05 p.m. with Resident #1's attending physician revealed the resident was very fragile and had very porous bones. The physician stated that she had been taking care of Resident #1 for many years and the resident has had fractures in the past. The physician confirmed Resident #1 had sustained the hip fracture after an inappropriate lift. Review of a memo from the facility to the State Agency regarding the incident revealed that it was determined that (Name of CNA #2) placed inappropriate sling under (Resident #1) to transfer using total lift. CNA #2 failed to obtain assistance when using total lift. Facility policies required all lifts to have two persons assist during use. The facility also reported that (Name of Resident #1's) condition with Osteopenia it is believed this was a major contributing factor to left hip fracture related to sudden jarring during transfer. Review of the home's "Policy for Using a Mechanical Lift" policy, revised 4/2007, noted "The portable lift requires two (2) nursing assistants to perform the procedure each time it is used."