Every finding on record at Elizabethtown Healthcare & Rehab Center

Based on observations, record review, and staff, Nurse Practitioner and the Medical Director's interviews, the facility failed to use the mechanical lift to transfer a non-weight bearing resident from a chair to the bed and instead used the stand and pivot method for transferring (A technique for moving where a resident stands with assistance and pivots on their feet then sits. This technique requires the ability to bear most of their body weight.) which resulted in a comminuted (the bone is broken into multiple small pieces) mildly displaced (bone fragments are slightly out of alignment) fracture of the distal tibia (large bone of the lower leg near the ankle) and proximal fibula (upper section of smaller bone in the lower leg just below the knee). This occurred for 1 of 3 residents reviewed for accidents (Resident #77). Findings included: Resident #77 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis of the knee (a breakdown of the protective cartilage that lines the bones and joints), osteopenia (a loss of bone density causing the bone to weaken and an increased risk of fractures) and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #77 was severely cognitively impaired and required extensive two-person assistance with transfers, and activities of daily living (ADLs). Resident #77 had no falls, a weight of 127 pounds, and received blood thinning medication. She was on Hospice services. The care plan dated 6/15/25 revealed Resident #77 had an ADL self-care deficit related to weakness, poor endurance, and poor cognition. Interventions included in part; total dependence with transfers using the mechanical lift with two-person assistance. A progress note dated 8/4/25 at 10:30 AM documented by the Hospice nurse revealed in part; this writer received notification today from the Hospice aide that Resident #77's right lower leg was noted to be bruised, swollen, and painful to touch this morning. Upon arrival Resident #77 was resting in bed with her eyes closed and aroused easily with verbal and tactile stimuli. She was oriented to person and unable to make her needs known and appeared weak and frail. Her right lower leg was bruised, bluish purple in color, swollen, and painful to touch She yelled out it hurts, it hurts when the area was touched and randomly when the area was not touched. Resident #77 was unable to state what happened to her right leg. The facility staff nurse (Nurse #2) was made aware of the right leg status. Resident #77 was medicated with Tylenol 650 milligrams during this visit for pain. Nurse Practitioner #1 is making rounds at the facility today and was notified. Resident #77 requires total assistance with all activities of daily living. A progress note dated 8/4/25 at 3:19 PM documented by Nurse #2 revealed Resident #77's x-ray impression revealed an acute nondisplaced oblique fracture of the proximal fibula, and distal tibia. Nurse Practitioner #1 was made aware. A progress note dated 8/4/25 at 6:32 PM documented by Nurse Practitioner #1 revealed in part; Resident #77 currently received hospice care. Nursing staff reported the presence of bruising on her right leg. Upon assessment, the right lower extremity exhibited mild swelling, and bluish discoloration consistent with bruising, and tenderness upon palpation. There was no active bleeding. The x-ray findings revealed an acute nondisplaced oblique fracture of the proximal fibula, and distal tibia. An orthopedic consult was ordered along with Tramadol 50 milligrams every 12 hours for pain. On 8/5/25 at 3:45 PM Resident #77 was transported by emergency medical services (EMS) to the hospital. A hospital note dated 8/5/25 at 10:56 PM revealed Resident #77 was seen in the emergency department, and vital signs were stable. X-rays showed oblique comminuted mildly displaced fracture of the distal tibial and proximal fibula. Orthopedics was consulted and recommended admission for pain control, there is no anticipated surgical intervention. A hospital orthopedic note dated 8/7/25 at 1:17 PM revealed Resident #77 was evaluated for a mildly displaced fracture of the distal tibial diaphysis and proximal fibular diaphysis. Impressions revealed fracture and osteoarthritis of the knee and osteopenia. Resident #77's Responsible Party stated Resident #77 had been non-ambulatory for several years, using a wheelchair and a slide board. She developed a urinary tract infection six months ago and has been bed bound since that time. The plan of care was to keep the splint in place and remain non-weight bearing. No orthopedic intervention was warranted at this time. Resident #77 returned to the facility. A facility investigation report on 8/5/25 revealed interviews were conducted with Nurse Aide #9 and #10 and concluded that the improper transfer of Resident #77 resulted in the fracture of the tibia and fibula. The Kardex audits concluded that several of the Kardex's needed to be updated and were updated today 8/5/25 by the Director of Nursing and the MDS nurse. Both Nurse Aide #9 and #10 were suspended until the investigation was complete. The timeline of events revealed:On 8/3/25 Resident #77 was up in her Geri chair most of the day at the nurses station. At approximately 7:00 PM Nurse Aide #9 and #10 went in to transfer Resident #77 back to bed. The lift sling was not positioned properly. They tried to reposition the sling, but Resident #77 resisted. Nurse Aide #9 and #10 got on each side and stood Resident #77 up and pivoted her a few steps to the bed from the chair. On 8/3/25 through 8/4/25 the night shift nurse and nurse aides (7:00 PM through 7:00 AM) reported Resident #77 rested well during the night. On 8/4/25 approximately 8:30 AM the nurse aide found a bruise to the outer right leg (shin) and notified Nurse #2. Nurse #2 notified the Nurse Practitioner and an x-ray was ordered. The x-ray resulted with a non-displaced fracture of the right lower leg.The root cause analysis determined Nurse Aide #9 and #10 did not follow the policy, or Resident #77's Kardex on the proper transfer which led to Resident #77 sustaining the injury. During an interview on 09/05/25 at 3:08 PM Nurse Aide #9 stated she had been a nurse aide for many years and was distraught when she learned that Resident #77 had fractured her leg after she and Nurse Aide #10 transferred Resident #77 back to bed on Sunday evening (8/3/25). Nurse Aide #9 stated they initially tried to transfer Resident #77 from the chair back to her bed using the mechanical lift, but the lift sling was not positioned right and kept sliding up her back because Resident #77 was agitated and flailing her arms. They decided since there were two of them and Resident #77 was small enough that they could get on each side of her and have her stand and pivot over to the bed. Nurse Aide #9 stated she was not aware that Resident #77 was non weight bearing and it never occurred to her that having Resident #77 stand and pivot could cause a fracture. She stated Resident #77 did not have any signs of an injury and no symptoms of pain or discomfort after being put back to bed or during the night. Nurse Aide #9 stated she was not aware of any injury until the following day (8/4/25) when she talked with the DON. She received education on 8/4/25 and was suspended from work. Nurse Aide #9 stated Resident #77's transfer status was listed on the Kardex which was located in her electronic medical record. Nurse Aide #9 indicated she did not review the Kardex that evening before attempting to transfer Resident #77. She stated she knew how to use the sling but due to Resident #77 becoming agitated they decided to stand and pivot her to the bed. Nurse Aide #9 stated she had provided care to Resident #77 many times and thought she would be safe to stand and pivot with two-person assistance, but she should not have done that. During a phone interview on 9/5/25 at 3:45 PM Nurse Aide #10 stated she and Nurse Aide #9 attempted to transfer Resident #77 back to bed that evening (8/3/25) with the mechanical lift, but the lift sling moved out of position. Resident #77 was yelling and agitated, so they decided not to use the lift and instead have her stand and pivot to her bed and thought that would be safe. Nurse Aide #10 stated she did not observe any injuries on Resident #77 after the transfer, and Resident #77 was not complaining of pain or discomfort once they got her back in the bed. She stated she did not review the Kardex which was located in the electronic medical record prior to transferring Resident #77. Nurse Aide #10 stated she was educated the following day (8/4/25) on properly transferring residents and reviewing the Kardex and was suspended from work. During an interview on 09/04/25 at 12:40 PM Nurse #2 stated she was the assigned nurse on Sunday 8/3/25 from 7:00 AM through 7:00 PM. Resident #77 was at her baseline and was up in her Geri chair at the nurses station for a while. She had dementia but no pain, no distress, and was talkative. When she returned to work the next morning (8/4/25) a nurse aide whose name she could not recall, asked her to come check Resident #77 because she noticed discoloration on one side of her lower leg and the area was painful to touch. Upon assessment Resident #77 would say no don't touch it. The Nurse Practitioner was in the facility at the time and came in to evaluate her. An x-ray was ordered which showed a right lower leg fracture. Resident #77 was administered pain medication. Nurse #2 stated the night shift nurse did not report any concerns regarding Resident #77 having pain or discomfort during the night. Nurse #2 indicated she was not sure of what the final determination was that caused the fracture and that Resident #77 had been on Hospice care. She stated Resident #77 was dependent on staff for care and required the use of the mechanical lift for transfers currently and prior to her fracture. An observation on 9/2/25 at 12:45 PM revealed Resident #77 was sitting up in bed being fed lunch by a staff member. She was oriented to person only and was smiling and talkative but could not engage in meaningful dialogue. A splint was in place on her right lower leg. There were no visible indicators of pain or discomfort. During an interview on 9/4/25 at 1:00 PM the Director of Nursing (DON) indicated Resident #77 was observed by Nurse #2 to have pain, swelling, and discoloration on the morning of 8/4/25. An x-ray was ordered and showed a lower leg fracture. An investigation on 8/4/25 determined Resident #77 was transferred inappropriately by the two nurse aides (Nurse Aide #9 and Nurse Aide #10) who worked the evening shift the previous night (8/3/25). The DON stated the nurse aides transferred Resident #77 back to bed without using the mechanical lift and instead had her stand and pivot. She stated initially Nurse Aide #9 and #10 attempted to transfer Resident #77 using the mechanical lift but the lift sling was not positioned properly underneath her. The nurse aides tried to reposition her, but Resident #77 resisted. The nurse aides then decided to get on each side of Resident #77 and have her stand and pivot to get into the bed. The DON stated Resident #77 had been non weight bearing for a while and required the use of the mechanical lift. She stated Nurse Aide #9 and Nurse Aide #10 were educated on 8/4/25 on the importance of following the Kardex (a resident care guide that shows essential information including transfer status) and correctly transferring residents, then were suspended until the investigation was completed. A phone interview was conducted on 9/16/25 at 3:00 PM with Nurse Practitioner #1. She stated she was notified on 8/4/25 of the bruising and swelling on Resident #77's lower leg. Nurse Practitioner #1 stated she ordered an x-ray which showed a hairline nondisplaced fracture of the tibia and fibula. During her evaluation of Resident #77 on 8/4/25 there were no deformities of the leg observed, and Resident #77 was not complaining of pain during that time. The decision was then made for conservative management due to being on Hospice care, having multiple comorbidities, and not being a surgical candidate. She discussed this plan of care with the Hospice nurse and Resident #77's Responsible Party who were in agreement. Nurse Practitioner #1 stated the following day the family decided to go ahead and send her to the hospital so that she could be seen by orthopedics sooner and she wrote the order on 8/5/25 to send Resident #77 out to the hospital. During an interview on 9/4/25 at 2:30 PM the Medical Director indicated she was made aware on 8/4/25 that Resident #77 had fractured her lower leg during a transfer. She stated Resident #77 had been non weight bearing for months and required the mechanical lift for transfers and was on Hospice services prior to the incident. The Medical Director indicted Resident #77 was able to continue to get up into the Geri chair, and she had no significant decline following the injury. During an interview on 9/5/25 at 3:00 PM the Administrator along with the Director of Nursing, and the Corporate Compliance Nurse each stated an investigation was initiated on 8/4/25 following the transfer that occurred on 8/3/25 which resulted in the injury. The root cause analysis determined the injury resulted when the two nurse aides (Nurse Aide #9 and #10) did not follow the policy or the Kardex on the proper transfer which led to Resident #77 sustaining the tibia- fibula fracture. The DON stated in-service training started with Nurse Aide #9 and #10 on 8/4/25, and Kardex audits began on 8/5/25 to ensure each residents transfer status was correct. The Administrator stated they made the decision to monitor residents for safe transfers and put it in their Quality Assurance (QA) program. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 8/4/25 at approximately 8:30 AM the nurse aide found a bruise to the outer right leg (shin) and notified Nurse #2. Nurse #2 notified the Nurse Practitioner and an x-ray was ordered. The x-ray resulted with a non-displaced fracture of the right lower leg. Resident #77 was assessed by Nurse Practitioner #1 on 8/4/25 and new orders were placed for an orthopedic consult and pain medications. On 8/4/25 the facility investigation of the injury revealed on 8/3/25 at approximately 7:00 PM Nurse Aide #9 and #10 went in to transfer Resident #77 back to bed. The lift sling was not positioned properly. They tried to reposition the sling, but Resident #77 resisted. Nurse Aide #9 and #10 stood Resident #77 up and pivoted her a few steps to the bed from the chair. On 8/4/25 Nurse Aide #9 and Nurse Aide #10 were given one-to-one education on the importance of following the Kardex and correctly transferring each resident to prevent injuries. The nurse aides were suspended until the investigation was completed. On 8/5/25 at 3:45 PM Resident #77 was sent to the emergency department per the family request for a quicker orthopedic consult. The Administrator and the DON completed a root cause analysis which determined Nurse Aide #9 and #10 did not follow the policy, or Resident #77's Kardex on the proper transfer which led to Resident #77 sustaining the injury. Address how the facility will identify other residents having the potential to be affected. On 8/5/25 the Director of Nursing along with the MDS nurse identified residents potentially impacted by the practice by completing Kardex audits on all current residents. The audit revealed 66 of 84 Kardex's had the correct transfer status. On 8/5/25 the Director of Nursing along with the MDS nurse interviewed the nurse aides and nurses on the halls for the correct transfer status of every resident and updated each Kardex. All Kardex's were updated by 8:00 PM on 8/5/25. Direct care staff were notified by the DON and the MDS nurse verbally in the facility on 8/5/25 and through in-service training conducted from 8/5/25 through 8/8/25 that the resident Kardex's had been updated and staff were to check the Kardex for all residents for accurate transfer status prior to transfers. On 8/5/25 the MDS nurse was informed she would be responsible for keeping the Kardex's updated to reflect the current transfer status of all residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 8/5/25 the Director of Nursing along with the Staff Development Coordinator in-serviced all staff including agency personnel on transfer safety, following the Kardex, and the facility transfer policy.All in-service training will be completed by 8/8/25. Any staff who had not completed education by 8/8/25 would not be allowed to work until training was completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 8/5/25 the decision was made by the Administrator to monitor the plan to ensure safe resident transfers and will be presented to the Quality Assurance Performance Improvement (QAPI) committee to include the Administrator, the Director of Nursing, MDS coordinator, therapist, and dietary manager. The Director of Nursing will monitor safe resident transfers through observations conducted on all shifts, along with reviewing resident care plans and auditing Kardex accuracy to ensure they reflect the correct transfer status using the quality assurance tool. This will be completed weekly for 2 weeks and monthly for three months to ensure compliance. Quality Assurance (QA) monitoring will begin the week of 8/11/25. Reports will be presented in the monthly QA committee by the Administrator or the Director of Nursing. Compliance will be monitored and the ongoing auditing program reviewed at the monthly QA meetings.The monthly QA meeting was held on 8/25/25 where the results of the audits and ongoing monitoring were discussed. The facility's alleged compliance date of the corrective action plan was 8/9/25. The corrective action plan was validated on 9/5/25. The following documentation was reviewed along with staff interviews and observations:Validation included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided. All of the staff members interviewed stated they had received training. In-service training included safe resident transfers, and the importance of reviewing the residents Kardex. Inservice logs were verified, and the initial and ongoing audits were verified. A resident transfer using the mechanical lift was observed. There were no concerns identified. The compliance date of 8/9/25 was validated.

Based on observations, and staff interviews the facility failed to discard expired nutritional supplements stored for use in 1 of 1 reach-in refrigerator in the kitchen. This practice had the potential to affect residents with physician ordered nutritional supplements. The findings included:An observation of the reach-in refrigerator in the kitchen was completed on 9/2/25 at 11:15 AM and revealed 10 bottles of a nutritional supplement with the expiration date 04/2025. The DM stated the nutritional supplement was expired and should not have been in the reach-in refrigerator. She further stated the staff must have just missed them when checking for expired food that morning. An interview was completed with the Administrator on 9/5/25 at 11:00 AM. The Administrator stated she was surprised to hear that there were expired nutritional supplements found in the reach-in refrigerator, because the dietary staff was very diligent about discarding expired and leftover food items. She further stated that the Registered Dietitian had just inspected the kitchen a couple of weeks ago and he had not found any expired food items. The Administrator indicated her expectation was that there be no expired food items in the kitchen or nourishment rooms.

Based on observation, record review, and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EHB) during high contact care for a resident with a pressure ulcer, when a nurse and the Wound Aide were providing wound care without wearing gowns for 2 of 6 staff observed for infection control (Nurse #1 and the Wound Aide).The findings included:The facility policy titled, Enhanced Barriers dated 9/22 stated in part: EBP requires the use of gown and gloves when providing high contact care activities for residents identified as requiring EBP. High contact resident care activities were listed as: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs and assisting with toileting, device care or use, central lines, urinary catheter, feeding tube, tracheostomy and wound care, any skin opening requiring a dressing.An observation of the Wound Aide and Nurse #1 changing Resident #9's pressure wound dressing occurred on 9/4/25 at 9:48 AM in the presence of the Staff Development Coordinator (SDC). The observation revealed Nurse #1 and the Wound Aide were only wearing gloves and did not apply a gown prior to the dressing change or during the dressing change. An interview with the Wound Aide was completed on 9/4/25 at 10:00 AM. The Wound Aide stated she always puts a gown on when changing dressings, but she was just nervous and forgot.A telephone interview was completed with Nurse #1 on 9/5/25 at 9:43 AM. Nurse #1 stated she didn't think she had to wear a gown since the Wound Aide was the one changing the dressing and she was just assisting with helping position the resident on her side.An interview with the SDC was completed on 9/5/25/at 8:50 AM. The SDC stated he was just in the room to observe the dressing change but did not think about the staff wearing gowns until he turned around and saw the personal protection equipment (PPE) on the back of the door. He stated the Wound Aide and Nurse #1 should have been wearing protective gowns while changing the dressing.An interview with the Director of Nursing (DON) was conducted on 9/5/25 at 11:19 AM. The DON stated that Nurse #1 and the Wound Aide should have been wearing gowns during the dressing change. She further stated she would have expected the SDC to remind them if they forgot.

Based on observations, and resident and staff interviews, the facility failed to ensure the bedside call light system was functioning and provide an alternate means of communicating with staff for 2 of 2 residents who were dependent on staff for assistance with activities of daily living (ADL) (Resident #59, and Resident #20). Findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses including congestive heart failure. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #20 was cognitively intact. He required limited one-person assistance with transfers and was wheelchair bound. Resident #59 was admitted to the facility on [DATE] with diagnoses including right lower leg fracture. The Minimum Data Set admission assessment dated [DATE] revealed Resident #59 was cognitively intact. He required extensive assistance with transfers and ADL and was wheelchair bound. Interviews and an observation were conducted on 9/2/25 at 12:00 PM with Resident #20 and Resident #59. Resident #20 and Resident #59 were roommates. Resident #20 stated the call light in their room did not work for three days from Friday 8/29/25 through Monday morning 9/1/25. Resident #20 stated when emergency medical services (EMS) brought his roommate (Resident #59) back from an outside appointment on Friday the call light cord got caught when Resident #59 was being transferred back to bed which caused the whole call light device system to be pulled away from the wall causing both call lights to not work. Resident #20 stated the call lights in the room were not repaired until Monday morning. He (Resident #20) indicated he and his roommate (Resident #59) both required staff assistance with transfers and care and were not provided another means or alternate device to alert staff if assistance was needed or in the event of an emergency. Resident #20 stated the nurses and aides did check on them during the time the call light was not working. Resident #59 indicated he was not provided an alternate device, but the nurses and nurse aides did come in and check on him during that time. During an observation on 9/2/25 at 12:05 PM the call light system in Resident #20 and Resident #59's room was observed to be working when the call light was activated. During an interview on 9/3/25 at 2:15 PM Nurse #1, the assigned nurse on 8/29/25 from 7:00 AM through 7:00 PM for Resident #20 and Resident #59 stated the call light in the resident's room was broken on 8/29/25 when EMS transferred Resident #59 either to or from his bed for an orthopedic appointment that morning. She stated the call light cords were pulled out of the wall and were not working and she verbally reported it to the Maintenance Director on Friday 8/29/25. Nurse #1 stated she checked on both residents at least every 2 hours during her shift. Nurse #1 stated when the call bells weren't functioning they had cow bells to put in the resident rooms for use, but she did not think to give a cow bell to Resident #20 or Resident #59. Nurse #1 stated she notified the assigned nurse aides that the call light was broken. Attempts were made on 9/3/25 at 3:40 PM and 9/5/25 at 1:05 PM to contact Nurse Aide #1 who was assigned to Resident #20 and Resident #59 on 8/29/25 from 7:00 AM through 7:00 PM. There was no response. During an interview on 9/3/25 at 2:30 PM the Maintenance Director stated he was not made aware that the call light system in the room Resident #20 and Resident #59 resided in was broken until Monday morning 9/1/25. He stated he was not notified on Friday, and he was at the facility until 5:30 PM on Friday 8/29/25. He stated if he had been notified on 8/29/25 he would have repaired the broken call light that day. He stated he was not in the facility over the weekend, but he could always be notified by phone on the weekends day or night if something needed to be repaired and he would have come in and repaired it. The Maintenance Director stated he was notified Monday morning (9/1/25) when he returned to work by the Director of Nursing and he fixed the call light right away. He stated it was an easy fix because he kept spare call lights on hand. He stated there was no system to notify Maintenance of needed repairs except through a phone call or finding him in the facility. He reported that he did not keep a record of when he was notified that something needed to be repaired or of what repairs were made. He stated cow bells were on hand and were kept at the nurses station to use if a call light issue occurred and stated the staff were aware that the cow bells were available for use. During an interview on 9/3/25 at 3:00 PM the Director of Nursing (DON) stated she was the assigned nurse for Resident #20 and Resident #59 on Friday night 8/29/25 from 7:00 PM through 7:00 AM. The DON stated the call light was not working and she emailed the Maintenance Director that night but stated she did not realize he could not check his emails outside of the facility and therefore he did not get the notification. She stated a cow bell was not offered but she checked on both residents every two hours throughout the night. During an interview on 9/4/25 at 12:30 PM Nurse #2 stated she was the assigned nurse for Resident #20 and Resident #59 on Saturday 8/30/25 and Sunday 9/1/25 from 7:00 AM through 7:00 PM. She was made aware in morning report that the call light in the room Resident #20 and Resident #59 resided in was not functioning. Nurse #2 stated she and the assigned nurse aide checked on both residents at least every two hours during her shift. She indicated she did not notify the Maintenance Director, and a cow bell was not offered to the residents. During a phone interview on 9/5/25 at 3:00 PM Nurse #3 stated she was the assigned nurse for Resident #20 and Resident #59 on Saturday 8/30/25 and Sunday 8/31/25 from 7:00 PM through 7:00 AM. She was aware the call light was not working in their room but stated she and the assigned nurse aide checked on the residents at least every two hours during the shift. She indicated a cow bell was not offered to the residents. During an interview on 9/3/25 at 3:15 PM Nurse Aide #2 stated she worked 3:00 PM until 11:00 PM on Sunday 8/31/25. She stated she was assigned to Resident #20 and Resident #59 and the call lights for both of the residents were not working because the call light was pulled away from the wall. Nurse Aide #2 stated she made rounds on both residents that day and the residents did not have a cow bell in their room during that time. During a phone interview on 09/05/25 at 1:10 PM Nurse Aide #3 stated she worked night shift 11:00 PM through 7:00 AM on Friday 8/29/25 and 11:00 PM through 7:00 AM on Sunday 8/31/25. She noticed early on the call light in the room Resident #20 and Resident #59 resided in was not working. Nurse Aide #3 stated she made frequent checks during the night, and the residents did not have a cow bell in their room during that time. During an interview on 9/5/25 at 10:00 AM the Administrator stated she was not made aware the call lights were not functioning in the room Resident #20 and Resident #59 resided in until they were repaired on Monday 9/1/25. She stated the Maintenance Director was in the facility on 8/29/25 the day it was broken, and he should have been notified at that time so that it could have been repaired sooner. The Administrator stated they kept the cow bells at the nurses station for use if the call lights were not functioning and the nurses were aware. She indicated the call light should have been repaired on Friday 8/29/25 since the Maintenance Director was available in the facility and had the supplies on hand to repair it. She stated Resident #20 and Resident #59 should have both been provided a cow bell to use to notify staff in case assistance was needed.

Based on record review and staff interviews, the facility failed to implement their abuse policy for staff to promptly report an allegation of staff to resident abuse to the facility management as soon as the allegation was communicated to the staff member. This occurred for 1 of 2 residents (Resident #21) reviewed for abuse. Findings included: The facility policy titled, Abuse Prohibition, last reviewed on 02/2024, indicated it was the responsibility of their employees, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property, to facility management. All reports of resident verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property shall be promptly and thoroughly investigated by facility management. A facility 24-Hour Initial Report dated 09/10/24 documented the following allegation description: On Monday 09/10/24 at 11:30 AM, Resident #21, with moderately impaired cognition, told the housekeeper, who reported to the Director of Nursing (DON), that the nurse aide swiped a rag across her face Saturday night and grabbed her mouth and tried to pour water in her mouth. The resident had a history of vascular dementia and was an unreliable source. She had a history of attention seeking behavior. The report was sent to the State Agency at [PHONE NUMBER] by the DON. A facility 5-Working Day Report dated 09/16/24 documented Resident #21 was not interviewable due to vascular dementia and alert only to self. Allegation details reiterated the description of the allegation described in the 24-Hour Initial Report and added body audits were done on all residents on that hallway and no issues were found. Interviews were conducted and no concerns were noted by any alert and oriented residents. Administration was not able to identify the staff person the resident described after multiple interviews with Resident #21. Local law enforcement and the Department of Social Services were notified of the allegation. The facility did not substantiate the allegation. The report was sent to the State Agency by the DON. Review of the undated summary of the investigation documented by the DON revealed the DON had spoken with a family member of Resident #21 on 09/09/24 who informed her that she (the family member) had reported the allegation of abuse to Nurse #1 on Sunday, 09/08/24. The DON interviewed Nurse #1 who stated that she had received the allegation on Sunday, 09/08/24 but didn't report it to administration because of the resident's repeated attention seeking behaviors. Nurse #1 was suspended for the rest of her shift on Monday, due to not reporting this shift, pending the rest of the investigation. An interview was conducted with Nurse #1 on 9/26/24 at 8:10 AM. She stated a family member came to the facility during her shift and told her that the night before a staff person had pinched Resident #21's facial cheeks together and popped her with a wet washcloth. Nurse #1 did not remember the date the family member reported the allegation to her. Nurse #1 could not remember why she did not report it to Administration but stated she had not. Nurse #1 recalled she had been suspended for the day and was re-educated regarding the abuse policy. She stated from now on she would report any allegations of abuse immediately. An interview was held with the DON on 9/25/24 at 3:39 PM. She stated the housekeeper came to her 09/09/24 and reported Resident #21 told her that the nurse aide swiped her across the face with a washcloth and tried to hold her mouth open to put water in it. She and the Staff Development Director interviewed Resident #21, and she reported the same allegation the housekeeper had reported. Resident #21 was asked to describe the nurse, and she described a blonde curly haired white girl. They talked to the roommate also and she said she didn't see anything and didn't want to talk about it. The roommate described the aide that night as having brown hair and being white. She called the family member on Monday, 09/09/24, who told her she had reported the incident to Nurse #1 on Sunday, 09/08/24. She interviewed Nurse #1 on 09/09/24 who said the allegation was told to her but thought it was attention seeking behavior and didn't report it. The DON stated she sent Nurse #1 home on suspension, pending the outcome of the investigation. The DON stated body audits were done on the 200-hall along with interviews with alert and oriented residents. Immediate abuse education was completed including the reporting of allegations. The DON reported she started audits to assess for any concerns or neglect x 5 residents and nonverbal residents x 6 weekly x 2 weeks then monthly x 3 months. The DON adjusted the care plan to advise staff to take someone into the room with them when providing care to Resident #21 as resident had attention seeking behavior by making false statements regarding accusations against the staff. She expected all staff to report any allegations of abuse immediately to either the supervisor or herself. The corrective action for the noncompliance dated 09/12/24 was as follows: 1. Immediately suspended Licensed Nurse #1 on 09/09/24 by the DON for not reporting the fact that a resident ' s family member reported to her that she stated that she was slapped in the face overnight with a washcloth, and her mouth was held open and the aide tried to pour water in it. She stated she did not report it to anyone because she thought the resident was just having more of her attention seeking behaviors. Immediately re-educated licensed Nurse #1, 09/09/24, by the DON on how to report abuse allegations, and how to report them in a timely manner. DON immediately assessed resident for signs and symptoms of abuse. 2. Re-education of all employees regarding timeliness of abuse reporting (i.e. immediately) to the abuse coordinator/Licensed Administrator, this re-education was completed by the Staff Development Director. All employees were re-educated on or before September 12, 2024. Alert and oriented residents were interviewed by the Staff Development Director regarding concerns associated with mistreatment by staff, this was completed on September 10, 2024, with no further skin findings of concern. All residents with a BIM ' s (Brief Interview for Mental Status) score of >12 were interviewed the DON and or the Staff Development Director on or before September 10, 2024 with no further findings of concern shared. 3. The DON and or the Administrator are ensuring through weekly monitoring that staff continue to be compliant with reporting any allegations of abuse (physical, sexual, and verbal), neglect, misappropriation of property to ensure compliance with immediately reporting. The monitoring was initiated the week of September 16, 2024 and is ongoing until the QAPI (Quality Assurance Process Improvement Committee) deem no longer necessary, however, for a minimum of 3 months and then ongoing based on results of the monitoring. The DON is responsible to ensure the results of the monitoring are brought to the monthly QAPI meeting. 4. The QAPI committee met on September 12, 2024 to review the concern and actions taken, along with the planned monitoring, this meeting was led by the Administrator and included the AQPI team members. The alleged date of compliance was 09/13/24. Validation of the corrective action plan was completed on 09/26/24. This included staff interviews and in-service training that was received to ensure understanding and knowledge of the training provided. Staff interviews revealed following in-service training they had a better understanding of the reporting requirement related to abuse allegations. The initial interviews were verified. Audits were documented and verified. There were no concerns identified. The last QAPI meeting was held on 09/12/24 where audit results were discussed. The corrective action plan was validated to be completed as of 09/13/24.

Based on observations, resident and staff interviews the facility a. failed to repair broken floor linoleum in resident rooms (215), b. failed to remove the black substance and caulk commode bases in resident rooms (100, 104, 209, 212, 301, and 403), c. failed to repair a broken free standing clothes cabinet door or handles in resident rooms (107B, 211B, and 304) d. failed to replace broken or missing bathroom door threshold strip in resident rooms (104, 106, 111, 113, 201, 203, 207, 209, 211, 211, 215, 307, and 308), e. failed to replace broken metal bathroom shelf in resident room (412), f. failed to repair resident's overhead light covers in room (100B and 108A, B, C), g. failed to replace broken window blinds in resident rooms (105 and 212), h. failed to clean and replace residents window air conditioner vent in resident rooms (406B, and 412B), i. failed to repair broken floor shower tile in shower room [ROOM NUMBER] by floor drain, and j. failed to repair loose floor base boards in room/bathroom in rooms (100, 207, 213, and 405). These failures occurred on 4 of 4 hallways (100, 200, 300, and 400 Halls) observed for a safe, clean, homelike environment. Findings included: a. An observation on 09/22/24 at 12:40 PM revealed broken floor linoleum in resident rooms (215). b. An observation on 09/22/24 at 12:40 PM revealed black substance and missing caulking from commode bases in resident rooms (100, 104, 209, 212, 301, and 403). c. An observation on 09/22/24 at 12:40 PM revealed broken standing clothes cabinets, with one having 2 of 6 door hinges broken, and two had broken handles in resident rooms (107B, 211B, and 304). d. An observation on 09/22/24 at 12:40 PM revealed broken or missing bathroom door threshold strip in resident rooms (104, 106, 111, 113, 201, 203, 207, 209, 211, 211, 215, 307, and 308), which could potentially be a tripping hazards to residents and staff. e. An observation on 09/22/24 at 12:40 PM revealed a bent down broken metal bathroom shelf in resident room (412). f. An observation on 09/22/24 at 12:40 PM revealed missing overhead light covers in room (100B and 108A, B, C). g. An observation on 09/22/24 at 12:40 PM revealed broken window blinds in resident rooms (105 and 212). h. An observation on 09/22/24 at 12:40 PM revealed dirty vent areas with black colored debris and broken vent covers in resident rooms (406B, and 412B). i. An observation on 09/22/24 at 12:40 PM revealed broken floor shower tiles in shower room [ROOM NUMBER] by floor drain. j. An observation on 09/22/24 at 12:40 PM revealed loose floor base boards in room/bathroom in rooms (100, 207, 213, and 405). An interview and follow-up facility tour were conducted on 09/25/24 at 9:45 AM with the Maintenance Director. The Maintenance Director agreed during the tour that there were multiple areas and room items on the 100, 200, 300, and 400 halls that still needed to be addressed, repaired, or replaced. He stated he had one and a half assistants but was keeping up with facility repairs. He said maintenance was responsible for repairing or replacing items in the facility. During the tour with the Maintenance Director, the environmental areas identified on the previous list were pointed out to the Maintenance Director, who agreed the items observed needed to be addressed. The Maintenance Director stated he would correct all the environment issues observed by cleaning, repairing, or replacing the issues that were pointed out to him during the tour observation. A follow-up facility tour was conducted on 09/25/24 at 10:00 AM of the facility with the Administrator. The tour revealed: Black substance around the base of resident commodes, in rooms (100, 104, 209, 212, 301, and 403), and broken tile in number 2 shower room, missing or broken threshold strips, above bed lights without covers, broken bathroom metal shelving, broken resident clothing cabinet door and handles, and broken blinds. She stated the areas pointed out on the 100, 200, 300, and 400 halls would be addressed and fixed, and it was her expectation for all the residents to have a safe and homelike environment that was clean and in good repair.

Based on observations, record review and staff interviews, the facility failed to follow a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] #4) observed. Findings included: Resident #4 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set annual assessment dated [DATE] revealed Resident #4 was cognitively impaired. A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer for a hemoglobin (a protein responsible for transporting oxygen in the blood) reading (lab result) less than 10 g/dL. The lab result recordings revealed the hemoglobin range was 12.0 – 16.0 g/dL. The hemoglobin result on 02/07/22 was 10.0 g/dL, on 02/14/22 the hemoglobin result was 11.0 g/dL, and on 02/21/22 the hemoglobin result was 10.2 g/dL. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #4 by Nurse #2 as evidenced by the nursing initials and checkmark on the MAR. An interview with Nurse #1 on 03/02/22 at 10:35 AM revealed Resident #4 was receiving the [MEDICATION(S)] due to her low red blood cell production. Nurse #1 explained on Monday of each week labs were ordered to obtain Resident #4 ' s hemoglobin levels to determine if the medication should be given or held based on the parameters written in the physician order. Nurse #1 further added that the labs were done on Monday to ensure we had the result before Friday (the day of administration). She stated that if the hemoglobin was less than 10 g/dl nursing was to administer the medication as ordered. An interview with the Physician on 03/03/22 at 9:30 AM revealed she expected nursing staff to follow the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated receiving the medication when the hemoglobin was above 10 g/dL would not necessarily harm the resident but it would put the resident at increased risk for [CONDITION(S)]. An interview with the Director of Nursing (DON) on 03/02/22 at 11:45 AM revealed she was made aware the [MEDICATION(S)] was being administered without regard to the parameters (give if hemoglobin less than 10 g/dL) previously when it was brought to her attention while reviewing the January pharmacy recommendation report. The DON stated she did not in service all staff with this incident and only in serviced the two nurses involved in January. She stated she did not know why Nurse #2 did not follow the order as written and administered the medication when the order indicated to give only if the hemoglobin was less than 10 g/dL. An interview with Nurse #2 on 03/03/22 at 3:00 PM revealed she was aware of the parameters within the written physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 stated she just got busy and distracted and did not follow the physicians order as she should have.

Based on observations, manufacturer's instructions and staff interviews the facility failed to remove an expired insulin pen belonging to Resident #57 from 1 of 3 medication carts reviewed for medication storage. Findings included: Resident #57 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of March 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of blood sugar readings for Resident #57 revealed between 02/25/22 and 03/03/22 blood sugar readings documented were within his normal range with no elevated readings. During an observation with Nurse #1 on 03/03/22 at 11:25 AM a [MEDICATION(S)] insulin injectable pen for Resident #57 was observed opened on the 400 hall medication cart. The insulin pen had a handwritten opened date of 1/27/22. The manufacturers label on the insulin pen directed to discard the insulin pen 28 days after opening. In an interview with Nurse #1 on 03/03/22 at 11:25 AM she stated she had not noticed the [MEDICATION(S)] insulin pen had expired. She reported she had used the expired insulin pen that morning to administer insulin to Resident #57. In an interview with the Director of Nursing on 03/03/22 at 11:15 AM she stated all nurses had been instructed on Monday, 02/28/22, to check all the medication carts to ensure no medications had expired. She assumed the nurses had checked all the medication carts and had discarded any expired medications. She herself had not inspected the carts. She calculated the insulin had expired on 02/24/22 but remained in use until 03/03/22. She stated the insulin pen should have been discarded 28 days after opening. She discarded the expired insulin pen. In an interview with the attending physician on 03/03/22 at 12:00 noon she stated it was possible for an expired insulin to lose it's potency resulting in elevated blood sugar readings. She recommended expired insulin be discarded on the appropriate date to avoid any potential complications.

Based on record review and staff and Psychiatric Nurse Practitioner (PNP) interviews the facility failed to administer a medication ordered by the PNP for 1 of 8 residents (Resident #19) whose medications were reviewed. Findings included: Resident #19 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #19 was moderately cognitively impaired and had verbal behaviors for 1-3 days of the look back period. Resident #19 did not reject care. The PNP Telephone Order dated 09/16/19 revealed an order for [REDACTED]. Review of the PNP progress note dated 09/16/19 and faxed to the facility on [DATE] revealed Resident #19's mood stabilizer would be adjusted to improve his mood and behaviors. The orders included in the progress note were to start [MEDICATION NAME] DR 125 mg every morning in addition to the 250 mg that were given at bedtime. The Medication Administration Record [REDACTED]. In a telephone interview on 10/09/19 at 4:14 PM the PNP stated that when she came in to the facility to see Resident #19 on 09/16/19 she had been told by the nursing staff that he was having an increase in behaviors that included cussing, being mean to staff, and being resistant to care. She expressed that she ordered the [MEDICATION NAME] DR to be given every morning to improve Resident #19's mood and behaviors. The PNP indicated that she had written the order on a telephone order sheet and left the chart with the order flagged on the nursing desk as was her usual practice. The PNP stated that her progress note regarding her visit with Resident #19 had also been faxed to the facility on [DATE]. She indicated that with the handwritten order and the order written on the progress note that the facility had two opportunities to begin the medication. The PNP expressed that it was very important for residents to receive the medications that were ordered and that she expected the orders she wrote to be followed. In an interview on 10/10/19 at 11:45 AM Nurse #1 verified that she was Resident #19's nurse on 09/16/19. She indicated that it was the responsibility of the nurse to check the resident's charts for orders after a physician or nurse practitioner had been in to see a resident and to transfer the orders into the electronic record. She stated that it was also the responsibility of the resident's nurse to review any progress notes left by the provider or faxed to the facility to see if they contained any orders. Nurse #1 clarified that the order for the [MEDICATION NAME] DR 125 mg every morning had been missed twice and had not been administered as ordered. In an interview on 10/10/19 at 11:57 AM the Director of Nursing (DON) stated she expected the nurses to transcribe orders into the electronic record and to review any faxes that came in that had to do with the residents they cared for that day. The DON expressed that she expected residents to receive the medications that were ordered by the providers.

Based on observation and staff interviews the facility failed to keep unattended medications secured by leaving them on top of a medication cart for 1 of 3 medication carts (100 hall medication cart) observed. Findings included: During an observation on 10/09/19 at 8:48 AM Nurse #1 was seen walking down the 100 hallway coming from the direction of the nurse's station to the medication cart which was outside room [ROOM NUMBER]. Nurse #1 carried a bottle of pills in her hand. There was a medication cup with applesauce sitting on top of the medication cart. The medication cup appeared to have pills in it. There was also a bubble pack of [MEDICATION NAME] 40 mg (milligrams) on top of the cart. In an interview on 10/09/19 at 8:49 AM Nurse #1 confirmed that she had left the medications unattended when she went to get a bottle of vitamins from medication storage. She stated that she had only been away from the medication cart for approximately 20 seconds. Nurse #1 confirmed that the cup with applesauce contained the medications [MEDICATION NAME] 12.5 mg and losartan 25 mg. Nurse #1 verified that the [MEDICATION NAME] 40 mg bubble pack contained 20 pills. Nurse #1 stated that medications should not be left on top of the medication carts because anyone could take them. In an interview on 10/10/19 at 11:57 AM the Director of Nursing (DON) stated that medications should never be left unattended on top of the medication carts. She expressed that Nurse #1 could have asked someone else to bring her the bottle of vitamins and then the medications would not have been left unattended. She indicated that if medications were left on top of the medication carts anyone could remove them.

Based on record review and staff interviews the facility failed to provide laboratory services as ordered by the physician for 1 of 5 residents (Resident #2) whose laboratory orders were reviewed. Findings included: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The medical record revealed there were no laboratory result reports for (YEAR) and the facility was unable to produce any laboratory reports for (YEAR) for Resident #2. The annual Minimum Data Set ((MDS) dated [DATE] revealed that Resident #2 was moderately cognitively impaired, had no behaviors, and did not reject care. Review of the (MONTH) (YEAR) Nursing Services Notes revealed no documentation that laboratory studies had been done or that blood draws had been refused by Resident #2. The hospital discharge laboratory results dated [DATE] revealed a CBC (complete blood count) and CMP (comprehensive metabolic panel) had been performed at the hospital and Resident #2's potassium level was within normal limits. The Physician order [REDACTED].#2 due to [DIAGNOSES REDACTED] (low potassium). In a telephone interview on 10/10/19 at 11:32 AM Nurse #2 stated that in (MONTH) (YEAR) she was responsible for ordering the laboratory studies. She expressed that she could not remember if she had ordered the studies or not. She clarified that if a resident refused to have their blood drawn it would be documented in the medical record. In an interview on 10/10/19 at 11:57 AM the Director of Nursing (DON) stated that sometimes residents would refuse to have their blood drawn. She indicated that if that happened, she would expect it to be documented in the nursing notes. The DON expressed that laboratory studies should be performed as ordered and were an important part of a resident's care.

Based on staff interviews and record review the facility failed to resolve discrepancy regarding code status for 1 of 2 sampled residents (Resident #76) whose code status were reviewed. Findings included: Record review revealed Resident #76 was admitted to the facility on [DATE], and most recently admitted to the facility on [DATE] following hospitalization s. The resident's documented [DIAGNOSES REDACTED]. The code status most recently documented in Resident #76's electronic and paper medical record was a physician order [REDACTED].>Record review revealed there was not a current physician order [REDACTED].#76's electronic medical record. Her code status was documented as full code dated [DATE]. Record review revealed the last code status documented in Resident #76's electronic medical record was full code which was effective from [DATE] through [DATE]. On [DATE] at 3:00 PM Resident #76's paper medical record was examined and there were the following forms: care plan with code status listed full code, face sheet with code status listed full code, and code status form with code status listed full code all dated [DATE]. A social services note dated [DATE] revealed Resident #76's responsible party (RP) received a copy of the bill of rights, policy manual and advance directives. Her stay was anticipated to be short term for therapy. She was a full code. A hospital palliative care consult note dated [DATE] at 5:07 PM for hospice and palliative care evaluation and recommendations for Resident #76 revealed consult an extensive discussion with the family member by the bedside. Family wanted the patient to be do not resuscitate (DNR)/do not intubate) DNI and order was placed. The resident had a hospital DNR form in the resident's chart dated [DATE]. A hospital discharge summary dated [DATE] for Resident #76 revealed palliative care was consulted for goals of care, and was currently DNR/DNI. A Medical Director (MD) progress note dated [DATE] for Resident #76 revealed resident was admitted to the skilled nursing facility (SNF) for palliative care. Family of resident assigned patient as DNR/DNI. The resident's family reportedly requested no reintubation if indicated and that patient's code status remain DNR/DNI. A palliative care consultation was done with family (including RP). Family members elected to have patient assigned as DNR/DNI. Resident's family members were made aware of patient's poor prognosis and guarded medical status. Family requested that patient be discharged to the nursing center instead of intermediate care facility for palliative care since patient had been employed there in the past, she would be among friends. Disposition planning team honored family's request to have patient discharged to the skilled nursing facility with the understanding that patient was DNR/DNI. Patient required total care, and had a poor prognosis. Patient was admitted to the SNF for palliative care only. Code status was DNR/DNI while hospitalized . Family requested no further work-up for patient's acute, life-threatening medical issues, and to re-establish DNR/DNI code status. Resident #76's [DATE] minimum data set (MDS) documented the resident had severe cognitive impairments. A nursing note date [DATE] at 3:44 PM revealed at approximately 7:00 PM Resident #76 was found with no respirations, no pulse, with cardio-pulmonary resuscitation (CPR) initiated at that time. CPR continued for approximately 5 minutes until emergency medical services (EMS) arrived and took over rescue efforts. Resident left facility at approximately 7:30 PM via stretcher per EMS staff with continued rescue efforts. A nurse called with report from hospital. The resident's RP was notified by phone. Prior to cardiac event resident had rested well throughout shift. Her blood sugars were increased at 398 which was normal for resident and resident was given sliding scale insulin as ordered. Her oxygenation was at 97% with pulse of 100. Resident was on oxygen at 2 liters per minute via nasal cannula. An interview on [DATE] at 10:53 AM with the Medical Director (MD) and Director of Nursing (DON) revealed Resident #76's code status should have been changed by the facility staff from full code to DNR/DNI on [DATE] to reflect resident's family/RP wishes, and was not. The MD stated the facility should have obtained a verbal confirmation for code status from the resident's RP at the time of admission, which they did not. The MD provided a copy of the facility's code status procedure dated ,[DATE], which read in part, If the resident representative (RP) is unable to sign the DNR Code Status Form immediately, a verbal confirmation witnessed by two nurses was acceptable until a signed DNR Code Status Form was obtained. The MD and DON said the facility failed to update the resident's code status, and failed to call the RP for a verbal confirmation in order to confirm code status. The MD said, she and the facility dropped the ball, and that Resident #76 should have been re-instated as a DNR/DNI upon admission on [DATE], and had not.

Based on observation and staff interview the facility failed to air dry pieces of kitchenware before stacking them on top of one another in storage and failed to clean the interior top of the microwave. Findings included: 1. During initial tour of the kitchen, beginning at 11:05 AM on 11/13/17, 9 of 12 tray pans stacked on top of one another had moisture trapped inside, 6 of 8 large baking pans stacked on top of one another had moisture trapped inside, and 1 of 1 small baking pans stacked on top of other kitchenware was wet. When these pieces of kitchenware were unstacked and separated water ran onto the floor. The acting dietary manager (DM) stated she was unsure if the kitchenware was stacked wet the night before or the morning of the observation. At 9:23 AM on 11/15/17 2 of 15 clear plastic bowls stacked on top of one another in storage had moisture trapped inside. At 10:50 AM on 11/16/17 the acting DM stated she was unsure if staff had been trained recently about the need to air dry pieces of kitchenware before stacking them on top of one another. However, she reported it was her expectation that kitchenware be dry and free from food particles before being stacked in storage. She explained the facility had two separate racks in the kitchen, one for air drying wet kitchenware and one for stacking clean and dry kitchenware in storage. The acting DM stated she still had not figured out who stacked the kitchenware when it was found wet on the morning of 11/13/17. According to the acting DM, moisture trapped between pieces of kitchenware could lead to the development of bacteria which could cause cross-contamination and possibly result in residents getting sick. At 2:38 PM on 11/16/17 a dietary employee stated she was taught to wash, rinse, sanitize, and air-dry pieces of kitchenware used in cooking before stacking them in storage. She reported moisture trapped between pieces of kitchenware could grow bacteria that was dangerous to the health of residents. 2. During initial tour of the kitchen, beginning at 11:05 AM on 11/13/17, yellow and tan dried food particles were found on the top interior surface of the microwave. At 9:19 AM on 11/15/17, during a follow-up tour of the kitchen, yellow and tan dried food particles were found on the top interior surface of the microwave. At 10:50 AM on 11/16/17 the acting dietary manager (DM) stated the dietary staff was supposed to clean all of the interior surfaces of the microwave after every use. As a double check she also reported staff were supposed to check the microwave for cleanliness at closing each night and as each day began in the mornings. She commented not cleaning the interior top of the microwave could cause bacteria to grow and cross-contaminate foods being heated in the microwave. At 2:38 PM on 11/16/17 a dietary employee stated the interior roof, back, sides, bottom, and door of the microwave were supposed to be cleaned nightly. She reported if dried food particles were not removed from the interior roof of the microwave they could fall into fresh food that was being heated and possibly make residents sick.

Based on observation, resident and staff interviews and record review, the facility instructed a resident to use her adult brief when she needed to use the bathroom for 1 of 1 residents observed for dignity (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #32 was cognitively intact, always continent of her bowels and bladder and was totally dependent on two staff for transfers and toileting. During an interview with Resident #32 on 09/26/16 at 4:46 p.m., Resident #32 stated she had been told by nursing assistants (NA ' s) to use her diaper (adult brief) when she called to go the bathroom. The resident stated she would much rather go to the bathroom and it made her feel terrible when she had to wet herself. During an interview with NA #1 on 09/30/16 at 9:20 a.m., NA #1 stated she could not toilet residents during meal times because of the risk of cross-contamination. NA #1 stated when Resident #32 had asked to use the bathroom, she had told the resident to use her diaper (adult brief) and she would change her later once the meal trays were off the hall. During an interview with the Administrator and the Director of Nursing (DON) on 09/30/16 at 9:53 a.m., the DON stated the expectation of the nursing staff was they toilet residents whenever they need to be toileted. The Administrator stated her expectation of the nursing staff and toileting residents was the same as the DON ' s.

Based on record review, observations and staff interviews, the facility failed to comprehensively assess positioning needs to ensure the appropriate leg rests were attached to a specialty chair to prohibit legs and feet from suspending above the floor and failed to assess the need for a specialty chair for 2 of 2 residents reviewed (Resident's #98 and #82). Findings included: 1-A review of the medical record revealed Resident # 98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #98 was severely cognitively impaired and required total assistance of 1 person with bed mobility, transfers, dressing and toileting. The MDS revealed the resident had impaired upper and lower extremity on the left side. The MDS also indicated Resident #98 had left arm/hand contracture and cervical neck contracture with splinting. A review of the Care Plan dated 8/8/2016 included Resident #98 ' s positioning needs and splint application for the left arm and positioning needs and splint application for the cervical spine/neck. An observation on 9/27/2016 at 10:27 AM revealed Resident #98 was seated in a specialty chair beside the nurse ' s station. Resident #98 was noted to have a left arm/hand contracture and the resident ' s head was leaning toward the right side. The specialty chair had 1 foot rest on the left side which was positioned against the left outer side of the chair with the foot rest in an upright position. Both of the resident ' s legs/feet were suspended approximately 6 inches above the floor. The resident ' s right foot/leg was observed to occasionally move and swing back and forth. The resident was observed in the same position on 9/27/2106 at 11:33 AM, 1:33 PM and 2:00 PM. An interview was conducted with the MDS nurse on 9/28/2016 at 10:30 AM. The MDS nurse reported she completed the assessment for Resident #98. The MDS nurse indicated the resident was up in the specialty chair almost every day. The MDS nurse stated she was unaware if the resident ' s chair had a positioning device for the legs or feet. The MDS nurse reported at the time of the assessment the resident ' s feet were not supported and they dangled above the floor. The MDS nurse stated she was not sure why she didn ' t address the need for positioning. An interview was conducted with the Nursing Assistant (NA) assigned to Resident #98 on 9/28/2016 at 11:14 AM. NA #9 reported the resident did not have any device for leg or foot positioning for the specialty chair which would prevent the resident ' s legs and feet from dangling. NA #9 stated Resident #98 ' s feet were always suspended approximately 6 inches from the floor when he was in the chair. NA #9 reported the resident was usually up in the chair daily. An interview was conducted with the Rehabilitation Department Director on 9/28/2016 at 2:16 PM. The Rehabilitation Director stated the current Therapy Department team had been in place in the facility since March 2016. The Rehabilitation Department Director stated they had not received a referral on Resident #98 for any positioning needs. The Rehabilitation Department Director was able to locate a referral from 2015 which referenced the need for splinting. There was no information located in regard to the positioning needs of Resident #98 ' s legs or feet while in the specialty chair. The Rehabilitation Department Director stated she recalled seeing Resident #98 sitting in the chair and indicated he had positioning needs. An observation on 9/29/2016 at 10:00 AM revealed Resident #98 seated in the specialty chair beside the nurse ' s station. The specialty chair had 1 foot rest on the left side which was positioned against the left outer side of the chair with the foot rest in an upright position. Both of the resident ' s legs/feet were suspended approximately 6 inches above the floor. The resident ' s right foot/leg was observed to occasionally move and swing back and forth. The resident was observed in the same position on 9/29/2106 at 11:15 AM. An interview was conducted with NA #5 on 9/29/2016 at 11:25 AM. NA #5 indicated she was the NA usually assigned to Resident #98. The NA stated there was a left foot pedal on the chair and she had not seen the right one in at least 6 months. NA #5 reported she did not use the left pedal because the resident would not rest his foot on it. NA #5 stated the resident ' s feet dangled at least 6 inches from the chair and never reached the floor. An interview was conducted with Resident #98 ' s nurse (nurse #3) on 9/29/2016 at 11:45 AM. Nurse #3 reported Resident #98 was on her regular assignment and she was very familiar with his care. Nurse #3 stated no recollection of Resident #98 having foot rests on the specialty chair. Nurse #98 reported the resident ' s feet were suspended when he was in the chair, which was usually daily. An interview was conducted with the Director of Nursing (DON) on 9/29/2016 at 11:59 AM. The DON stated she was familiar with Resident #98 but did not recall the location of his feet while in the specialty chair. The DON stated the expectation was for comprehensive assessments to be completed so the resident ' s needs were addressed to enable proper care and treatment for [REDACTED]. 2. Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #82 was severely cognitively impaired and was totally dependent on one staff member for all her Activities of Daily Living (ADL ' s). The MDS indicated the resident had no impairment in her bilateral upper and lower extremities. A review of Resident #82 ' s Care Plan revealed there was no Care Plan provided related to the resident ' s need for a specialty chair. During an observation of Resident #82 on 09/26/16 at 5:53 p.m., the resident was observed sitting in a two-piece specialty chair in her room. The resident ' s bottom was lower than her thighs which caused her legs to be raised in such a manner her knees were at the level of her abdomen. Subsequent observations on 09/27/16 at 11:37 a.m., 09/28/16 at 2:30 p.m. and 09/29/16 at 8:30 a.m. revealed the resident to be sitting in the specialty chair in the same position. An observation of the empty specialty chair on 09/28/16 at 3:45 p.m. revealed a chair and an ottoman which connected to each other by Velcro strips. The seat of the chair contained a scooped-out area in which a person would be seated. During an interview with the Director of Nursing (DON) on 09/29/16 at 9:00 a.m., the DON stated Resident #82 was admitted in 2013 and had never had good posture. The DON stated the resident had not been able to adjust to any chair with a straight back such as a wheelchair, Geri chair or Broda chair. The DON stated the specialty chair in the resident ' s room was the only chair the resident had been comfortable in. During an interview with the MDS Coordinator on 09/29/16 at 2:04 p.m., the MDS Coordinator stated she did the MDS assessments and care plans. The MDS Coordinator stated she had felt the chair was more of a comfort chair than a specialty chair. The MDS Coordinator stated she should have assessed the resident ' s need for the specialty chair and care planned it. She stated she must have missed it. During an interview with the Administrator on 09/29/16 at 2:11 p.m., the Administrator stated when a resident needs a specialty item such as a chair it was her expectation the resident be assessed for it and care planned for it. During an interview with the DON on 09/29/16 at 2:18 p.m., the DON stated the expectation of the MD Coordinator was she assess residents with special needs and care plan those needs.

Based on observation, staff interviews and record review, the facility failed to develop a care plan that addressed a resident ' s need for a specialty chair and a resident ' s need for appropriate positioning in a specialty chair for 2 of 2 residents reviewed. (Resident #82 and #98). The findings included: 1. Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #82 was severely cognitively impaired and was totally dependent on one staff member for all her Activities of Daily Living (ADL ' s). A review of Resident #82 ' s Care Plan revealed there was no Care Plan provided related to the resident ' s need for a specialty chair. During an observation of Resident #82 on 09/26/16 at 5:53 p.m., the resident was observed sitting in a two-piece specialty chair in her room. The resident ' s bottom was lower than her thighs which caused her legs to be raised in such a manner her knees were at the level of her abdomen. Subsequent observations on 09/27/16 at 11:37 a.m., 09/28/16 at 2:30 p.m. and 09/29/16 at 8:30 a.m. revealed the resident to be sitting in the specialty chair in the same position. An observation of the empty specialty chair on 09/28/16 at 3:45 p.m. revealed a chair and an ottoman which connected to each other by Velcro strips. The seat of the chair contained a scooped-out area in which a person would be seated. During an interview with the Director of Nursing (DON) on 09/29/16 at 9:00 a.m., the DON stated Resident #82 was admitted in 2013 and had never had good posture. The DON stated the resident had not been able to adjust to any chair with a straight back such as a wheelchair, Geri chair or Broda chair. The DON stated the specialty chair in the resident ' s room was the only chair the resident had been comfortable in. During an interview with the MDS Coordinator on 09/29/16 at 2:04 p.m., the MDS Coordinator stated she did not recall when Resident #82 was placed in the specialty chair. The MDS Coordinator stated she did the MDS assessments and care planned what spits out on the Care Area Assessments (CAA ' s). The MDS Coordinator stated the specialty chair was not triggered and therefore not care planned. The MDS Coordinator stated she had felt the chair was more of a comfort chair than a specialty chair. The MDS Coordinator stated she should have care planned the specialty chair and stated she must have missed care planning it. During an interview with the Administrator on 09/29/16 at 2:11 p.m., the Administrator stated when a resident needs a specialty item such as a chair it was her expectation the resident be assessed for it and care planned for it. During an interview with the DON on 09/29/16 at 2:18 p.m., the DON stated the expectation of the MD Coordinator was she assess residents with special needs and care plan those needs. 2. A review of the medical record revealed Resident # 98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #98 was severely cognitively impaired and required total assistance of 1 person with bed mobility, transfers, dressing and toileting. The MDS revealed the resident had impaired upper and lower extremity on the left side. The MDS also indicated Resident #98 had left arm/hand contracture and cervical neck contracture with splinting. A review of the Care Plan dated 8/8/2016 included Resident #98 ' s positioning needs and splint application for the left arm and positioning needs and splint application for the cervical spine/neck. There was no mention of the resident ' s need for a specialty chair or the resident ' s lower extremity positioning needs. An observation on 9/27/2016 at 10:27 AM revealed Resident #98 was seated in a specialty chair beside the nurse ' s station. The specialty chair had 1 foot rest on the left side which was positioned against the left outer side of the chair with the foot rest in an upright position. Both of the resident ' s legs/feet were suspended approximately 6 inches above the floor. The resident ' s right foot/leg was observed to occasionally move and swing back and forth. The resident was observed in the same position on 9/27/2106 at 11:33 AM, 1:33 PM and 2:00 PM. An interview was conducted with the MDS nurse on 9/28/2016 at 10:30 AM. The MDS nurse reported she completed the assessment for Resident #98. The MDS nurse reported she was responsible for the Care Plans. The MDS nurse indicated the resident was up in the specialty chair almost every day. The MDS nurse stated she was unaware if the resident ' s chair had a positioning device for the legs or feet. The MDS nurse reported at the time of the assessment the resident ' s feet were not supported and they dangled above the floor. The MDS nurse stated she was not sure why she didn ' t address the need for a specialty chair or lower extremity positioning needs for Resident #98 on his Care Plan. An interview was conducted with the Nursing Assistant (NA) assigned to Resident #98 on 9/28/2016 at 11:14 AM. NA #9 reported the resident did not have any device for leg or foot positioning for the specialty chair which would prevent the resident ' s legs and feet from dangling. NA #9 stated Resident #98 ' s feet were always suspended approximately 6 inches from the floor when he was in the chair. NA #9 reported the resident was usually out of bed daily and always used the specialty chair. An observation on 9/29/2016 at 10:00 AM revealed Resident #98 seated in the specialty chair beside the nurse ' s station. The specialty chair had 1 foot rest on the left side which was positioned against the left outer side of the chair with the foot rest in an upright position. Both of the resident ' s legs/feet were suspended approximately 6 inches above the floor. The resident ' s right foot/leg was observed to occasionally move and swing back and forth. The resident was observed in the same position on 9/29/2106 at 11:15 AM. An interview was conducted with the Director of Nursing (DON) on 9/29/2016 at 11:59 AM. The DON stated she was familiar with Resident #98 but did not recall the location of his feet while in the specialty chair. The DON stated the expectation was for Care Plans to be accurate so the resident ' s individual care needs were available to staff to ensure proper care and treatment.

Based on observations, record reviews and staff and resident interviews, the facility failed to provide safe side rails for 3 of 4 residents with side rails (Residents #30, 95 and 71). Findings included: 1-Record review revealed Resident #30 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated the resident had no cognitive impairment and required extensive assistance of 1 person for bed mobility. The MDS indicated side rails were not used. There was no Care Plan for side rails in the medical record. On 9/27/2016 at 9:52 AM, Resident #30 was interviewed in her room. The resident was observed lying in bed with full side rails on both sides of the bed. The rails were loose and could be moved away from the bed for a distance of 5 to 6 inches on each side. The rail on the right side of the bed measured 5 inches between the mattress and the rail. The resident stated the rails were not used for positioning as she was unable to position herself in bed without assistance. The resident stated she did not request the rails but they might prevent her from falling. The resident reported she had not fallen since admission to the facility. The resident stated the rails were very loose and occasionally a man came to her room and tightened them, but the rails were loose again before he got out the door . Further record review revealed a side rail assessment screen completed by the MDS nurse dated 7/14/2016. The screen listed the resident as non-ambulatory, unable to get in/out of bed, no history of falls and poor bed mobility, The assessment screen decision specified side rails were indicated for support and positioning and served as an enabler for the resident. An interview was conducted with the MDS nurse on 9/29/2016 at 2:42 PM. The MDS nurse stated she completed the side rail assessment for Resident #30. The MDS nurse stated the resident requested the rails and the resident used the rails for positioning. Section G of the MDS was reviewed with the MDS nurse. The MDS nurse reported the resident did require 1 person assist for bed mobility and stated the rails were probably an enabler for the staff and not the resident. On 9/29/2016 at 4:30 PM Resident #30 's bed was rechecked and the side rails were in the same position and condition as previously noted on 9/27/2016 at 9:52 AM. On 9/30/2016 at 10:00 AM there were no side rails on Resident #30 's bed. Resident #30 stated the rails were removed the night before. The resident reported it didn't matter to her if the rails were removed. 2. Resident #95 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] noted Resident #95 was cognitively intact and needed limited to total care for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. On 9/26/2016 at 4:00 PM, Resident #95 was interviewed in her room. The bed had full metal side rails on both sides of the bed. The rails were loose and could be pulled away from the bed for a distance of 4 inches on the side of the bed closest to the window, and a distance of 5 inches on the side of the bed closest to the door. There was a space between the mattress and the bed rail of 3 inches on the side closest to the window, and a space between the mattress and the bed rail of 3 inches on the side closest to the door. Resident #95 stated she would use the side rails to move herself around in bed, except the rails were so wobbly she had trouble holding on to them. Resident #95 stated she was paralyzed on one side of her body and needed help to get up or to have a bath. The MDS indicated side rails were not used and there was no care plan for side rails. There was a side rail assessment and a decision stating side rails were indicated and served as an enabler to promote independence. A review of orders revealed on 6/9/2016: Resident uses side rails x 2 for turning and repositioning while in bed and to promote independence. The September orders from pharmacy noted Resident uses side rails x 2 for turning and repositioning while in bed and to promote independence. On 9/28/2016 2:30 PM, in an interview Resident #95 stated the side rail was loose on the side of the bed near the window, but the maintenance director had tightened the rail closest to the door. Resident #95 noted the side rail near the window was loose and she would have him fix it. Resident #95 stated she did not think the side rail prevented her from moving around in the bed. On 9/30/2016 at 10:00 AM the side rails on Resident #95 's bed had been removed. Resident #95 stated she did not care if the rails were removed. 3. Resident #71 was admitted [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] noted Resident #71 to be cognitively impaired and needed extensive to total assistance for all Activities of Daily Living (ADLs), with the physical assistance of two persons. The Care Area Assessment (CAA) noted areas of falls and communication to be concerns. The MDS did not code Resident #71 as using a bed rail. A side rail assessment was reviewed and revealed side rails were indicated and used as an enabler. A physician order [REDACTED]. On 9/29/2016 at 4:00 PM, Resident #71 was observed in bed with full length side rails up on both sides of the bed. Resident #71 's bed was against the wall with a side rail up. The other side of the bed also had a full length side rail that was loose and would pull away from the bed a distance of 4 inches. There was a 2 ½ inch gap between the mattress and the rail. On 9/29/2016 at 4:20 PM, in an interview, after the Administrator was informed of a concern regarding side rails being loose and not fitting the bed, the Administrator stated the facility is replacing beds in the building at the rate of 3 per month. The Administrator stated she thought an audit was completed monthly, and there had been no accidents concerning side rails. On 9/30/2016 at 10:39 AM, in an interview, the Maintenance Director stated he completes the audits monthly. The Maintenance Director noted all side rails were removed after the survey the previous year and were gradually added back, and sometimes, the family wanted the side rails on a resident ' s bed. The Maintenance Director indicated the side rails are all shaky and loose because they are worn out, and the long side rails are not made anymore. The Maintenance Director noted the last audit was 9/14/2016 and a review of that audit noted all rails were documented as safe. The Maintenance Director stated when he conducted the audit he would try to put his arm between the mattress and the rail and if it would go between the mattress and the rail he would document it as unsafe and replace it with another long rail that had been taken off of a bed in the past. The Maintenance Director stated the previous day the Administrator told him to remove all of the full length rails. The Maintenance Director stated the facility is ordering new beds at the rate of 2 per month, although 4 beds will be ordered in October. The Maintenance Director stated he attended Quality Assurance (QA) meetings and was asked about the audits and the rail replacements. On 9/30/2016 at 11:46 AM, the Administrator stated her expectation was when the side rails were raised, the mattress and rails would meet, so there would be no entrapment issues. 2. Resident #95 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] noted Resident #95 was cognitively intact and needed limited to total care for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. On 9/26/2016 at 4:00 PM, Resident #95 was interviewed in her room. The bed had full metal side rails on both sides of the bed. The rails were loose and could be pulled away from the bed for a distance of 4 inches on the side of the bed closest to the window, and a distance of 5 inches on the side of the bed closest to the door. There was a space between the mattress and the bed rail of 3 inches on the side closest to the window, and a space between the mattress and the bed rail of 3 inches on the side closest to the door. Resident #95 stated she would use the side rails to move herself around in bed, except the rails were so wobbly she had trouble holding on to them. Resident #95 stated she was paralyzed on one side of her body and needed help to get up or to have a bath. The MDS indicated side rails were not used and there was no care plan for side rails. There was a side rail assessment and a decision stating side rails were indicated and served as an enabler to promote independence. A review of orders revealed on 6/9/2016: Resident uses side rails x 2 for turning and repositioning while in bed and to promote independence. The September orders from pharmacy noted Resident uses side rails x 2 for turning and repositioning while in bed and to promote independence. On 9/28/2016 2:30 PM, in an interview Resident #95 stated the side rail was loose on the side of the bed near the window, but the maintenance director had tightened the rail closest to the door. Resident #95 noted the side rail near the window was loose and she would have him fix it. Resident #95 stated she did not think the side rail prevented her from moving around in the bed. On 9/30/2016 at 10:00 AM the side rails on Resident #95 's bed had been removed. Resident #95 stated she did not care if the rails were removed. 3. Resident #71 was admitted [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] noted Resident #71 to be cognitively impaired and needed extensive to total assistance for all Activities of Daily Living (ADLs), with the physical assistance of two persons. The Care Area Assessment (CAA) noted areas of falls and communication to be concerns. The MDS did not code Resident #71 as using a bed rail. A side rail assessment was reviewed and revealed side rails were indicated and used as an enabler. A physician order [REDACTED]. On 9/29/2016 at 4:00 PM, Resident #71 was observed in bed with full length side rails up on both sides of the bed. Resident #71 's bed was against the wall with a side rail up. The other side of the bed also had a full length side rail that was loose and would pull away from the bed a distance of 4 inches. There was a 2 ½ inch gap between the mattress and the rail. On 9/29/2016 at 4:20 PM, in an interview, after the Administrator was informed of a concern regarding side rails being loose and not fitting the bed, the Administrator stated the facility is replacing beds in the building at the rate of 3 per month. The Administrator stated she thought an audit was completed monthly, and there had been no accidents concerning side rails. On 9/30/2016 at 10:39 AM, in an interview, the Maintenance Director stated he completes the audits monthly. The Maintenance Director noted all side rails were removed after the survey the previous year and were gradually added back, and sometimes, the family wanted the side rails on a resident ' s bed. The Maintenance Director indicated the side rails are all shaky and loose because they are worn out, and the long side rails are not made anymore. The Maintenance Director noted the last audit was 9/14/2016 and a review of that audit noted all rails were documented as safe. The Maintenance Director stated when he conducted the audit he would try to put his arm between the mattress and the rail and if it would go between the mattress and the rail he would document it as unsafe and replace it with another long rail that had been taken off of a bed in the past. The Maintenance Director stated the previous day the Administrator told him to remove all of the full length rails. The Maintenance Director stated the facility is ordering new beds at the rate of 2 per month, although 4 beds will be ordered in October. The Maintenance Director stated he attended Quality Assurance (QA) meetings and was asked about the audits and the rail replacements. On 9/30/2016 at 11:46 AM, the Administrator stated her expectation was when the side rails were raised, the mattress and rails would meet, so there would be no entrapment issues.

Based on observation, interview and record review the facility failed to ensure biologicals and supplements were not expired in one of two medication rooms (100 hall medication room) and 2 of three medication carts (200 and 400 medication carts). Findings included: On 9/29/2016 at 11:00 AM, the 200 hall cart was checked. There was a canister of Beneprotein supplement 8 oz. with a best by date of 29 August 2016. On 9/29/2016 at 11:00 AM, the 100/200 hall medication room was checked and the refrigerator contained one box of Tuberculin skin test. There was a vial inside labeled as Tuberculin skin test with no open date on the box or the open vial. On 9/29/2016 at 11:15 AM, the 400 hall medication cart was checked. There was a canister of Beneprotein supplement 8 oz. with a best by dated of 24 [DATE]. On 9/29/2016 at 2:45 PM, in an interview, the Director of Nursing (DON) stated her expectation was that the medication carts, rooms and refrigerators would be audited on a regular basis by the staff and would be free of expired medications.

Based on observation, staff and resident interviews and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain and monitor interventions that were put into place 11/13/2015. These interventions were in an area originally cited in the recertification survey of 10/30/2015 and recited in the recertification survey of 9/29/2016. The deficiency was in the area of Accidents/Hazards. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAA program. Findings included: This citation is cross referenced to: F323 -Based on observations, record reviews and staff and resident interviews, the facility failed to provide safe side rails for seven of seven residents with side rails (Residents #13, 20, 32, 95, 31, 94 and 58). The facility was cited during the 10/30/2015 recertification survey F323 for failing to provide safe side rails. During the current survey, the facility continued to fail to provide safe side rails During an interview with the Administrator on 09/30/16 at 11:46 PM, the Administrator stated the QAA Committee met monthly and identified, developed and implemented plans of action to correct identified quality deficiencies. The Administrator stated a QAA meeting was held after the recertification survey of 10/30/2015 and discussed the action plan to correct the deficiency. The Administrator stated the Maintenance Director was properly in-serviced on the facility's expectations for safe side rails. The Administrator stated she thought the breakdown that caused the repeated deficiency was the Maintenance Directors perception of what was considered a safe space between the mattress and the side rails.

Based on observations, record reviews and staff and resident interviews, the facility failed to provide safe side rails for seven of seven residents with side rails (Residents #13, 20, 32, 95, 31, 94 and 58). Findings included: 1. Record review indicated Resident #13 was admitted to the facility on [DATE]. The resident's Minimum Data Sets ((MDS) dated [DATE] indicated the resident had no cognitive impairment. The MDS indicated the resident required extensive assistance of one person for positioning and turning. A side rail screen dated 9/8/2015 indicated the resident was non-ambulatory, exhibited poor bed mobility or difficulty moving in bed, had poor balance, no reason to believe resident could climb over side rails and expressed a desire to have side rails raised while in bed. The decision following the assessment indicated side rails were indicated and serve as an enabler to promote independence. An observation on 10/27/2015 at 11:16 AM was done in the resident ' s room. The resident was lying on the bed, and full side rails were up on both sides of the bed. The rails were loose, and a space approximately 5 inches was measured between the rails and mattress. 2. Record review indicated Resident #20 was admitted to the facility on [DATE]. The resident's current cumulative [DIAGNOSES REDACTED]. The resident's Minimum Data Sets ((MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of one person for positioning and turning. A side rail screen dated 10/6/2015 indicated the resident was non-ambulatory, exhibited poor bed mobility or difficulty moving in bed, had poor balance, was on medications which would require increased safety measures, no reason to believe resident could climb over side rails and expressed a desire to have side rails raised while in bed. The decision following the assessment indicated side rails were indicated and serve as an enabler to promote independence. An observation on 10/27/2015 at 4:20 PM was conducted of the resident ' s side rails. The side rail on the right side of bed was raised and locked into position. The rail was very loose when moved from side to side. There was space between the rail and the mattress which measured 5 ½ inches. 3. Record review indicated Resident #32 was admitted to the facility on [DATE]. The resident's cumulative [DIAGNOSES REDACTED]. The resident's Minimum Data Sets ((MDS) dated [DATE] and 10/5/2015 indicated the resident had severe cognitive impairment and required extensive assistance with transfers and positioning. A side rail screen dated 7/6/2015 indicated the resident was non-ambulatory, exhibited poor bed mobility or difficulty moving in bed, had poor balance was on medications which required increased safety precautions, no reason to believe resident could climb over side rails and expressed a desire to have side rails raised while in bed. The decision following the assessment indicated side rails were indicated and serve as an enabler to promote independence. The resident was observed lying on her bed on her back on 10/27/2015. The head of the bed was elevated 30 degrees. The resident was awake on approach. The resident mumbled various words when spoken to. Full side rails were observed up on both sides of the bed. The rails were very loose when checked, and there was a gap between the mattress and the rails on both sides approximately 5 inches. 4. Record review indicated Resident #95 was admitted on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of 2 persons for positioning. A side rail assessment dated [DATE] indicated the resident was non ambulatory, comatose, semi-comatose and fluctuating level of consciousness. The assessment also indicated the resident had difficulty with balance and was on medications that required increased safety precautions. The assessment indicated the resident was not currently using side rails. At the end of the assessment, the decision for use of bed rails was not completed. The resident was observed on the initial tour on 10/26/2015 around 6:30 PM in her room. She was lying on her back on her bed. Both full metal side rails were raised. The rails had a parallel bar between the top and bottom rail running the length of the rail. Both rails were loose when checked and moved very easily away from the bed and mattress. On the left side of the bed, the space noted between the mattress and the side rail was approximately 5-6 inches before moving the side rail. 5. Record review indicated Resident #31 was admitted to the facility on [DATE]. The resident's Minimum Data Sets ((MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent of one person for positioning and turning. A side rail screen dated 9/2/2015 indicated the resident was non-ambulatory, exhibited poor bed mobility or difficulty moving in bed, had poor balance, no reason to believe resident could climb over side rails and expressed a desire to have side rails raised while in bed. The decision following the assessment indicated side rails were indicated and serve as an enabler to promote independence. An observation was conducted in the resident ' s room on 10/28/2015 at 9:57 AM. Both full side rails were observed in the up position with resident lying on the bed. The rails on both sides were loose when checked, pulled away from bed easily leaving a gap of approximately 5 inches between the mattress and the rails. 6. Record review indicated Resident #94 was admitted to the facility on [DATE]. The resident's Minimum Data Sets ((MDS) dated [DATE] indicated the resident had no cognitive impairment. The MDS indicated the resident required total dependence of one person for positioning and turning. A side rail screen dated 9/24/2015 indicated the resident was non-ambulatory, exhibited poor bed mobility or difficulty moving in bed, had poor balance, no reason to believe resident could climb over side rails and expressed a desire to have side rails raised while in bed. The decision following the assessment indicated side rails were indicated and serve as an enabler to promote independence. The resident was observed lying on her bed on her back on 10/27/2015. The head of the bed was elevated 30 degrees. The resident was awake and alert on approach. The rails were very loose when checked, and there was about a 4 to 5 inch gap between the mattress and the rails on both sides. 7. Record review indicated Resident #58 was admitted to the facility in 2014. The resident's cumulative [DIAGNOSES REDACTED]. The resident's Minimum Data Sets ((MDS) dated [DATE] indicated the resident had no cognitive impairment. The MDS indicated the resident required extensive assistance of one person for positioning and turning. A side rail screen dated 10/12/2015 indicated the resident was non-ambulatory, exhibited poor bed mobility or difficulty moving in bed, had poor balance, no reason to believe resident could climb over side rails and expressed a desire to have side rails raised while in bed. The decision following the assessment indicated side rails were indicated and serve as an enabler to promote independence. An observation was conducted in the resident ' s room on 10/28/2015 at 10:26 AM. The resident was lying on the bed. Two full side rails were observed in the up position. Both rails were very loose when touched and pulled away easily from the side of the bed. The Maintenance Director was interviewed on 10/30/2015 at 9:37 AM. He stated the beds and rails were being used in the facility when he was hired [AGE] years ago. He stated they probably weren ' t made anymore, and he had no manufacturer information for the bed or rails. The facility Administrator was interviewed on 10/30/2015 at 10:54 AM. The Administrator stated most of the beds/rails were older and not manufactured anymore. She also stated the facility was phasing the old beds and rails out and replacing them a few at a time with new rails. The Administrator further stated no injuries had occurred related to bed rails.

Based on observation, record review and staff interviews, the facility staff failed to supervise 2 of 2 sampled cognitively impaired residents assessed as being at risk for elopement (Resident #94 and Resident #76). Immediate Jeopardy began on 07/01/12 when Resident #94 left the facility unsupervised and was found by police at a grocery store. Resident #76 exited the facility and was found by the road in front of the facility on 08/09/12. Immediate Jeopardy was identified on 11/29/12 at 9:00 AM and was removed on 11/30/12 at 1:00 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D with more that minimal potential for harm that is not immediate jeopardy. The findings include: 1a. Resident #94 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A facility elopement risk assessment dated [DATE] showed that Resident #94 had a history of [REDACTED]. The resident ' s care plan last updated 04/19/12 showed that the resident was at risk for elopement with a goal for the resident to be re-directed by staff before leaving the facility during elopement attempts. Interventions included: " Assign staff to account for resident ' s whereabouts at all times. Alert staff to resident ' s elopement behavior. Place resident in an area where constant observation is possible. Note which exits resident favors for elopement from facility. Alert staff working near those areas. If resident elopes from the facility, implement facility protocol for locating resident. " The most recent Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #94 was severely cognitively impaired. The MDS showed that the resident was independent with wheelchair mobility and used a cane as an assistive device for walking. The MDS showed that the resident had exhibited wandering behaviors which occurred 1-3 days during the review period. The MDS showed that the resident received medications for anxiety and agitation as needed. The elopement risk assessment dated [DATE] showed that the resident had a history of [REDACTED]. The elopement assessment had a section for potential interventions. None of the interventions were checked. A nurse ' s note written by Nurse #1 dated 07/01/12 at 6:45 AM read: " Rsdt (resident) not in room was last seen around 5:30 AM. Facility and grounds searched thoroughly by staff and nurse in charge, unable to locate rsdt. Rsdt ambulating on foot with cane, wheelchair in room. Called DON (Director of Nursing) and police notified. Rsdt found by police in (name of supermarket) parking lot. Staff went to pick up rsdt. Assessment upon arrival back to facility. No signs/symptoms of acute distress noted. No signs/symptoms of injury noted. " On 11/28/12 at 3:00 PM, Resident #94 was observed sitting in his wheelchair in his room next to the bed with his eyes closed. On 11/28/12 at 4:45 PM, Resident #94 was sitting in his wheelchair in his room. The resident was observed to stand up and the chair alarm sounded. Nurse #1 stated in an interview on 11/28/12 at 8:45 AM that she was working on the morning of 07/01/12. The Nurse stated that Resident #94 was confused and a lot of the time he talked about leaving the building. The Nurse stated that she was passing medications around 6:00 AM and a nursing assistant said he was not in his room. The Nurse stated that the resident ' s alarm did not sound on his wheelchair. The Nurse stated that she called the police and had staff search the building inside and outside. The Nurse stated that the resident was found at a local grocery store by the police and that Nurse #3 brought the resident back to the facility. The Nurse stated that she did not know how long the resident was gone from the facility. An interview was conducted with Nursing Assistant (NA) #1 who was assigned to Resident #94 on 07/01/12. The NA stated that the last time she saw the resident was at 5:30 AM in his room. The NA stated that Nurse #2 told her the resident was missing. Nurse #3 stated in an interview on 11/29/12 at 1:50 PM that he was on his way to work when he learned that Resident #94 was missing. The Nurse stated that Resident #94 had made attempts to leave the building but they usually would catch him before he left the parking lot. The Nurse stated that he picked up the resident at the grocery store. The Nurse stated when he brought the resident back to the building he tried to get him to calm down and he called a family member and re-oriented him back to the facility. The Nurse stated that he checked the resident for injuries and the resident was able to move all extremities. The Nurse stated that he knew that Resident #94 wandered and he was aware that staff needed to keep an eye on him, however, the resident was fast. During an interview on 11/29/12 at 3:30 PM, the Director of Nursing (DON) stated she was called on the morning Resident #94 left the facility. The DON stated that she arrived at the facility within ten minutes and helped with the search of the facility and the grounds. The DON stated that Nurse #3 picked up the resident at the grocery store and returned him to the building unharmed. The DON stated that the resident was assigned a sitter from July 1-8, 2012. The DON stated there were no revisions to the resident ' s care plan because he had already been care planned. The DON stated that she made sure that the resident was safe. The MDS Coordinator stated in an interview on 11/29/12 at 4:35 PM that everyone in the building was aware of the resident ' s wandering behaviors. On 11/30/12 at 3:30 PM the mileage from the facility to the grocery store was observed to be three tenths of a mile or 1584 feet. There were 3 traffic lanes in front of the facility and at the end of the street the resident would have to cross 5 traffic lanes to reach the grocery store where he was found. 1b. A nurse ' s note written by Nurse #4 dated 10/14/12 at 5:15 PM read: " Resident out of facility in wheelchair attempting to leave out of facility parking lot. Resident stated " I ' ve got to go see family member. " Assisted back to facility x (times) 2. " Nurse #4 stated in an interview on 11/28/12 at 4:55 PM that on the morning of 10/14/12 she was going out of the front door of the facility and saw the resident in the parking lot. The Nurse stated it just so happened that she was going out the front door and saw the resident. The Nurse stated that the resident was found on the left side of the facility away from the carport and did not know how long the resident had been outside. The Nurse stated that she brought the resident back inside the building. The Nurse stated that the resident had gotten outside before. The Nurse stated that she did not know what was in place to prevent the resident ' s elopement but a chair alarm was put on his wheelchair when he first tried to get out. The MDS Coordinator stated in an interview on 11/29/12 at 4:35 PM that the only thing added to the resident ' s care plan was to call his family member. She stated that she did not know what else to add. The Coordinator stated that there had been a lot of in-services and elopement drills. An interview was conducted with the DON and the Administrator on 11/29/12 at 5:30 PM. The DON stated that after the resident got out of the building on 10/14/12 they did the same thing as before. Someone was assigned to sit with the resident the entire shift. The Administrator stated that they had elopement drills during which a staff person would pose as a resident that had eloped from the facility and the staff would search for the staff person posing as a resident. On 11/30/12 the estimated distance from the front door of the facility to the area of the parking lot where Nurse #4 found the resident on 10/14/12 was forty one feet. 1c. A nurse ' s note written by Nurse #5 dated 11/07/12 at 5:15 PM read: " Resident found outside by staff wandering around the building near dining room door. Resident had no falls noted from incidence. Asked what resident was doing, he stated, going out trying to get a car. " Nurse #5 stated in an interview on 11/28/12 at 5:10 PM that she was passing medications at 5:00 PM on 11/07/12. The Nurse stated that students were in the building that night and saw Resident #94 go out the front door but thought he was a visitor. The Nurse stated that she saw the resident ' s wheelchair inside the front door and there was no alarm sounding. The Nurse stated that she found Resident #94 standing outside at the corner of the facility on the sidewalk and he refused to come back in through the front door. The Nurse stated that one of the students and a housekeeping staff member assisted the resident around the back of the building and brought him back in through the dining room door. The Nurse stated that the resident had tried to leave the facility earlier in the day. During the interview, the nurse was observed to walk out the front door to the area where she found the resident. The estimated distance from the front door to the left side corner of the facility was 125 feet. An interview was conducted with the Administrator and the DON on 11/28/12 at 5:30 PM. The Administrator stated that alarms were placed on all exit doors except for the front door and the dining room door. The Administrator stated that they purchased a system to alert staff to resident ' s trying to leave the building but the alarm was not very loud and could not be heard by staff so the system was sent back to the company. The Administrator stated they had looked at another system but the cost was between $10,000 to $15,000 dollars. 2a. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 09/26/12 showed that the resident was severely cognitively impaired. The MDS showed that the resident required extensive 2 person assist for mobility but once in the wheelchair was independent with mobility. The MDS did not note wandering behaviors for the review period. A nurse ' s note dated 08/09/12 at 10:20 AM by Nurse 6 read: " Resident up in wheelchair propelling self through facility. Nursing assistant looking out front window, saw resident in wheelchair at road. Resident brought in per staff, resident states, " I looked for cars. " Explained to resident please do not go outside, said he wouldn ' t. Will monitor. " The resident ' s care plan updated on 08/09/12 showed that the resident attempted to elope from the facility on 08/09/12. The goal on the care plan was for the resident to not suffer any injuries due to elopement attempts. The interventions included: Place resident in area where frequent observation is possible. Place chair alarm in chair. Alert staff to resident ' s elopement attempts. If resident is attempting to elope away from unit, instruct staff to stay with resident, converse and gently persuade resident to come back to designated area with them. Assign staff to account for resident ' s whereabouts throughout the day. Note which exits resident favors for elopement from facility. Alert staff working near those exits. Nurse #6 stated in an interview on 11/29/12 at 3:30 PM that Nursing Assistant (NA) #4 came to her and told her that she looked out the window and noticed Resident #76 outside. The Nurse stated that she went outside and observed the resident sitting in his wheelchair on the left side of the parking lot in front of the facility. The Nurse stated that she brought the resident back into the building and explained that he could not leave like that. The Nurse stated that she had been in-serviced on watching the resident and re-directing him to activities. The Nurse stated that she tried to involve the resident in activities to get his mind off trying to leave the facility. The Nurse stated that the resident had a bed and chair alarm pad that would alarm if he got up. NA #4 stated in an interview on 11/30/12 at 10:45 AM that on 08/09/12 she was in a resident ' s room making up beds and she opened the blinds in the room and saw Resident #76 sitting in his wheelchair sitting at the road where the cars were parked at the edge of the grass. The NA stated that she called the nurse on the hall and ran outside to get the resident. The NA stated that the resident ' s wheelchair was on the pavement and he was trying to scoot to get up on the grass. The NA stated that the resident was looking for a ride to an area where he used to live. The NA stated that she brought the resident back to his room and tried to get his mind off of going outside. The NA stated that this was not the first time that Resident #76 had got out of the building. The NA stated that visitors assumed it was OK for the resident to go outside but he could not unless someone was outside to supervise him. The NA stated that she had received inservices regarding the resident ' s elopement attempts. During the interview, the NA pointed out where the resident was found in the parking lot and stated that the resident was sitting between parked cars at the edge of the grass. There was an area of grass approximately 6-7 feet that led from the parking lot to a sidewalk that was along the edge of the street. The estimated distance from the front door of the facility to the street in front of the facility was 93 feet. An interview was conducted with the Director of Nursing (DON) and the Administrator on 11/29/12 at 5:30 PM. The DON stated that after the incident an elopement drill was completed on 08/13/12. The Administrator stated that during an elopement drill a staff person would pose as a resident that had eloped from the facility and other staff would search for the staff person posing as the resident. The MDS Coordinator stated in an interview on 11/30/12 at 10:55 AM that the resident ' s last care plan meeting was held on 09/26/12 and that she had not included the resident ' s elopement on 08/09/12. 2b. A nurse ' s note dated 08/15/12 read: " Resident up in wheelchair propelling self, went out front door and down sidewalk part way. Staff redirected resident to come back in facility. Resident back in facility, no further attempts to leave. " Nurse #7 stated in an interview on 11/29/12 at 4:05 PM that Resident #76 had gotten out of the building and was partway down the walkway along the side of the building. The Nurse stated that she did not know how long the resident had been outside. During the interview, Nurse #7 was observed to go outside of the building to point out where she found the resident on 08/15/12. The Nurse stated that the resident had propelled his wheelchair from the front door to the right and to the third handicapped parking sign in the parking lot. The estimated distance was thirty six feet. The DON stated in an interview on 11/29/12 at 5:30 PM that elopement drills had been conducted with the staff on 08/01/12 and 08/03/12. The MDS Coordinator stated in an interview on 11/30/12 at 11:00 AM that the resident last care plan meeting was held on 09/26/12 and that no additional information regarding the resident ' s elopement was added to the resident ' s care plan. 2c. A nurse ' s note written by Nurse #5 dated 11/07/12 at 6:25 PM read: " Resident found outside in parking lot after being notified by visitor, in wheelchair. Resident brought back inside and oriented to facility. " Nurse #5 stated in an interview on 11/29/12 at 5:44 PM that on 11/07/12 a visitor notified her that Resident #76 was in the parking lot. The Nurse stated that the resident had gotten off the edge of the carport. The Nurse stated that she re-oriented the resident to the facility and reminded him that it was cold outside and that he could get injured. The Nurse stated that she took the resident back to his room and he was watching television. The Nurse stated that she usually had the resident follow her while she passed medications. The Nurse pointed out the area where the resident was found and the estimated distance from the front door was twenty two feet. The DON stated in an interview on 11/30/12 at 3:00 PM that Resident #76 was easily re-directed and that he wanted fresh air. The DON stated that elopement inservices were done on 11/08/12. The Administrator was notified of the Immediate Jeopardy on 11/29/12 at 9:00 AM. The facility provided an acceptable credible allegation of compliance on 11/30/12 at 1:00 PM. The allegation of compliance indicated: CREDIBLE ALLEGATION OF COMPLIANCE On July 1, 2012 at approximately 6:45am, resident #94 was noted to be out of facility unattended. Staff at facility searched the facility and facility grounds per facility protocol. After it was determined resident was not on facility premises, the Police Department and the Director of Nursing were called to notify them of a missing resident at the facility. Approximately five minutes later, the Police Officer notified Nurse #1 that resident had been located approximately three blocks from facility. Director of Nursing had arrived and brought resident back to facility. Resident was assessed for any injuries, none noted. Resident stated to Director of Nursing that he wanted to leave to go see (name of family member). A nursing assistant was placed with resident for one on one care for the entire weekend. Resident was placed on the acute charting to monitor for any increased confusion and elopement risks. On October 14, 2012; resident was found out in facility parking lot in wheelchair by Nurse #4. Nurse brought resident back in facility. Resident stated he wanted to see (name of family member). Resident ' s family member notified of attempt and resident ' s request to see her. A sitter was placed with resident for the rest of the day. Staff made aware of residents elopement and Nurse #4 told all staff that they must be aware of the resident will elope. The next day, October 15, 2012, residents family member came and picked him up for LOA (leave of abscence) to his home. Returned to facility on October 16, 2012 and appeared to be very satisfied and happy. On November 7, 2012 at approximately 5:40am, resident was witnessed going out dining room door by Dietary Aide #1. Dietary Aide #1 and Nursing Assistant #3 got to resident just as he past the threshold of the door. His wheelchair tipped over and he fell to the ground. Resident got up and was back in his wheelchair when the staff members approached the resident. Nurse #2 was notified and resident was assessed for injuries from the fall. Resident was noted to have skin tears. Treatment was applied by nurse. Resident could move all extremites without difficulty. Resident ' s Responsible Party and Physician were notified of event. Nurse #2 made staff aware of residents elopement and the need for constant surveillance of this resident. On the same day at approximately 5:15pm, staff found resident outside of dining room door in his wheelchair. Resident stated he was going out to move his car. Resident was taken to room and a nursing assistant was placed with him for one on one care. Resident was noted to rest well the rest of the night. Responsible Party and Physician made aware. No more elopement attempts noted. This resident has been placed as of November 30, 2012 in an Assisted Living ' s Alzheimer ' s Unit. The move also brings him closer to his family. On August 9, 2012 , at approximately 10:20 am, resident #76 was witnessed by nursing assistant in his wheelchair sitting at the curbside. Resident immediately brought back in facility. Nurse #6 spoke with resident and asked him not to go outside without assistance as resident is easily redirected. Resident was taken to the dining room for bingo. After bingo, resident ' s family member came in facility and continued to stay with resident. A sitter has been placed with resident for twenty four hour to prevent any elopement attempts. Elopement of two residents at Elizabethtown Healthcare and Rehabilitation Center: November 28, 2012: For those residents affected by the same deficient practice, due to the fact that the front door is not alarmed, personnel shall be stationed there 24-hours per day to ensure the identified residents do not elope or attempt to elope . All other exit doors to the facility are alarmed and are in proper working order. On November 29, 2012, all staff were re-in-serviced on the elopement protocol of the facility and were made aware of the two residents that being focused upon. The facility in-service instructed staff to approach residents calmly and redirect them as to not cause undue agitation are focused. The facility " Elopement Intervention Plan " is the system in place outlining how staff should respond to elopement of residents. This plan was also included in the in-service for staff on November 29, 2012. An updated photo was obtained of each resident and will be displayed at nurses station and will be updated as needed. All exit doors were secured immediately ensuring that alarms were in working order, the alarm sounds from the alarm mechanism attached to each door and can be heard throughout the entire facility. All staff were instructed that they are to respond to alarms heard throughout the facility. On November 28, 2012, at approximately 5:45pm rounds were immediately made by Maintenance Director, Administrator, Director of Nursing, MDS Coordinator, Social Worker, HR Director and Nurses to ensure all residents were accounted for. All residents were accounted for at that time. All exit door locking mechanisms were checked by the Maintenance Director immediately and were found in proper working order. The dining exit door was noted to be without proper alarming mechanism. The Maintenance Director installed an alarm noted to have the tradename " EXIT STOPPER " alarm on the dining room exit door. The alarm is identical to the alarms on the other facility exit doors and alarms at the mechanism creating a loud noise that can be heard throughout facility. A sign was posted on the dining room exit door rerouting traffic. The surveyors were provided with documentation that the door for the dining room has been ordered and the date it will be installed. Elopement drills are being done quarterly, there are several documented twice monthly. All documentation of elopement drill and inservices have been provided to the surveyors. All residents have been reassessed using the " Elopement Risk Assessment " tool and will be careplanned accordingly. Any resident noted to be at risk for elopement will be assigned a 24 hour sitter. Identification of Residents that may be affected by the same alleged deficient practice and Monitoring: For those residents having the potential to be affected by the same alleged deficient practice, all residents ' were re-assessed by Administrative Nurses on November 29, 2012 using the facility ' s Elopement Risk Assessment form. No other residents were found to be at risk for elopement. The front door of the facility will be secured by placing an individual in lobby to stop any elopement attempts until an alarm system is installed for the front door. The door will be secured by an individual 24 hours a day/ 7 days a week until the " Wanderguard " system is installed. The surveyors were provided with the documentation from the company stating that the facility has ordered the system. Those residents identified as having a " having a history of leaving the facility without needed supervision, " shall receive a 24 hour sitter. The front door shall remain supervised by staff 24-hours per day. Those residents identified as being at risk for elopement shall have an elopement care plan initiated and shall have approaches in place to prevent the residents elopement. Pursuant to the facility ' s Elopement Policy, all residents shall continue to be assessed for their elopement risk on admission and quarterly thereafter. All facility staff have been re in-serviced on the elopement policy and protocol and the missing persons protocol and policy. These policies have been in place since October 2006. The Elopement and Missing Persons " protocol will be included in the new hire procedure and will be given on a quarterly basis to all employees. In the case of missing persons, the hall nurse will assign individuals to search specific areas including, but not limited to: all rooms (identifying who is each bed and looking under the bed, bathrooms, closets, bathing rooms, offices, kitchen, freezers and coolers, storage rooms, linen rooms, laundry room, beauty shop, dining room, day room, conference room, maintenance storage, housekeeping and outside quadrants identified for the facility. All locked doors will be unlocked and checked. After checking locked rooms, the room should be locked. After initial search the missing person protocol will be followed accordingly. Individuals have been secured to man the front door 24 hours / day, seven days a week . The individual will be monitored by the administrative staff during the week and the Registered Nurses on the weekends. The Maintenance Director will check the doors weekly to make sure that they are functioning properly using the " Door Check " audit tool, which consists of the Maintenance Director checking the door functions and placing his initials by the date checked. Quality Assurance of Elopement Risks: The Director of Nursing and/or Administrative Nurse Designee will review all new admissions and the " acute charting " of residents daily. During these reviews, the Director of Nursing and/or Administrative Nurse Designee will review records for safety concerns and will ensure preventative measures are implemented as needed. Residents identified as at risk for elopement will be followed in the " Patient At Risk " QA meetings weekly ensuring that all safety measures are in place. Director of Nursing and Administrative Nurses will continue to monitor the acute charting daily and bring any new " at risk " behaviors to the Careplan team and QA committee. In addition, Nurses have been instructed to complete an incident report on elopement attempts and investigation of the occurrence immediately after the attempt noted. All " at risk " behaviors will be followed in the QA meetings until deemed resolved by the committee. The credible allegation was verified by reviewing documentation provided by the facility of inservices and elopement drills completed as a result of the elopement incidences. Staff was questioned about their knowledge of elopement procedures, such as what to do if a resident left the facility and what to do if they heard the sounds of alarms. Staff were aware of the two residents that had eloped from the facility. In-services and elopement drills were verified by in-service sheets as well as staff interviews. Several staff was interviewed regarding the in-services they received on elopements, what to do if a resident was missing and what to do when a sitter (one-on-one staff) took a break. Staff interviewed and their responses are noted below: 11/30/12 at 2:00 PM NA# 12 stated she had received an in-service on elopements. She revealed the two residents that would attempt to leave the facility were Resident #76 and Resident #94. NA# 12 stated if she was a sitter for one of the residents and needed to take a break, she would inform someone and she would not leave the resident until someone took her place. She stated if a resident was missing she would inform the Administrator and assist in the search of the facility. 11/30/12 at 2:15 PM NA# 13 stated she had been in-serviced on elopements. She stated if she heard an alarm sound, she would locate where the sound of the alarm was coming from. She revealed if a resident was missing from the facility she would notify her supervisor and management staff and she would assist in the search of the facility. NA#13 stated Resident #94 and Resident #76 were residents that would attempt to leave the facility. She revealed if she was assigned one-on-one with a resident and needed a break, she would inform someone and she would not leave the resident until someone relieved her. 11/30/12 at 2:20 PM Staff Nurse #8 on 400 Hall. She stated that she had just received an in-service on elopements. She stated if a resident had a staff member watching them one-on-one, when the staff member took a break, another staff member must cover during the break. If a resident was missing, staff members would look for the resident, notify the administrator and if unable to find the resident call the police. 11/30/12 at 2:30PM Nursing Assistant #9 (NA#9) stated that she had just received an in-service on elopements. If she was unable to find a resident, she would notify the charge nurse and look for the resident. If doing one-on-one with a resident she would get someone to relieve her for breaks. If a chair alarm went off, she would go and check on the resident. If she saw a resident going out the door she would bring the resident back in. 11/30/12 at 2:35 PM Housekeeping Staff# 1 stated that if she saw a resident going out the door, she would bring them back in and notify the nurse. 11/30/12 at 2:45 PM a picture was observed of Resident #76 at the nurse' s station as being a resident at risk for elopement. Nurse #6 stated that the other resident (Resident #94) had been transferred to another facility. The Nurse stated that she had just received an in-service on elopements. The Nurse stated that if a resident was observed going out the door, she would bring them back in and notify the DON or the Administrator. The Nurse stated that staff sitting with resident that were being observed after elopement attempt must be relieved by another staff member for breaks. 11/30/12 at 2:50 PM Staff Nurse#4 sated she had received an in-service on elopements. The Nurse stated that Resident #76 and Resident #94 would try to go out of the building. If she observed these residents going out the door, she would bring the residents back in and notify administration. She further stated that Staff assigned to one-on-one with residents after elopement attempt must be relieved by another staff member for breaks. 11/30/12 at 3:00 PM NA #10 stated she had just received an in-service on elopements. The NA stated Resident #94 and Resident #76 were at risk for elopement and if she saw one of them going out the door, she would bring them back in and notify the nurse. The NA stated that if doing one-on-one with a resident, she must be relieved by another staff member for breaks. 11/30/12 at 3:15 PM NA# 7 stated Resident #76 was at risk for elopement. If she saw him going out the door would bring him back in and notify the nurse. The NA stated that she had just received an in-service on elopements and if sitting with a resident after an attempt to get out of the building she would not leave to take a break until someone relieved her. 11/30/12 at 3:20 PM NA# 8 stated she has just had an in-service on elopements. She stated Resident #76 would try to go out of the front door. If she saw him try to go out, she would bring him back in and notify the nurse. 11/30/12 at 3:25 PM NA# 9 stated she had received an in-service on elopements. She stated Resident #94 and Resident #76 had gotten out of the building. If she saw one of them going out of the door she would bring them back in and notify the nurse. The NA stated if she was one-on-one with a resident that had tried to elope, she would need to sit with the resident for the NA to take a break. 11/30/12 at 3:28 PM NA# 10 stated that she had received an in-service on elopements. She stated Resident #76 was at risk for elopement. If she saw him trying to leave the building she would notify the nurse. If sitting with the resident after an elopement attempt, she would not leave to take a break until someone relieved her. 11/30/12 at 3:45 PM NA #11 stated she received in-services on elopement. She stated if a resident eloped from the facility, she would notify her supervisor and the management staff and she would assist in the search, both inside and outside of the facility. She stated if she heard an alarm sound she would locate where the alarm was coming from. She stated the two residents that would attempt to leave the facility were Resident #76 and Resident #94. She revealed that if she was a sitter an