Every finding on record at Delmar Gardens of Smyrna

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Expiration Guidelines, the facility failed to discard expired supplements in two of two medication rooms and on two of four medication carts. This deficient practice created the potential for expired or improperly stored supplements to be used in resident care, placing residents at risk for compromised safety, potential adverse consequences. Findings Include:Review of the facility's policy Medication Expiration Guidelines revealed under section Oral Guidelines: If the liquid is dispensed in the manufactures bottle, the expiration date is the manufacturer's expiration date printed on the actual medication bottle.Observation on [DATE] at 11:34 AM of two of two medication storage rooms and two of four medication carts located in Front Annex A & B section and C Hall Annex revealed the following:Biologicals Supplements observed included Nephro, 2 Cal HN and Glucerna with outdated expiration dates.Observation on [DATE] at 11:34 AM in the Main storage room revealed three bottles of 2 cal HN: one which was dated Sept (September) 2024 with two residents in the facility that were on this supplement; Nephro supplements outdated from [DATE] with three residents in the facility that received this supplement; Glucerna Supplement outdated from [DATE].Interview and observation of medication storage room on [DATE] at 11:36 AM with Licensed Practical Nurse (LPN) EE confirmed outdated supplements in the main supply room on the annex hall. She revealed that nurses were responsible for obtaining and checking the supplements when they retrieved them from the supply room, but they were stocked and controlled by medical records.Observation on [DATE] at 9:20 AM revealed LPN BB with a tray of supplements in the hallway. LPN BB revealed that only nurses hand out the supplements and she always verified on the carton the expiration date prior to delivery. She stated these supplements were usually located on the medication cart with ice and they must obtain them from the storage room where they should check the date prior to bringing them to the hall.Interview on [DATE] at 9:13 AM with Certified Medication Aide (CMA) CC revealed that she checked the expiration date when giving her supplements and she checked the date when she obtained them from the medication room.Interview on [DATE] 9:36 AM with the Administrator revealed that in this building medical records were also in charge of central supply and putting supplements in the storage room for nursing. Nursing should then check the dates prior to administration of the product. He revealed that any problems with nursing issues on the floors, such as nursing supplies would be directed to the Clinical Manager and the Director of Nursing.

Based on observations, staff interview and record review, the facility failed to follow physician's orders to administer a nutritional enteral feeding and hydration according to the physician orders for one of three residents (R) (R99) receiving tube feeding in the facility. The deficient practice had the potential for the resident not to receive the correct amount of nutrition ordered by the physician which could result in a negative outcome for the resident. Findings include:Review of the facility's policy titled Tube Feeding Enteral revealed under Procedure: Review the physician's orders. The order should specify the amount of formula, and the flow rate.Observations on 02/10/2026 at 9:00 AM of the tube feeding in R99's room revealed tube feeding was not running but still connected to the resident. Syringe was in a container but not bagged or labeled.Observations on 02/10/2026 at 2:00 PM observed resident R99 up in bed. Tube feeding was not running per physician orders to start at 1:00 PM.Observations on 02/10/2026 at 3:00 PM observed resident R99 resting in bed, tube feeding was not running per physician orders.Observations on 02/11/2026 at 11:19 AM observed tube feeding infusing at 70ml (milliters) per hour. Tube feeding per physician orders are to be stopped at 9:00 AM.Record Review for R99 revealed admission to the facility on with diagnoses that included but not limited to: aphasia following cerebral infarction; dysphagia following cerebral infarction; encounter for attention to gastrostomy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R99 had a Brief Interview for Mental Status (BIMS) score of 15, which reflected intact cognitive status. R99 is dependent on staff for ADL's (activities of daily living) and receives tube feeding as a source of nutrition.Review of the Physician orders dated, revealed:Jevity 1.5 Cal (lactose-reduced food with fiber) liquid; 0.06 gram-1.5 kcal/mL; amt: 70 ml; oral; Special Instructions: Enteral Feeding: Formula:( Jevity ) Strength:(1.5 ) Flow Rate:(70ML/HR x 20 hrs. ON at 1 PM and OFF at 9 AM. every shift , days, nights. Continuous 11/04/2025Review of the Care Plan for R99 revealed:Problem Start Date: 02/12/2025 Category: Nutritional Status: R99 is at risk for alterations in nutritional status (R/T) (related to) Dx (diagnosis): dysphagia following cerebral infarction. He receives G (gastrostomy) tube feeding as primary source of nutrition. 02/20/2025 Pureed diet to supplement tube feeding / No liquids by mouth. 03/01/2025 Followed by ST (speech therapy). Long Term Goal Target Date: 03/10/2026 Will consume food/fluids to comfort and satisfaction through next review date. Approach Start Date: 12/01/2025: Notify Hospice of changes.Review of R99 Dietary Notes revealed:Quarterly Nutrition Assessment and TF note: R99 admitted for cerebral infarction with past medical history (PMH) of hemiplegia, hemiparesis, aphasia, dysphagia, hepatitis C, liver cell carcinoma, hyperlipidemia. Hospice enrolled. Pt. Has desirable weight gain of 10.77%/14# over last 90 days. Resident has a healthy/gradual rate of weight gain. Diet order is Pureed Diet with NPO liquids and TF. Tube feed is Jevity 1.5 70ml/hr x 20 hours(off9a-1p) with 125ml water flush every 4 hours plus 30ml water pre and post meds every 4 hours. TF meets 100% of needs providing 2100kcal 70ml/hr x 20 hours(off9a-1p) with 125ml water flush every 4 hours plus 30ml water pre and post meds every 4 hours. TF meets 100% of needs providing2100kcal (32.1kcal/kg); 89g protein (1.4g/kg BW); Total fluids 1814ml/d(27.7ml/kg). PO intake is low with Pureed foods offered. PO fluids are NPO. Meds reviewed.Interview on 02/12/2026 8:33 AM with the Director of Nursing (DON) revealed that she has expectations of her nursing staff to follow physician orders on tube feedings. She expected them to follow the stop and start orders, check placement and basically all the orders the physician wrote. She revealed that if there were problems, she would have education provided, she expected the nursing staff on the floor to be adequately trained.Interview on 02/12/2026 8:43 AM with Staff Educator FF revealed that nursing staff have a skill checklist performed on hire and they update in the computer with Relias training annually. She revealed that if a problem arises in Nursing or comes from QAPI then education is given at that time.Interview on 02/12/2026 at 9:10 AM with Certified Nursing Assistant (CNA)DD revealed that when she is performing care with a resident that has a tube feeding, she puts the feeding on hold and then restarts when she is finished. She revealed that if she goes into a room and the machine is beeping, she will go get the nurse. She stated CNA staff do not monitor tube feedings that this is a nursing skill. Interview on 02/11/2026 at 11:19 AM in R99's room, with Licensed Practical Nurse (LPN) EE revealed that she confirmed the tube feeding was still infusing. She revealed that she had not turned the feeding off per physician orders at 9:00 am.

Based on record review, staff interviews, and review of the facility policy tilted, Abuse, Neglect, and Exploitation, Free From, the facility failed to protect residents from sexual abuse by another resident by not immediately reporting nonconsensual sexual abuse between two resident (R) (R2) and (R3).The deficient practice diminished the facility's potential to protect R2 from possible future abuse and ensure a safe environment for other residents.Findings include:A review of the facility's policy titled Abuse, Neglect, and Exploitation, Free From revealed under Facility Safety Position Statement: It is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse, (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Under Definitions: Sexual abuse is nonconsensual sexual contact of any type with a resident which includes, but not limited to, sexual harassment, sexual coercion or sexual assault. Sexual contact is considered nonconsensual when the resident appears to want the contact but does not have the cognitive ability to consent, the resident does not want the contact and the resident is sedated or unconscious. Immediately-CMS (Centers For Medicare and Medicaid Services) believes reporting immediately means not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Review of R2's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility with diagnoses which included but not limited to Alzheimer's disease with late onset, displaced intertrochanteric fracture of left femur, sequela, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type 2 diabetes mellitus with hyperglycemia, generalized anxiety disorder, essential (primary) hypertension, fall on same level, unspecified, subsequent encounter, need for assistance with personal care, enterocolitis due to Clostridium difficile, not specified as recurrent.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident has moderate cognitive impairment.A review of Nursing Notes found under the Notes tab of the EMR dated [DATE] at 10:12 pm revealed, Full body assessment completed on R2, noted redness to the groin area and buttocks, protected with barrier cream. No other findings recorded.During an interview on [DATE] at 2:10 am with R2 regarding the concern of inappropriate touch in the complaint, R2 revealed that she did not remember the incident and did not remember if she was receiving any services. R2 could not remember what she had for lunch. She came back from lunch before the interview.Review of R3 s Face Sheet located under the Profile tab of EMR revealed she was admitted to the facility with diagnoses which included but not limited to chronic obstructive pulmonary disease, unspecified, Alzheimer's disease with late onset, encounter for palliative care, pneumonia, unspecified organism, atherosclerotic heart disease of native coronary artery without angina pectoris, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, unspecified conjunctivitis, poly osteoarthritis, unspecified, metabolic encephalopathy, major depressive disorder, single episode, unspecified.Review of R3's quarterly MDS with an ARD of [DATE]-significant change assessment located in the MDS tab of the EMR, revealed a BIMS score of 3, which indicated the resident has severe cognitive impairment.A review of Nursing Notes found under the Notes tab of the EMR dated [DATE] at 10:44 pm revealed Observed patient (R3) touching a female resident( R2) inappropriately in her groin area. Separated resident (R3) from the female resident and implemented Psych/social monitoring for 3 days for each shift. Patients' daughter [NAME] was notified of incident. Psych PA (physician's assistant) notified as well. Completed hourly charting for 1 week and two hours charting for the second week on patient's behavior. During an interview with the Administrator on [DATE] at 12:22 pm, he revealed the facility process in reporting abuse was that staff had 2 hours to report abuse to the Administrator or any departmental head if he was not available and they would report it to him. He stated that he consulted the area [NAME] President and they made the decision if the abuse was going to be reportable. He stated that they should report abuse immediately to the state or within 2 hours of occurrence. He stated that sexual abuse between R2 and R3 occurred on [DATE]. He stated that he reported the abuse to the State on [DATE].During an interview on [DATE] at 12:45 pm with the Director of Nursing (DON), she stated that as soon as staff reported abuse to her, she reported to the Administrator and then identified what type of abuse, if the abuse was mental, emotional, or physical, and she would put in psychosocial monitoring and notify the psych Nurse Practitioner (NP), Nurse Practitioner (NP) , and Medical Director (MD), and waited for further orders. She further stated that if it was /sexual physical abuse they would complete a full body assessment. She stated staff were expected to report any kind of abuse immediately to the DON or Administrator. She stated that the facility had only a 2 hour window to report to the State. She stated that R2 ‘s BIM score was too low for her to receive therapy.Findings include:A review of the facility's policy titled Abuse, Neglect, and Exploitation , Free From It is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment , abuse, (verbal, physical, mental or sexual ), neglect, corporal punishment involuntary seclusion and misappropriation of property. Under Definition: Sexual abuse is non consensual sexual contact of any type with a resident which includes, but not limited to, sexual harassment, sexual coercion or sexual assault . Sexual contact is considered non consensual when the resident appears to want the contact but does not have the cognitive ability to consent , the resident does not want the contact and the is sedated or unconscious . Immediately-CMS believes reporting immediately : means not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury , or not later than 24 hours if the even that cause the allegation do not involve abuse and do not result in serious bodily injury , to the administrator of the facility and to other officials ( including to the State Agency and Adult protective services where state law provides for jurisdiction in long-term care facilities ) in accordance with State law through established procedures . Review of R2 s Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility initially on Initial admission [DATE] with diagnoses which included but not limited to Alzheimer's disease with late onset, Displaced intertrochanteric fracture of left femur, sequela, Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Type 2 diabetes mellitus with hyperglycemia, Generalized anxiety disorder, Essential (primary) hypertension, Insomnia, unspecified, Muscle weakness (generalized), Hyperlipidemia, unspecified, Vitamin D deficiency, unspecified, Constipation, unspecified, Fall on same level, unspecified, subsequent encounter, Personal history of urinary (tract) infections, Need for assistance with personal care, Enterocolitis due to Clostridium difficile, not specified as recurrent Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS)of 9 which indicated the resident had moderate cognitive impairment. A review of Nursing Notes, found under Notes tab of EMR, [DATE] 10:12 PM revealed Full body assessment completed on R2, noted redness to the groin area and buttocks, protected with barrier cream. No other findings recorded. During an interview on [DATE] at 2:10 am with R2 regarding the concern of inappropriate touch in the complaint, R2 revealed that she does not remember the incident and does not remember if she is receiving any services . R2 could not remember what she had for lunch as she came back from lunch before the interview. Review of R3 s Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility initially on [DATE]. Status: Expired - [DATE] with diagnoses which included but not limited to Chronic obstructive pulmonary disease, unspecified, Alzheimer's disease with late onset, Encounter for palliative care, Pneumonia, unspecified organism, Atherosclerotic heart disease of native coronary artery without angina pectoris, Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Acute respiratory failure with hypoxia, Rhabdomyolysis, Dysphagia, oropharyngeal phase, Unspecified conjunctivitis, Poly osteoarthritis, unspecified, Metabolic encephalopathy, Major depressive disorder, single episode, unspecified Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE]-significant change assessment located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS)of 3 which indicated the resident has cognitive impairment. A review of Nursing Notes, found under Notes tab of EMR, [DATE] 10:44 PM revealed observed patient (R3) touching a female resident( R2) inappropriately in her groin area. Separated resident from the female resident and implemented Psych/social monitoring for 3 days for each shift. Patients' daughter [NAME] was notified of incident. [NAME] Psych PA notified as well. Completed hourly charting for 1 week and two hours charting for the second week on patient's behavior. During an interview with Administrator on [DATE] at 12:22 pm he revealed the facility process in reporting abuse is that staff has 2 hrs to report abuse to the administrator or any departmental head if he is not available and they report to him. He stated that he consults the area vice president and they make decision if the abuse is going to be reportable. He stated that they should report abuse immediately to the state or within 2 hrs of occurrence . He stated that sexual abuse between R2 and R3 occurred in [DATE] . He stated that he reported the abuse to the state on [DATE] . During an interview on [DATE] at 12:45 pm with Director of Nursing ( DON). she stated that as soon as staff report abuse to her, she reports to the administration and then identify what type abuse and if the abuse is mental/emotional /physical that she will put in psycho social monitoring and notify the psych Nurse Practitioner ( (NP), Nurse Practitioner (NP) , and Medical Director (MD) and wait for further orders and if its /sexual physical abuse they will complete a full body assessment . she stated staff are expected to report any kind of abuse immediately to the DON or Administrator . she stated that the facility has only 2 hrs window to report to the state. She stated that R2 ‘s BIM is too low for her to receive therapy .

Based on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, Freedom From, the facility failed to protect the residents' right to be free from misappropriation of property for one of eight sampled residents (R ) (R1). Specifically, R1 had her bank card stolen from her handbag stored in her closet.Findings include:Review of the facility policy titled Abuse, Neglect, and Exploitation, Freedom From revised January 2019, Revised June 2021, July 2022, and September, 2022 revealed under Facility Safety Position Statement: it is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment , abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Under Definitions: Exploitation Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats , or coercion . Misappropriation of resident property means the deliberate misplacement , exploitation or wrongful, temporary or permanent use of a residents belonging or money without the residents' consent.Review of the clinical record revealed R1 was admitted to the facility with the diagnoses of but not limited to acute respiratory failure with hypoxia, rhabdomyolysis, polyneuropathy, unspecified, unspecified toxic encephalopathy, essential (primary) hypertension, major depressive disorder, recurrent, unspecified, primary osteoarthritis, other specified site, muscle wasting and atrophy, not elsewhere classified, right lower leg, type 2 diabetes mellitus with diabetic neuropathy, unspecified, displaced intertrochanteric fracture of right femur, sequela, dysphagia, oral phase, gastro-esophageal reflux disease without esophagitis , muscle weakness (generalized), rash and other nonspecific skin eruption, unspecified fall, subsequent encounter. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Section GG (Functional Abilities and Goals) indicates use of wheelchair, eating /oral hygiene-setup or clean-up assistance, toileting hygiene/Shower/bathe self-substantial/maximal assistance. Upper body dressing-supervision or touching assistance. Lower body dressing-partial/moderate assistance.Interview on 8/4/2025 at 12:15 pm with R1 regarding her bank card that was charged outside the facility revealed she didn't know who took the card or when it was taken. She stated that the card was in her wallet in her hand bag and the hand bag was in her closet. She stated that the card was charged in a convenience store down the road from the facility and that she has never been to that convenience store. R1 stated that she stayed in her room and did not participate in facility activities because they had nothing that interested her. She stated that she watched TV in her room. R1 revealed that the Administrator conducted an investigation and could not find out who took the card.During an interview with Administrator on 8/6/2025 at 12:22 pm, he revealed that he conducted an investigation and staff interviews which were inconclusive. He stated that the convenience store clerk provided the time and date of the purchase but could not provide the video, stating that management were the only ones that could access the video. He stated that he was waiting for management to retrieve the video from the gas station to be able to identify who took the card. When asked how he planned to protect residents from loss of their property, he stated that upon admission they informed residents to keep valuables at home and if they had cash money, they had the option to open up a resident fund. He stated that the residents also had the option to place their valuable in a safe in the business office. He revealed they were waiting for the convenience store management to get the video footage regarding R1's stolen card. During the exit conference the Administrator stated that R1's card was found by a staff member in another resident's room.Findings included:Review of the facility policy titled, , Abuse, Neglect, and Exploitation, Freedom From , dated January, Revised June 2021,July, 2022 and September , 2022 revealed it is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment , abuse (verbal, physical, mental or sexual), neglect, corporal punishment , involuntary seclusion and misappropriation of property. Under Definitions Exploitation Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats , or coercion . Misappropriation of resident property means the deliberate misplacement , exploitation or wrongful, temporary or permanent use of a residents belonging or money without the residents' consent . Review of the clinical record revealed R1 was admitted to the facility with the diagnoses of but not limited to Acute respiratory failure with hypoxia, Rhabdomyolysis, Polyneuropathy, unspecified Unspecified toxic encephalopathy, Essential (primary) hypertension, Major depressive disorder, recurrent, unspecified, Primary osteoarthritis, other specified site, Muscle wasting and atrophy, not elsewhere classified, right lower leg, Type 2 diabetes mellitus with diabetic neuropathy, unspecified, Displaced intertrochanteric fracture of right femur, sequela, Dysphagia, oral phase, Gastro-esophageal reflux disease without esophagitis , Muscle weakness (generalized), Rash and other nonspecific skin eruption, Unspecified fall, subsequent encounter Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Section GG indicates -use of wheelchair , Eating /Oral hygiene-Setup or clean-up assistance, Toileting hygiene/Shower/bathe self-Substantial/maximal assistance. Upper body dressing-Supervision or touching assistance. Lower body dressing-Partial/moderate assistance. During an interview on 8/4/2025 at 12:15 pm with R1 regarding her bank card that was charged outside the facility. Resident revealed that she doesn't know who took the card or when it was taken. she stated that the card was in her wallet in her hand bag and the hand bag was in her closet. She stated that the card was charged in a Quick trip down the road from the facility and that she has never been to that quick trip. R1 stated that she stays in her room and does not participate in facility activities because they have nothing that interest her . she stated that she watches TV in her room. R1 stated that the administrator conducted an investigation and could not find out who took the cardDuring an interview with Administrator on 8/6/2025 at 12:22 pm he revealed that he conducted an investigation and staff interview which is inconclusive. He stated that the quick trip clerk provided the time and date of the purchase but could provide the video stating that LE are the only ones that can assess the video . He stated that he is waiting for LE to retrieve the video from the gas station to be able to identify who took the card. when asked how he plans to protect residents from loss of their property . He stated that upon admission they inform residents to keep valuable at home and if they have cash money, they have the option to open up a resident fund . He stated that the residents also have an option to place their valuable in a safe in business office. He stated that they are waiting for LE to get the footage from Quick trip regarding R1's misappropriate fund. During the exit conference the administrator stated that R1's card was found by a staff member in another resident's room.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Handling of Soiled Linen and Resident Clothing, Isolation Precautions/Transmission Based Precautions, Hand Washing, and Cleaning Guidelines for Resident Care Equipment, the facility failed to ensure infection control procedures were followed. Specifically, the facility failed to ensure clean linen was covered during transport on one of five halls, failed to ensure Transmission Based Precautions (TBP) were followed for one resident (R) (R40) on TBP, failed to ensure a continuous positive airway pressure (CPAP) mask was properly stored when not in use for one R (R85), failed to ensure proper hand hygiene during medication pass, and failed to ensure shared medical equipment was cleaned between resident use. The deficient practices created the potential for cross-contamination and the spread of infections to the residents. The facility's census was 90 residents. Findings included: 1. Review of the facility's policy titled, Handling of Soiled Linen and Resident Clothing, dated 2/2024, revealed the Purpose section stated, The community is required to provide clean linen and must clean resident's clothing. Personnel must handle, store, process, and transport linen to prevent the spread of infection. The Linen Transport section included, Clean linen must be transported in clean covered carts. Observation on 12/17/2024 at 11:58 am in the hallway revealed housekeeping staff transporting residents' hanging laundry uncovered. Observation on 12/18/2024 at 9:23 am revealed Housekeeper MM transporting a clean laundry cart on the 9200 Hall with clean linen on it. The cover for the cart was draped over the side of the cart, and the linen was uncovered. After filling up the floor cart, she left the cart unattended and uncovered in the hallway. In an interview on 12/18/2024 at 9:23 am, Housekeeper MM stated the clean linen laundry cart should be covered when being pushed throughout the building. Housekeeper MM verified that the clean linen was not covered. In an interview on 12/18/2024 at 10:46 am, the Housekeeping Director stated he expected clean laundry being transported in carts and hanging racks to be covered using a blanket during transport. In an interview on 12/18/2024 at 2:14 pm, the Infection Preventionist (IP) stated she expected clean linen and laundry to be covered during transport. 2. Review of the facility's policy titled, Isolation Precautions/Transmission Based Precautions, revised 2/2024, revealed the Purpose section stated, It is the policy of this community to, when necessary; prevent the transmission of infections within the community through the use of Isolation Precautions. The Transmission-Based Precautions section included 3. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. The above includes epidemiologically important organisms (multidrug-resistant organisms) such as methicillin-resistant Staphylococcus aureus (MRSA). Review of R40's electronic medical record (EMR) revealed diagnoses including, but not limited to, MRSA infection, neurogenic bladder, pressure ulcer of sacral region stage four, and a pressure ulcer of right heel stage four. Review of R40's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 7 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R40 was dependent on staff for activities of daily living (ADLs) and mobility. Section H (Bladder and Bowel) documented R40 had an indwelling catheter and ostomy bag. Review of R40's care plan, dated 12/17/2024, indicated a Problem area of Infection and documented Resident has a multi-drug resistant organism MRSA that required the use of personal protective equipment during high contact activities. Goals included but were not limited to Resident will not exhibit complications to MDRO. Approaches included Resident is on Enhanced Barrier Precautions (EBP), staff must perform hand hygiene before and after providing care . Review of R40's Physician's Orders revealed an order dated 12/16/2024 for Bactrim DS (sulfamethoxazole-trimethoprim double strength) (a medication used to treat bacterial infections) 800-160 milligram (mg), one tablet by mouth twice a day for 10 days for MRSA. Observation on 12/17/2024 at 12:41 pm of R40's door revealed an EBP sign on the door and personal protective equipment (PPE) hanging inside the room on R40's closet door. Observation made on 12/18/2024 at 8:59 am of R40's door revealed no Transmission Based Precautions (TBP) sign on the door. Further observation revealed Certified Nursing Assistant (CNA) FF providing ADL care for R40 with gloves on but no gown. In an interview on 12/18/2024 at 9:08 am, CNA FF revealed she was cleaning R40's hands, washing her face, and removing nail polish from her nails. She confirmed she was wearing gloves and no gown. In an interview on 12/18/2024 at 1:57 pm, the IP confirmed that R40 was being treated for MRSA and should be on TBP. The IP stated there should be a sign on R40's door indicating TBP use. She confirmed staff should wear gloves and gowns while providing care to residents on EBP and TBP. In an interview on 12/19/2024 at 1:14 pm, the Director of Nursing (DON) stated TBP and contact precautions should be used for residents with MRSA. She further stated TBP signage should be on a resident's door to alert staff of the required PPE. 3. Review of R85's EMR revealed diagnoses including, but not limited to, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), history of pneumonia, and chronic combined systolic and diastolic heart failure (CHF). Review of R85's Quarterly MDS assessment dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented R85 received oxygen therapy and a non-invasive mechanical ventilator. Review of R85's care plan dated 9/10/2024 revealed a Problem area of Respiratory and documented R85 required oxygen and a CPAP machine related to a history of COPD, CHF, and respiratory failure. Approaches included CPAP settings as ordered. Review of R85's Physician's Orders included an order dated 9/19/2024 for CPAP with home setting at 8 to 12 centimeters of water pressure (cm H20) at bedtime. Observation on 12/17/2024 at 11:48 am in R85's room revealed a CPAP mask at the bedside, not in use or placed in a bag. Observation made on 12/18/2024 at 9:38 am in R85's room revealed a CPAP mask at the bedside not being used, not in a bag, hanging from a bedside table, and lying on the floor. In an interview on 12/18/2024 at 9:46 am, Licensed Practical Nurse (LPN) EE confirmed the CPAP machine mask was not in use, unbagged, and lying on the floor. She stated the mask should be placed in a bag when not in use. In an interview on 12/18/2024 at 2:12 pm, the IP stated CPAP masks should be wiped down between uses and placed in a plastic bag by the bedside when not in use. In an interview on 12/19/2024 at 1:07 pm, the DON stated CPAP masks should be kept in a bag on the dresser and not lying on the floor when not in use. 50940 4. Review of the facility policy titled, Hand Washing, revised 2/2024, revealed the When to use Alcohol Hand Sanitizer section included . Before entering the resident's room. Before exiting the resident's room. Review of the facility's undated policy titled, Cleaning Guidelines for Resident Care Equipment, revealed the Policy section included, It is the policy of this facility that all resident care equipment will be cleaned after use and will be prepared for reuse by the same or another resident. The Procedure section included, 1. Resident equipment which is shared between residents must be cleaned after each use with an approved EPA [Environmental Protection Agency] disinfectant .The following items are recommended but not limited to: Blood pressure cuffs, Stethoscopes, Electronic thermometers, Glucometers . During observation of medication pass on 12/18/2024 at 8:25 am, observation revealed LPN BB checked a resident's blood pressure without cleaning the blood pressure equipment before or after use and returned the equipment to the medication cart without cleaning it. Further observation revealed LPN BB entered a resident's room for medication administration without sanitizing her hands. In an interview on 12/18/2024 at 8:35 am, LPN BB confirmed she failed to clean the blood pressure equipment before or after using it to check a resident's blood pressure and stated she should have cleaned it. She further confirmed she failed to sanitize her hands before entering the resident's room and stated she should have. In an interview on 12/18/2024 at 1:18 pm, the DON stated she expected staff to always perform hand hygiene before entering and upon leaving a resident's room. She further stated that shared medical equipment, such as blood pressure equipment and glucometers, should be cleaned between residents.

Based on observations, staff and family interviews, record review, and a review of the facility policy titled, Condition Change of the Resident, the facility failed to promptly notify the responsible party of a change in condition for one of 19 residents (R) (R62) reviewed for change in condition related to a deep tissue injury. Findings include: A review of the policy titled, Condition Change of the Resident, revised 7/2012, revealed the Procedure section included . 5. Notify resident's responsible party . Review of R62's Face Sheet revealed diagnoses included pressure-induced deep tissue damage of left 1st toe, non-pressure chronic ulcer of other part of left foot with fat layer exposed - left distal foot and left 2nd toe, vascular dementia, and hemiplegia ad hemiparesis right dominant side. Review of R62's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R62 required substantial/maximal assistance with bed mobility. Section M (Skin Conditions) documented no pressure ulcers or other skin conditions. Review of the care plan revealed a Problem area of the resident was at risk for skin breakdown. 10/30/2024: Left great toe discoloration and assessed as unstageable deep tissue injury pressure ulcer. The Approach section included treatment as ordered with a start date of 11/14/2024. Review of R62's Progress Notes revealed an entry dated 11/26/2024 of Resident returned from vascular appointment with new treatment order to paint left toes with and in between toes with Betadine and keep left foot dry. Further review revealed an entry dated 12/2/2024 of Resident returned from vascular appointment, post angiogram left foot. Dressing dry and intact, instruction to elevate leg above heart 24/7 as much as possible to reduce reperfusion edema. Review of R62's clinical record revealed no documentation of resident representative notification of R62's change in condition or treatment orders on 11/26/2024 or 12/2/2024. In an interview on 12/19/2024 at 12:22 pm, R62's resident representative stated she was not informed of the worsening of R62's toe or treatment plan. In an interview on 12/19/2024 at 1:22 pm, Unit Manager (UM) II confirmed there was no documentation to indicate when or how the resident representative was initially informed of the resident's toe condition. In an interview on 3/6/2020 at 1:26 pm, the Director of Nursing (DON) revealed that she expected the resident representative to be notified when the resident's condition or treatment plan changed.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Bed Mobility Assist Devices, the facility failed to ensure one of six residents (R) (R63) reviewed had the necessary consent, physician's order and completed assessment for the use of bilateral half-side rails on their bed. This deficient practice had the potential to place R63 at risk of physical injury and entrapment. Findings include: Review of the facility policy titled, Bed Mobility Assist Devices, dated 2/2021, revealed the Procedure section included, . 3. Once appropriate alternatives have been trialed and failed, a physician's order for an assist device should be obtained if the need for an assist device for bed mobility and transfer still exists. 4. A Bed Mobility Device Evaluation should be completed by the nurse upon the assessed need, quarterly, annually, and with significant change thereafter. 5. Bed Mobility Assist Device Informed Consent and Release form should be reviewed and signed by the resident and /or their representative upon the application of the assist device and yearly thereafter. Scan for in the EHR [electronic health record]. Review of R63's electronic medical record (EMR) revealed diagnoses included, but were not limited to, dementia, muscle weakness, and a history of falls. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 12 (indicating moderate cognitive impairment). Section P (Restraints and Alarms) documented bed rails were not used. Review of R63's Physician Orders revealed no order for the use of bed rails. Review of the EMR revealed no bed rail assessment was conducted. Review of R63's care plan dated 9/20/2024 documented that the resident was at risk for falls. Review of the Quarterly Risk assessment dated [DATE] indicated that the resident was at medium fall risk, with a Morse Fall Scale score of 40. Observations on 12/17/2024 at 10:08 am, 12/18/2024 at 9:30 am, 10:30 am, 1:05 pm, and 2:15 pm revealed R63 in bed with bilateral half-side rails in the up position. In an interview on 12/17/2024 at 10:08 am, R63 stated he did not know why the side rails were up. During an interview on 12/18/2024 at 1:10 pm, Licensed Practical Nurse (LPN) BB stated R63 was considered a fall risk, and the family requested side rails. She verified there was no physician's order, consent, or assessment for the use of side rails for R63. During an interview on 12/18/2024 at 1:30 pm, the Director of Nursing (DON) stated the steps required for using side rails were obtaining consent from the resident or responsible party, completing an observational assessment, and obtaining a physician's order. The DON confirmed that none of these steps were documented for R63. During an interview on 12/18/2024 at 1:45 pm, the MDS Coordinator stated a consent must be obtained prior to using side rails.

Based on observations, staff interviews, records review, and review of the facility policy titled, Care Management, the facility failed to ensure reasonable accommodation of needs was provided for one of 28 sampled residents (R) (R62) related to providing a wheelchair to accommodate a physician's order to elevate both feet at all times. The deficient practice had the potential to place R62 at risk for medical complications, unmet needs, and a diminished quality of life. Findings Include 1. Review of the facility policy titled, Care Management, revised 5/2021, revealed the Policy section included A. All Resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotional state. Review of R62's electronic medical record (EMR) revealed diagnoses including impaired mobility and reperfusion edema. Review of R62's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented that R62 had an impaired range of motion of upper and lower extremities on one side, used a wheelchair, required substantial/maximal assistance with mobility, was dependent on transfers, and was non-ambulatory. Review of R62's Physician's Orders revealed an order dated 12/2/2024 of Elevate legs above heart level all the time to reduce reperfusion edema. Review of R62's care plan dated 12/6/2024 revealed a Problem area of ADL (activities of daily living)/Mobility. Approaches included keeping the resident's legs elevated above heart level at all times. Observation on 12/17/2024 at 8:49 am of R62 in her room revealed her in a wheelchair with both feet on the floor. Observation on 12/17/2024 at 2:22 pm of R62 in the dining room revealed her in a wheelchair with her left foot on the floor. In an interview on 12/18/2024 at 10:25 am, Registered Nurse (RN) JJ stated R62's physician's orders included elevating her feet at all times. She confirmed R62's feet were not elevated and stated the facility didn't have an appropriate wheelchair available to elevate both of her feet. In an interview on 12/19/2024 at 12:41 pm, Unit Manager License Practical Nurse (LPN) II confirmed an order to keep R62's feet elevated at all times. She acknowledged compliance with the order was inconsistent and stated it may have been due to the facility not having the proper wheelchair equipment to ensure her feet remained elevated. In an interview on 12/19/2024 at 1:39 pm, the Director of Nursing (DON) confirmed R62's feet were not consistently elevated and stated the lack of proper wheelchair equipment contributed to this issue. She stated there was a delay in equipment availability.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medications, Self-Administration of, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 28 sampled residents (R) (R85). This deficient practice had the potential to allow unauthorized access to unsecured medications to R85, other residents, and visitors. Findings include: Review of the facility's policy titled, Medications, Self-Administration of, reviewed 6/2021, revealed the Procedure section included 1. Before a resident is considered for self-administration of medications, an assessment will be performed by the charge nurse and reviewed by the interdisciplinary care plan team for approval. 2. Following approval of the assessment, the charge nurse will obtain a physician's order for the resident to self-administer medications, noting which medications may be self-administered. Review of R85's electronic medical record (EMR) revealed diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), respiratory failure, heart failure, dysphagia, and major depression. Review of R85's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 9 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented R85 was dependent on a helper for toileting, bathing, lower body dressing, and transfers. Review of R85's care plan revealed no care plan area for self-administration of medications. Review of R85's Physician's Orders revealed an order dated 9/19/2024 for fluticasone furoate-vilanterol (a medication used to treat asthma and COPD) blister with device 100-25 micrograms (mcg)/dose, one puff inhalation once a day. Further review revealed no order for self-administration of medications. Review of R85's EMR revealed no assessment for self-administration of medications. Observation on 12/18/2024 at 9:38 am in R85's room revealed a fluticasone furoate and vilanterol inhaler on R85's bedside dresser. In an interview on 12/18/2024 at 9:46 am, Licensed Practical Nurse (LPN) EE confirmed the inhaler was on R85's bedside dresser and should not be. LPN EE further confirmed that R85 was not assessed for medication self-administration. In an interview on 12/19/2024 at 1:06 pm, the Director of Nursing (DON) stated that medications should not be kept at residents' bedside unless there was a physician's order for medication self-administration. She further stated she expected that the nurse should be administering medications for residents who are not assessed for medication self-administration.

Based on observation, staff and resident interviews, record review, and review of the facility-provided document titled, Residents' Rights, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of five residents (R) (R48) who had an indwelling urinary catheter. This deficient practice had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the undated facility-provided document titled Residents' Rights included Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. A review of R48's Face Sheet revealed diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms. A review of R48's Quarterly Minimum Data Set (MDS) Assessment, dated 11/20/2024, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment) and Section H (Bowel and Bladder) documented R48 had an indwelling urinary catheter. Observations on 12/17/2024 at 9:49 am and 12/18/2024 at 10:39 am revealed R48 was in bed, and a urinary catheter drainage bag was secured to the resident's bed, uncovered and visible from the hallway. During an observation on 12/18/2024 at 10:37 am, License Practical Nurse (LPN) HH confirmed R48's urinary catheter drainage bag was uncovered and visible from the hallway. In an interview on 12/18/2024 at 10:47 am, LPN HH stated urinary catheter drainage bags should always be in a privacy bag when visible to other residents, staff, and visitors. In an interview on 12/19/2024 at 1:39 pm, the Director of Nursing (DON) stated she expected staff to ensure urinary catheter drainage bags were covered in a privacy bag after each urinary catheter care incident.

Based on observations, staff and resident interviews, and record review, the facility failed to provide accurate Minimum Data Set (MDS) assessment data for two of 28 sampled residents (R) (R26 and R40). This deficient practice had the potential to affect the assessment of R26 and R40's care needs. Findings include: A facility policy for resident assessments was requested but not provided. 1. Review of R26's Face Sheet revealed diagnoses including, but not limited to, unspecified bilateral hearing loss. Review of R26's Admission MDS assessment dated [DATE] revealed Section B (Hearing, Speech, and Vision) documented R26's ability to hear was highly impaired, and speech clarity was coded as no speech-absence of spoken words. Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Review of R26's care plan dated 10/18/2024 revealed a Problem area of bilateral hearing loss. Goals included the resident will compensate for hearing loss by reading. Approaches included utilizing a communication board and providing a quiet, non-hurried environment, free of background noises and distractions. Review of R26's Physician's Orders revealed an order dated 10/18/2024 of Resident is deaf, please communicate with whiteboard. In an interview on 12/17/2024 at 10:46 am, a conversation was held with R26 by this surveyor writing on the whiteboard, and R26 responded verbally. 2. Review of R40's Face Sheet revealed diagnoses including, but not limited to, unspecified dementia. Review of R40's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 7 (indicating severe cognitive impairment). Section I (Active Diagnoses) did not document a diagnosis of dementia. Review of R40's care plan dated 10/8/2020 indicated a Problem of Cognitive Loss/Dementia. Approaches included approaching resident in a calm manner. Review of R40's Physician's Orders revealed an order dated 9/18/2024 for memantine (a medication used to treat dementia) tablet 5 milligrams (mg) once a day. In an interview on 12/19/2024 at 10:39 am, the MDS Coordinator revealed she was responsible for the MDS assessments. She confirmed that R26 could speak verbally and was hard of hearing. She further confirmed that Section B of R26's MDS assessment inaccurately stated that R26 had no speech and should be revised. She confirmed R40's active diagnoses included dementia, and Section I of R40's MDS assessment was inaccurate, stating it should include a diagnosis of dementia. She stated the importance of accurate MDS assessments was to provide an adequate picture of the individual and what care should be provided.

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plan Conference Interdisciplinary, the facility failed to develop a baseline care plan for enteral tube feeding for one of three residents (R) (R502) who received enteral tube feeding, within 48 hours of admission. This deficient practice had the potential to place R502 at risk for not receiving treatment and/or care according to their needs. Findings include: 1. Review of the facility policy titled, Care Plan Conference Interdisciplinary, revised May 2021, revealed the Standard section included An Interdisciplinary Care Plan Conference identifies resident needs and establishes obtainable goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents . Documentation is done in the care conference action of the EHR [electronic health record]. The Purpose section included . 6. Initial care plan should be completed in (electronic health record) within 48 hours. Review of R502's clinical record revealed admitted [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery and pneumonitis due to inhalation of food and vomit. Review of R502's Entry Tracking Record Minimum Data Set (MDS) dated [DATE] revealed it was in process and all care areas not completed . Review of R502's Physician's Orders revealed an order dated 12/12/2024 of Enteral Feeding: Formula (Nepro) 50 milliliters (ml) per hour. Review of R502's care plan dated 12/12/2024 revealed there was no care plan for enteral tube feeding. During initial screening on 12/17/2024 at 2:23 pm, observation revealed R502 was receiving enteral feeding via a feeding tube. Observation on 12/18/2024 at 12:49 pm revealed R502 lying in bed receiving enteral feeding via a feeding tube. During an interview on 12/19/2024 at 11:00 am, the Director of Nursing (DON ) stated she expected an accurate care plan to be created for residents upon admission. During an interview on 12/19/2024 at 11:10 am, the MDS Director acknowledged that there was no baseline care plan created for enteral tube feeding for R502 and there should be one.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plan Conference Interdisciplinary, the facility failed to ensure a comprehensive person-centered care plan was developed for one of seven residents (R) (R26) reviewed for the use of unnecessary medications. This deficient practice had the potential to place R26 at risk for not receiving treatment and/or care according to their needs. Findings include: Review of the facility's policy titled, Care Management, revised 5/2021, revealed the Policy section included A. All resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotional state. B. Coordination of the plan of care is the responsibility of nursing. However, planning, implementation, and evaluation requires joint participation by each discipline rendering service. C. 5. The plan of care is reviewed and revised to reflect the current needs of the resident. Review of R26's electronic medical record (EMR) revealed R26 was admitted to the facility on [DATE] with diagnoses including spinal stenosis, sacroiliitis, and generalized anxiety disorder. Review of R26's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section M (Medications) documented R26 received an antipsychotic, an antianxiety, and an antidepressant. Review of R26's care plan revealed no care plan areas for the use of antidepressants, antipsychotics, or antianxiety. Review of R26's Physician's Orders revealed orders dated 10/18/2024 for amitriptyline (a medication used to treat depression) tablet 10 milligram (mg) oral at bedtime, 10/18/2024 for lorazepam (a medication used to treat anxiety) tablet 0.5mg oral twice a day, 10/18/2024 mirtazapine (a medication used to treat depression) disintegrating tablet 15 mg oral at bedtime, quetiapine (an antipsychotic medication) tablet 50 mg oral at bedtime, and trazodone (a medication used to treat depression) tablet 50mg oral at bedtime. In an interview on 12/19/2024 at 10:48 am, the MDS Coordinator (MDSC) verified she was involved with care plan development. She confirmed R26 received antipsychotic, antidepressant, and antianxiety medications. She further confirmed that there was no care plan areas for the medications and stated there should be. The MDSC stated that the importance of having care plan areas and interventions was to inform staff of the resident's care needs.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Shaving, the facility failed to provide Activities of Daily Living (ADL) care for one of 28 sampled residents (R) (R21). Specifically, the facility failed to remove excessive facial hair for R21. This deficient practice placed R21 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's policy titled, Shaving, reviewed 5/2021, revealed the Purpose section included To remove excessive hair from the face. To promote cleanliness. To improve resident morale and appearance. Review of R21's Face Sheet revealed diagnoses including, but not limited to, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, and muscle weakness. Review of R21's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R21 had impairment on one side for upper and lower extremities, was dependent for bathing, and required substantial/maximal assistance for personal hygiene. Review of R21's care plan dated 11/1/2023 revealed a Problem of ADL/Mobility with a deficit in ADL functioning and impaired mobility related to weakness and a history of cerebral Infarction with residual. Approaches included assisting with ADLs as needed or requested. Observations on 12/17/2024 at 11:33 am in R21's room revealed R21 with an excessive mustache and chin hair. Observation made on 12/18/2024 at 9:18 am in R21's room revealed R21 with an excessive mustache and chin hair. This observation was made the morning after R21's scheduled shower. In an interview on 12/19/2024 at 11:43 am, Certified Nursing Assistant (CNA) DD revealed she provided shaving assistance as she noticed facial hair growing. CNA DD stated that R21 never refused bathing or grooming. CNA DD confirmed that R21's facial hair was excessive and needed shaving. In an interview on 12/19/2024 at 12:37 pm, the Director of Nursing (DON) stated her expectations for ADL care for dependent residents included face washing and grooming. The DON stated her expectations for shaving female residents were that if the female resident would allow staff to shave, then staff should assist.

Based on staff interviews, record review, and review of the facility's policy titled, Hemodialysis, the facility failed to ensure communication between the facility and dialysis center was documented after each dialysis session for one of one resident (R) (R85) reviewed for dialysis care. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. The sample size was 25. Findings include: Review of the facility's policy titled, Hemodialysis, revised 1/2021, revealed the Policy section stated, To ensure effective communication and collaboration between the community and the resident's dialysis center. The Procedure section included 1. Nurse staff must complete the Dialysis Communication Form (DGE108) on days the resident attends dialysis. 2. Nursing staff must fax and/or send the Dialysis Communication Form to the dialysis. 5. Scan/drop completed Dialysis Communication Form received from dialysis center into the resident HER (electronic health record). Review of R85's electronic medical record (EMR) revealed diagnoses included, but were not limited to, end-stage renal disease and dependence on renal dialysis. Review of R85's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented R85 received dialysis. Review of R85's care plan dated 9/10/2024 indicated a Problem area of dialysis. Approaches included Obtain and document pre and post-dialysis vital signs. Review of R85's Physician's Orders included an order dated 11/14/2024 for 11-7 to complete dialysis communication form and send to dialysis with patient. Once A Day on Mon, Wed, Fri. In an interview on 12/18/2024 at 9:46 am, Licensed Practical Nurse (LPN) EE stated the facility kept the dialysis communication forms for R85 in a binder at the nurse's station. In an interview on 12/18/2024 at 10:11 am, LPN EE confirmed R85 started dialysis on her admitted [DATE], but the first documented communication form was dated 11/20/2024. LPN EE stated the communication forms should have been completed since the first day of R85's dialysis sessions. LPN EE further stated the importance of maintaining communication between the facility and the dialysis center to provide continuity of care. In an interview on 12/19/2024 at 1:04 pm, the Director of Nursing (DON) stated she expected the dialysis communication form to be sent to the dialysis center with the resident and received back from the dialysis clinic. She confirmed there should be a communication form for each visit. She stated that maintaining communication between the facility and the dialysis center was important to monitor for side effects of dialysis.

Based on interviews, record review, and review of the facility's policy titled, Behaviors Using Person-Centered Care, Accommodating, the facility failed to ensure psychotropic medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of seven residents (R) (R31) reviewed for the use of unnecessary medications. This deficient practice had the potential to affect R31's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of the facility's policy titled, Behaviors Using Person-Centered Care, Accommodating, revised 2/2021, revealed the Overview section included, VI. A PRN order for psychotropic medications should only be limited to 14 days. Review of R31's electronic medical record (EMR) revealed diagnoses including anxiety. Review of R31's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section N (Medications) documented R31 received an antianxiety medication. Review of R31's Physician's Orders included an order dated 12/18/2023 for Ativan (lorazepam) [a psychotropic medication used to treat anxiety] tablet 0.5 milligrams (mg) for anxiety every 4 hours PRN. The end date was open-ended. In an interview on 12/19/2024 at 12:46 pm, the Director of Nursing (DON) confirmed there was no stop date for the physician's order of lorazepam 0.5 mg every four hours PRN. She further stated the order should have a definitive stop date.

AMENDED 8/31/23 Based on record review, family and staff interviews, and review of the policy titled Abuse, Neglect and Exploitation, Freedom From, the facility failed to thoroughly investigate and follow-up on an allegation of verbal abuse for one of 32 sampled residents (R) (R#53). Actual harm was identified to have occurred on 8/2/23 when Administrations was made aware that R#53 made an alligation of abuse and failed to complete a though investigation. During an interview on 8/9/23 2:54 p.m. with R#53 revealed she is still scared for her life. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, Freedom From last revised September 2022 indicated, I. Procedure for investigation 1. Administrator or designee on duty will assess the resident (including the size, location, etc. of any injury), and assure proper documentation of the date, time, and location of the reported or suspected incident. 2. The supervisor will do everything possible to protect the resident's welfare and safety from harm during the investigations. 3. An incident report will be completed. 4. The physician and family will be notified as soon as possible. 5. The Administrator or Director of Nursing is responsible to notify their Regional Nursing Supervisor to report alleged violation of the resident safety policy to assure prompt investigation and corrective action are in place. 6. Any employee suspected of violation of these resident safety policies, may be suspended pending investigation. A review of the clinical record revealed R#53 was admitted to the facility on [DATE] with diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, diabetes mellitus, hypertension, contracture, left ankle, atherosclerotic heart disease of native coronary artery without angina pectoris, secondary osteoarthritis, and difficulty in walking. A review of R#53's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which indicated no cognitive impairment; Section D and E - Psychosocial Well-Being revealed resident never or one day with feeling down, depressed, hopeless, and no behavior exhibited toward others to reject care; and Section G - ADL Functional/Rehabilitation Potential revealed resident requires extensive assistance with one person assistance. A review of care plan revised 6/18/23 revealed R#53 has problem of verbal behavioral symptoms directed toward others of screaming at others, cursing at others. Continues with verbal aggression toward others. There are reports that she is cursing at staff. Resident claims that she is not usually the aggressor but responds to defend herself. Interventions approaches are keeping resident involved in the altercation at separate table during meals. Instruct resident to refrain from becoming physically aggressive to other residents. Social service intervention as appropriate. Instruct resident to refrain from becoming physically aggressive (hitting, grabbing, pushing etc.). toward other residents. Praise resident when behavior is appropriate. Problem of resident has history of suicidal attempt. History of depression. Interventions approaches are medication as ordered, psych eval as needed, restrict access to potentially harmful items (e.g., glass, scissors, needles, razors, lighters, knives, medications, etc.)., convey an attitude of acceptance toward the resident, assess past effective and ineffective coping mechanisms, and assess if depression endangers the resident by intervening if necessary. A review of the facility's grievance book revealed a hand-written statement, 8/7/23 - Certified Nursing Assistant (CNA) NN said she was going to throw me across the street. Resident told Admission staff that everybody wants to beat her up. I went up to her and ask her who. She said, CNA NN. A review of Nurses Progress Note dated 6/1/23 at 9:57 a.m. revealed, Resident continues to verbalize that she believes staff is against her. She will only allow certain staff to provide her care. Attempted to redirect in AM (morning). Resident has spoken to Social Services and DON (Director of Nursing). Will continue to monitor behaviors closely. During an interview on 8/8/23 at 12:39 p.m. with R#53 mentioned she had experienced verbal abuse from CNA NN. She revealed CNA NN threatened that she would put her in her wheelchair and push her down the main ramp and let her roll into the parking lot or main street to fall if she continues to complain to the Administrator about her care. During an interview on 8/8/23 at 4:34 p.m. with Administrator and DON confirmed they did not report the incident to the state agency or suspend the CNA NN because the resident changed her story of making a joke when asked about the allegations she filed in the grievance. During an interview on 8/9/23 2:54 p.m. with R#53 revealed she is still scared for her life. She said the Administrator and DON lied on her about changing her story and saying she was joking about the abuse that is mentioned in the grievance logbook. During an interview on 8/10/23 at 9:08 a.m. with Administrator revealed she filed a state reportable on the incident on 8/9/23. She further mentioned the alleged abusive employee, CNA NN was suspended effectively on 8/10/23 because she was scheduled yesterday but did not come in due to her being sick. During an interview on 8/10/23 at 11:05 a.m. with CNA GG, mentioned she has been employed for 3 months at the facility. She further mentioned she has had in-service education training on abuse during new employee orientation. She normally immediately informs the DON if she has a resident that reports abuse. During an interview on 8/10/23 at 11:15 a.m. with Certified Medical Assistant (CMA) HH mentioned she has been employed since October 2022. She further mentioned she received several in-service education trainings on abuse. She stated that normally if she has a resident that reports abuse, she immediately informs the DON and the Abuse Director, who is their Administrator. During an interview on 8/10/23 at 11:55 a.m. over the phone with family of R#53 revealed he received a call from R#53 on 8/2/23 regarding CNA NN verbally abusing her with threats to harm her. He further mentioned the CNA NN told R#53, She would put her in her wheelchair and push her down to the side ramp so she can fall over and injure herself. He stated that he called 8/3/23 and 8/8/23 to speak to the Administrator about R#53 fearing for her life and safety but still had not heard back from her or any other facility representative to address the severity of concern for her safety. He stated for weeks, he had received multiple incidents of verbal abuse or threats from R#53 about the same CNA NN threatening to hurt her family members if anybody called the state to complain. He further mentioned the facility has not responded in a timely manner on this level of abuse or any other complaints regarding her care and safety. During an interview on 8/10/23 at 1:35 p.m. with Assistant Director of Nursing (ADON), mentioned they have in-service education training on abuse once a week and some months, once every two weeks. She further mentioned that new staff are educated during orientation every other Thursday and Friday about how to discuss and handle abuse. She stated they have a nursing go to book at each nursing station as a quick reference guide refresher on abuse. During an interview on 8/10/23 at 2:30 p.m. with Administrator and DON revealed their procedure with the staff on reporting abuse is to report it immediately to either one of them. DON stated they have signs at each nursing station how to report. Administrator mentioned that during new staff orientation, they are informed that she is the Abuse Director so they can effectively report it. Administrator verified any abuse should be reported within two hours and timeline to follow-up on alleged abuse is five days. During an interview on 8/10/23 at 4:30 p.m. with R#53 revealed she first notified Administrator and DON on 8/2/23 around 10:45 a.m. about being verbally abused by CNA NN. She further mentioned that she requested to them for her not to be on or around her hall because of the verbal abuse and threats made towards her family members that she reported the abuse to. During an interview on 8/10/23 at 4:40 p.m. with Social Services Director (SSD) revealed she was first made aware of the resident's alleged abuse on 8/7/2023 from Licensed Practical Nurse (LPN) Unit Manager (UM) CC assigned to R#53's hall. SSD immediately went to the resident for her to properly file a grievance statement. During an interview on 8/10/23 at 4:50 p.m. with LPN UM CC revealed while R#53 was seating in her wheelchair visiting others in the corridor area, she overheard the resident openly discussing a conversation about receiving an abusive threat from CNA NN. She decided to inform the SSD about the alleged threat from the staff member. During an interview on 8/10/23 at 4:55 p.m. with Administrator verified she was first made aware of the abuse on 8/2/23. She further revealed the CNA was removed from her hall assignment near R#53's room but continued working without a suspension. She further verified she did not notify R#53's family member. She revealed she did not report the abuse on the day the resident originally made her aware of it on 8/2/2023. She revealed on 8/7/23, the SSD informed her that R#53 filed a grievance about the incident again and then informed the DON.

Based on observations, staff interviews, and review of the facility policy titled, All foods stored will be properly labeled according to the following guidelines the facility failed to ensure opened food items in the refrigerator and the dry storage room were properly labeled and dated; and failed to dry cleaned dishes appropriately. This deficient practice affects 98 of 100 residents. Findings included: During an initial kitchen tour with the Dietary Cook AA on 8/8/23 at 9:40 a.m., the following was identified: observation of the refrigerator revealed one medium size clear container of various chopped and shredded vegetable was not dated; one half empty 5-pound container of pimento cheese to was not labeled with an opened date; one opened 2-pound butter was not labeled with an opened date; and one opened 5-pound Blue Cheese was not labeled with an opened date. These observations were verified by the Dietary Cook AA. Further observation revealed three stacks of steam table serving pans stacked on the storage rack with visible moisture between the pans; four sheet pans stacked on top of each other with visible moisture between the pans; and four stacks of plastic plate covers stacked on a rolling cart with visible moisture between the plate covers. Dietary Cook AA verified they did not have enough space on the drying rack so they would just wash the items and stack them for storage instead of allowing the items to dry properly. During an observation in the kitchen on 8/9/23 8:35 a.m., the dry storage area was observed with the Dietary Manager. This observation revealed two food containers with rice and flour that were not labeled or dated. Further observation revealed the fryer had debris of food and the oil in the fryer appeared old. The Dietary Manager revealed that the fryer is drained on Saturdays. Further observation of the oven revealed burnt scrapes and debris in the oven. The dietary manager revealed that the oven needs to be cleaned. A review of the facility policy titled, All foods stored will be properly labeled according to the following guidelines, dated September 2014, Under Policy revealed once a case is opened, the individual refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the the first in-first out method of rotation. Further review of policy revealed Once a case is opened, the individual food items from the case are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation. Further review revealed that fryer will be cleaned on a routine basis and ovens should be cleaned after each use. During an interview on 8/8/23 at 9:12 a.m. with Dietary Cook AA revealed food item should be labeled with an open date when opened. She revealed all dietary staff were responsible for ensuring food items were labeled with an open date when opened and stored. Interview on 8/8/23 at 9:15 a.m. with Dietary Aide BB revealed that he had stacked that dishes without allowing them to dry properly and that he was aware that dishes should be dried properly prior to storage to prevent bacteria growth. He revealed the items were stacked together to dry due to lack of space to dry them. During an interview on 8/10/23 at 8:30 a.m. with the Administrator, she revealed her expectation of the dietary staff is to date and label all opened food items and to throw away opened food items that are not labeled and dated. She further revealed that dietary staff should maintain a cleaning schedule for the oven and the fryer, as well as other kitchen equipment. During an interview on 8/10/23 at 9:40 a.m. with the Dietary Manager revealed her expectation of the dietary staff is to follow the cleaning schedule to ensure kitchen equipment are cleaned properly and to ensure food items are properly labeled and dated.

Based on observations, record review, staff interviews, the facility failed: (1) to ensure that comfortable water temperatures were maintained for 11 of 66 resident rooms (Rooms 9222, 9224, 9225, 9226, 9227, 9228, 9229, 9230, 9231, 9232, and 9233); (2) to ensure that the facility was maintained in a safe, clean, and comfortable home-like environment for three of 66 resident rooms (rooms [ROOM NUMBER]) related to unlabeled and unbagged contoured bedpan, fracture bedpan, graduated urinal containers, specimen collector pans, wash basins, and a dirty bedside toilet commode. Findings included: 1. A review of the policy titled, Monitoring Water Temperatures revised November 2022 indicated, This facility will safeguard residents who cannot fully guard themselves from environmental hazards to which they are likely to be exposed, including, but not limited to being exposed to water that is too hot. Purpose: Hot water can cause scalding, i.e., second and third degree burns in which the skin blisters and swells. This facility believes in the necessity for checking the temperature of the hot water at the sinks, tubs, and showers used by residents. The water temperature shall not exceed 110 degrees Fahrenheit (F) according to regulation. During an observation on 8/8/23 at 10:25 a.m., the water in multiple residents rooms felt hot to touch. The Maintenance Director confirmed that the water felt hot. During environmental rounds on 8/8/23 at 12:34 p.m. with the Maintenance Director, the following was observed and confirmed by the Maintenance Director: In room [ROOM NUMBER], the water temperature measured at 114.4 degrees F. In room [ROOM NUMBER], the water temperature measured at 115.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 116.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 115.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 116.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 115.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 115.7 degrees F. In room [ROOM NUMBER], the water temperature measured at 114.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 115.6 degrees F. In room [ROOM NUMBER], the water temperature measured at 115.0 degrees F. In room [ROOM NUMBER], the water temperature measured at 114.4 degrees F. During an interview on 8/9/23 at 9:34 a.m. with the Maintenance Director, he revealed that on 8/3/23 and 8/4/23 the water heaters went out for the residents and parts of the kitchen. He stated that he was notified and called the water heater company to come out. They came out and indicated they would need to order a part. He indicated the part came in and the water heater was fixed and began to run again on 8/7/23. He has been adjusting the water to bring it back up to temperature as soon as possible. He was checking the temperature in all areas of the facility. He indicated all temperatures have been below 110 degrees F and that he checks the water temperatures daily on a scheduled basis. 2. During an observation on 8/8/23 at 10:32 a.m. in the shared bathroom of room [ROOM NUMBER], a specimen collector pan stored on the floor, bedpan hanging on a wall hook unlabeled and unbagged. During an observation on 8/8/23 at 10:41 a.m. in the shared bathroom of room [ROOM NUMBER], one graduated urinal container turned down on a paper towel resting on back of toilet commode top unlabeled and unbagged. Contoured bedpan, graduated urinal container, and fracture bedpan nested together on the floor not secured in a bag. One more additional fracture bedpan on floor uncovered labeled with a resident's name that does not reside in that room. During an observation on 8/8/23 at 11:11 a.m. in the shared bathroom of room [ROOM NUMBER], wash basin resting on the top of the toilet commode tank unbagged and unlabeled. One wash basin on the floor unbagged and unlabeled. Dirty dark brown substance on the top of bedside toilet commode lid. During an interview on 8/9/23 with Administrator and Director of Nursing (DON) stated that all bedpans, graduated urinal containers, fracture pans, specimen collector pans, and wash basins, should have been properly labeled and covered with a bag. During an interview on 8/9/23 at 4:45 p.m. with Infection Preventionist revealed their policy titled, Administration of Bedpan or Urinal, does not state the residents' containers for elimination need to be covered with a bag. She further revealed the staff quick reference guide does not instruct them to train on labeling and storing multiple elimination containers in a bag, even if the residents are sharing a bathroom.

Based on record review, family and staff interviews, and review of the policy titled Abuse, Neglect and Exploitation, Freedom From, the facility failed to ensure that an allegation of verbal abuse was reported to the State Agency (SA) for one of 32 sampled residents (R) (R#53) in a timely manner of within the required two hours of discovery. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, Freedom From last revised September 2022 indicated, H. Reporting suspected violations 3. The administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately, not later than 2 hours after the allegation is made, to other officials in accordance with state law including to the state survey and certification agency. I. Procedure for investigation 6. Any employee suspected of violation of these resident safety policies, may be suspended pending investigation. A review of the Electronic Medical Record (EMR) revealed R#53 was admitted to the facility on [DATE] with diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, diabetes mellitus, hypertension, contracture, left ankle, atherosclerotic heart disease of native coronary artery without angina pectoris, secondary osteoarthritis, and difficulty walking. A review of R#53's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which indicated no cognitive impairment; Psychosocial Well-Being revealed resident never or one day with feeling down, depressed, hopeless, and no behavior exhibited toward others to reject care; and that R#53 requires extensive assistance with one person assistance for Activities of Daily Living (ADL) care. A review of the facility's grievance book revealed a hand-written statement, 8/7/23 - Certified Nursing Assistant (CNA) NN said she was going to throw me across the street. (R#53) told Admission staff that everybody wants to beat her up. I went up to her and ask her who. She said, CNA NN. A review of Facility Incident Report (FRI) revealed Administrator filed the form regarding R#53's allegation of verbal abuse threat on 8/9/23. Further review of the FRIs revealed a pattern of other incidents not being reported in a timely manner. FRIs not filed on time: 1. Original date filed: 7/31/23 Follow-Up report date: 8/7/23 2. Original date filed: 5/3/23 Follow-Up report date: 5/10/23 3. Original date filed: 4/14/23 Follow-Up report date: 4/21/23 4. Original date filed: 4/6/23 Follow-Up report date: 4/14/23 5. Original date filed: 11/17/22 Follow-Up report date: 11/28/22 During an interview on 8/8/23 at 12:39 p.m. with R#53 mentioned she had experienced verbal abuse from CNA NN. She revealed CNA NN threatened that she would put her in her wheelchair and push her down the main ramp and let her roll into the parking lot or main street to fall if she continues to complain to the Administrator about her care. During an interview on 8/10/23 at 2:30 p.m., the Administrator verified any abuse should be reported within two hours and timeline to follow-up on alleged abuse is five days. During an interview on 8/10/2023 at 4:30 p.m. with R#53 she stated that she first notified Administrator and DON on 8/2/23 around 10:45 a.m. about being verbally abused by CNA NN. During an interview on 8/10/23 at 4:40 p.m. with Social Services Director (SSD) she stated that she was first made aware of R#53's allegation of abuse on 8/7/23 from the Unit Manager, Licensed Practical Nurse (LPN) CC, who was assigned to R#53's hall. The SSD stated that she immediately went to the resident for her to properly file a grievance statement. During an interview on 8/10/23 at 4:55 p.m. with Administrator she verified she was first made aware of the allegation of abuse for R#53 on 8/2/23 but had not reported the incident to the state until 8/9/23 because when questioned about the incident, the resident stated that she was just joking.

Based on observation, clinical record review, staff interview, hospital document review, and Nursing Policy and Procedure Manual, Residents at Risk of Elopement policy review, the facility administration failed to ensure adequate resident supervision, in accordance with a physician's orders [REDACTED]. This failure resulted in the elopement of one (1) resident (#1), for whom the facility failed to utilize a WanderGuard (Departure Alert Bracelet) as ordered for the early detection of elopement attempts due to wandering, of ten (10) residents assessed to be at risk of elopement, on the survey sample of seventeen (17) residents. Facility staff failed to ensure the placement of the Departure Alert Bracelet, as ordered by the physician, for Resident #1 after the resident was readmitted to the facility following a stay in the hospital. Resident #1 then eloped from the facility without the knowledge of staff, fell from the wheelchair in the facility ' s parking lot, and sustained a [MEDICAL CONDITION] that was noted with heavy bleeding. Resident #1 required transfer to the hospital, was diagnosed with [REDACTED]. This resulted in a situation in which the facility ' s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of immediate jeopardy on [DATE], at 12:04 p.m. The non-compliance involving facility staffs' failure to provide adequate supervision of Resident #1, who had been determined by the facility to be at risk for elopement, which caused the immediate jeopardy was identified to have existed on [DATE] (the day Resident #1 eloped from the facility, fell , and sustained multiple injuries which required transfer to the hospital) continued through [DATE], and was removed on [DATE]. The facility implemented an Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. During interview on [DATE], at 12:09 p.m., the Administrator indicated that she had been unaware of any problems related to resident elopement in the past, further acknowledging the facility ' s determination that corrective actions had been needed after the incident of elopement involving Resident #1. An Allegation of Jeopardy Removal was received from the facility on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement via a newly implemented Policy and Procedure, and completed a process of staff in-service training related to the newly implemented procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents at risk for elopement and who utilized elopement alert devices. Findings include: Cross refer to F323. Based on observation, record review, staff interview, and facility investigation follow-up report review, the facility failed to ensure that Resident #1 received adequate supervision to prevent elopement. Resident #1 had a history of [REDACTED]. A physician's order [REDACTED]. attempts due to wandering. This Departure Alert Bracelet had then been added to the Care Plan of Resident #1 as an intervention for the noted problem of the resident exhibiting exit seeking behaviors and verbalizing he/she wanted to leave the facility. However, upon Resident #1 requiring hospital transfer due to a fall and being subsequently readmitted to the facility on [DATE], facility nursing staff failed to ensure the placement of the Departure Alert Bracelet upon facility readmission, even though a physician's orders [REDACTED]. Facility staff also failed to check for the function and placement of the Departure Alert Bracelet for Resident #1, per the facility protocol, the day following the resident's facility readmission, even though a facility staff person was specifically assigned to check the device on that day. Resident #1 then eloped on [DATE], two days after facility readmission, sustained a fall, was transferred to the hospital, and was diagnosed with [REDACTED]. The resident later expired. Review of the facility's Nursing Policy and Procedure Manual, Elopement, Residents at Risk Policy which was in place at the time of Resident #1's elopement revealed that the Policy addressed resident assessment for elopement risk at the time of facility admission, and at least quarterly thereafter. The Policy and Procedure also specified the application of a Departure Alert device, and a Care Plan update, as appropriate. However, further review of this Policy and Procedure related to resident elopement revealed no evidence of a procedure addressing resident readmission, such as readmission from the hospital, to ensure the continuation of prior interventions which had been in place and were ordered for the prevention of elopement. There was also no evidence of a process to ensure the availability of Departure Alert Devices, if the need for such devices arose after hours. Review of procedures put into place after Resident #1's [DATE] elopement revealed that, after this incident, facility administration had enacted a number of procedural changes related to resident supervision to prevent elopement, to include a double-check by two separate nurses regarding all physicians' orders both at the time of resident admission and readmission, and also the storage of extra Departure Alert Bracelets in the Medication Room to ensure after-hours availability. During an interview conducted on [DATE] at 1:40 p.m., when questioned about the facility's process of resident readmission from the hospital, including residents who had been determined to be at risk for elopement, the DON stated that in the past, it had been the responsibility of the nurse on duty to receive orders for resident readmission, and had also been the responsibility of this nurse to conduct a physical assessment. This physical assessment was to be accomplished utilizing a specified facility assessment form which had been in place at the time of Resident #1's facility readmission on [DATE] from the hospital. However, the DON acknowledged that there had been nothing on the facility assessment form which had been in use for resident assessment upon facility readmission that would prompt facility nursing staff to check for the presence of, or the need to apply, a Departure Alert Bracelet. The DON further acknowledged that it was only after Resident #1's elopement following nursing staffs' failure to ensure the presence of the Departure Alert Bracelet as ordered upon readmission to the facility on [DATE], that the facility had modified the readmission process to ensure that the nurse specifically verified the presence and function of a Departure Alert Bracelet at that time. During an interview with the Administrator conducted on [DATE] at 12:09 p.m., when questioned regarding the elopement incident of Resident #1 and the facility's overall procedures for supervising residents at risk for elopement, the Administrator stated that she had not been aware of any problems related to resident elopement prior to the [DATE] incident of elopement involving Resident #1. During a later interview with the Administrator conducted on [DATE] at 1:45 p.m., the Administrator acknowledged that after the elopement and falling accident involving Resident #1, the facility had identified the need to review the existing protocols of supervising residents at risk for elopement. The Administrator acknowledged that, upon this review, the facility had identified the need to make multiple modifications to the existing process of elopement prevention, such as requiring more frequent checks of resident Departure Alert Bracelets to ensure that the devices were applied as ordered. This review had resulted in the determination that the frequency of Departure Alert Bracelet checks being utilized by the facility needed to be increased from the prior procedure requiring weekly checks to a new procedure which required daily checks for function and per-shift checks for presence. Based on the above, the facility's administration failed to maintain a system which ensured the necessary supervision of residents at risk for elopement. The facility's system failed to ensure WanderGuard bracelet placement as ordered, both initially upon resident facility readmission and also during the days following resident facility readmission. This resulted in the failure of facility staff to ensure the application of Resident #1's Departure Alert Bracelet after readmission from the hospital, allowing the resident to elope. It was determined that the immediate jeopardy was removed on [DATE], a which time the facility had implemented an Allegation of Jeopardy Removal with the following interventions: 1. On [DATE], the facility's Medical Records Director conducted a check of all residents with Departure Alert Bracelets for presence and function. 2. On [DATE], the facility conducted a review and assessment of all residents utilizing Departure Alert Bracelets for ongoing need and appropriateness, based on physicians' orders. 3. On [DATE], the facility implemented a procedure by which a current monthly list of residents utilizing Departure Alert Bracelets would be placed at the front of each MAR indicated [REDACTED] 4. On [DATE], the facility reviewed and revised the Facility's Elopement, Residents at Risk Policy and Procedure. The revised Policy and Procedure required an increase in the testing of Departure Alert Bracelet function from a weekly to a daily basis, to be checked for function by the Charge Nurse on the 3:00 p.m.-11:00 p.m. shift. Also, a visual check of resident Departure Alert Bracelets would be done by the Charge Nurse every shift. A notation was to be made on resident MARs for documentation of visual checks for placement and testing for function. 5. On [DATE], the facility implemented a procedure by which the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) would conduct weekly MAR indicated [REDACTED]. This audit will be accomplished utilizing the Weekly Departure Alert Bracelet Function Documentation Audit on MAR form. 6. On [DATE], the Elopement Book was reviewed and placed at both the front desk and the front nursing station for quick reference. The procedure also involved the Medical Records Director/Medical Records Assistant updating the Elopement Book weekly, and as needed, with admissions and discharge orders. 7. On [DATE], the facility implemented a procedure by which the attendant at the facility's front door exit would have increased daily hours until 10:00 p.m. until physical adjustments were made to the interior lobby doors. The front door, which is the exterior lobby door exit, would be powered off when the attendant left, so that the doors did not automatically slide open. Signage would include the facility telephone number for visitors to contact staff to gain entrance into the facility after hours. 8. On [DATE], the facility implemented a procedure specifying that if the attendant at the front door had to leave unexpectedly, he/she would notify the Administrator/HR Director/Weekend Manager/Charge Nurse to assure that someone would cover the front door during the attendant's absence. 9. On [DATE], the facility implemented a procedure by which all other doors of egress would be checked monthly and as needed as part of the ongoing Preventative Maintenance Program by the Maintenance Director to ensure they were functioning properly. 10. On [DATE], the facility noted the use of Departure Alert Bracelets in the Care Plans of all residents who utilized these bracelets. 11. On [DATE], the facility implemented a procedure by which the Charge Nurse who checked the Departure Alert Bracelets daily would communicate to the Medical Records Director/Medical Records Assistant/Weekend Nurse Manager if there were any problems with bracelet function for proper replacement. After hours, extra Departure Alert Bracelets would be maintained in the medication room. 12. On [DATE], the DON, ADON, SDC, and MDS Coordinator conducted staff in-service training for all staff on the revised Elopement, Residents at Risk Policy and Procedure, the changes in the process of monitoring the function of Departure Alert Bracelets from weekly to daily, and the demonstration of the use of the signaling device tester. Training also included stressing prompt response to the alarm elicited by resident Departure Alert Bracelets, and identifying residents at high risk for elopement utilizing the Elopement Risk Assessment. As of [DATE], 110 staff had been trained, with eight (8) staff remaining to receive this in-service training. Employees would not be allowed to work until they had received the in-service training and could demonstrate an appropriate understanding of the revised Elopement, Residents at Risk Policy and Procedure. 13. On [DATE], the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet. If a resident who had been ordered and designated to wear a Departure Alert Bracelet was observed without a bracelet in place, the CNA would immediately notify the resident's Charge Nurse for action. The findings of such incidents would be documented on the 24 Hour Nursing Report by the Charge Nurse. 14. On [DATE], the facility implemented a procedure by which physicians' orders for all resident admissions and readmissions would be checked by the Charge Nurse, and checked and documented by the signature of a second Charge Nurse, on the same shift of resident admission/readmission. 15. On [DATE], other potentially affected residents, such as mobile residents with cognitive impairment and/or residents with dementia or wandering behaviors, were assessed for the risk for elopement and/or exit-seeking behaviors. 16. On [DATE], the Quality Assurance (QA) Committee met to ensure that the specific steps/interventions undertaken, as indicated above, adequately eliminated and corrected the causative factors identified in the incident of elopement involving Resident #1. 17. On [DATE], the facility established a procedure by which the QA Committee would conduct an audit related to the revised Policy and Procedure to determine the effectiveness and staff compliance. Audit data would be collected via audits by the Administrator/DON utilizing the QA Audit Checklist Tool which would be conducted weekly for the first month. If one-hundred percent compliance was observed, the audits would then occur monthly for three (3) months. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had revised the Elopement, Residents at Risk Policy and Procedure. A procedure had been implemented by which a visual check of Departure Alert Bracelets would be done every shift, and a check of Bracelets for function would be done every day by the Charge Nurse, with a notation of these checks for placement and function to be placed on resident MARs. Also, the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet, allowing CNAs to monitor residents who were to wear Departure Alert Bracelets for bracelet placement, and to notify the Charge Nurse of noted problems. On [DATE], staff in-service training was conducted for staff related to the revised Elopement, Residents at Risk Policy and Procedure, and the changes in the frequency and method of monitoring of the Departure Alert Bracelets. As of [DATE], 110 staff had been trained, but eight (8) staff had been unavailable for training as of that date, and would thus need to receive training upon their return to work. Therefore, the completion of staff in-service training could not be evaluated at the time of survey completion. Additionally, on [DATE], the facility implemented an audit tool, the QA Audit Checklist Tool, allowing for the Administrator/DON to collect data, via audits, to monitor facility staffs' application of, and compliance with, these new facility policies and procedures. The information from this Audit Checklist Tool was to be utilized, and analyzed, by the facility's QA Committee. However, this QA Audit Checklist Tool had only been implemented on [DATE], the day before the [DATE] exit date of this complaint survey. Therefore, the ongoing application and completion of this Tool could not be evaluated at the time of survey exit. Additionally, the QA Committee would conduct an audit of the revised Policy and Procedure to determine the effectiveness and staff compliance. The QA Committee had met on [DATE] to assess the steps and interventions put into place by the facility to address Resident #1's elopement, but the Committee was scheduled to meet again on [DATE], the day after the completion of this complaint survey, to perform a root cause analysis to determine the need for the implementation of additional systems related to this incident of elopement. Therefore, the Committee's ongoing process of system oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, with the scope and severity reduced to the "D" level.

Based on observation, record review, staff interview, facility Residents at Risk for Elopement Policy and Procedure review, hospital History and Physical Final Report form review, hospital Consults report review, Psychiatric Consultation: Initial Evaluation report review, facility staff written statement review, and facility investigation follow-up report review, the facility failed to ensure adequate resident supervision to prevent elopement by failing to ensure the placement of a WanderGuard (Departure Alert) Bracelet, in accordance with a physician's orders [REDACTED]. Facility staff failed to ensure the placement of a Departure Alert Bracelet, as ordered by the physician, for Resident #1 upon the resident's readmission to the facility following a hospital transfer. Resident #1 subsequently exited the facility without the knowledge of facility staff, fell from the wheelchair in the facility's parking lot, and sustained a heavily-bleeding laceration to the forehead. The resident was transferred to the hospital and was determined to have sustained C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. The resident later expired in the hospital. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of immediate jeopardy on [DATE], at 12:04 p.m. The non-compliance involving facility staffs' failure to provide adequate supervision of Resident #1, who was at risk of elopement, which caused the immediate jeopardy was identified to have existed on [DATE] (the day Resident #1 eloped from the facility, fell , and sustained multiple injuries requiring hospital transfer), continued through [DATE], and was removed on [DATE]. The facility implemented an Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. During an interview with the Administrator conducted on [DATE] at 12:09 p.m., the Administrator acknowledged awareness of the incident of elopement involving Resident #1. During this interview, the Administrator stated she had not been aware of any elopement problems prior to the elopement incident involving Resident #1, but that the facility was considering placing a key pad lock on the facility's currently unlocked interior lobby doors. During a later interview conducted on [DATE] at 12:02 p.m. with the Administrator and Director of Nursing (DON), the Administrator referenced multiple interventions related to resident assessment and supervision regarding the prevention of resident elopement which had been initiated and implemented, via revised Policies and Procedures, as a result of the elopement incident involving Resident #1. The interventions included an increase in the frequency of monitoring for Departure Alert Bracelets, and a modified process for reviewing resident admission/readmission orders [REDACTED]. An Allegation of Jeopardy Removal was received from the facility on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement via a newly implemented Policy and Procedure, and completed a process of staff in-service training related to the new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents at risk for elopement and who utilized WanderGuard alert devices. Findings include: Review of the facility's Nursing Policy and Procedure Manual revealed a Policy and Procedure, entitled Residents at Risk for Elopement, which specified that upon admission, residents would be assessed for elopement potential. Residents identified as being at risk of elopement would receive a WanderGuard (Departure Alert Bracelet). The risk of elopement would be indicated on resident Care Plans, along with the interventions which were put in place for the prevention of elopement. The indicated Purpose of this Policy and Procedure was to prevent injury/loss of life due to wandering. Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of [DATE] which documented an Entry Date of [DATE], and which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #1 had a Brief Interview For Mental Status (BIMS) score of 08, indicating that the resident had moderate impairment in cognitive status. Section G - Functional Status indicated that the resident utilized a wheelchair as a mobility device. A subsequent Quarterly MDS with an Assessment Referenced Date of [DATE] documented a decline in Resident #1's BIMS score to 07, indicating that the resident at that time had more severe impairment in cognitive status, while Section G - Functional Status indicated that the resident continued to utilize a wheelchair as a mobility device. Further record review for Resident #1 revealed a Nurse's Notes entry of [DATE] at 3:50 p.m. which documented that the resident was alert but with periods of confusion, and Nurse's Notes entries of [DATE] at 2:25 p.m. and 4:00 p.m. also documented that the resident was experiencing confusion at times. A Nurse's Notes entry of [DATE] at 7:34 p.m. documented that Resident #1 remained alert, and was oriented to person, but also documented that the resident required frequent reassurance, redirection and reality orientation for wandering and requesting to be taken to the bus. A subsequent [DATE], 3:50 p.m. Nurse's Notes entry for Resident #1 (two days after the [DATE] Nurse's Notes entry referenced above which documented that redirection had been required related to wandering and the resident's request to leave) then documented that the resident was repeatedly asking staff about "the way out of this building", further documenting that the resident stated that he/she needed "to catch a train to Alabama." This [DATE] Nurse's Notes entry also documented that a Departure Alert Bracelet was being applied to the resident for exit-seeking behavior. A Physician's Telephone Orders form dated [DATE] for Resident #1 specified that a Departure Alert device be utilized for Resident #1 for exit-seeking behaviors, as indicated in the [DATE] Nurse's Notes entry referenced above. Review of the [DATE] monthly Physicians Orders form for Resident #1 revealed a physician's orders [REDACTED]. A Nurse's Notes entry of [DATE] at 3:05 p.m. documented that Resident #1 had noted confusion, and a later Nurse's Notes entry of [DATE] (noted as being a later entry for [DATE] at 9:00 p.m.) documented that Resident #1 had required redirection after having been observed by the Director of Nursing wandering in and out of residents' rooms. A Psychiatric Consultation: Initial Evaluation report dated [DATE] for Resident #1 documented that the resident had exhibited increased aggressive behaviors which occurred often. This Psychiatric Consultation report further documented that when Resident #1 was asked about these behaviors, the resident was confused throughout the conversation and denied aggressiveness, but did state "I just want to get in my truck and head to Alabama where my home is." This Psychiatric Consultation report also documented that Resident #1 had dementia and that his/her judgement/insight were impaired due to the disease process. During an interview with the Director of Nursing (DON) conducted on [DATE] at 12:15 p.m., the DON acknowledged that around August of 2013, Resident #1 had started making statements about wanting to go home, and had also started to exhibit more behaviors such as wandering around the building. The DON also acknowledged that the use of a Departure Alert Bracelet had been initiated for Resident #1. A Nurse's Notes entry of [DATE] at 2:00 p.m. documented that Resident #1 had been attempting to pick up an envelope and had fallen to the floor. This entry documented that a skin tear was noted on the resident's left arm, and redness was noted on the side of the resident's head. The entry also documented that Resident #1 complained of a headache, and was thus transferred to the hospital for evaluation. The hospital History and Physical (H&P) Final Report for Resident #1, related to the [DATE] hospital transfer, documented that the resident had been admitted to the hospital on that date following a fall from a wheelchair while attempting to obtain a card from the floor. This H&P Final Report for Resident #1 documented that a Computed Tomography (CT) scan of the resident's cervical spine during this hospital admission revealed findings of no acute fractures, and of normal alignment. Further review of Resident #1's facility clinical record revealed a Nurse's Notes entry of [DATE] at 5:30 p.m. which documented that the resident had returned to the nursing facility from the hospital, and that the resident was alert but experiencing periodic confusion. This entry documented that the physician was notified of Resident #1's return to the facility, and that the resident's previous orders were to be continued. As referenced above, Resident #1's [DATE] monthly Physicians Orders form (the orders in effect prior to the resident's [DATE] hospital transfer) listed a physician's orders [REDACTED]. However, further record review for Resident #1, to include review of the [DATE], 5:30 p.m. Nurse's Notes entry for Resident #1 referenced above and the accompanying Admission Resident Assessment form dated [DATE] for Resident #1, revealed no evidence to indicate that a Departure Alert Bracelet was applied as ordered at the time of Resident #1's readmission on that date. During a [DATE], 3:00 p.m. post-survey telephone interview with Nurse "FF", the nurse who had readmitted Resident #1 to the facility on [DATE], Nurse "FF" acknowledged that when Resident #1 had returned to the facility, the resident was not wearing a Departure Alert Bracelet, and that a bracelet was not applied at the time of readmission. In addition, subsequent to Resident #1's facility readmission, clinical record review, to include review of Nurse's Notes entries of [DATE] at 5:15 a.m., [DATE] at 8:00 p.m., and [DATE] at 3:30 p.m., revealed no evidence to indicate that nursing staff confirmed the placement of the Departure Alert Bracelet, or reapplied a Departure Alert Bracelet, after Resident #1's [DATE] readmission to the facility from the hospital. The [DATE] Treatment Sheet for Resident #1 listed the bracelet alarm as an intervention for safety and early detection of elopement attempts, but there was also a notation on the resident's Treatment Sheet adjacent to the bracelet reference which indicated that the listing of the alert bracelet on the Treatment Sheet was for informational purposes, and there was no documentation to indicate the actual application of the bracelet alert device on or after the resident's [DATE] facility readmission after the hospital stay. The [DATE], 3:30 p.m. Nurse's Notes entry referenced above document that at that time, Resident #1 was observed seated in a wheelchair, and was alert with confusion. A later Nurse's Notes entry of [DATE] at 4:40 p.m., signed by Nurse "AA", then documented that a resident family member had notified the nurse that an individual in a wheelchair had just fallen outside of the building. This entry documented that the nurse then went outside and observed Resident #1 laying on his/her left side on the entrance ramp from the parking lot, with the wheelchair chair located behind the resident. Resident #1 was noted to have a laceration to the forehead which was bleeding heavily. This Nurse's Notes entry documented that as pressure was applied to Resident #1's forehead laceration, the resident was attempting to hit staff, and that staff made attempts to keep the resident from fighting. The entry further documented that Emergency Medical Services (EMS) 911 was called and the resident was transported to the hospital. Further record review for Resident #1 revealed an undated Nurse's Notes entry, noted as being a late entry signed by Nurse "AA" and entered directly below the [DATE], 4:40 p.m. Nurse's Notes entry referenced above, which documented that Resident #1 had not had a Departure Alert Bracelet device on at the time of the incident of elopement and fall. Review of the hospital History and Physical (H&P) report dated [DATE], related to Resident #1's hospital transfer after being found to have fallen in the facility's parking lot, revealed a hospital admission date of [DATE]. This H&P documented, in the Reason for Admission section, that Resident #1 had been admitted to the hospital after a fall with multiple injuries. This H&P documented, in the History of Present Illness section, that Resident #1 had a past medical history of [REDACTED]. The H&P documented that Resident #1 was diagnosed to have C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. The Diagnostics section of this H&P more specifically documented that a CT scan of Resident #1's cervical spine revealed a fracture of the C2 vertebral body at the base of the dens, with posterior displacement of the dens and C2 with respect to the C1, and a fracture of the anterior arch of C1 bilaterally. This CT scan also documented a left fifth metacarpal fracture. Additionally, a hospital Consults report dated [DATE] for Resident #1 documented the reason for consultation as a facial fracture, and also documented that a CT scan of the resident's facial bones had revealed a comminuted bilateral type 2 nasal fracture. This Consults report documented, in the Assessment section, that Resident #1 was status [REDACTED]. In a written statement signed by Nurse "AA" (the nurse who responded after Resident #1's elopement and fall, as documented in the [DATE], 4:40 p.m. Nurse's Notes entry referenced above), which had been obtained as part of the facility's investigation into Resident #1's [DATE] elopement and fall, Nurse "AA" documented that on [DATE] at approximately 3:50 p.m., she had observed Resident #1 sitting near the facility's Computer Lab in the wheelchair. Nurse "AA" documented that at approximately 4:15 p.m., a visitor had then come into the facility calling out that an individual in a wheelchair had fallen outside. Nurse"AA" documented that she ran outside and observed Resident #1 laying on the ground, with the wheelchair positioned by the sidewalk before the entrance ramp. Nurse "AA" documented that Resident #1 was bleeding heavily from the forehead and nose, and that another staff member brought towels and gloves. The nurse documented that pressure was applied to Resident #1's forehead, lip, and right arm, and that EMS 911, when called, responded in ten-to-fifteen minutes and transported the resident to the hospital. Nurse "AA" further documented that before Resident #1 left for hospital transport, staff checked for the presence of a Departure Alert Bracelet, and that none was found. During an interview with Nurse "AA" conducted during this complaint survey on [DATE] at 11:51 a.m., this nurse stated she was working on the 3:00 p.m.-11:00 p.m. shift on [DATE] and was the charge nurse for the unit upon which Resident #1 resided. Nurse "AA" stated that she had observed Resident #1 seated by the Computer Room on the A Hall around 3:45 p.m. Nurse "AA" stated that a female later came into the building stating that an individual had fallen and was lying out in the parking lot. The nurse stated she ran outside and found Resident #1, who had fallen and was bleeding from the forehead. She stated that staff applied pressure to the resident's wound while she called 911, and then she returned outside to assist with the resident. She stated that Resident #1's Departure Alert Bracelet was not on at that time. In a written statement dated [DATE] provided by Certified Nursing Assistant (CNA) "BB" as part of the facility's investigation into the [DATE] incident of elopement involving Resident #1, CNA "BB" documented that she had assisted another CNA in providing the resident with a shower at approximately 3:30 p.m. on [DATE]. CNA "BB" documented that during the shower, she had performed a skin assessment on Resident #1, but that the resident was not wearing an arm band, and that "nothing" was seen on the resident's arm. During an interview with CNA "BB" conducted during this complaint survey on [DATE] at 2:25 p.m., CNA "BB" stated that she had bathed Resident #1 around 3:30 p.m. on [DATE], the day of the accident. CNA "BB" stated that at the time of the bath, she had done a skin assessment, and that Resident #1 did not have any type of band on his/her wrist or anywhere else on his/her body at that time. CNA "BB" stated that she later saw Resident #1 seated in the Dining Room, and then, once hearing that someone had fallen outside, she went outside and observed Resident #1 lying in the parking lot. She stated that when she observed Resident #1 lying in the parking lot, the resident was positioned right next to the walkway. The facility presented a [DATE] facility investigation follow-up report (IFR) which documented the facility's investigation of the [DATE] elopement and fall incident of Resident #1 referenced above. This IFR documented that at 4:15 p.m. on [DATE], after being informed by a visitor that someone had fallen outside, Nurse "AA" had gone outside to find Resident #1 lying on the ground bleeding heavily from the forehead. Nurse "AA" and other staff had attended the resident, EMS 911 was called, and the resident was then transported to the hospital. This IFR documented that hospital reports documented Resident #1's injuries, including fractures of C1 and C2, a fracture of the left fifth metacarpal, and a comminutes nasal bone fracture. The IFR also documented that Resident #1 had died in the hospital on [DATE]. The IFR, in reference to the facility's physical plant configuration, documented that there was only one unlocked facility exit, which was the front door exit. The facility's front door exit consisted of two sets of unlocked glass doors leading to the outside. The interior doors (which opened into a lobby area from an interior facility hallway) were alarmed with a Departure Alert alarm for residents with wristbands, and also had a handicapped access push pad to open the doors which swung open for access. In the lobby area (into which these interior doors opened), there was then a set of exterior doors, consisting of sliding glass doors which opened automatically when approached, and which lead to the outside of the facility. This IFR documented that on [DATE], when Resident #1 was reported to have fallen in the parking lot, Nurse "AA" responded and observed the resident lying on the ground, and observed the wheelchair at the end of the sidewalk that extended straight out from the front door (the unlocked front exterior exit doors referenced above) and ended at the parking lot, a distance of approximately 85 feet. Observation in the facility's front lobby, front door area, and exit sidewalk, conducted on [DATE] at 3:05 p.m. revealed a set of unlocked, alarmed interior double doors which opened into the facility's front lobby/reception area. The interior doors were located approximately 10 feet from a nurse's station, and could be opened manually or by pressing an automatic switch located to the left of the double doors in the lobby area. At the opposite end of the lobby/reception area, a set of sliding glass exit doors, which were unlocked and opened automatically, opened to the exterior of the building. Upon exiting these front exit doors, a walkway proceeded downward at a slight decline, ending at the parking lot. The walkway lead directly from the exit doors in a straight direction, proceeded downward at a slight decline for approximately 30 feet, became flat and level for approximately 20 feet, then proceeded with a downward decline for approximately another 30 feet, where it ended adjacent to the parking lot where Resident #1 was found to have fallen. The facility's IFR referenced above also documented that prior to Resident #1's [DATE] elopement and fall incident, Resident #1 had experienced a previous fall on [DATE] which had resulted in the resident's hospital transfer and return to the facility on [DATE]. The IFR documented that upon readmission to the facility on [DATE], a physician's orders [REDACTED]. However, this IFR documented that the facility's investigation of Resident #1's Departure Alert wristband placement had determined that the bracelet placement had not been verified by the readmission nurse on [DATE] (upon Resident #1's readmission to the facility from the hospital). The IFR also documented that a Medical Records staff person who was assigned to check the functioning of resident Departure Alert Bracelets weekly on Wednesday, per facility procedure, had not checked, as scheduled, for the placement/functioning of Resident #1's Departure Alert wristband on Wednesday, [DATE], after the resident had returned from the hospital on Tuesday, [DATE]. Additionally, this IFR indicated that a receptionist was scheduled to be stationed at a desk located in the front lobby area, in view of the unlocked front door exit, daily from 9:00 a.m. to 5:30 p.m.. However, the IFR further indicated that this receptionist, normally on duty until 5:30 p.m. daily, had actually left at 4:00 p.m. on [DATE], the date of the resident's elopement. The IFR thus documented that since Resident #1 was not reported to be outside until 4:15 p.m., the facility surmised that Resident #1 had not been directly observed for a fifteen (15) minute period of time. During an interview with the DON conducted on [DATE] at 10:18 a.m., the DON acknowledged the facility's procedure of having a receptionist in the lobby from 9:00 a.m. until 5:30 p.m. daily. During this interview, the DON further acknowledged that on [DATE], the receptionist had been positioned at the front lobby desk until 4:00 p.m., but had then left, therefore leaving no one at the desk in sight of the exit after 4:00 p.m. on the day and at the time that Resident #1 eloped. The DON also acknowledged, during an interview conducted on [DATE] at 1:40 p.m., that there had been a standing physician's orders [REDACTED]. Also, during a [DATE], 12:15 p.m. interview, the DON acknowledged that the Medical Records staff member who had been assigned to perform resident Departure Alert Bracelet checks weekly on Wednesdays had not checked for the placement of Resident #1's WanderGuard bracelet on Wednesday, [DATE], even though the resident had been readmitted to the facility on Tuesday, [DATE]. Based on the above, despite Resident #1 having dementia and a history of expressing a desire to leave the facility, despite the facility assessing the resident to have exit-seeking behaviors, and despite a physician's orders [REDACTED]. to the facility from the hospital. Facility staff also failed to check Resident #1 the day following facility readmission, per facility procedure, during a regularly scheduled weekly check intended to determine the proper function of resident Departure Alert Bracelets, thus again failing to observe for and ensure placement of Resident #1's bracelet. Resident #1 later exited the facility without the knowledge of staff, sustained an unwitnessed fall from the wheelchair at the terminal end of the sidewalk leading from the facility's front entrance/exit doors, and was noted to have a heavily-bleeding laceration to the forehead. Resident #1 was then transferred via EMS to the hospital, where the resident was determined to have sustained C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. Resident #1 later expired in the hospital. It was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented an Allegation of Jeopardy Removal with the following interventions: 1. On [DATE], the facility's Medical Records Director conducted a check of all residents with Departure Alert Bracelets for presence and function. 2. On [DATE], the facility conducted a review and assessment of all residents utilizing Departure Alert Bracelets for ongoing need and appropriateness, based on physicians' orders. 3. On [DATE], the facility implemented a procedure by which a current monthly list of residents utilizing Departure Alert Bracelets would be placed at the front of each MAR on each facility hallway. 4. On [DATE], the facility reviewed and revised the Facility's Elopement, Residents at Risk Policy and Procedure. The revised Policy and Procedure required an increase in the testing of Departure Alert Bracelet function from a weekly to a daily basis, to be checked for function by the Charge Nurse on the 3:00 p.m.-11:00 p.m. shift. Also, a visual check of resident Departure Alert Bracelets would be done by the Charge Nurse every shift. A notation was to be made on resident MARs for documentation of visual checks for placement and testing for function. 5. On [DATE], the facility implemented a procedure by which the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) would conduct weekly MAR audits to monitor staffs' compliance with Departure Alert Bracelet checks, to ensure accuracy and completion. This audit will be accomplished utilizing the Weekly Departure Alert Bracelet Function Documentation Audit on MAR form. 6. On [DATE], the Elopement Book was reviewed and placed at both the front desk and the front nursing station for quick reference. The procedure also involved the Medical Records Director/Medical Records Assistant updating the Elopement Book weekly, and as needed, with admissions and discharge orders. 7. On [DATE], the facility implemented a procedure by which the attendant at the facility's front door exit would have increased daily hours until 10:00 p.m. until physical adjustments were made to the interior lobby doors. The front door, which is the exterior lobby door exit, would be powered off when the attendant left, so that the doors did not automatically slide open. Signage would include the facility telephone number for visitors to contact staff to gain entrance into the facility after hours. 8. On [DATE], the facility implemented a procedure specifying that if the attendant at the front door had to leave unexpectedly, he/she would notify the Administrator/HR Director/Weekend Manager/Charge Nurse to assure that someone would cover the front door during the attendant's absence. 9. On [DATE], the facility implemented a procedure by which all other doors of egress would be checked monthly and as needed as part of the ongoing Preventative Maintenance Program by the Maintenance Director to ensure they were functioning properly. 10. On [DATE], the facility noted the use of Departure Alert Bracelets in the Care Plans of all residents who utilized these bracelets. 11. On [DATE], the facility implemented a procedure by which the Charge Nurse who checked the Departure Alert Bracelets daily would communicate to the Medical Records Director/Medical Records Assistant/Weekend Nurse Manager if there were any problems with bracelet function for proper replacement. After hours, extra Departure Alert Bracelets would be maintained in the medication room. 12. On [DATE], the DON, ADON, SDC, and MDS Coordinator conducted staff in-service training for all staff on the revised Elopement, Residents at Risk Policy and Procedure, the changes in the process of monitoring the function of Departure Alert Bracelets from weekly to daily, and the demonstration of the use of the signaling device tester. Training also included stressing prompt response to the alarm elicited by resident Departure Alert Bracelets, and identifying residents at high risk for elopement utilizing the Elopement Risk Assessment. As of [DATE], 110 staff had been trained, with eight (8) staff remaining to receive this in-service training. Employees would not be allowed to work until they had received the in-service training and could demonstrate an appropriate understanding of the revised Elopement, Residents at Risk Policy and Procedure. 13. On [DATE], the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet. If a resident who had been ordered and designated to wear a Departure Alert Bracelet was observed without a bracelet in place, the CNA would immediately notify the resident's Charge Nurse for action. The findings of such incidents would be documented on the 24 Hour Nursing Report by the Charge Nurse. 14. On [DATE], the facility implemented a procedure by which physicians' orders for all resident admissions and readmissions would be checked by the Charge Nurse, and checked and documented by the signature of a second Charge Nurse, on the same shift of resident admission/readmission. 15. On [DATE], other potentially affected residents, such as mobile residents with cognitive impairment and/or residents with dementia or wandering behaviors, were assessed for the risk for elopement and/or exit-seeking behaviors. 16. On [DATE], the Quality Assurance (QA) Committee met to ensure that the specific steps/interventions undertaken, as indicated above, adequately eliminated and corrected the causative factors identified in the incident of elopement involving Resident #1. 17. On [DATE], the facility established a procedure by which the QA Committee would conduct an audit related to the revised Policy and Procedure to determine the effectiveness and staff compliance. Audit data would be collected via audits by the Administrator/DON utilizing the QA Audit Checklist Tool which would be conducted weekly for the first month. If one-hundred percent compliance was observed, the audits would then occur monthly for three (3) months. Based on these corrective actions which had been deve

Based on record review, staff interview, hospital History and Physical Report form review, and facility investigation follow-up report review, the facility failed to ensure that supervision to prevent elopement was provided, as specified by a Care Plan Approach requiring the use of a Wanderguard (Departure Alert) bracelet, for one (1) resident (#1) who had a Care Plan entry which identified exit-seeking behaviors and specified the use of a Departure Alert Bracelet, of ten (10) residents on the survey sample assessed as being at risk of elopement, on the total survey sample of seventeen (17) residents. Facility staff failed to ensure that the Departure Alert Bracelet was in place, as specified by the Care Plan, after Resident #1 had been transferred to the hospital and then returned and readmitted to the facility. Resident #1 then exited the facility, without staff being aware of his/her exit, experienced a fall in the parking lot, and was noted to have a bleeding laceration to the forehead. The resident was transferred to the hospital and was determined to have sustained C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. Resident #1 later expired. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of immediate jeopardy on [DATE], at 12:04 p.m. The non-compliance, which involved facility staffs' failure to provide adequate supervision for Resident #1 who was at risk of elopement and whose Care Plan specified the application of a Departure Alert Bracelet, thus causing the immediate jeopardy, was identified to have existed on [DATE] (the day Resident #1 eloped, sustained a fall and multiple injuries, and was transferred to the hospital), continued through [DATE], and was removed on [DATE]. The facility implemented an Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. During an interview with the Administrator conducted on [DATE] at 12:09 p.m., the Administrator acknowledged awareness of the incident of elopement involving Resident #1, but denied knowledge of a problem with resident elopement prior to this incident. During an interview conducted on [DATE] at 12:02 p.m. with the Administrator and Director of Nursing (DON), the Administrator stated that a number of corrective interventions regarding the prevention of resident elopement had been developed and implemented since Resident #1's elopement. These interventions included the ongoing assessment of residents having Departure Alert Bracelets for the need and appropriateness of the bracelets, and inclusion in the Care Plan. During this interview, the Administrator acknowledged that the facility had not developed a method of comprehensive oversight of these interventions at that time. An Allegation of Jeopardy Removal was received from the facility on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement via a newly implemented Policy and Procedure, and completed a process of staff in-service training related to the new procedures. This Policy and Procedure included the review and assessment of all potentially affected residents for the risk of elopement and/or exit-seeking behaviors, to ensure a plan of care based on physicians' orders. Observations were made to assess staff performance related to these new procedures included in the Policy and Procedure. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents at risk for elopement and who utilized Departure Alert Bracelet devices. Findings include: Record review for Resident #1 revealed an Admission Minimum Data Set assessment of [DATE] which documented admission on [DATE], and documented diagnoses, in Section I - Active Diagnoses, which included Diabetes Mellitus, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Section G - Functional Status indicated that Resident #1 utilized a wheelchair for mobility. Review of Resident #1's Care Plan revealed a Problem dated [DATE] which indicated that the resident was exhibiting exit-seeking behaviors and verbalizing that he/she wanted to leave the facility. Approaches to address the resident's exit-seeking behaviors included the application of a Departure Alert Bracelet for safety. Resident #1's Care Plan also noted a Problem dated [DATE] which indicated that the resident was at risk for falls related to multiple risk factors, three of which were dementia, impulsive behaviors with poor safety awareness, and wandering behaviors. One of the Approaches to address this resident's fall risk specified for staff to continue to monitor the resident's behaviors. The [DATE] monthly Physicians Orders for Resident #1 specified the use of a Departure Alert Bracelet alarm (as did the Care Plan) for detection of elopement attempts due to wandering. An [DATE], 2:00 p.m. Nurse's Notes entry documented that Resident #1 had fallen, complained of a headache, and had been transferred to the hospital. A Nurse's Notes entry of [DATE] at 5:30 p.m. then documented Resident #1's return and readmission to the facility, and that the previous physician's orders [REDACTED]. As referenced above, Resident #1 had a previous [DATE] order for a Departure Alert Bracelet. Review of Resident #1's Care Plan referenced above revealed that, after the resident's [DATE] return from the hospital and readmission to the facility, the Care Plan continued to identify that Resident #1 was at risk for exit-seeking behaviors, and continued to specify the application of a Departure Alert Bracelet for safety. The Care Plan also continued to reference Resident #1's risk for falls related to reasons which included dementia and wandering behaviors, and continued to specify the monitoring of behaviors. However, further review of Resident #1's clinical record, to include review of the readmission [DATE], 5:30 p.m. Nurse's Notes entry above, revealed no documented evidence to indicate that nursing staff applied a Departure Alert Bracelet, or confirmed the placement of a Departure Alert Bracelet, when Resident #1 was readmitted to the facility on [DATE]. This was despite the Care Plan entry for Resident #1 which identified exit-seeking behaviors, and which specified the use of a Departure Alert Bracelet for safety. A Nurse's Notes entry of [DATE] at 4:40 p.m. for Resident #1, two days after the resident's facility readmission, documented that Nurse "AA" was notified by a visitor that someone had fallen outside. Nurse "AA" documented she went outside to observe Resident #1 laying on the entrance ramp from the parking lot, and a wheelchair chair behind the resident. Nurse "AA" documented that a laceration on Resident #1's forehead was bleeding heavily, so Emergency Medical Services was called and the resident was transported to the hospital. A "Late entry" Nurse's Notes entry signed by Nurse "AA" documented that no Departure Alert Bracelet was on Resident #1. During a [DATE], 11:51 a.m. interview with Nurse "AA", Nurse "AA" acknowledged that when told by a visitor on [DATE] that someone had fallen in the parking lot, she had gone outside and found Resident #1 to have fallen. Nurse "AA" stated she had observed that Resident #1's Departure Alert Bracelet was not applied. Review a [DATE] hospital History and Physical (H&P) report for Resident #1 for the hospital transfer revealed documentation that indicated the resident had been admitted after a fall. The H&P documented that Resident #1 was diagnosed with [REDACTED]. A [DATE] facility investigation follow-up report (IFR) related to Resident #1's [DATE] elopement documented Resident #1's previous [DATE] facility readmission, and that upon readmission, facility staff had verified to resume Resident #1's previous orders (including the Departure Alert Bracelet). However, this IFR further documented that the placement of Resident #1's Departure Alert Bracelet had not been verified by staff upon the resident's [DATE] readmission to the facility, nor after that date. This IFR also documented Resident #1's [DATE] fall and hospital transfer, with [DIAGNOSES REDACTED].#1's subsequent death on [DATE]. During an interview conducted on [DATE] at 1:40 p.m., the DON acknowledged that Resident #1 was to utilize a Departure Alert Bracelet. Based on the above, despite Resident #1 having [DIAGNOSES REDACTED]. [REDACTED]. to the facility from the hospital. Resident #1 later exited the facility without the knowledge of staff, sustained an unwitnessed fall from the wheelchair, was noted to have a heavily bleeding [MEDICAL CONDITION], and was transferred to the hospital and determined to have sustained C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. Resident #1 later expired. Cross refer to F323 for more information regarding Resident #1. It was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented an Allegation of Jeopardy Removal with the following interventions: 1. On [DATE], the facility's Medical Records Director conducted a check of all residents with Departure Alert Bracelets for presence and function. 2. On [DATE], the facility conducted a review and assessment of all residents utilizing Departure Alert Bracelets for ongoing need and appropriateness, based on physicians' orders. 3. On [DATE], the facility implemented a procedure by which a current monthly list of residents utilizing Departure Alert Bracelets would be placed at the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 4. On [DATE], the facility reviewed and revised the Facility's Elopement, Residents at Risk Policy and Procedure. The revised Policy and Procedure required an increase in the testing of Departure Alert Bracelet function from a weekly to a daily basis, to be checked for function by the Charge Nurse on the 3:00 p.m.-11:00 p.m. shift. Also, a visual check of resident Departure Alert Bracelets would be done by the Charge Nurse every shift. A notation was to be made on resident MARs for documentation of visual checks for placement and testing for function. 5. On [DATE], the facility implemented a procedure by which the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) would conduct weekly MAR indicated [REDACTED]. This audit will be accomplished utilizing the Weekly Departure Alert Bracelet Function Documentation Audit on MAR form. 6. On [DATE], the Elopement Book was reviewed and placed at both the front desk and the front nursing station for quick reference. The procedure also involved the Medical Records Director/Medical Records Assistant updating the Elopement Book weekly, and as needed, with admissions and discharge orders. 7. On [DATE], the facility implemented a procedure by which the attendant at the facility's front door exit would have increased daily hours until 10:00 p.m. until physical adjustments were made to the interior lobby doors. The front door, which is the exterior lobby door exit, would be powered off when the attendant left, so that the doors did not automatically slide open. Signage would include the facility telephone number for visitors to contact staff to gain entrance into the facility after hours. 8. On [DATE], the facility implemented a procedure specifying that if the attendant at the front door had to leave unexpectedly, he/she would notify the Administrator/HR Director/Weekend Manager/Charge Nurse to assure that someone would cover the front door during the attendant's absence. 9. On [DATE], the facility implemented a procedure by which all other doors of egress would be checked monthly and as needed as part of the ongoing Preventative Maintenance Program by the Maintenance Director to ensure they were functioning properly. 10. On [DATE], the facility noted the use of Departure Alert Bracelets in the Care Plans of all residents who utilized these bracelets. 11. On [DATE], the facility implemented a procedure by which the Charge Nurse who checked the Departure Alert Bracelets daily would communicate to the Medical Records Director/Medical Records Assistant/Weekend Nurse Manager if there were any problems with bracelet function for proper replacement. After hours, extra Departure Alert Bracelets would be maintained in the medication room. 12. On [DATE], the DON, ADON, SDC, and MDS Coordinator conducted staff in-service training for all staff on the revised Elopement, Residents at Risk Policy and Procedure, the changes in the process of monitoring the function of Departure Alert Bracelets from weekly to daily, and the demonstration of the use of the signaling device tester. Training also included stressing prompt response to the alarm elicited by resident Departure Alert Bracelets, and identifying residents at high risk for elopement utilizing the Elopement Risk Assessment. As of [DATE], 110 staff had been trained, with eight (8) staff remaining to receive this in-service training. Employees would not be allowed to work until they had received the in-service training and could demonstrate an appropriate understanding of the revised Elopement, Residents at Risk Policy and Procedure. 13. On [DATE], the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet. If a resident who had been ordered and designated to wear a Departure Alert Bracelet was observed without a bracelet in place, the CNA would immediately notify the resident's Charge Nurse for action. The findings of such incidents would be documented on the 24 Hour Nursing Report by the Charge Nurse. 14. On [DATE], the facility implemented a procedure by which physicians' orders for all resident admissions and readmissions would be checked by the Charge Nurse, and checked and documented by the signature of a second Charge Nurse, on the same shift of resident admission/readmission. 15. On [DATE], other potentially affected residents, such as mobile residents with cognitive impairment and/or residents with dementia or wandering behaviors, were assessed for the risk for elopement and/or exit-seeking behaviors. 16. On [DATE], the Quality Assurance (QA) Committee met to ensure that the specific steps/interventions undertaken, as indicated above, adequately eliminated and corrected the causative factors identified in the incident of elopement involving Resident #1. 17. On [DATE], the facility established a procedure by which the QA Committee would conduct an audit related to the revised Policy and Procedure to determine the effectiveness and staff compliance. Audit data would be collected via audits by the Administrator/DON utilizing the QA Audit Checklist Tool which would be conducted weekly for the first month. If one-hundred percent compliance was observed, the audits would then occur monthly for three (3) months. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had revised the Elopement, Residents at Risk Policy and Procedure. A procedure had been implemented by which a visual check of Departure Alert Bracelets would be done every shift, and a check of Bracelets for function would be done every day by the Charge Nurse, with a notation of these checks for placement and function to be placed on resident MARs. Also, the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet, allowing CNAs to monitor residents who were to wear Departure Alert Bracelets for bracelet placement, and to notify the Charge Nurse of noted problems. On [DATE], staff in-service training was conducted for staff related to the revised Elopement, Residents at Risk Policy and Procedure, and the changes in the frequency and method of monitoring of the Departure Alert Bracelets. As of [DATE], 110 staff had been trained, but eight (8) staff had been unavailable for training as of that date, and would thus need to receive training upon their return to work. Therefore, the completion of staff in-service training could not be evaluated at the time of survey completion. Additionally, on [DATE], the facility implemented an audit tool, the QA Audit Checklist Tool, allowing for the Administrator/DON to collect data, via audits, to monitor facility staffs' application of, and compliance with, these new facility policies and procedures. The information from this Audit Checklist Tool was to be utilized, and analyzed, by the facility's QA Committee. However, this QA Audit Checklist Tool had only been implemented on [DATE], the day before the [DATE] exit date of this complaint survey. Therefore, the ongoing application and completion of this Tool could not be evaluated at the time of survey exit. Additionally, the QA Committee would conduct an audit of the revised Policy and Procedure to determine the effectiveness and staff compliance. The QA Committee had met on [DATE] to assess the steps and interventions put into place by the facility to address Resident #1's elopement, but the Committee was scheduled to meet again on [DATE], the day after the completion of this complaint survey, to perform a root cause analysis to determine the need for the implementation of additional systems related to this incident of elopement. Therefore, the Committee's ongoing process of system oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, with the scope and severity reduced to the "D" level.

Based on record review, staff interview, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, hospital History and Physical Final Report form review, and facility investigation follow-up report review, facility nursing staff failed to adequately supervise one (1) resident (#1), per professional standards of quality, by failing to ensure the placement of a WanderGuard (Departure Alert Bracelet) intended to monitor the resident regarding exit-seeing behaviors, of ten (10) residents on the survey sample assessed as being at risk of elopement, on the total survey sample of seventeen (17) residents. Facility staff failed to ensure the placement of a Departure Alert Bracelet, in accordance with professional standards and as ordered by the physician, upon Resident #1's readmission from the hospital. Resident #1 then eloped, and sustained a fall and a heavily-bleeding [MEDICAL CONDITION]. The resident was transferred to the hospital, was determined to have C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture, and later expired. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of immediate jeopardy on [DATE], at 12:04 p.m. The non-compliance involving facility staffs' failure to provide adequate supervision of Resident #1, who was at risk of elopement, which caused the immediate jeopardy was identified to have existed on [DATE] (the day Resident #1 eloped from the facility, fell , and sustained multiple injuries requiring hospital transfer), continued through [DATE], and was removed on [DATE]. The facility implemented an Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. During an interview conducted on [DATE] at 12:02 p.m. with the Administrator and Director of Nursing (DON), the Administrator acknowledged, in reference to Resident #1's elopement, that the facility had developed interventions as corrective actions related to resident supervision necessitated by the elopement incident involving Resident #1. An Allegation of Jeopardy Removal was received from the facility on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement via a newly implemented Policy and Procedure, and completed a process of staff in-service training related to the new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents at risk for elopement and who utilized Departure Alert Bracelet devices. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, revealed that Chapter 2 - Standards of Nursing Practice, Section 2.2.2, Standards Related to Registered Nurse (RN) Responsibility for Nursing Practice Implementation, requires in Section 2.2.2(g) that the nurse implements treatment. Section 2.2.2 (i) requires that the nurse demonstrates attentiveness and provides client surveillance and monitoring, and Section 2.2.2(o) requires that the nurse takes preventive measures to protect the client. Record review for Resident #1 revealed a Minimum Data Set of [DATE] which documented diagnoses, in Section I - Active Diagnoses, including Diabetes Mellitus, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of Resident #1's [DATE] monthly Physicians Orders revealed an order specifying the use of a Departure Alert alarm for the detection of elopement attempts due to wandering. In addition, Resident #1's Care Plan identified that the resident exhibited exhibiting exit-seeking behaviors, and specified a Departure Alert Bracelet for safety. Further review of Resident #1's clinical record revealed an [DATE], 4:40 p.m. Nurses Notes entry which documented that Nurse "AA" had been informed by a resident family member that someone had fallen outside, and that Nurse "AA" went outside to observe Resident #1 laying on the entrance ramp from the parking lot. Nurse "AA" documented that Resident #1 had a heavily-bleeding [MEDICAL CONDITION] requiring Emergency Medical Services (EMS) notification and transport to the hospital. Nurse "AA" also documented, in an undated "late entry" Nurse's Notes entry, that Resident #1 was not wearing a Departure Alert Bracelet at the time of the incident. During an interview with Nurse "AA" conducted on [DATE] at 11:51 a.m., Nurse "AA" stated that on [DATE], when told by a visitor that someone had fallen in the parking lot, she ran outside to find Resident #1, who had fallen and was bleeding from the forehead, and thus she called 911. Nurse "AA" acknowledged that Resident #1's Departure Alert Bracelet was not applied at that time. The hospital History and Physical (H&P) report documented that Resident #1 had been admitted to the hospital on [DATE] after a fall with multiple injuries, and that the resident was diagnosed to have C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. Further record review for Resident #1 revealed that prior to the resident's [DATE] elopement and fall, as referenced above, a Nurse's Notes entry of [DATE] at 2:00 p.m. had documented that Resident #1 had fallen, sustained a left arm skin tear and redness to the side of the head, complained of a headache, and was transferred to the hospital. An [DATE], 5:30 p.m. Nurse's Notes entry documented Resident #1's return to the facility, and that when notified, the physician ordered to continue the previous orders, which included the [DATE] monthly Physicians Order for a Departure Alert Bracelet. However, further record review for Resident #1, including review of the [DATE], 5:30 p.m. Nurses Notes entry which documented the resident's readmission, and review of all Nurses Notes entries subsequent to that date, revealed no evidence to indicate that nursing staff either confirmed the placement of the Departure Alert Bracelet, or reapplied a Departure Alert Bracelet as ordered, on or after the resident's [DATE] facility readmission. During a post-survey telephone interview with Nurse "FF" conducted on [DATE] at 3:00 p.m., Nurse "FF" stated she was the nurse who had readmitted Resident #1 to the facility from the hospital on [DATE]. Nurse "FF" stated the physician had ordered that Resident #1's previous physician's orders [REDACTED]. She stated she had observed upon Resident #1's readmission that the resident was not wearing a Departure Alert Bracelet at the time of readmission. However, Nurse "FF" stated that at the time of Resident #1's after-hours readmission, she did not have access to an alert bracelet, and thus did not place a bracelet on Resident #1 when the resident was readmitted . Nurse "FF" further acknowledged that she did not mention the need for the placement of an alert bracelet to nursing staff on the next shift, when her shift was completed. A facility investigation follow-up report (IFR) documented Resident #1's [DATE] elopement, and documented Resident #1's previous [DATE] fall, hospital transfer and [DATE] facility return with a physician's orders [REDACTED]. However, this IFR acknowledged that the readmitting nurse had failed to verify the Departure Alert Bracelet placement when Resident #1 was readmitted to the facility on [DATE], and that facility staff had not checked for the placement of the bracelet after the resident's readmission. The IFR then documented that on [DATE], Nurse "AA" had found Resident #1 lying outside on the ground bleeding from the forehead and that the resident was transferred to the hospital. This IFR documented Resident #1's injuries, including fractures of C1 and C2, a [MEDICAL CONDITION] fifth metacarpal, and a comminutes nasal bone fracture, and that Resident #1 had died in the hospital on [DATE]. In a written statement by Nurse "AA" obtained as part of the facility's investigation, Nurse "AA" documented that on [DATE], when Resident #1 was found to have fallen outside of the facility and sustained injury, before the resident had left for hospital transport via EMS, staff had checked for a Departure Alert Bracelet, but none was found. During an interview conducted on [DATE] at 1:40 p.m., the Director Of Nursing acknowledged that Resident #1 had a physician's orders [REDACTED]. Based on the above, despite Resident #1 having dementia and the facility having assessed the resident to have exit-seeking behaviors, and despite a physician's orders [REDACTED]. Therefore, facility nursing staff failed to ensure the implementation of the Departure Alert Bracelet as ordered as a preventative and protective measure related to the exit-seeking behaviors of Resident #1, and thus failed to provide the necessary surveillance and monitoring of the resident, in accordance with professional standards of practice. Resident #1 later eloped from the facility without the knowledge of staff, sustained an unwitnessed fall from the wheelchair, and was noted to have a heavily-bleeding laceration to the forehead. Resident #1 was transferred to the hospital and was determined to have sustained C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. Resident #1 later expired in the hospital. Cross refer to F323 for more information regarding Resident #1. It was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented an Allegation of Jeopardy Removal with the following interventions: 1. On [DATE], the facility's Medical Records Director conducted a check of all residents with Departure Alert Bracelets for presence and function. 2. On [DATE], the facility conducted a review and assessment of all residents utilizing Departure Alert Bracelets for ongoing need and appropriateness, based on physicians' orders. 3. On [DATE], the facility implemented a procedure by which a current monthly list of residents utilizing Departure Alert Bracelets would be placed at the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 4. On [DATE], the facility reviewed and revised the Facility's Elopement, Residents at Risk Policy and Procedure. The revised Policy and Procedure required an increase in the testing of Departure Alert Bracelet function from a weekly to a daily basis, to be checked for function by the Charge Nurse on the 3:00 p.m.-11:00 p.m. shift. Also, a visual check of resident Departure Alert Bracelets would be done by the Charge Nurse every shift. A notation was to be made on resident MARs for documentation of visual checks for placement and testing for function. 5. On [DATE], the facility implemented a procedure by which the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) would conduct weekly MAR indicated [REDACTED]. This audit will be accomplished utilizing the Weekly Departure Alert Bracelet Function Documentation Audit on MAR form. 6. On [DATE], the Elopement Book was reviewed and placed at both the front desk and the front nursing station for quick reference. The procedure also involved the Medical Records Director/Medical Records Assistant updating the Elopement Book weekly, and as needed, with admissions and discharge orders. 7. On [DATE], the facility implemented a procedure by which the attendant at the facility's front door exit would have increased daily hours until 10:00 p.m. until physical adjustments were made to the interior lobby doors. The front door, which is the exterior lobby door exit, would be powered off when the attendant left, so that the doors did not automatically slide open. Signage would include the facility telephone number for visitors to contact staff to gain entrance into the facility after hours. 8. On [DATE], the facility implemented a procedure specifying that if the attendant at the front door had to leave unexpectedly, he/she would notify the Administrator/HR Director/Weekend Manager/Charge Nurse to assure that someone would cover the front door during the attendant's absence. 9. On [DATE], the facility implemented a procedure by which all other doors of egress would be checked monthly and as needed as part of the ongoing Preventative Maintenance Program by the Maintenance Director to ensure they were functioning properly. 10. On [DATE], the facility noted the use of Departure Alert Bracelets in the Care Plans of all residents who utilized these bracelets. 11. On [DATE], the facility implemented a procedure by which the Charge Nurse who checked the Departure Alert Bracelets daily would communicate to the Medical Records Director/Medical Records Assistant/Weekend Nurse Manager if there were any problems with bracelet function for proper replacement. After hours, extra Departure Alert Bracelets would be maintained in the medication room. 12. On [DATE], the DON, ADON, SDC, and MDS Coordinator conducted staff in-service training for all staff on the revised Elopement, Residents at Risk Policy and Procedure, the changes in the process of monitoring the function of Departure Alert Bracelets from weekly to daily, and the demonstration of the use of the signaling device tester. Training also included stressing prompt response to the alarm elicited by resident Departure Alert Bracelets, and identifying residents at high risk for elopement utilizing the Elopement Risk Assessment. As of [DATE], 110 staff had been trained, with eight (8) staff remaining to receive this in-service training. Employees would not be allowed to work until they had received the in-service training and could demonstrate an appropriate understanding of the revised Elopement, Residents at Risk Policy and Procedure. 13. On [DATE], the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet. If a resident who had been ordered and designated to wear a Departure Alert Bracelet was observed without a bracelet in place, the CNA would immediately notify the resident's Charge Nurse for action. The findings of such incidents would be documented on the 24 Hour Nursing Report by the Charge Nurse. 14. On [DATE], the facility implemented a procedure by which physicians' orders for all resident admissions and readmissions would be checked by the Charge Nurse, and checked and documented by the signature of a second Charge Nurse, on the same shift of resident admission/readmission. 15. On [DATE], other potentially affected residents, such as mobile residents with cognitive impairment and/or residents with dementia or wandering behaviors, were assessed for the risk for elopement and/or exit-seeking behaviors. 16. On [DATE], the Quality Assurance (QA) Committee met to ensure that the specific steps/interventions undertaken, as indicated above, adequately eliminated and corrected the causative factors identified in the incident of elopement involving Resident #1. 17. On [DATE], the facility established a procedure by which the QA Committee would conduct an audit related to the revised Policy and Procedure to determine the effectiveness and staff compliance. Audit data would be collected via audits by the Administrator/DON utilizing the QA Audit Checklist Tool which would be conducted weekly for the first month. If one-hundred percent compliance was observed, the audits would then occur monthly for three (3) months. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had revised the Elopement, Residents at Risk Policy and Procedure. A procedure had been implemented by which a visual check of Departure Alert Bracelets would be done every shift, and a check of Bracelets for function would be done every day by the Charge Nurse, with a notation of these checks for placement and function to be placed on resident MARs. Also, the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet, allowing CNAs to monitor residents who were to wear Departure Alert Bracelets for bracelet placement, and to notify the Charge Nurse of noted problems. On [DATE], staff in-service training was conducted for staff related to the revised Elopement, Residents at Risk Policy and Procedure, and the changes in the frequency and method of monitoring of the Departure Alert Bracelets. As of [DATE], 110 staff had been trained, but eight (8) staff had been unavailable for training as of that date, and would thus need to receive training upon their return to work. Therefore, the completion of staff in-service training could not be evaluated at the time of survey completion. Additionally, on [DATE], the facility implemented an audit tool, the QA Audit Checklist Tool, allowing for the Administrator/DON to collected data, via audits, to monitor facility staffs' application of, and compliance with, these new facility policies and procedures. The information from this Audit Checklist Tool was to be utilized, and analyzed, by the facility's QA Committee. However, this QA Audit Checklist Tool had only been implemented on [DATE], the day before the [DATE] exit date of this complaint survey. Therefore, the ongoing application and completion of this Tool could not be evaluated at the time of survey exit. Additionally, the QA Committee would conduct an audit of the revised Policy and Procedure to determine the effectiveness and staff compliance. The QA Committee had met on [DATE] to assess the steps and interventions put into place by the facility to address Resident #1's elopement, but the Committee was scheduled to meet again on [DATE], the day after the completion of this complaint survey, to perform a root cause analysis to determine the need for the implementation of additional systems related to this incident of elopement. Therefore, the Committee's ongoing process of system oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, with the scope and severity reduced to the "D" level

Based on clinical record review, staff interview, hospital History and Physical Report form review, and facility investigation follow-up report review, the facility failed to prevent neglect by failing to ensure adequate supervision, via a WanderGuard bracelet (Departure Alert Bracelet) as ordered by the physician, for one (1) resident (#1), who had exit-seeking behaviors, of ten (10) residents on the survey sample assessed as being at risk of elopement, on the total survey sample of seventeen (17) residents. Facility staff failed to ensure placement of the alert bracelet, as ordered by the physician, for Resident #1 upon the resident's facility readmission from the hospital, thus allowing Resident #1 to elope from the facility without the knowledge of facility staff, fall in the facility's parking lot, and sustain a heavily-bleeding laceration to the forehead. The resident was transferred to the hospital and diagnosed with [REDACTED]. Resident #1 later expired. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of immediate jeopardy on [DATE], at 12:04 p.m. The non-compliance involving facility staffs' failure to provide adequate supervision of Resident #1, who was at risk of elopement, which caused the immediate jeopardy was identified to have existed on [DATE] (the day Resident #1 eloped from the facility, fell , and sustained multiple injuries requiring hospital transfer), continued through [DATE], and was removed on [DATE]. The facility implemented an Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. During an interview with the Administrator conducted on [DATE] at 12:09 p.m., the Administrator acknowledged awareness of the incident of elopement involving Resident #1, but denied awareness of elopement issues prior to Resident #1's elopement. During a later interview conducted on [DATE] at 12:02 p.m. with the Administrator, the Administrator acknowledged the facility having implemented multiple interventions related to resident supervision and the prevention of elopement since Resident #1's elopement, which included a modified process for reviewing resident admission/readmission orders [REDACTED]. However, the Administrator further acknowledged that the facility had not developed a method of comprehensive oversight for these new interventions to evaluate their effectiveness. An Allegation of Jeopardy Removal was received from the facility on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring the necessary supervision of residents at risk of elopement via a newly implemented Policy and Procedure, and completed a process staff in-service training related to the new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents at risk for elopement and who utilized alert bracelet devices. Findings include: Record review for Resident #1 revealed a Minimum Data Set assessment of [DATE] which documented in Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status indicated that the resident utilized a wheelchair. An [DATE], 3:50 p.m. Nurse's Notes entry documented that Resident #1 was asking staff about leaving the building, and that a WanderGuard bracelet (Departure Alert Bracelet) was applied. An [DATE] Physician's Telephone Order specified a Departure Alert Bracelet be utilized for Resident #1, and the resident's [DATE] Physicians Orders also specified application of a Departure Alert Bracelet. A Nurse's Notes entry of [DATE] at 2:00 p.m. documented that Resident #1 had fallen and was transferred to the hospital. An [DATE], 5:30 p.m. Nurse's Notes entry then documented that Resident #1 had returned, and that when notified of Resident #1's facility return, the physician specified that the previous orders were to be continued, to include the Departure Alert Bracelet, per the previous [DATE] monthly Physicians Orders. However, further record review for Resident #1 revealed no evidence to indicate that facility staff assessed the resident for the presence of the Departure Alert Bracelet, or that staff placed a bracelet on the resident, either at the time of Resident #1's [DATE] facility readmission (as documented in the [DATE], 5:30 p.m. Nurse's Notes entry referenced above), or at any time after the [DATE] facility readmission. Then, a Nurse's Notes entry of [DATE] at 4:40 p.m. for Resident #1 documented that Nurse "AA" was informed by a resident family member that someone in a wheelchair had fallen outside. Nurse "AA" documented that she went outside and observed Resident #1 laying on an entrance ramp. Nurse "AA" noted that Resident #1 had a heavily bleeding [MEDICAL CONDITION], and that 911 was called for transport to the hospital. An undated Nurse's Notes entry signed by Nurse "AA" then documented that Resident #1 was not wearing a Departure Alert Bracelet at the time of the elopement and fall. The hospital History and Physical (H&P) report for Resident #1's hospital transfer after the [DATE] elopement and fall documented Resident #1 was admitted after a fall with injuries. This H&P documented that Resident #1 was diagnosed to have C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. The [DATE] facility investigation follow-up report (IFR), which documented the facility's investigation of Resident #1's [DATE] elopement and fall, also documented Resident #1's previous fall and hospital transfer on [DATE]. This IFR documented Resident #1's [DATE] facility readmission with a physician's orders [REDACTED]. However, in this IFR, the facility acknowledged that facility nursing staff failed to verify Resident #1's Departure Alert Bracelet placement when the resident was readmitted to the facility on [DATE], and further acknowledged that a Medical Records staff person, assigned to check resident Departure Alert Bracelets on Wednesdays, had not checked Resident #1 for the Departure Alert wristband on [DATE] (Wednesday), after the resident's Tuesday, [DATE], readmission. Additionally, the [DATE] IFR documented that on [DATE], when Resident #1 had fallen in the parking lot and Nurse "AA" had responded, the nurse had observed the resident on the ground and the wheelchair at the end of the sidewalk that extended from the facility's front doors to the parking lot. This IFR documented that these front doors, which were alarmed, represented the only unlocked facility exit, and that a receptionist was normally positioned daily from 9:00 a.m. through 5:30 p.m. in the lobby within view of this unlocked front exit. However, this IFR further documented that this receptionist had left at 4:00 p.m. on [DATE], the date of Resident #1's elopement, thus leaving the doors unattended. During an interview with the Director Of Nursing (DON) conducted on [DATE] at 1:40 p.m., the DON acknowledged Resident #1's physician's orders [REDACTED]. The DON stated that at the time of Resident #1's [DATE] readmission, the nurse was to receive readmission orders [REDACTED]. During a [DATE], 12:15 p.m. interview, the DON also acknowledged that the Medical Records staff member had failed to perform the Departure Alert Bracelet check for Resident #1 on Wednesday, [DATE], as scheduled. Based on the above, despite Resident #1 having [MEDICAL CONDITION] and a history of expressing a desire to leave the facility, and despite a physician's orders [REDACTED].#1 by failing to ensure the placement of the alert bracelet upon readmission to the facility from the hospital. Facility staff also neglected to check Resident #1 the day following facility readmission, during a scheduled weekly Wednesday check to determine the function of alert bracelets. Resident #1 later exited the facility without the knowledge of staff, sustained an unwitnessed fall from the wheelchair at the terminal end of the sidewalk leading from the facility's alarmed front entrance/exit doors, and was noted to have a bleeding [MEDICAL CONDITION]. Resident #1 was transferred via EMS to the hospital, where the resident was determined to have sustained C1 and C2 cervical spine fractures, a left fifth metacarpal fracture, and a comminuted nasal bone fracture. The resident later expired. Cross refer to F323 for more information regarding Resident #1. It was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented an Allegation of Jeopardy Removal with the following interventions: 1. On [DATE], the facility's Medical Records Director conducted a check of all residents with Departure Alert Bracelets for presence and function. 2. On [DATE], the facility conducted a review and assessment of all residents utilizing Departure Alert Bracelets for ongoing need and appropriateness, based on physicians' orders. 3. On [DATE], the facility implemented a procedure by which a current monthly list of residents utilizing Departure Alert Bracelets would be placed at the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 4. On [DATE], the facility reviewed and revised the Facility's Elopement, Residents at Risk Policy and Procedure. The revised Policy and Procedure required an increase in the testing of Departure Alert Bracelet function from a weekly to a daily basis, to be checked for function by the Charge Nurse on the 3:00 p.m.-11:00 p.m. shift. Also, a visual check of resident Departure Alert Bracelets would be done by the Charge Nurse every shift. A notation was to be made on resident MARs for documentation of visual checks for placement and testing for function. 5. On [DATE], the facility implemented a procedure by which the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) would conduct weekly MAR indicated [REDACTED]. This audit will be accomplished utilizing the Weekly Departure Alert Bracelet Function Documentation Audit on MAR form. 6. On [DATE], the Elopement Book was reviewed and placed at both the front desk and the front nursing station for quick reference. The procedure also involved the Medical Records Director/Medical Records Assistant updating the Elopement Book weekly, and as needed, with admissions and discharge orders. 7. On [DATE], the facility implemented a procedure by which the attendant at the facility's front door exit would have increased daily hours until 10:00 p.m. until physical adjustments were made to the interior lobby doors. The front door, which is the exterior lobby door exit, would be powered off when the attendant left, so that the doors did not automatically slide open. Signage would include the facility telephone number for visitors to contact staff to gain entrance into the facility after hours. 8. On [DATE], the facility implemented a procedure specifying that if the attendant at the front door had to leave unexpectedly, he/she would notify the Administrator/HR Director/Weekend Manager/Charge Nurse to assure that someone would cover the front door during the attendant's absence. 9. On [DATE], the facility implemented a procedure by which all other doors of egress would be checked monthly and as needed as part of the ongoing Preventative Maintenance Program by the Maintenance Director to ensure they were functioning properly. 10. On [DATE], the facility noted the use of Departure Alert Bracelets in the Care Plans of all residents who utilized these bracelets. 11. On [DATE], the facility implemented a procedure by which the Charge Nurse who checked the Departure Alert Bracelets daily would communicate to the Medical Records Director/Medical Records Assistant/Weekend Nurse Manager if there were any problems with bracelet function for proper replacement. After hours, extra Departure Alert Bracelets would be maintained in the medication room. 12. On [DATE], the DON, ADON, SDC, and MDS Coordinator conducted staff in-service training for all staff on the revised Elopement, Residents at Risk Policy and Procedure, the changes in the process of monitoring the function of Departure Alert Bracelets from weekly to daily, and the demonstration of the use of the signaling device tester. Training also included stressing prompt response to the alarm elicited by resident Departure Alert Bracelets, and identifying residents at high risk for elopement utilizing the Elopement Risk Assessment. As of [DATE], 110 staff had been trained, with eight (8) staff remaining to receive this in-service training. Employees would not be allowed to work until they had received the in-service training and could demonstrate an appropriate understanding of the revised Elopement, Residents at Risk Policy and Procedure. 13. On [DATE], the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet. If a resident who had been ordered and designated to wear a Departure Alert Bracelet was observed without a bracelet in place, the CNA would immediately notify the resident's Charge Nurse for action. The findings of such incidents would be documented on the 24 Hour Nursing Report by the Charge Nurse. 14. On [DATE], the facility implemented a procedure by which physicians' orders for all resident admissions and readmissions would be checked by the Charge Nurse, and checked and documented by the signature of a second Charge Nurse, on the same shift of resident admission/readmission. 15. On [DATE], other potentially affected residents, such as mobile residents with cognitive impairment and/or residents with dementia or wandering behaviors, were assessed for the risk for elopement and/or exit-seeking behaviors. 16. On [DATE], the Quality Assurance (QA) Committee met to ensure that the specific steps/interventions undertaken, as indicated above, adequately eliminated and corrected the causative factors identified in the incident of elopement involving Resident #1. 17. On [DATE], the facility established a procedure by which the QA Committee would conduct an audit related to the revised Policy and Procedure to determine the effectiveness and staff compliance. Audit data would be collected via audits by the Administrator/DON utilizing the QA Audit Checklist Tool which would be conducted weekly for the first month. If one-hundred percent compliance was observed, the audits would then occur monthly for three (3) months. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had revised the Elopement, Residents at Risk Policy and Procedure. A procedure had been implemented by which a visual check of Departure Alert Bracelets would be done every shift, and a check of Bracelets for function would be done every day by the Charge Nurse, with a notation of these checks for placement and function to be placed on resident MARs. Also, the facility implemented a procedure by which the CNA Daily Assignment Sheet would identify residents wearing a Departure Alert Bracelet, allowing CNAs to monitor residents who were to wear Departure Alert Bracelets for bracelet placement, and to notify the Charge Nurse of noted problems. On [DATE], staff in-service training was conducted for staff related to the revised Elopement, Residents at Risk Policy and Procedure, and the changes in the frequency and method of monitoring of the Departure Alert Bracelets. As of [DATE], 110 staff had been trained, but eight (8) staff had been unavailable for training as of that date, and would thus need to receive training upon their return to work. Therefore, the completion of staff in-service training could not be evaluated at the time of survey completion. Additionally, on [DATE], the facility implemented an audit tool, the QA Audit Checklist Tool, allowing for the Administrator/DON to collected data, via audits, to monitor facility staffs' application of, and compliance with, these new facility policies and procedures. The information from this Audit Checklist Tool was to be utilized, and analyzed, by the facility's QA Committee. However, this QA Audit Checklist Tool had only been implemented on [DATE], the day before the [DATE] exit date of this complaint survey. Therefore, the ongoing application and completion of this Tool could not be evaluated at the time of survey exit. Additionally, the QA Committee would conduct an audit of the revised Policy and Procedure to determine the effectiveness and staff compliance. The QA Committee had met on [DATE] to assess the steps and interventions put into place by the facility to address Resident #1's elopement, but the Committee was scheduled to meet again on [DATE], the day after the completion of this complaint survey, to perform a root cause analysis to determine the need for the implementation of additional systems related to this incident of elopement. Therefore, the Committee's ongoing process of system oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, with the scope and severity reduced to the "D" level.