Every finding on record at Country Lawn CTR for Rehab

Based on record review, observation and interview the facility failed to implement Resident #3's care plan in regards to percutaneous endoscopic gastrostomy (PEG) tube insertion site care. This affected one resident (#3) of two residents observed for PEG tube care. The facility census was 74. Findings include: Review of Resident #3's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure, throat cancer, and percutaneous endoscopic gastrostomy (feeding) tube. Review of the care plan dated 02/18/25 revealed Resident #3 received tube feeding related to having a nothing by mouth (NPO) status. Interventions included administer skin treatments to PEG tube site as ordered. Review of Resident #3's physician orders for February 2025 through March 2025 revealed an order to cleanse tube (PEG) site with normal saline and apply a T-sponge twice daily. Observation on 03/06/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #849 revealed Resident #3 had a PEG tube with nutritional formula infusing. Observation of the the PEG tube insertion site revealed a split gauze dressing that was dated 02/28/25. Interview with LPN #849 at time of observation confirmed the split gauze dressing was dated 02/28/25. LPN #849 stated the dressing was to be changed daily. At 11:10 A.M. the Director of Nursing entered Resident #3's room to assist with care and also confirmed the split gauze dressing was dated 02/28/25.

Based on record review, observation and interview the facility failed to ensure a resident who was dependent for personal hygiene received the necessary care and services to ensure secretions from a tracheostomy were managed to prevent the accumulation of dried mucous on the resident's gown, bed linens, and a washcloth placed beneath the tracheostomy tube. This affected one resident (#3) of three residents observed who required assistance with activities of daily living. The facility census was 74. Findings include: Review of Resident #3's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure, muscle weakness and need for personal care assistance. Review of the care plan dated 02/18/25 revealed an intervention to provide Resident #3 assistance with activities of daily living (ADL) care per orders. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 was rarely understood and was dependent for toileting, bathing and personal hygiene. Observation on 03/06/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #849 revealed Resident #3 was sleeping in bed. Resident #3 and had tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the mouth and nose). Further observation revealed brownish/red colored dried debris on a washcloth that had been placed below Resident #3's tracheostomy. The same brownish/red colored dried debris was also observed on Resident #3's gown, pillowcase and sheets. LPN #849 confirmed the observations and stated she would have the aides come in and provide Resident #3 with ADL care. While in the room speaking to LPN #849, Certified Nursing Assistants (CNAs) #831 and #836 entered the room. CNAs #831 and #836 stated Resident #3 was dependent for all ADLs and confirmed Resident #3's gown and bed linens were soiled. CNAs #831 and #836 proceeded to roll Resident #3 onto his right side revealing Resident #3's sheets, mattress pad and reverse side of his pillow case were soiled and had a foul odor. CNA #831 and #836 stated the resident's gown and bedding should be changed daily and as needed. This deficiency represents noncompliance investigated under Complaint Number OH00163187.

Based on record review, observation and interview the facility failed to ensure documentation in the medical record was accurate. This affected one resident (#3) of three residents whose medical record were reviewed. The facility census was 74. Findings include: Review of Resident #3's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure, throat cancer, and percutaneous endoscopic gastrostomy (PEG) tube. Review of the care plan dated 02/18/25 revealed Resident #3 received tube feeding related to having a nothing by mouth (NPO) status. Interventions included administer skin treatments to PEG tube site as ordered. Review of Resident #3's physician orders for February 2025 through March 2025 revealed an order to cleanse tube (PEG) site with normal saline and apply a T-sponge twice daily. Observation on 03/06/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #849 revealed Resident #3 had a PEG tube with nutritional formula infusing. Observation of the PEG tube insertion site revealed a split gauze dressing that was dated 02/28/25. Interview with LPN #849 at time of observation confirmed the split gauze dressing was dated 02/28/25. LPN #849 stated the dressing was to be changed daily. At 11:10 A.M. the Director of Nursing (DON) entered Resident #3's room to assist with care and also confirmed the split gauze dressing was dated 02/28/25. Review of Resident #3's Treatment Administration Record (TAR) revealed from 02/28/25 though 03/05/25 staff had documented the PEG tube site was cleansed with normal saline and a T-sponge dressing was applied twice daily. Interview on 03/10/25 at 10:37 A.M. with the DON confirmed Resident #3's TAR had documentation indicating the PEG tube insertion site was cleansed with normal saline and a T-sponge dressing was applied twice daily from 02/28/25 through 03/05/25. The DON indicated staff should not document treatments as being completed when they had not been done.

Based on observation, interview, record review, policy review and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate personal protective equipment (PPE) was worn while providing direct care when there was a risk of splash or spray, failed to ensure appropriate glove use and hand hygiene, and failed to prevent the possibility of cross contamination when using a soiled washcloth to clean an oxygen mask and around a tracheostomy. This affected one resident (#3) of one resident observed for tracheostomy care. The facility census was 74. Findings include: Review of Resident #3's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure, throat cancer and dysphasia (difficulty swallowing). Review of the care plan dated 02/18/25 revealed Resident #3 had a potential for complications related to tracheostomy. Interventions included provide tracheostomy care every shift. Review of the physician orders for March 2025 revealed an order for trach care each shift and use enhanced barrier precautions (EBP). Observation on 03/06/25 at 10:24 A.M. revealed Resident #3 was resting in bed and had a tracheostomy and PEG (feeding) tube. There was a sign indicating Resident #3 was in EBP. At the time of observation Licensed Practical Nurse (LPN) #849 entered Resident #3's room to provide tracheostomy care. LPN #849 was not wearing a mask or face shield. LPN #849 proceeded to remove a soiled washcloth from underneath Resident #3's tracheostomy and used it to clean the inside of Resident #3's oxygen mask. Resident #3 began coughing expelling a large amount of thick green colored sputum from his tracheostomy and LPN #849 used the same washcloth to wipe away the mucus and clean around Resident #3's tracheostomy. Without changing her gloves or washing her hands, LPN #849 proceeded to fill the water canister, used for humidification for Resident #3's oxygen, with a gallon of distilled water. Immediately after this observation LPN #849 exited Resident #3's room. At 11:10 A.M. the Director of Nursing (DON) entered Resident #3's room and was notified of the observation. The DON stated LPN #849 should have been wearing a mask while performing tracheostomy care and stated LPN #849 should not have used a soiled washcloth to clean Resident #3's oxygen mask and around his tracheostomy site. Review of facility's undated Tracheostomy Care policy revealed tracheostomy care was to be performed every shift or per physician orders. Staff were to wear a gown, mask and face shield and use sterile gauze pads dipped in peroxide solution to clean around the tracheostomy site, wiping in one direction with each pad until area was clear. Review of facility's Infection Control Protocol for all Nursing Procedures revised November 2019, revealed standard precautions were to be used in the care of residents regardless of their infection status. Standard precautions applied to body fluids and secretions and/or mucus membranes, staff were to wear personal protective equipment as necessary to prevent exposure to body fluids, and wash hands before any procedure and after completion of procedure. Review of the CDC EBP guidance dated 04/02/24 revealed residents with any of the following should be on EBP. Infection or colonization with a Multi Drug Resistant Organism (MDRO) when Contact Precautions do not apply. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. PPE used for these situations: During high-contact resident care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing. Gloves and gown prior to the high-contact care activity Face protection may also be needed if performing activity with risk of splash or spray This deficiency represents non-compliance investigated under Complaint Number OH00163187.Review of the CDC EBP guidance dated 04/02/24 revealed residents with any of the following should be on EBP. Infection or colonization with a Multi Drug Resistant Organism (MDRO) when Contact Precautions do not apply. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. PPE used for these situations: During high-contact resident care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing. Gloves and gown prior to the high-contact care activity Face protection may also be needed if performing activity with risk of splash or spray This deficiency represents non-compliance investigated under Complaint Number OH00163187.

Based on record review, observation and interviews the facility failed to develop a comprehensive care plan for Resident #15, #23, #31, #42 and #68. This affected five residents (#15, #23, #31, #42 and #68) of 20 residents reviewed for care plans. The facility census was 79. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included delusional disorder, dementia with behavioral disturbance, anxiety disorder and restlessness and agitation. Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively impaired. Her behaviors were marked as worse indicating she had physical and verbal behaviors and was resistive to care one to three days a week. Review of the progress noted dated 02/08/24 and timed at 7:01 P.M. and authored by Registered Nurse (RN) #201 revealed Resident #23 was combative and striking out at other residents. A noted dated 02/09/24 at 10:35 A.M. and authored by RN #105 revealed Resident #23 grabbed a glass plate and started hitting a State Testing Nursing Assistant. Review of the care plan initiated 02/14/23 for Resident #23 revealed she had the behavior of wandering. Interview on 06/25/24 at 5:00 P.M. with MDS #193 verified the care plan was not revised to include physical behaviors therefore no interventions for physical behaviors were included in the care plan. Interview on 06/25/24 at 5:15 P.M. with MDS #193 and Regional Nurse Consultant (RNC) #114 verified the progress notes dated 02/08/24 and 02/09/24 revealed Resident #23 had episodes of physical behaviors leading to her being hospitalized . Review of the facility policy titled Care Plan-Use of, dated 11/2016 revealed documentation in the medical record must be consistent with the resident's care plan. 42015 2. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included end stage renal disease, heart failure, and diastolic congestive heart failure. Interview on 06/26/24 at 9:55 A.M. with Resident #15 revealed she attended dialysis three times a week, utilized a port but recently received a fistula ( an access point for dialysis) in her right arm, and once the fistula healed it will be used for her dialysis treatment. Review of Resident #15's care plan revealed she did not have a comprehensive care plan indicating she was receiving dialysis treatment. Review of Resident #15's physician orders dated 01/31/24 revealed an order for Dialysis every Tuesday, Thursday, and Saturday. Interview on 06/26/24 at 4:05 P.M. Regional Nurse Consultant #115 confirmed the facility did not implement a care plan regarding Resident #15 receiving dialysis treatment. 3. Review of Resident #42's medical record revealed an admitted [DATE]. Diagnosis included vascular dementia, atrial fibrillation, and diastolic heart failure. Review of Resident #42's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was cognitively intact and received anticoagulant medication. Review of Resident #42's June 2024 physician orders revealed an order for Eliquis (anticoagulant also known as blood thinning medication) five milligrams twice daily for chronic atrial fibrillation. Continued review revealed the facility had no orders in place to monitor the resident for side effects related to the high-risk medication. Review of Resident #42's Comprehensive Care Plan revealed the facility had not developed a care plan related to the residents atrial fibrillation and need for anticoagulant medication. Interview on 06/27/24 at 10:33 A.M. with Regional Nurse Consultant #114 confirmed the facility had not developed a comprehensive care plan indicating the resident had atrial fibrillation and required an anticoagulant medication. 35765 4. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included peritonitis, gastrointestinal hemorrhage, anemia, congestive heart failure, end stage renal disease, atrial fibrillation, dependent on renal dialysis, pulmonary hypertension, anxiety, dermatitis , respiratory failure, Parkinson's disease, and obstructive sleep apnea. Review of the Five-Day Medicare Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #68 had intact cognation. Review of the June 2024 physician's orders revealed Resident #68 had orders for calamine lotion to be applied to her rash four times daily dated 06/07/24, Eucerin cream to be applied to her rash twice daily dated 06/18/24, and hydroxyzine (antihistamine) 10 milligrams three times daily for itching dated 06/11/24. Review of the progress note dated 05/15/24 at 9:30 A.M. revealed Resident #68 arrived to the facility by ambulance. She was alert and oriented with no complaints of distress or discomfort. She had a red rash to the trunk of her body, her arms and her legs with an unknown cause. Review of the progress note dated 05/31/24 at 11:57 A.M. revealed Resident #68 was sent out to the hospital for altered mental status. Review of the progress note dated 06/01/24 at 12:07 A.M. revealed Resident #68 was admitted to the hospital with diagnoses of rash and altered mental status. Review of the progress note dated 06/08/24 at 5:44 A.M. revealed Resident #68's skin was reddened with a tough texture to touch. Review of the progress note dated 06/08/24 at 4:40 P.M. revealed Resident #68 was resting in bed with her eyes closed. She had edema to her bilateral forearms and wrists, and her skin was red tinted all over. Review of the progress note dated 06/23/24 at 2:27 P.M. revealed Resident #68's skin was bright red, dry, and scaly. Review of the plan of care for Resident #68 revealed no evidence of addressing her itching or rash. Observation on 06/24/24 at 11:05 A.M. revealed the skin of Resident #68 was bright red and peeling in large pieces on her face, neck and arms. An interview at this time with Resident #68 revealed she had an allergic reaction at the hospital. She stated the rash itched alot. On 06/26/24 at 2:55 P.M. an interview with Regional Nurse Consultant # 114 confirmed there was no plan of care for the rash which covered most of Resident #68's body. Review of the facility policy titled Care Plan-Use of, dated 11/2016 revealed documentation in the medical record must be consistent with the resident's care plan. 5. Review of the medial record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, rhabdomyolysis, pancreatitis, need for assistance, sepsis, elevated white blood, pyelonephritis, kidney failure, abdominal pain, major depressive disorder, psychotic disorder, cerebral infarction, chronic pain syndrome, anemia, osteoporosis, impulse disorder, obstructive and reflux uropathy and protein-calorie. Review of the June 2024 physician's orders revealed Resident #31 had an order for a indwelling catheter to straight drain for malignant neoplasm of the prostate. Review of the Admission Minimum Data Set 3.0 assessment dated [DATE] reveled Resident #31 was cognitively intact and had an indwelling catheter. On 06/27/24 at 11:24 A.M. an interview with Regional Nurse Consultant # 115 confirmed there was no indwelling catheter plan of care for Resident #31. Review of the facility policy titled Care Plan-Use of, dated 11/2016 revealed documentation in the medical record must be consistent with the resident's care plan.

Based on observation, review of the medical record, and interview with staff the facility failed to maintain privacy for Resident #44 during medication administration. This affected one resident ( Resident #44) of seven residents observed for medication administration. The facility census was 79. Findings included: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE]. Diagnoses included nontraumatic subarachnoid hemorrhage, respiratory failure, hydrocephalus, aneurysm, need for personal care, aphonia, right cerebral shunt, encephalopathy, chronic obstructive pulmonary disease, hypothyroidism, gastrostomy, tracheostomy, dysphagia, major depression disorder, cachexia, incontinence, protein-calorie malnutrition, bipolar disorder, anxiety disorder, rheumatoid arthritis, insomnia, nystagmus, cataract, and pseudobulbar affect. An observation was conducted on 06/26/24 at 11:35 A.M. with Registered Nurse (RN) #186 who entered into the room of Resident #44 to administer medications via the percutaneous endoscopic gastrostomy (PEG) tube for Resident #44. RN #186 did not close the door to the room or pull the privacy curtain and proceeded to pull up the residents hospital gown exposing her bare abdomen and incontinence brief. RN #186 then proceeded to administer Resident #44's medications via per PEG tube. RN #186 verified at this time she had not provided privacy and should have closed the room door and/or pulled the privacy curtain before exposing the resident.

Based on observations, review of the medical record and interview with facility staff the facility failed to provide assistance with shaving for Resident #31 and #77. This affected two residents (Resident #31 and #77) of 20 residents reviewed for activities of daily living (ADL). The facility census was 79. Findings include: 1. Review of the medial record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, rhabdomyolysis, pancreatitis, need for assistance, sepsis, elevated white blood, pyelonephritis, kidney failure, abdominal pain, major depressive disorder, psychotic disorder, cerebral infarction, chronic pain syndrome, anemia, osteoporosis, impulse disorder, obstructive and reflux uropathy. Review of the progress notes from 05/02/24 to 06/26/24 revealed no evidence Resident #31 refused to be shaved. Review of the Admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact and required substantial assistance with personal hygiene/care. Observation on 06/24/24 at 3:25 P.M. revealed Resident #31 had long beard hairs. An interview with Resident #31 at this time revealed he had not been shaved for awhile and would like to be shaved. On 06/26/24 at 2:55 P.M. an interview with Registered Nurse # 118 revealed the male residents were shaved on shower days or as needed. On 06/26/24 at 3:21 P.M. an interview with Registered Nurse #170 confirmed Resident #31 needed shaved. 2. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses included severe sepsis, need for assistance with personal care, dysphagia, respiratory failure, metabolic acidosis, atrial fibrillation, Brown-Sequard syndrome, cerebellar ataxia, hydronephrosis, benign prostatic hyperplasia, moderate protein-calorie malnutrion, anxiety disorder, Review of the Admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #77 had intact cognation and required substantial assistance for personal hygiene. Review of the progress notes from 05/02/24 to 06/26/24 revealed no evidence Resident #77 refused to be shaved. Observation on 06/25/24 at 10:50 A.M. revealed Resident #77 had long beard hairs. Observation on 06/26/24 at 9:40 A.M. revealed Resident #77 still had not been shaved. On 06/26/24 at 11:00 A.M. an interview with Resident #77 revealed he wanted shaved. On 06/26/24 at 2:55 P.M. an interview with Registered Nurse # 118 revealed the male residents were shaved on shower days or as needed. On 06/26/24 at 3:21 P.M. an interview with Registered Nurse #170 confirmed Resident #31 needed shaved.

Based on interview and record review the facility failed to adequately monitor the use of an anticoagulant medication for side effects for Resident #42. This affected one resident (Resident #42) out of five residents reviewed for unnecessary medication. The facility census was 79. Findings include: Review of Resident #42's medical record revealed an admitted [DATE]. Diagnosis included vascular dementia, atrial fibrillation, and diastolic heart failure. Review of Resident #42's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was cognitively intact and received anticoagulant medication. Review of Resident #42's June 2024 physician orders revealed an order for Eliquis (anticoagulant also known as blood thinning medication) five milligrams twice daily for chronic atrial fibrillation. Continued review revealed the facility had no orders in place to monitor the resident for side effects related to the high-risk medication. Continued review of the resident's medical record including Point of Care system for State tested Nursing Aides and the residents care plan revealed the facility did not have any evidence for monitoring for the resident's anticoagulant medication. Interview on 06/27/24 at 10:33 A.M. with Regional Nurse Consultant #114 confirmed the facility was not monitoring for side effects related to Resident #42's anticoagulant medication.

Based on record review and interview the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of the as needed (PRN) anti-anxiety medication, [MEDICATION(S)] for Resident #44. This affected one resident (#44) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia, Alzheimer's Disease, [CONDITION(S)] disorder and restlessness. Review of Resident #44's care plan, dated 09/24/20 related to psychoactive medication use revealed to offer non-pharmacological approaches prior to as needed medications such as redirection, distraction, food, beverage, toileting or re-location to quieter areas, etc. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment, dated 03/17/21 revealed the resident exhibited severe cognitive impairment. Review of Resident #44's physician's orders revealed an order, dated 05/10/21 for the anti-anxiety medication, [MEDICATION(S)] 0.5 mg (milligrams) twice a day as needed for anxiety. Review of Resident #44's medication administration record (MAR) from 06/01/21 to 07/15/21 revealed the resident was administered [MEDICATION(S)] on 06/01/21 at 6:38 P.M., 06/06/21 at 4:57 P.M., 06/09/21 at 1:44 P.M., 06/12/21 at 3:56 P.M., 06/18/21 at 5:44 P.M., 06/25/21 at 5:59 P.M., 06/26/21 at 7:28 P.M., 06/27/21 at 5:35 P.M., 07/02/21 at 5:13 P.M. and 07/04/21 at 5:25 P.M. Review of Resident #44's progress notes and administration records from 06/01/21 to 07/15/21 revealed no evidence non-pharmacological interventions were attempted prior to administration of the [MEDICATION(S)] medication on the dates noted above. On 07/15/21 between 12:54 P.M. and 1:18 P.M. interview with the Director of Nursing (DON), Registered Nurse (RN) #101 and Licensed Practical Nurse (LPN) #102 verified Resident #44's medical record did not contain evidence non-pharmacological interventions were attempted prior to administration of the as needed anti-anxiety medication, [MEDICATION(S)] on the dates above.

Based on interview and record review, the facility failed to provide prompt care and treatment for [REDACTED]. This affected one of four residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set assessment dated [DATE] revealed the resident was alert and oriented, required extensive assistance with her activities of daily living and did not have any skin impairments. Review of a care plan dated 01/16/19 revealed Resident #24 was at risk for skin breakdown due to impaired mobility and incontinence. The resident was to be encouraged to change position frequently and a pressure redistribution cushion and mattress were ordered. Observation of Resident #24 on 03/04/19 at 2:57 P.M. revealed her lying in bed. Interview with her revealed she had recently received a walking boot and was back in therapy, since her weight bearing status had increased from non -weight bearing to weight bearing as tolerated when wearing the boot. She said she had some pain around the left ankle area. She said she felt the boot was rubbing on her foot. She said she had told a nurse about the concern earlier that day and the nurse had said she would put a dressing on the area. She said the nurse had not yet put the dressing on her ankle. Review of the medical record did not reveal any documentation regarding any impaired skin until a order from the nurse practitioner was written on 03/05/19 at 9:54 A.M. This order directed nursing staff to pad and protect the left ankle. The dressing was to be changed three times a week. Review of the treatment administration record indicated the dressing was applied on 03/05/19, however the time of the dressing application could not be determined. There was no documentation in the nursing notes or elsewhere in the medical record regarding Resident 24's reports of her left ankle pain and the boot rubbing on 03/04/19 and no documentation of the appearance of the left ankle area. Review of the medical record again on 03/06/19 revealed no documentation related to Resident #24's left ankle pain and no documentation of the area for which the physician ordered a dressing to pad and protect the left ankle. On 03/06/19 at 1:30 P.M., documentation regarding Resident #24's left ankle area was requested. A note was provided by the assistant director of nursing, Registered Nurse (RN) #400, dated 03/06/19 at 2:53 P.M. This note indicated Resident #24 had an in-house acquired pressure ulcer area which was found on her left outer ankle. The pressure ulcer measured 0.4 centimeters (cm) by 0.4 cm with the depth marked as UTA, unable to assess. The area was recorded as an area of blanchable redness on the left outer ankle with a small area of rough skin in the center. Interview with RN #400 on 03/07/19 at 9:15 A.M. revealed she found out about the skin area on 03/06/19 and measured the area then. A nursing note from 03/07/19 at 10:06 A.M., was dated for 03/05/19 at 9:45 A.M., and was written by the Director of Nursing (DON). The DON indicated a nurse told her Resident #24 had complained of tenderness on the right ankle around the incision line and said the area was a little red but blanches. The DON documented the nurse practioner was called and she received an order for [REDACTED]. An interview with the DON on 03/07/19 at 1:30 P.M. verified she had just entered the nursing note regarding Resident #24's concerns and the impaired skin area on 03/07/19. She verified she had entered the note indicating the area was to the right ankle, but stated that was a mistake and she should have documented it as the left ankle. The DON verified an assessment of the pressure ulcer area should have been documented on 03/05/19 when the pad and protect order was given. She stated she was not sure who was told about the impaired skin area on 03/04/19, and indicated it could have been any staff member. Telephone interview with RN #401 on 03/07/19 at 1:45 P.M. revealed she worked on 03/04/19 and 03/05/19. She stated she did not remember talking to Resident #24 about a concern with her ankle on 03/04/19. She did say a therapist told her about the resident having pain to her ankle on 03/05/19 and then she examined Resident #24's left ankle and talked with the DON. She verified the pad and protect was ordered was received on 03/05/19. She verified she did not document any assessment of Resident #24's left ankle pressure ulcer area or her conversation with either the resident or the therapist.

Based on record review, observations and interviews, the facility failed to provide adequate supervision for residents to prevent inappropriate intimate contact. This affected three (Residents #42, #43, and #44) of six residents whose medical records were reviewed for quality of care. Findings include: Review of Facility Reported Incident # 8 indicated on 09/09/18 at 4:45 A.M., Residents #42 and #44 were observed kissing and hugging in the hallway of the secured dementia unit. Resident #44 was redirected down another hall while a state tested nursing assistant stayed with Resident #42 until the nurse administered medication for a headache. A witness statement by State tested Nursing Assistant (STNA) #85 indicated Resident #42 was a willful participant to the kissing and hugging. Review of Facility Reported Incident # 9 indicated on 09/09/18 at 5:50 A.M., Resident #44 was observed placing his hand on Resident #43's chest. Resident #44 was redirected. A witness statement written by the administrator regarding a phone interview with STNA #80 indicated Resident #44 walked down the hall, stopped beside Resident #43's wheelchair and spoke to her. Resident #44 was observed reaching over with his right hand and placing his hand on Resident #43's chest. STNA #80 reported she told Resident #44 not to do that and Resident #44 walked down the hall mumbling to himself. Review of Resident #44's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A behavioral care plan dated 05/15/18 indicated Resident #44 exhibited behaviors including inappropriate sexual behaviors at times. Interventions included observing and reporting socially inappropriate or wandering behaviors that were disruptive to other residents. When Resident #44 began to become socially inappropriate/disruptive behavior, or was wandering, staff were to provide comfort measures for basic needs. Staff were to observe behavior that endanger the resident and/or others and carefully intervene to promote safety. A nursing note dated 06/22/18 at 5:40 P.M. indicated the psychiatrist ordered [MEDICATION NAME] medication for increased sexual behaviors. There was no documentation of what sexual behaviors Resident #44 was exhibiting and the psychiatrist notes were not on the medical record. A nursing note dated 07/01/18 at 9:58 P.M. indicated Resident #44 repeatedly attempted to get female residents into his room. Staff constantly had to redirect him and watch him. A nursing note dated 07/02/18 at 1:53 P.M. indicated Resident #44 was able to be redirected away from other residents with simple requests to read the newspaper, take a nap, and turning music on in the sensory room. On 07/09/18, [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 was able to make himself understood and understood others. Resident #44 was severely cognitive impaired with a Brief Interview for Mental Status (BIMS) score of 4. Resident #44 exhibited physical and behavioral symptoms directed toward others 1-3 days during the seven day reference period and exhibited other behavioral symptoms not directed toward others 4-6 days. Resident #44 wandered 4-6 days. The MDS also indicated Resident #44 walked in his room independently and in the corridor with supervision. A nursing note dated 07/12/18 at 12:45 P.M. indicated Resident #44 started on [MEDICATION NAME] medication to decrease inappropriate sexual drive (order dated 07/09/18). A nursing note dated 08/21/18 at 4:11 A.M. indicated Resident #44 was up wandering and went into another female resident's room and was pulling the curtain. A state tested nursing assistant caught him and escorted him out of the room. A nursing note dated 09/09/18 at 6:25 A.M. indicated Resident #44 was observed kissing another female resident on the lips. Resident #44 was escorted to another area. A nursing note dated 09/09/18 at 6:29 A.M. indicated Resident #44 was observed inappropriately touching another female resident. Resident #44 was escorted to another area. A nursing note dated 09/09/18 at 8:16 A.M. indicated the Director of Nursing (DON), the on call Nurse Practitioner (NP) and psychiatrist were notified of the incident and that 1:1 supervision was initiated. All were in agreement with calling psychiatric units to check bed availability. A nursing note dated 09/09/18 at 4:30 P.M. indicated Resident #44 was transported to psychiatric care. One on one observation was continued until Resident #44 left the building. Review of Resident #42's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A significant change in status MDS assessment dated [DATE] indicated Resident #42 had short and long term memory problems and moderately impaired cognitive skills for daily decision making. Resident #42 transferred and walked independently. A nursing note dated 09/09/18 at 6:24 A.M. indicated Resident #42 was receptive to a kiss by a male resident. The male resident was escorted to another area. Review of Resident #43's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated Resident #43 was rarely or never able to make herself understood. Resident #43 was assessed with [REDACTED]. Resident #43 required extensive assistance for transfers and did not walk. A nursing note dated 09/09/18 at 6:30 A.M. indicated a STNA reported she witnessed a physical interaction on top of Resident #43's clothing between her and a male resident. The male resident was escorted to another area. None of the three residents, #42, #43, or #44, had evaluations related to whether they were cognitively able to consent to sexual/intimate activity. Observations of the secured dementia unit on 09/12/18 at 10:35 A.M. revealed Resident #44's room was across the hall from Residents #42 and #43. At the end of that hall, the corridor split to the left and to the right. At the end of the corridor to the right, one had to turn right to get to a lounge. Resident #42 was observed ambulating in the halls with no signs of distress. Resident #42 was confused but did state she did not have any problems with anybody. Resident #43 was sitting in a wheelchair in the hall near her room. Resident #43 did not respond appropriately when spoken to, being confused and unable to respond according to the conversation. On 09/12/18 at 10:43 A.M., STNA #105 was interviewed and stated Resident #44 had a history of [REDACTED].#44 would wander into female residents' rooms and tried to hug on them. Any time Resident #44 was wandering, there was a chance of him going into another resident's room and acting inappropriately. When Resident #44 wandered, she would ensure she or another staff member kept him in sight. On 09/12/18 at 11:30 A.M., the Administrator verified although Resident #44 had medications ordered related to staff reports of inappropriate sexual behavior, the only documentation she found was on 07/01/18 when he was trying to get female residents to go in his room. The Administrator indicated Resident #44's psychiatrist was in the facility and would ask him to explain the medication necessity since the medical record did not describe the behaviors for which the medications were ordered/added. Phone numbers were requested for STNA #80, STNA #81 and the nurse working on 09/09/18 when Resident #44 exhibited the behaviors. On 09/12/18 at 11:52 A.M., Psychiatrist #90 was interviewed and stated Resident #44's sexually inappropriate behaviors for which he was prescribed the [MEDICATION NAME] and [MEDICATION NAME] included touching and trying to kiss other residents. Psychiatrist #90 indicated the person who transcribed notes for him had not been working so his notes were not in the medical record. Psychiatrist #90 indicated Resident #44 was not aggressive in his approach with other residents. Resident #44 had serious dementia and he was working with the family to have Resident #44 admitted to an all male unit. Psychiatrist #90 stated he did not believe Resident #44 was able to comprehend his actions or physically capable of doing anything more than kissing and that Resident #44 was acting on instinct. On 09/12/18 at 12:49 P.M., Unit Manager #95 stated when she spoke with Resident #44 she did not find him able to stay focused. Resident #44 was able to comprehend and follow simple commands. Unit Manager #95 was uncertain when staff initiated the one to one supervision for Resident #44 on 09/09/18. Unit Manager #95 stated Resident #44 wandered a lot. On 09/12/18 at 1:00 P.M., a telephone interview was conducted with Registered Nurse (RN) #100 who was the nurse assigned to the secured dementia unit the morning the incidents occurred. RN #100 stated Resident #44 was non-combative, easily redirected and able to follow commands. However, Resident #44 was not mentally aware of much. RN #100 stated Resident #44 wandered a lot and would enter rooms with open doors, more so with female residents. RN #100 stated when she went to do her routine rounds, the aide told her Resident #44 was kissing Resident #42 again. RN #100 stated although Resident #42 was confused, she believed Resident #42 comprehended more than Resident #44 and was receptive to the hugging and kissing. RN #100 stated Resident #44 thought female residents were his wife and which one he thought was his wife varied day to day. RN #100 stated she thought it was probably about 4:00 or 4:30 A.M. when she learned of Resident #44 kissing and hugging Resident #42. RN #44 was uncertain where Resident #44 was redirected to after the incident, stating possibly his room or the television room. After the incident in which Resident #44 had his hand on Resident #43's chest, he was told he was not able to be there and he left. No other action was taken at that time. RN #100 stated she reported the behaviors to the oncoming nurse during report. The oncoming nurse spoke with STNA #85 who was upset (about more than Resident #44's behavior) and decided to notify the unit manager. RN #100 stated the oncoming nurse told her she was informed the incidents needed to be documented in the medical records. RN #100 stated she left the facility around 7:15 A.M. on 09/09/18 and vaguely remembered one on one supervision for Resident #44 being discussed but she did not know if it had been initiated. A psychiatric note dated (MONTH) (YEAR) for Resident #44 indicated staff reported increased sexual behaviors. During the interview, Resident #44 was able to maintain eye contact and meaningful conversation. Resident #44 was alert and oriented to himself. Resident #44 remained delusional. Remote memory was fair. Insight was superficial and impulse control was poor. Judgment remained impaired. The note indicated the [MEDICATION NAME] was ordered for sexual inappropriateness had not been very effective and [MEDICATION NAME] 1.25 milligrams once a day was being added for sexual inappropriateness. On 09/12/18 at 1:12 P.M., an attempt to contact STNA #80 was unsuccessful. STNA #80 did not return a phone call. The phone number for STNA #85 was never provided as requested.

Based on observation, interview, review of the medical record, witness statement, police report, and Elopement Assessment policy, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #1), who was cognitively impaired, independently mobile but unsteady while walking, and assessed as being at high-risk for elopement. This resulted in Immediate Jeopardy for Resident #1 who exited the building through his bedroom window without staff knowledge on 05/03/18, after two prior elopement attempts to leave through a window. The potential for serious harm occurred when Resident #1 was observed approximately one-half mile away from the facility, walking on a two-lane road in heavy rain before being noticed by a concerned citizen who alerted the facility. This affected one of 25 residents assessed as being at risk for elopement. The facility census was 70 residents. On 05/14/18 at 4:00 P.M. the administrator and Regional Director of Operations (RDO) #9 were notified the Immediate Jeopardy began on 05/03/18 at 4:45 P.M. when Resident #1 was last seen prior to exiting the building. Staff were not aware Resident #1 was not in the facility until a concerned citizen called the facility on 05/03/18 at 5:15 P.M. The Immediate Jeopardy was removed on 05/07/18 when the facility implemented the following corrective actions: On 05/03/18 at 5:35 P.M., six employees, who were involved the elopement incident of Resident #1, were educated on responding to the magnet locking doors and the policy on elopement. On 05/03/18 from 7:30 P.M. to 8:30 P.M., 34 employees were educated by the administrator on the facility's policy and procedure for a missing resident and elopement. On 05/03/18 at 8:13 P.M., Director of Maintenance (DM) #5 placed screws on the upper and lower window guards in Resident #1's bedroom window. On 05/03/18 at 10:15 P.M., one-to-one supervision was begun for Resident #1, which continued until 05/07/18 at 6:00 P.M. On 05/03/18, the facility confirmed all residents identified at-risk for elopement from the secured unit were in the elopement binders. On 05/04/18 at 9:30 A.M., DM #5 educated 20 employees on the facility Elopement policy. On 05/04/18 from 9:00 A.M. to 10:00 A.M., Human Resources Director #25 educated 15 employees on the facility Elopement policy. On 05/04/18 at 11:30 A.M., DM #5 conducted an elopement drill and 16 employees were educated on the alarming magnet locking doors and the facility Elopement policy. On 05/04/18 at 5:05 P.M., Medical Director #18 ordered medication ([MEDICATION NAME] sprinkles, 250 milligrams twice a day) for Resident #1 to address the resident's [DIAGNOSES REDACTED]. On 05/04/18, DM #5 evaluated all the windows in the facility to ensure they had screws placed into the window guards or had a metal angle bracket into the window frame. On 05/06/18 at 4:10 A.M., DM #5 conducted another elopement drill. On 05/07/18 at 2:15 P.M., STNAs and nurses completed 15 minute checks for Resident #1, which continued until 05/09/18 at 12:00 A.M. On 05/07/18, Resident #1's room was changed to a room where the exit window's egress was to the secured courtyard. On 05/07/18, a television was installed in Resident #1's room after family discussion revealed Resident #1 enjoyed watching television alone instead of in the common area On 05/11/18 at 1:15 P.M. and 3:30 P.M., and on 05/12/18 at 3:00P.M., DM #5 conducted additional elopement drills. On 05/14/18 from 10:39 A.M. to 11:28 A.M., interviews with State tested Nurse Aide (STNA) #1, Licensed Practical Nurse (LPN) #2, STNA #3, STNA #4, STNA #6, and Registered Nurse (RN) #7 revealed they were educated on the elopement policy Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of monitoring the resident and evaluating staff response to his behaviors in order to ensure the prevention of future elopements. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He resided on the secured, dementia unit. Review of the 04/03/18 hospital case worker progress note, written prior to facility admission, indicated Resident #1 was very pleasantly confused but accurate with some facts, and Resident #1's family member said Resident #1 wandered off and did not know where he was at. Review of the 04/03/18 psychiatrist hospital progress note indicated Resident #1 was confused at home, driving his car somewhere and thinking there were kids in the car. Review of the 04/04/18 internal medicine hospital progress note indicated Resident #1 needed placement unless family had 24-hour supervision as the resident wandered outside. Review of the 04/05/18 Clinical Admission Documentation assessment completed by LPN #19 indicated Resident #1 was at moderate-risk for elopement as the resident had delusions, was able to ambulate and had a [DIAGNOSES REDACTED].#17 indicated Resident #1 was moderately-cognitively impaired; wandered one to three days during the assessment time frame; required supervision while walking in his room and walking in the corridor; was not steady, but able to stabilize without staff assistance while walking; and normally did not use any mobility devices. Review of the nursing progress note written by LPN #2 on 04/09/18 at 9:51 A.M. revealed at 8:00 A.M., Resident #1 stated, I want out of here now. The nurse attempted to talk with Resident #1 but he walked away yelling and sat in the lounge area. Resident #1 was walking to the doors to the courtyard and shaking them, trying to open the door. Review of the nursing progress note, written by RN #7 as a late entry on 04/11/18 at 6:00 P.M., which documented information for 04/10/18 at 10:00 AM., indicated as therapy was bringing Resident #1 back to the secured dementia unit, ran the resident off the unit through an open door and ran to another unit and attempted to leave through the door at the end of the hall. Resident #1 was redirected and returned to the secured, dementia unit without incident. Resident #1 appeared calm, pleasant and was sitting in the sensory room after this incident. When RN #7 went to leave the unit for break, a commotion was heard and Resident #1 was found with the top-half of his body hanging out of a first-floor window (room [ROOM NUMBER]) of another resident's room in an attempt to elope. Director of Maintenance (DM) #5 was outside of the window of the bedroom in an attempt to get Resident #1 back inside as RN #7 assisted from inside the room. Resident #1 was cooperative and got himself back inside. Resident #1 stated he wanted to go home. There was no evidence that the facility increased supervision of the resident after this incident. Review of the witness statement written by DM #5 on 04/10/18 revealed DM #5 was outside near the sprinkler building when he saw Resident #1 open the window, and tear off the screen in room [ROOM NUMBER]. Resident #1 then threw out some clothing and attempted to exit through the window. DM #5 braced Resident #1's shoulders to prevent him from exiting. DM #5 yelled for help from the nursing staff. RN #7 responded and redirected Resident #1. Resident #1's head and right arm were all that were outside of the window. DM #5 then installed window guards in room [ROOM NUMBER] and inspected all other windows on the unit to ensure the metal or plastic guards were in place in the window tracks to disable the windows from raising more than six inches. Review of the 04/13/18 Admission MDS Observations Assessment completed by RN #17 indicated Resident #1 was at high-risk for elopement as the resident was searching and making verbal statements of needing to leave. Review of the nursing progress note written by LPN #19 on 04/13/18 at 9:38 P.M. revealed Resident #1 was pacing hall exit seeking, increased agitation. LPN #19 attempted several times to redirect him, however, Resident #1 was uncooperative and continued to pace the hallway. Review of the nursing progress note written by RN #20 on 04/13/18 at 11:03 P.M. indicated Resident #1 said he should not have to stay at the facility overnight and would be going home in the morning. Review of the 04/18/18 Behavioral Symptoms Care Plan indicated Resident #1 had a history of [REDACTED]. Interventions included observe for behavior that endangers Resident #1 and/or others; and staff were to carefully intervene to promote safety of Resident #1, other residents and staff. Review of the nursing progress note, written by RN #20 as a late entry on 04/24/18 at 2:52 A.M., which documented information from 04/24/18 at 12:35 A.M., indicated Resident #1 woke up and asked STNA #21 where the door was that he could leave out of. STNA #21 told Resident #1 that everyone was staying there for the night and Resident #1 became very aggressive towards STNA #21 and began kicking the wall across from the sensory room. Review of the nursing progress note written by LPN #22 on 04/26/18 at 6:30 A.M. revealed Resident #1 was exit seeking, banging on the door, and had personal items packed in a bag trying to leave. Resident #1 was redirected several times by LPN #22 when he began to yell and was redirected again. Review of the nursing progress note written by LPN #22 on 04/26/18 at 2:01 P.M. revealed Resident #1 continued to be exit seeking at times and was redirected several times by LPN #22, STNA #24, and STNA #26 throughout the shift. Review of the nursing progress note written on 04/26/18 at 5:59 P.M. by RN #23 indicated Resident #1 continued to exit seek. Review of the nursing progress note, written by RN #23 as a late entry on 04/27/18 at 12:44 P.M which documented information from 04/26/18 at 9:43 P.M., indicated the screen was replaced to the window, no further exit seeking via the window. Review of the nursing progress note written by RN #23 on 04/26/18 at 10:20 P.M. revealed Resident #1 tried to exit his room by knocking the screen out of his window. The STNA was able to redirect Resident #1 to the television room. According to a Facility Alert Form dated 05/03/18 at 5:15 P.M., Resident #1 successfully eloped from the facility. There was no evidence that Resident #1's elopement was documented in the medical record. The staff witness statements associated with this elopement included the witness statement written by Receptionist #13, who said a concerned citizen called on 05/03/18 at approximately 5:15 P.M. about an elderly gentleman walking on the two-lane road hitch hiking. The lady indicated he was going South towards a town. Receptionist #13 notified everyone for a head check and Resident #1 was discovered missing. The witness statement written by STNA #10 on 05/03/18 indicated Resident #1 ate dinner at 4:45 P.M. then was sitting in the television room for a little while. At that time, STNA #10 and STNA #11 were cleaning up the dining area. STNA #10 and STNA #11 then received a call to do a head count and immediately started the head count. Everyone was accounted for except Resident #1. STNA #10 and STNA #11 checked all the rooms and both STNAs noticed Resident #1's window was closed so both STNAs thought someone let him out of the main door. The witness statement written by STNA #11 on 05/03/18 indicated STNA #11 last saw Resident #1 sitting at the dining room table. Resident #1 asked STNA #11 to warm up his coffee and STNA #11 gave him a dinner plate. When asked to do a head count was when STNA #11 discovered Resident #1 was missing. The witness statement written by LPN #12 on 05/03/18 indicated an STNA informed LPN #12 that while doing a head count, Resident #1 was not anywhere on the unit. LPN #12 left another unit and immediately came to help search. When LPN #12 checked Resident #1's room and attempted to open the window, the window was unlocked and the screen was cut out and the window [MEDICATION NAME] were missing. The witness statement written by LPN #14 on 05/03/18 indicated LPN #14 received a call from RN #15 that Resident #1 was missing. LPN #14 was at home and immediately got in the car and started looking for Resident #1. LPN #14 got a call from Passerby #8 who said they picked up a guy that Passerby #8 thought walked down the street from the facility, so Passerby #8 took Resident #1 to a neighboring town police station. LPN #14 arrived at the police station and Resident #1 was upset saying he wasn't going back to jail. LPN #14 attempted to talk Resident #1 into coming back with her and Resident #1 stated, no way, no how. Resident #1 then talked to his family member and wanted the family member to take him home. Resident #1's family member told him he was going back to the facility. The police offered to take Resident #1 to the hospital and the resident agreed. LPN #14 went back to the facility and notified another family member of Resident #1 of the incident. Review of the police report dated 05/03/18 from 5:30 P.M. to 5:45 P.M. indicated Officer #16 was dispatched to the facility for a well-being check. An unknown caller advised that they saw an elderly male walking along the road near the facility. While in route to the facility, a neighboring fire department advised that Resident #1 was located at the neighboring town's police department. Officer #16 responded to that police department, and the fire department left the scene. The police department said they had Resident #1 and were transporting him to the hospital. Officer #16 responded to the facility and made contact with LPN #14 who stated Resident #1 was not happy with being at the facility and has tried to leave many times. Officer #16 responded to the hospital and spoke with Resident #1. Resident #1 said he was tired of staying at the facility and they would not allow him to leave so he walked away. Review of the nursing progress note written by RN #17 on 05/03/18 at 7:12 P.M. indicated Nurse Practitioner (NP) #27 was notified of the incident and the transfer of Resident #1 to the hospital. Review of the nursing progress note written by RN #20 as a late entry on 05/03/18 at 11:56 P.M., which documented information from 05/03/18 at 10:15 P.M., indicated Resident #1 was returned to the unit from the hospital by his family members at 10:15 P.M. While at the hospital, Resident #1 was examined with no injuries found, no complaints of pain and all vital signs were within normal limits. A skin check was performed after the return to the unit and no abnormalities were noted and there were no complaints of pain from Resident #1. Resident #1 had one-on-one supervision throughout the night. Review of the one-on-one supervision schedule from 05/03/18 at 10:15 P.M. to 05/07/18 at 6:00 P.M. revealed supervision of Resident #1 was scheduled and completed by Director of Dietary #28, Receptionist #13, STNA #11, STNA #29, STNA #3, Medical Records Clerk #30, STNA #11, STNA #31, STNA #32, STNA #33, and STNA #34. On 05/14/18 at 10:52 A.M., observation of Resident #1 revealed he was sitting in his room, in a lounge chair, dressed in street clothes, wearing glasses, watching television, and was pleasant. Resident #1's bedroom window faced a secured, outside courtyard which was surround by facility walls. Resident #1's window opened six inches and there were two screws on each side of the upper and lower window guards to secure the window guards to the window frame. There was also a screw on each side of the thumb tabs to prevent the window from opening in towards Resident #1's room. Resident #1 was interviewed at this time and he did not want to discuss the incident when he left the facility through his window a couple of weeks prior. Interview on 05/14/18 at 11:16 A.M. with DM #5 revealed when Resident #5 eloped from the facility on 05/03/18, he used a fork to pry off the upper window guards and cut the screen. DM #5 also revealed on the evening of 05/03/18 after Resident #1 eloped, DM #2 placed two screws in each of the upper and each of the lower window guards to ensure the window guards weren't pried out and a screw in both thumb knobs to disable the window from popping out of the window frame in Resident #1's room. Interview on 05/14/18 at 11:36 A.M. with the administrator revealed Resident #1's upper window guards and fork were found by LPN #14 in the resident's room. The administrtor also revealed the secured unit was served dinner from 4:45 P.M. to 5:00 P.M. which was when Resident #1 was last seen in the facility. Interview on 05/14/18 at 1:12 P.M. with Passerby #8 revealed on 05/03/18 at approximately 5:35 P.M., Passerby #8 was driving South on a two-lane road and Resident #1 was observed approximately one-half mile South of the facility walking on the side of the road with his thumb out like a hitchhiker. Passerby #8 turned the car around and Resident #1 stated, he was heading into town and Passerby #8 told Resident #1 she would give him a ride. Resident #1 got in the car. Resident #1's clothes were wet since it was raining hard and the resident was holding a bundle of items. Resident #1 stated, he was going into town to his family member's house and he was coming from West Virginia. Resident #1 asked Passerby #8 if she knew his family member. Passerby #8 realized that was an odd question. Resident #1 did not have a phone number or address for his family member and when Passerby #8 asked Resident #1 where to go once in town, Resident #1 replied, keep going straight. Passerby #8 took Resident #1 to the police department. Interview on 05/14/18 at 1:50 P.M. with the administrator, DON and RDO #9 verified they were not aware of Resident #1's 04/10/18 attempt of elopement when the resident was found hanging out of the window from room [ROOM NUMBER]. Interview on 05/14/18 at 2:41 P.M., with RDO #9, the DON, and the administrator revealed RN #23 put a dresser in front of the resident's window after the 04/26/18 incident when he kicked out the screen of the window. However, they verified there was no care plan update or nursing progress notes of that intervention, or any other new interventions following the elopement attempt added to the care plan. Interview on 05/15/18 at 11:30 A.M. with the administrator and RDO #9 verified Resident #1's elopement was not documented in his medical record. Observation on 05/15/18 from 3:34 P.M. to 3:45 P.M. with DM #5 revealed the secured unit had five exit doors which all could not be opened when the door handle was pushed in attempt to open the door. Interview with DM #5 revealed the five doors could only be opened when the correct code was entered into the keypad by the door or if the fire alarm rang. Interview on 05/15/18 at 3:50 P.M. with STNA #11 (who was working on the secured unit on 05/03/18 when Resident #1 eloped) revealed Resident #1 had finished eating dinner and was sitting in the television lounge, watching television, which was in the same room as the dining room. STNA #11 and STNA #10 were cleaning off the tables from dinner when Resident #1 walked over to STNA #10 and said, see ya later, which Resident #1 normally said and STNA #11 thought he was going back to his room to lay down which was his normal routine. About five minutes later, STNA #10 and STNA #11 got the call to complete a head count and Resident #1 was missing. Interview on 05/15/18 at 4:05 P.M. with STNA #10 (who was working on the secured unit on 05/03/18 when Resident #1 eloped) revealed Resident #1 was eating dinner at 4:45 P.M. and when he was done eating, he went to sit in the television lounge which was in the same room as the dining room. While STNA #10 and STNA #11 were cleaning the tables from dinner, Resident #1 got up from the chair, waved at STNA #10 and said, see ya later, which he normally said and would go back to his room. About 10 minutes later, STNA #10 and STNA #11 got a call to complete a head count and Resident #1 was missing. STNA #10 and STNA #11 checked Resident #1's room and the window was closed. Observation on 05/15/18 at 5:00 P.M. revealed Resident #1 was standing in the dining room, next to a dining room table, during meal time, chatting with Resident #61. Interview on 05/16/18 at 8:55 A.M. with RN #17 revealed on 05/03/18 at approximately 5:25 P.M., Receptionist #13 received a call from a citizen concerned about an elderly gentleman walking on the two-lane road hitch hiking. Receptionist #13 instructed the floor staff to complete a head count. Receptionist #13 then notified RN #17 that Resident #1 was not accounted for. RN #17 called the administrator and Receptionist #13 called the police station. RN #17 got in the car and drove South on a two-lane road towards a neighboring town to search for Resident #1. RN #17 called LPN #14 since LPN #14 lived close to the neighboring town. RN #17 and LPN #14 were both searching for Resident #1 in the neighboring town. RN #17 stopped at a gas station to ask if a tall, gentleman who was hitchhiking had been seen. LPN #14 called RN #17 to report that Passerby #8 had given a tall, gentleman, a ride to the police station. RN #17 went to the police station. Resident #1 did not want to return to the facility so it was decided Resident #1 was going to go to the hospital. Resident #1's clothes were wet from the rain. Interview on 05/16/18 at 9:23 A.M. with LPN #14 revealed RN #17 called her at home on 05/03/18 at approximately 5:30 P.M. to notify LPN #14 that Resident #1 was missing from the facility. LPN #14 left her house and headed towards the neighboring town. While driving around searching for Resident #1, Passerby #8 called LPN #14 to notify her that she had picked up a gentleman and dropped him off at the police station. LPN #14 went to the police station and RN #17 was already there with Resident #1. LPN #14 tried to talk Resident #1 into going back to the facility however Resident #1 refused. Resident #1 finally agreed to go to the hospital. LPN #14 went to the facility and saw Resident #1's bedroom window screen was missing. The top plastic guards and a fork were found in Resident #1's dresser drawer. Observation on 05/16/18 at 12:50 P.M. revealed Resident #1 was sitting in his room, in a lounge chair, dressed in street clothes, wearing glasses, watching television, and was pleasant. Review of the National Weather Office Service Forecast daily climate report revealed a high temperature on 05/03/18 of 77 degrees Fahrenheit (F), a low temperature of 64 degrees F and light rain, rain and thunderstorms were recorded. Review of the undated elopement assessment policy indicated the facility's policy was to provide a safe environment, while using the least restrictive means.

Based on record review, interview and policy review, the facility failed to ensure Resident #1's elopement was accurately documented in the medical record. This affected one (Resident #1) of three residents reviewed for elopement. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He resided on the secured, dementia unit. Review of the 04/12/18 Minimum Data Set (MDS) 3.0 admission assessment completed by RN #17 indicated Resident #1 was moderately-cognitively impaired; wandered one to three days during the assessment time frame; required supervision while walking in his room and walking in the corridor; was not steady, but able to stabilize without staff assistance while walking; and normally did not use any mobility devices. Review of the nursing progress note written by LPN #2 on 04/09/18 at 9:51 A.M. revealed at 8:00 A.M., Resident #1 stated, I want out of here now and the nurse attempted to talk with Resident #1 but he walked away yelling. Resident #1 then walked away and sat in the lounge area. Resident #1 was walking to doors to courtyard and shaking the doors trying to open the door. Review of the nursing progress note, written by Registered Nures (RN) #7 as a late entry on 04/11/18 at 6:00 P.M., which documented information from 04/10/18 at 10:00 AM., indicated as therapy was bringing Resident #1 back to the secured, dementia unit, Resident #1 ran off the unit through an opened door and ran to another unit and attempted to leave through the door at the end of the hall. Resident #1 was redirected and returned to the secured, dementia unit without incident. Resident #1 appeared calm, pleasant and was sitting in the sensory room after this incident. When RN #7 went to leave the unit for break, a commotion was heard and Resident #1 was found with the top-half of his body hanging out of a first-floor window (room [ROOM NUMBER]) of another resident's room in an attempt to elope. Director of Maintenance (DM) #5 was outside of the window of the bedroom in an attempt to get Resident #1 back in and RN #7 assisted from the inside. Resident #1 again was cooperative and got himself back inside. Resident #1 stated he wanted to go home. There was no evidence that the facility increased supervision of this resident after this incident. Review of the 04/13/18 Admission MDS Observations Assessment completed by RN #17 indicated Resident #1 was at high-risk for elopement as Resident #1 was searching and making verbal statements of needing to leave. Review of the nursing progress note written by Licensed Practical Nurse (LPN) #19 on 04/13/18 at 9:38 P.M. revealed Resident #1 passing hall exit seeking, increased agitation. Resident #1 attempted several times to redirect, Resident #1 was uncooperative and continued to pace the hallway. Review of the nursing progress note written by RN #20 on 04/13/18 at 11:03 P.M. indicated Resident #1 said he should not have to stay here overnight and will be going home in the morning. Review of the 04/18/18 Behavioral Symptoms Care Plan indicated Resident #1 had a history of [REDACTED]. This included an intervention to observe for behavior that endangers Resident #1 and/or others, staff to carefully intervene to promote safety of Resident #1, other residents and staff. Review of the nursing progress note, written by RN #20 as a late entry on 04/24/18 at 2:52 A.M. which documented information from 04/24/18 at 12:35 A.M., indicated Resident #1 woke up and asked State tested Nurse Aide (STNA) #21 where the door was that he could leave out of. STNA #21 told Resident #1 that everyone was staying here for the night and Resident #1 became very aggressive towards STNA #21 and began kicking the wall across from the sensory room. Resident #1 went to the bathroom and shut the door. STNA #21 left to get RN #20 while STNA #24 stayed on the unit. As RN #20 prepared to administer medication with the help of both STNA's, Resident #1 attempted to strike RN #20, STNA #21, and STNA #24 and did hit STNA #21 in the chin with Resident #1's fist. Review of the nursing progress note written by LPN #22 on 04/26/18 at 6:30 A.M. revealed Resident #1 was exit seeking at this time, banging on the door, and had personal items packed in a bag trying to leave. Resident #1 was redirected several times by LPN #22 when Resident #1 began to yell and was redirected again. Review of the nursing progress note written by LPN #22 on 04/26/18 at 2:01 P.M. revealed Resident #1 continued to be exit seeking at times and was redirected several times by LPN #22, STNA #24 and STNA #26 throughout the shift. Review of the nursing progress note written on 04/26/18 at 5:59 P.M. by RN #23 indicated Resident #1 continued to exit seek. Review of the nursing progress note, written by RN #23 as a late entry on 04/27/18 at 12:44 P.M which documented information from 04/26/18 at 9:43 P.M., indicated the screen was replaced to the window, no further exit seeking via the window. Review of the nursing progress note written by RN #23 on 04/26/18 at 10:20 P.M. revealed Resident #1 tried to exit his room by knocking the screen out of his window. The STNA was able to redirect Resident #1 to the television room. Review of the nursing progress note written by RN #17 on 05/03/18 at 7:12 P.M. indicated the Nurse Practitioner (NP) #27 was notified of the incident and the transfer of Resident #1 to the hospital. Review of the nursing progress note written by RN #20 as a late entry on 05/03/18 at 11:56 P.M. which documented information from 05/03/18 at 10:15 P.M., indicated Resident #1 returned to the unit from the hospital by Resident #1's family members at 10:15 P.M. While at the hospital, Resident #1 was examined with no injuries found, no complaints of pain and all vital signs were within normal limits. A skin check was performed after the return to the unit and no abnormalities were noted and no complaints of pain from Resident #1. Resident #1 would have one-on-one supervision throughout the night. According to a Facility Alert Form dated 05/03/18 at 5:15 P.M., Resident #1 successfully eloped from the facility. There was no evidence that Resident #1's elopement was documented in the medical record. Interview on 05/15/18 at 11:30 A.M. with the Administrator and Regional Director of Operations (RDO) #9 verified Resident #1's elopement was not documented in Resident #1's medical record. Review of the (MONTH) (YEAR) Missing Resident policy indicated to complete an incident report and charting of the incident in appropriate resident records. This deficiency resulted from incidental findings discovered during this complaint investigation.

Based on observation, policy review and staff interview, the facility failed to ensure cleaning procedures for an isolation room to prevent the spread of infection. This had the potential to affect all 72 residents in the facility. Findings include: Observation of the cleaning of an isolation room on 01/24/18 at 1:35 P.M. with Housekeeper (HSKG) #70 revealed HSKG #70 cleaning Resident #16's room who was in isolation for [MEDICAL CONDITION] Resistant [DIAGNOSES REDACTED] Aureus (MRSA) of the wound. HSKG #70 gloved and gowned. She used a bleach wipe and wiped the overbed table and frame of bulletin board. HSKP #70 set a bucket on the floor then picked it up and wiped off sink, walker, two bedside tables, two heaters and all surfaces including the bed frame. HSKG #70 retrieved a broom and dust pan from the housekeeping cart parked outside the door, swept the floor sweeping the debris into a dust pan. The debris was placed in a red bag. She then returned the broom and dust pan to the cleaning cart. She got the mop out of the bucket of water on the cleaning cart and mopped the floor and returned it to the bucket. HSKG #70 revealed the toilet brush in the housekeeping cart was used in all rooms including the isolation rooms. The isolation room did not have a dedicated toilet brush. HSKP #70 took off personal protective equipment and washed her hands. She then pushed the housekeeping cart back to the housekeeping room. Observation 01/24/18 at 2:00 P.M. revealed HSKG #70 removing the mop head and placing it in a bag. She said she was taking the bag with the mop head to the laundry and put it in the isolation bin. HSKG #70 emptied the bucket, rinsed it and cleansed it with a bleach wipe but did not clean the mop handle, ringer handle or disinfectant bucket that had been placed on the floor in the isolation room. She did nothing with the broom or dust pan. She said the broom, dust pan and toilet brush were not exclusive to the isolation room and she used them in the other resident rooms also without cleaning. On 01/25/18 at 2:08 P.M. interview of HSKP #70 affirmed she used the same broom, dust pan and toilet brush used in the isolation rooms in the regular rooms without cleaning them. The facility currently had two resident's in isolation. One [MEDICAL CONDITION] and one for [MEDICAL CONDITION]. Review of the undated Procedure for Daily Cleaning a Contact Isolation Room Cleaning did not address how to handle the toilet brush, broom or dust pan used to clean the room. The policy included after cleaning the room to clean all equipment with bleach wipes ie: mop handles, wringer handle and disinfectant bottle. Remove gloves and put in trash. Wash your hands. On 01/24/18 at 2:10 P.M. interview of Director of Housekeeping/Laundry #84 affirmed taking the broom, dust pan and toilet brush from isolation rooms to regular resident rooms would spread bacteria. Director of Housekeeping/Laundry #84 verified the housekeeping room did not have a sink to wash hands per policy and the facility policy did not include a procedure for sweeping the room, use of the dust pan or toilet brush.

Based on observation, interview and record review the facility failed to ensure Residents #21 and #24, who were cognitively impaired and not able to self initiate activities, were provided activities to meet the residents' interests and support their psychosocial well-being. This affected two of two residents reviewed for activities. Findings include: Review of the December 2017 and January 2018 activity calendars revealed on most days two group activities were scheduled at 10:00 A.M. and 2:00 P.M. with additional activities scheduled at 3:00 P.M. On 01/25/18 at 10:05 A.M., interview with Activities coordinator (AC) #305 revealed he had been working at the facility since November 2017. He was full time and worked Monday through Friday 8:00 A.M. to 4:00 P.M. He had one full time assistant who worked every other weekend from 8:00 A.M. to 4:00 P.M. He indicated the department added a part time, 20 to 27 hour position a couple weeks ago and the employee worked between 9:30 A.M. and 3:30 P.M. Starting 01/26/18 they were going to have an activity staff work evening hours from 1:30 P.M. to 7:30 P.M. two days a week. AC #305 verified there were no evening activities since he started working; the latest activities were scheduled at 3:00 P.M. There were currently three residents on one to one activity programs. Resident #21 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and was dependent on at least two staff with the use of a mechanical lift for transfers and was dependent on staff for transportation. Review of the activities assessment dated [DATE] revealed the resident liked social interaction activities and music groups. The assessment indicated to continue with current care plan. Review of the current care plan revealed the resident had a short attention span and at times could become loud in activities. The approach included encourage resident to attend church and bible study, redirect by removing from group if interrupts or becomes loud and involve resident with those who have common interests such as music, church, coffee and socializing. Further review of the activities care plan revealed ensure resident approaches were based on the activities preferences for everyday living inventory (PELI). Review of the PELI dated 02/15/16 revealed it was not completed. Review of the December 2017 activity calendar revealed there were many social interaction activities and music and/or church activities were offered nine times. Review of Resident #21's activity participation log for December 2017 revealed she had a one to one visit on 12/20/17, on 12/22/17 she attended a movie. There was no evidence the resident attended any of the social interaction activities and/or music or church activities. Review of the January 2018 activity calendar revealed there were many social interaction activities and music and/or church activities were offered 11 times. Review of Resident #21's activity participation log for January 2018 revealed she had two one to one visits on 01/13/18 and 01/23/18. There was no evidence the resident attended any of the social interaction activity and/or music or church activities. On 01/23/18 all residents were confined to their rooms due to an influenza outbreak. Intermittent observations of Resident #21 between 8:30 A.M. and 6:30 P.M. revealed she was not engaged in meaningful activity. On 01/24/18 at 9:30 A.M. and 10:10 A.M., the resident was observed alone in her room with the TV on. On 01/24/18 at 10:12 A.M., an attempt to interview the resident was unsuccessful due to cognitive impairment; the resident started yelling and extended a box of tissue towards the surveyor. On 01/24/18 at 10:15 A.M., interview with State tested nursing assistant (STNA) #303 revealed the cognition of Resident #21 prevented her from following and being engaged in TV programs. On 01/24/18 at 2:34 P.M. and 3:00 P.M., the resident was observed alone in her room with the TV on. On 01/25/18 at 8:00 A.M., 9:35 A.M. and 11:00 A.M., Resident #21 was observed sitting in the hall in a wheelchair without any interaction from staff, visitors or other residents. On 01/25/18 at 10:05 A.M., interview with AC #305 revealed Resident #21 was not interviewable and he had not been able to talk with her family about her activity preferences. AC #305 said sometimes the resident acted out and was not appropriate for group activities but the resident could be assisted with independent activities and would benefit from one to one visits. After reviewing the participation logs, AC #305 verified Resident #21 was not attending group activities. Resident # 24 was on 03/19/13 with a [DIAGNOSES REDACTED]. The resident needed the assistance of one to two staff for activities of daily living. Review of the activities assessment dated [DATE] revealed the resident liked music and independent activities. Review of the current care plan revealed the resident had a short attention span and needed lots of encouragement to attend activities but once there had a great time. She enjoyed folding clothes, babysitting dolls and caring for her belongings. The resident needed escorted to activities. The care plan indicated to provide in room activities as needed. Further review of the activities care plan revealed ensure resident approaches were based on the activities PELI. Review of the PELI dated 06/01/16 revealed it was started but not completed. Review of the December 2017 activity calendar revealed there were many social interaction and music activities. Review of Resident #24's activity participation log for December 2017 revealed the only activity she attended was a music activity on 12/04/17. Review of the January 2018 activity calendar revealed there were many social interaction activities and music activities. Review of Resident #24's activity participation log for January 2018 revealed the resident did not attend any activities. She had two one to one visits on 01/13/18 and 01/23/18. On 01/23/18 all residents remained in their rooms due to an influenza outbreak. Intermittent observations of Resident #24 between 8:30 A.M. and 6:30 P.M. revealed she was not engaged in meaningful activity. On 01/24/18 at 10:00 A.M., interview with Resident #24's family member revealed the resident had impaired communication and was not able to express her needs. On 01/24/18 at 10:05 A.M., the resident was observed at a small round table in her wheelchair starring down at and picking at the table. There was nothing on the table. On 01/24/18 at 2:05 P.M., the resident was observed at the same table scratching on the table but nothing was on the table. On 01/24/18 at 3:20 P.M., Resident #24 was observed reclined in a recliner chair in the common area looking around at her surroundings. On 01/25/18 at 7:58 A.M., Resident #24 was observed at the small round table rubbing her hands together without anything on the table. On 01/25/18 at 9:28 A.M., the resident was observed in a reclining chair in the common area looking around at her surroundings. On 01/25/18 at 10:05 A.M., interview with AC #305 revealed Resident #24 was not able to self initiate activities and did not communicate verbally. He said the resident's daughter visited and engaged the resident in activities. After review of her participation logs, AC #305 indicated the resident would benefit from one to one activities and staff should be encouraged to provide the resident with independent activities including holding baby dolls. On 01/25/18 at 11:35 A.M., interview with the administrator revealed she was making efforts to enhance the activity programs and had recently hired a part time staff to assist with evening hours and/or weekends as needed.

Based on observation, interview and record review the facility failed to ensure care planned fall interventions were appropriate and consistently implemented as ordered/care planned for one resident (Resident #21). This affected one of two residents reviewed for falls. Findings include: Resident #21 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and was dependent on at least two staff and the use of a mechanical lift for transfers. Review of Resident #21's care planned interventions and corresponding state tested nursing assistant (STNA) Kardex revealed on 03/10/17 a Dycem (non skid mat) was to be placed in the seat of the resident's chair. On 03/12/17 the resident was to be slightly reclined in a tilt and space wheelchair due to a history of falls. On 06/12/17 the tilt and space wheelchair was discontinued and the resident was to be in a Broda (geriatric) chair. On 06/29/17 the resident was to wear hipsters. Review of the nursing note for a 07/28/17 fall revealed the resident was in her Broda chair in her room when the STNA left the room. The resident was observed a few minutes later on her buttocks on the floor in front of the chair. Review of the undated incident reassessment summary for the 07/28/17 fall at 8:15 P.M. revealed the STNA was going to put the resident in bed and left the room briefly and when she came back the resident was observed on the floor. The resident attempted to self transfer because she had no safety awareness. The resident needed a mechanical lift for transfers. No injuries were noted. The STNA was counseled and a new intervention was written to keep the resident in the common area until ready for bed. Review of an event witness statement for this same fall, dated 07/28/17, revealed when STNA #302 came back from her break the resident was sitting on the edge of her chair. She attempted to sit the resident back in the chair and then took the resident back to her room to get ready for bed. The STNA exited the room to get a night gown. When she returned the resident had slid out of the chair and was sitting on her foot rest. Review of the event report, completed 08/06/17, revealed the resident was in her chair alone and tried to get out of the chair. She was observed sitting on her buttock in front of her chair. After the incident staff was coached not to leave confused residents unattended in their rooms. The STNA was counseled for not ensuring the safety of the resident. Review of the nursing note related to a 08/31/17 fall revealed Resident #21 was observed on the floor in her room in front of the television (TV). The resident was making statements that she wanted to go home. Resident #21 was educated to use the call light for assistance and was re-oriented to the room and staff. The resident indicated she wanted to go to the common area. Review of the undated incident reassessment summary for the 08/31/17 fall at 5:20 P.M., revealed Resident #21 was observed on the floor in her room in front of the TV. The resident attempted to self transfer out of the chair. The immediate safety approaches included educate resident to ask for assistance as needed and assist to wear gripper socks. Review of the event report, completed 09/05/17, revealed no additional information. Review of the care plan interventions and corresponding STNA Kardex after the fall revealed as of 08/31/17 the staff were to encourage and assist Resident #21 to wear gripper socks while out of bed, encourage use of the call light for transfer/ambulation assistance and evaluate safety devices/enablers quarterly for possible reduction/elimination. On 01/24/18 at 9:30 A.M. and 10:10 A.M., Resident #21 observed in her room in a reclined tilt and space wheelchair and the call light was out of reach. The resident was playing with a box of tissues. An attempt to interview the resident on 01/24/18 at 10:12 A.M. was unsuccessful due to the resident's cognitive impairment. On 01/24/18 at 10:15 A.M., interview with STNA #303 verified the call light was out of reach. STNA #303 indicated the resident did not understand what the call light was or how to use the call light. STNA #303 indicated the resident did not refuse to go to the common area but sometimes she was loud and was disruptive to other residents and therefore had to be removed from the common areas. On 01/24/18 at 2:34 P.M. and 3:00 P.M., the resident was observed in her room reclined in the tilt and space wheelchair. On 01/24/18 at 3:05 P.M., STNA #304 enter the resident's room and told the resident she would be back in a little bit to assist her to get ready for dinner. On 01/24/18 at 3:08 P.M., interview with STNA #304 revealed she started work at 2:00 P.M. and the resident had been in her room since she began her shift. STNA #304 indicated the resident should be in the common area when in her chair because she was a high risk for falls. The resident had not refused to go to the common area. STNA #304 also indicated the resident was not capable of using the call light due to cognitive impairment and was taken to her room when she became disruptive. On 01/25/18 at 8:15 A.M., interview with the DON verified the resident was not to be left alone in her room and she was unsupervised in her room when she fell on [DATE]. Review of the nursing notes with the DON verified there was no documented evidence the resident refused to be in the common area as planned and verified the call light intervention and re education were not effective interventions related to the resident's severe cognitive impairment.

Based on observation, interview and record review the facility failed to ensure a comprehensive bowel and bladder program was in place to ensure Resident #321 was provided the care and services to remain continent. This affected one of one resident reviewed for bowel and bladder continence, and one of 59 residents identified by the facility as being incontinent and needing assistance with toileting. Findings include: Review of the undated bowel and bladder program policy and procedure revealed a three day bladder and bowel tracker would be completed on each resident upon admission, re-admission, with significant change, annual assessment and/or upon discontinuation of a urinary catheter. After the tracker was completed an incontinence program assessment would be completed to determine the type of incontinence and if a toileting program would be beneficial. Medical record review revealed Resident #321 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, was continent of bowel and bladder, was not on a toileting program and needed the assistance of one person for toileting. Review of the point of care history for January 2018 revealed the resident had incontinence episodes on 01/01/18, 01/02/18, 01/04/18, 01/14/18 and 01/22/18. On 01/23/18 at 12:00 P.M., observation of the resident revealed she was sitting in a reclining chair in her room. The room had a distinct odor of bowel movement. Interview with the resident at the time of the observation revealed she was usually continent but had a couple accidents since being admitted to the facility because she needed staff assistant to take her to the toilet. On 01/23/18 at 12:40 P.M., interview with State tested nurse aide (STNA) #304 revealed the resident was not on a toileting plan and needed assistance for her toileting needs. She was usually continent but had some accidents because she did not ask for help. On 01/25/18 at 10:45 A.M., interview with Corporate registered nurse (RN), RN #300 and the director of nursing (DON) revealed the resident was continent when she was admitted and had since had some episodes of incontinence. The DON revealed a bowel and bladder tracker and assessment had not been completed and therefore a plan of care was not developed. The DON verified the resident needed the assistance of one person for toileting. On 01/25/17 at 1:20 P.M., the resident was observed being toileted by STNA #301. The resident needed assistance to transfer on and off of the toilet and into the wheelchair. STNA #301 then wheeled the resident to her room and assisted with transferring her from the wheelchair to the recliner chair. On 01/25/17 at 1:25 P.M., interview with STNA #301 revealed she took the residents to the toilet after meals but there was no specific plan. She said Resident #321 did not wear an incontinence brief nor would she ask for assistance when she needed to use the restroom. On 01/25/18 at 1:30 PM., interview with RN #300 and the DON revealed the assistant director of nursing (ADON) was responsible for completing the bowel and bladder trackers and assessments. The ADON had not completed any bowel and bladder trackers or assessments since the middle of November 2017. The DON became aware the assessments were not being completed on 01/22/17 and implemented three day bowel and bladder trackers on two of the four units. The DON indicated the other two units would be completed when the first two units were completed. The ADON was no longer employed by the facility.

Based on record review and interview, the facility failed to ensure Resident #16 was given adequate notice that skilled therapy services were ending, and did not ensure Resident #85's Notice of Medicare Non-Coverage (NOMNC) form accurately reflected what skilled services were ending. This affected two of four residents reviewed for liability notices. Findings include: 1. Review of Resident #16's liability notice revealed the facility issued a NOMNC form that indicated physical therapy was ending on 08/29/16. Resident #16's Power of Attorney signed the letter on 08/28/16. Interview with the Administrator on 10/26/16 at 10:33 A.M. confirmed that Resident #16's NOMNC was signed on 08/28/16, one day before skilled therapy was ending. 2. Review of Resident #85's liability notice revealed the facility issued a NOMNC form that indicated occupational therapy was ending on 08/25/16. Review of Resident #85's therapy discharge notes revealed physical therapy services ended on 08/25/16 and occupational therapy services ended on 08/19/16. Interview with the Administrator on 10/26/16 at 10:11 A.M. revealed Resident #85's NOMNC letter should have stated physical therapy ended on 08/25/16, because occupational therapy ended on 08/19/16.

Based on record review, policy review and interview, the facility failed to offer Residents #55, and Resident #29 pneumococcal immunizations. This affected two of five residents reviewed for immunizations. Findings include: 1. Review of the medical record revealed Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #55's immunization record revealed the resident's guardian declined the pneumococcal immunization on 09/27/15. There was no evidence of when Resident #55 last received a pneumococcal immunization or that the resident was offered the pneumococcal vaccine since 09/27/15. Interview on 10/26/16 at 3:01 P.M. with the DON confirmed Resident #55 had not been re-offered the pneumococcal immunization and did not have an updated consent for the resident. 2. Review of the medical record revealed Resident #29 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's immunization record revealed the resident consented to receive the pneumococcal immunization and had last received a pneumococcal immunization in October 2001. The consent form had a publication date of 10/06/09 but the signed consent was undated. There was no evidence Resident #29 had been re-offered the pneumococcal immunization. Interview on 10/26/16 at 3:01 P.M. with the DON revealed the facility had not re-offered the resident the recommended pneumococcal immunization, or had an updated consent on file. The DON was unsure what the publication date meant on Resident #29's prior consent. Review of the facility Pneumococcal Vaccine policy (undated) revealed administration of the pneumococcal vaccination or revaccinations will be made in accordance with the current Centers for Disease Control and Prevention recommendation at the time of vaccination. If a resident or authorized representative refuses the vaccination upon admission, the facility will offer the vaccine on an annual basis.

Based on observation and interview, the facility failed to ensure food was served under sanitary conditions. This affected one (Resident #36) of five residents observed for hall tray breakfast service. Findings include: Observation on 10/25/16 at 7:37 A.M. of the Friendship unit hall tray breakfast service revealed State tested Nurse Aide (STNA) #90 entered Resident #36's room with a breakfast tray and placed it on the resident's bedside table. STNA #90 picked Resident #36's fall mat off the floor with her bare hands and moved Resident #36's bedside table across the resident's lap. STNA #90 did not wash or sanitize her hands and then touched Resident #36's french toast and peeled banana with her bare hands. Interview on 10/25/16 at 7:40 A.M. with STNA #90 confirmed she picked Resident #36's fall mat off the floor, did not wash her hands, and then touched Resident #36's food with her bare hands.