Every finding on record at Evangeline Oaks Guest House

Based on observations, interviews, and record review, the facility failed to distribute, store, and serve food in accordance with professional standards for food service safety by failing to ensure staff: 1 Labeled food items in the freezer with an open date;2. wore a beard restraint while preparing food items; 3. used hygienic practices while checking food temperatures on the serving line; and4. maintained a daily temperature log for the cooler and freezer. This deficient practice had the potential to affect the 72 residents who consumed food from the kitchen. Findings: On 06/02/2026, a review of the facility's policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices with no review date, read in part Policy Statement - Food services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food. On 06/02/2026, a review of the facility's policy titled, Food Receiving and Storage, with no review date, read in part .Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation.7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date.).11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food service manager or designee and documented according to state specific requirements. 1. On 06/01/2026 at 8:30 a.m., an initial tour of the kitchen was conducted with S3DM. Upon entering the freezer, one opened clear plastic bag was observed that contained garlic cheddar biscuits with a small hole in the bottom of the bag. The package was not labeled with a date that it was opened. On 06/01/2026 at 8:31 a.m., an observation and interview was conducted with S3DM, who confirmed the bag was opened and not labeled and stated it should have been labeled and dated. 2. On 06/01/2026 at 8:35 a.m., further observation of the kitchen was conducted with S3DM. S4CH was preparing the dessert and placing the fruit crisp into small bowls. S4CH had a beard and was not wearing a beard restraint. On 06/01/2026 at 8:36 a.m., an interview was conducted with S3DM who confirmed S4CH should have been wearing a beard restraint while in the kitchen. 3. On 06/01/2026 at 9:04 a.m., a review of the kitchen's cooler and freezer temperature logs was conducted with S3DM. The temperature logs for the freezer and the cooler were not completed on the following dates in 2026: -March: 14th ,15th, 22nd, 23rd, 28th, and 29th. -April: 4th, 5th, 11th ,12th, 18th, 19th, 25th, 26th, and 31st. May 2nd, 3rd, 9th, 10th, 16th, and 17th. On 06/01/2026 at 9:05 a.m., an interview was conducted with S3DM who confirmed staff should have been documenting the temperatures for the cooler and freezer daily. 4. On 06/01/2026 at 9:40 a.m., S5C was observed putting the temperature monitor inside her pants pocket. The temperature gauge had a red string attached to it. S5C was then observed removing the temperature gauge from her pants pocket, removing the protective cover from the temperature gauge and placing it in the rice pan. The red string and the temperature gauge were observed resting on the rice. S5C was then observed replacing the protective covering on the tip of the temperature gauge and placing it inside of her pants pocket. On 06/01/2026 at 9:41 a.m., an interview was conducted with S5C who confirmed the string from the thermometer had been resting on the rice and stated she should not have placed the temperature gauge inside of her pants pocket.

Based on observations and interviews, the facility failed to ensure the kitchen equipment was maintained in safe operating condition as evidenced by a leaking faucet on the three-compartment sink and exposed electrical wires on the mixer. Findings: On 06/01/2026 at 9:12 a.m., an observation of the 3-compartment sink was conducted with S3DM (Dietary Manager). The water on the cold-water side could not be fully turned off. When asked about the process of reporting kitchen items in need of repairs, S3DM stated she had a maintenance book. She stated that every morning maintenance checked the book to see if anything needed repairs and signed off on the item once the repairs were completed. A review of the maintenance book with S3DM revealed the last date of requested maintenance on any kitchen item was on 11/28/2025. On 06/01/2026 at 9:13 a.m., a follow-up interview was conducted with S3DM who confirmed the sink faucet had been leaking and she and her staff had failed to inform maintenance that it needed to be repaired. On 06/01/2026 at 9:23 a.m., further observation of the kitchen with S3DM revealed a mixer with exposed electrical wires. The black casing for the electrical wires was split open with green, white, and black wires visible. The black wire was almost disconnected from the electrical port. S5C stated she tried to use the stand mixer on 05/31/2026 and it just made a funny noise and stopped working. She stated the mixer had not been working properly for some time. S5C confirmed she had not notified S3DM or maintenance that the mixer needed repair. On 06/01/2026 at 9:24 a.m., an interview was conducted with S3DM. She confirmed staff should have made her aware of the mixer being in disrepair. S3DM stated it should have also been documented on the maintenance log for repair.

Based on observation, record review, and interviews, the facility failed to implement EBP (Enhanced Barrier Precautions) for a resident with an indwelling medical device for 1 (#3) of 33 residents sampled. Findings:On 06/03/2026, a review of the facility's policy titled Enhanced Barrier Precautions with a last review date of 03/01/2026, read in part, Enhanced Barrier Precautions: Policy Explanation and Compliance Guidelines- 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism.) 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. b. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. dressing, c. transferring. g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Review of Resident #3's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage renal disease, dependence of renal dialysis, and morbid obesity. A review of Resident #3's physician orders failed to reveal an order for EBP.A review of a physician Encounter Report dated 03/24/2026, read in part, LIJ (left internal jugular) Vas (Vascular) Cath (Catheter) placed on 01/14/2026. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. On 06/02/2026 at 4:20 p.m., an interview was conducted with Resident #3. He stated that staff had never used gowns when caring for him; only gloves.On 06/03/2026 at 4:26 p.m., an observation and interview of S11CNA and S12CNA was conducted in Resident #3's room. S11CNA and S12CNA transferred Resident #3 from his wheelchair to his bed and changed his clothing, wearing gloves but no gown. A dressing to his left chest wall was visualized. Both S11CNA and S12CNA confirmed they did not wear a gown, and stated that gloves were the only form of PPE required when providing care for Resident #3. On 06/03/2026 at 12:10 p.m., an interview was performed with S2DON. She confirmed that Resident #3 had an indwelling medical device (central line) and had not been placed on EBP per facility policy. She further confirmed that staff should have worn gowns along with their gloves for high contact activities that included dressing and transferring. On 06/03/2026 at 12:20 p.m., an interview was conducted with S13IP. She confirmed that Resident #3 had an indwelling medical device (central line) and had not been placed on EBP per facility policy. She further confirmed that staff should have worn gowns with their gloves for high contact activities that included dressing and transferring.

Based on interview and record review, the facility failed to ensure medical records were accurately documented and maintained in accordance with professional standards of practice for 1 (Resident #2) out of 33 sampled residents.Findings:Review of the facility's policy titled, Colostomy/Ileostomy Care, with a last reviewed date of 03/01/2026 read in part, Documentation: The following information should be recorded in the resident's medical record. 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of individual(s) who provided the colostomy/ileostomy care. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included but were not limited to: constipation, acquired absence of other specified parts of digestive tract, and encounter for attention to colostomy.Review of Resident #2's physician's orders revealed an order dated 05/28/2025 which read: Colostomy care every day and night shift for colostomy status related to encounter for attention to colostomy. Review of Resident #2's care plan revealed the following in part: Resident has a colostomy with external drainage bag requiring ongoing management with interventions that included in part, colostomy/urostomy care as ordered. Review of Resident #2's January 2026-June 2026 TAR (Treatment Administration Record) revealed the following in part: Colostomy care every day and night shift for colostomy status related to encounter for attention to colostomy with a start date of 5/28/2025. Further review revealed the TAR failed to include the nurse's initials or evidence that the treatment was administered for the following:-January 2026: 3 days on the 7:00 a.m. - 7:00 p.m. shift and 10 days on the 7:00 p.m. - 7:00 a.m. shift.-February 2026: 2 days on the 7:00 a.m. - 7:00 p.m. shift and 11 days on the 7:00 p.m. - 7:00 a.m. shift.-March 2026: 25 days on the 7:00 p.m. - 7:00 a.m. shift-April 2026: 23 days on the 7:00 a.m. - 7:00 p.m. shift.-May 2026: 21 days on the 7:00 p.m. - 7:00 a.m. shift.-June 2026: 2 days on the 7:00 p.m. - 7:00 a.m. shift. On 06/03/2026 at 9:55 a.m., an interview and a record review of Resident #2's TAR from January 2026 to June 2026 was conducted with S2DON. She confirmed the above physician's order for colostomy care to be provided each shift, and acknowledged the missing initials mentioned above on the resident's TAR. S2DON stated the day and night shift nurses should have documented that they monitored the resident's colostomy by initialing each box on the TAR.

Based on record review and interview, the facility failed to ensure ongoing assessment and monitoring of the resident's dialysis access sites consistent with accepted professional standards for 1 (#3) out of 1 (#3) resident investigated for dialysis.Findings: Review of Resident #3 electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage renal disease, dependence of renal dialysis, and morbid obesity. A review of a physician Encounter Report dated 03/24/2026, read in part, LIJ (left internal jugular) Vas (Vascular) Cath (Catheter) placed on 01/14/2026. Review of Resident #3's Order Summary Report revealed a physician orders: 1. dated 07/30/2025, Patient to go dialysis every Monday, Wednesday, and Friday at dialysis provider. 2. dated 06/01/2026, Surgical vascular access keep incision clean and dry, cleanse daily with soap and water after the initial post-procedure period and apply a clean dressing daily. As needed. The order did not specify the location of the vascular access site. 3. dated 06/01/2026, Surgical vascular access Keep incision clean and dry, cleanse daily with soap and water after the initial post-procedure period and apply a clean dressing daily until healed. Every day shift 4. dated 02/02/2024, Monitor AV (arteriovenous) fistula right arm every shift. A review of Resident #25's MAR's (Medication Administration Record) and TAR's (Treatment Administration Record) for the months of February, March, April, May, and June 2026 failed to include monitoring of an LIJ (Left Internal Jugular) dialysis access that was placed on 01/14/2026. On 06/02/2026 at 12:30 p.m., an interview was conducted with S10LPN. S10LPN stated that she was the nurse assigned to Resident #3. When questioned about Resident #3's dialysis access sites, she stated that the resident only had a dialysis access site in his right arm. She stated that she is not aware of a chest wall dialysis access. On 06/03/2026 at 12:10 p.m., an interview and record review was conducted with S2DON. S2DON confirmed that Resident #3 had a LIJ (Left Internal Jugular) dialysis access on the left chest wall that was placed on 01/14/2026. She further confirmed that there was also a recent surgical site to the right arm dialysis access. She confirmed that there was no documentation that specified that the LIJ dialysis access was monitored for the months of February, March, April, May, and June of 2026 on the MAR or TAR. S2DON stated that the physician order should have been placed on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) to prompt staff to monitor the access sites. She stated that this was the process for which the nurses would be informed of where the dialysis accesses were located to monitor. S2DON confirmed the process had not been implemented to monitor the LIJ dialysis access.

Based on observation, record review, and interview, the facility failed to ensure the resident was receiving continuous oxygen at the ordered flow rate for 1 (#49) out of 33 sampled residents.Findings:Resident #49. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included congestive heart failure. Review of the resident's current physician's orders revealed an order for O2 (oxygen) at 1 Liter per nasal cannula continuously. On 06/03/2026 at 9:40 a.m., the resident was observed sitting up in her wheelchair in therapy room waiting for the physical therapist. During this observation, the resident was observed with oxygen in use at 2 liters per nasal cannula per portable oxygen tank. The portable oxygen tank was observed attached to the back of the resident's wheelchair. On 06/03/2026 at 9:42 a.m., S6LPN observed the resident in the therapy room. S6LPN checked the oxygen tank flow rate setting and confirmed the resident was receiving 2 liters of oxygen and not 1 liter of oxygen as ordered. After reviewing the resident's clinical record, S6LPN confirmed that there was no change in the orders and was not receiving the oxygen flow rate that was ordered.

Based on record review, observations, and interviews, the facility failed to address the needs of a resident experiencing impaired nutrition, by failing to implement physician orders and registered dietician recommendations for 1 (Resident #25) out of 7 residents investigated for nutrition. Findings:Review of Resident #25's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, schizoaffective disorder, bipolar type and major depressive disorder. Review of Resident #25's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating his cognition was intact.A review of Resident #25's Weights and Vitals Summary revealed a weight of 208.2 pounds on 11/21/2025 and a weight of 179.6 pounds on 05/06/2026. This indicated Resident #25 had a weight loss of 13.74% in 6 months. A review of Resident #25's Order Summary Report revealed the following physician orders in part:-04/23/2026 Add ice cream or pudding to lunch and supper daily,-04/23/2026 House supplement 4 ounces three times a day.A review of a dietary note on 04/22/2026 by the registered dietician revealed recommendations for house supplement 4 oz (ounces) tid (three times daily) and ice cream or pudding with lunch and supper.A review or Resident #25's dietary card for 06/02/2026 for lunch and dinner revealed no instructions for adding ice cream or pudding.A review or Resident #25's April, May, and June 2026 MAR (Medication Administration Record) revealed House Supplement three times a day anorexia 4 ounces with the letter X documented for every day. On 06/02/2026 at 10:45 a.m., an interview and record review was conducted with S10LPN who was assigned to Resident #25. After reviewing the MAR, S10LPN confirmed Resident #25 had an order for house supplement and stated she had not been offering it to the resident. On 06/03/2026 at 11:38 a.m., an interview and observation of Resident #25's lunch tray was conducted with Resident #25. The lunch tray did not contain ice cream or pudding. Resident #25 stated that he only received them sometimes. He also stated that no staff had been offering him a supplement. On 06/03/2026 at 11:42 a.m. an interview was conducted with S14LPN who was assigned to Resident #25. She stated I know for sure, he is not on any supplements when referring to Resident #25. On 06/03/2026 at 11:57 a.m., an interview and review of Resident #25's 06/02/2026 dietary card for lunch and supper was conducted with S3DM. She stated that she was not aware Resident #25 had an order for ice cream or pudding. She confirmed that the resident did not have any instruction for ice cream or pudding on his dietary card for lunch or supper and stated that he had only been receiving this when he had requested it. On 06/03/2026 at 12:10 p.m., an interview and record review was conducted with S2DON. She confirmed that the physician order for a house supplement for Resident #25 was not entered correctly in the software, and this was the reason X's are seen instead of staff initials on the MAR. She stated this was also the reason nurses were not notified by the software, during medication administration, to offer a supplement to the resident. She confirmed the resident should have had ice cream or pudding on his lunch or supper tray per the physician orders and registered dietician recommendations. S2DON stated that the dietary card should have had instructions to add ice cream or pudding with lunch and supper and it did not.

Based on record review, observations, and interviews, the facility failed to ensure that a resident who smoked was free from potential accidents and hazards by staff failing to hold resident's lit cigarette for 1 (#15) out of 1 (#15) resident investigated for unsafe smoking. Findings:A review of the facility's smoking policy titled, Smoking Policy, with a last reviewed date of 03/01/2026, read in part.Policy: When the resident requests to smoke, the interdisciplinary team will assess the resident's capabilities and deficits to determine appropriate supervision and assistance.Procedure:.5. Any resident choosing to smoke will be assessed by a member of the interdisciplinary team utilizing the smoking evaluation form. This assessment will be completed upon admission, quarterly, with a change of condition and as needed. Individualized approaches and directions for safety and assistance will be documented in the resident plan of care and communicated to direct care staff.Review of Resident #15's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebrovascular disease, quadriplegia, muscle wasting and atrophy, and diffuse traumatic brain injury. Review of Resident #15's Smoking Safety Evaluation dated 03/03/2026 read in part.Evaluation:.4. Total or limited ROM (range of motion) in arms or hands.checked yes.Insufficient fine motor skills needed to securely hold cigarette.checked yes.Drops ashes on self.checked yes .Concerns:. 11. Unable to hold a cigarette safely.checked yes.Review of Resident #15's care plan read in part .unsafe smoker-wears two aprons when smoking, cigarette is lit and held by staff .A review of Resident #15's facility's document titled, Special Instructions, revealed in part. cigarette must be lit and held by staff .On 06/01/2026 at 1:17 p.m., an observation was made of Resident #15 in the smoking area, smoking a cigarette. The resident was observed with the cigarette held in her right hand.On 06/02/2026 at 12:50 p.m., an observation was made of Resident #15 in the smoking area. S7CNAS was observed handing the resident a cigarette, and lighting the cigarette. Resident #15 was observed smoking a cigarette with the cigarette held in her right hand. S7CNAS and S8CNA were observed monitoring the residents in the area.On 06/02/2026 at 12:55 p.m., an interview was conducted with S8CNA. She stated that Resident #15 was an unsafe smoker and the resident holds her own cigarette. Resident #15 continued to smoke with the cigarette held in her right hand.On 06/02/2026 at 2:06 p.m., an interview was conducted with S7CNAS. She stated Resident #15 was an unsafe smoker. She stated that staff had to light her cigarette, but the resident held her own cigarette to smoke.On 06/02/2026 at 2:08 p.m., a record review and interview was conducted with S9MDS. S9MDS reviewed Resident #15's Smoking Safety Evaluation, care plan, and facility's document titled, Special Instructions and confirmed the above documentation stated cigarette was to be held by staff. She further confirmed the resident should not have held her own cigarette.

Based on record review and interview, the facility failed to ensure that a resident admitted to a facility without pressure ulcers received care to prevent the development of pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (#54) out 2 (#7, #54) residents investigated for pressure ulcers out of a total sample of 33 residents. Findings:Resident #54. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, dementia, moderate-protein calorie malnutrition, and anorexia. Review of the resident's admission MDS (Minimum Data Set) dated 02/04/2026 revealed the resident was admitted without any pressure ulcers. Further review of the MDS revealed the resident required moderate assistance to roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed; required substantial to maximal assistance for chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair or wheelchair.Review of the resident's Braden Risk assessment dated [DATE] revealed the resident was at moderate risk for pressure ulcer. Review of the resident's skin evaluation note dated 03/10/2026, that was created by S2DON, revealed there was no documentation concerning skin issues with the resident's heels. Review of the resident's skin evaluation note dated 03/11/2026 revealed, Observation during am care revealed a deep tissue injury (DTI) to right heel; 3.5cm (centimeter) x 3.0cm 100% dark .On 06/02/2026 at 2:20 p.m., an interview was conducted with S2DON. S2DON stated that a skin evaluation was conducted on 03/10/2026 and confirmed that she did not assess the resident's heels. S1DON stated that she could not provide documentation the resident's heels were being floated and that heel boots were being used as an intervention prior to the development of the DTI to resident's right heel. S1DON confirmed the order for floating the heels was after the development of the DTI to the resident's right heel.

Based on observation, interview, and record review, the facility failed to ensure the nurse maintained infection control practices while administering wound care treatments for 1 resident (#2) out of 2 resident's reviewed for wound care in a sample of 3 residents.Findings: Review of the facility's policy titled Handwashing/Hand Hygiene, with a last review date of 02/05/2026, read in part: Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin;.k. After handling used dressings, contaminated equipment, etc.m. After removing gloves. Review of the facility's policy titled Enhanced Barrier Precautions, with a last reviewed date of 02/05/2026, read in part: 2. EBPs (Enhanced Barrier Precautions) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.h. wound care (any skin opening requiring a dressing).5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds .6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound. Review of Resident #2's EHR (Electronic Health Record) revealed the resident had diagnoses including, but not limited to: Pressure ulcer of sacral region stage 4, type 2 diabetes, and UTI (Urinary Tract Infection). Review of Resident #2's physician's orders revealed the following order dated 01/20/2026 that read: Sacrum - cleanse with wound cleanser, apply gentian violet to wound then apply collagen and silver alginate to wound bed, cover with dry dressing and prn (as needed). On 02/24/2026 at 8:41 a.m., an observation was made of S4TNAgency perform Resident #2's wound care. S5CNA was also present during the wound care observation. There was a sign posted on the outside of the resident's door that read: Enhanced Barrier Precautions. Providers and staff must also: Wear gloves and a gown for the following High- Contact Resident Care Activities .Wound care. S4TNAgency and S5CNA did not wear gowns during Resident #2's wound care. During the wound care observation, S4TNAgency removed Resident #2's soiled dressing. S4TNAgency then removed her used gloves, placed them on the bedside table, and then put on clean gloves. S4TNAgency did not perform hand hygiene between glove changes. S4TNAgency proceeded to clean the resident's wound with wound cleanser and then applied gentian violet to the resident's wound. She did not change her gloves and/or perform hand hygiene after cleansing the resident's wound. At this time, Resident #2 began to have a bowel movement. S4TNAgency removed her gloves and placed them on the bed sheet. She did not perform hand hygiene. She left out of the resident's room and returned with wipes and gloves. S4TNAgency proceeded to put on clean gloves and began to clean the resident's bowel movement. She did not perform hand hygiene prior to putting on clean gloves. S4TNAgency cleansed the resident's bowel movement, removed her gloves, placed her used gloves on the bed sheet, and applied clean gloves. She did not perform hand hygiene after removing her used gloves. She then placed a clean brief under the resident, removed her gloves, and applied clean gloves. S4TNAgency did not perform hand hygiene prior to putting on clean gloves. S4TNAgency then applied silver alginate and collagen to the resident's wound. At this time, the resident began having a second bowel movement. She removed her gloves, placed them on the bed, and left out of the room. She did not perform hand hygiene after removing her used gloves before exiting the room. She returned to the room, applied clean gloves, but did not perform hand hygiene. S4TNAgency proceeded to clean the resident's bowel movement, then removed her used gloves and applied clean gloves. She did not conduct hand hygiene between glove changes. S4TNAgency then placed the resident's clean dressing to her wound. On 02/24/2026 at 9:25 a.m., an interview was conducted with S4TNAgency. S4TNAgency confirmed that she did not bring hand sanitizer into Resident #2's room during the wound care observation. She confirmed that she did not conduct hand hygiene using hand sanitizer or wash her hands using soap and water between glove changes, and she knew that she was supposed to sanitize or wash her hands between glove changes. S4TNAgency also confirmed that after cleansing the resident's wound, she did not change her gloves and proceeded to apply gentian violet to the resident's wound. S4TNAgency also confirmed that she placed soiled gloves on the resident's bed, and did not discard them in the trash after changing her gloves and should have. On 02/24/2026 at 10:06 a.m., an interview was conducted with S2DON/IC. S2DON/IC confirmed that S4TNAgency should have conducted hand hygiene between glove changes, changed gloves after cleansing the resident's wound, and should not have placed soiled gloves on the resident's bed. She also confirmed used gloves should have been placed in the trash can. On 02/24/2026 at 11:49 a.m., an interview was conducted with S5CNA. S5CNA confirmed that the Resident #2 had a sign for EBP posted on her door, and she did not wear a gown during the resident's wound care. S5CNA stated that she knew she had to wear a gown and gloves when having direct contact with a resident on EBP. On 02/24/2026 at 11:55 a.m., another interview was conducted with S4TNAgency. S4TNAgency was asked if she should have worn a gown during Resident #2's wound care because the resident was on EBP. She stated the resident should not be on EBP, and the sign should have been taken off of the door because the resident's wound was not draining. On 02/24/2026 at 12:01 p.m., an interview was conducted with S3NS who assisted the Director of Nursing with infection control throughout the facility. S3NS stated that because the resident had a chronic stage 4 wound, according to EBP, the treatment nurse and CNA should have worn PPE including gown and gloves during wound care.

Based on observations, interview and record review, the facility failed to ensure licensed agency nurses had specific competencies and skills sets necessary to appropriately administer wound care to 1 resident (#2) out of 2 resident's reviewed for wound care in a sample of 3 residents. Findings:Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 06/14/2017 and diagnoses including, but not limited to: Pressure ulcer of sacral region stage 4, type 2 diabetes, and UTI (Urinary Tract Infection).Review of Resident #2's physician's orders revealed the following order dated 01/20/2026, that read: Sacrum - cleanse with wound cleanser, apply gentian violet to wound then apply collagen and silver alginate to wound bed, cover with dry dressing and prn (as needed). On 02/24/2026 at 8:41 a.m., an observation was made of S4TNAgency perform Resident #2's wound care. S5CNA was also present during the wound care observation. There was a sign posted on the outside of the resident's door that read: Enhanced Barrier Precautions. Providers and staff must also: Wear gloves and a gown for the following High- Contact Resident Care Activities .Wound care. S4TNAgency and S5CNA did not wear gowns during Resident #2's wound care. During the wound care observation, S4TNAgency removed Resident #2's soiled dressing. S4TNAgency then removed her used gloves, placed them on the bedside table, and then put on clean gloves. S4TNAgency did not perform hand hygiene between glove changes. S4TNAgency proceeded to clean the resident's wound with wound cleanser and then applied gentian violet to the resident's wound. She did not change her gloves and/or perform hand hygiene after cleansing the resident's wound. At this time, Resident #2 began to have a bowel movement. S4TNAgency removed her gloves and placed them on the bed sheet. She did not perform hand hygiene. She left out of the resident's room and returned with wipes and gloves. S4TNAgency proceeded to put on clean gloves and began to clean the resident's bowel movement. She did not perform hand hygiene prior to putting on clean gloves. S4TNAgency cleansed the resident's bowel movement, removed her gloves, placed her used gloves on the bed sheet, and applied clean gloves. She did not perform hand hygiene after removing her used gloves. She then placed a clean brief under the resident, removed her gloves, and applied clean gloves. S4TNAgency did not perform hand hygiene prior to putting on clean gloves. S4TNAgency then applied silver alginate and collagen to the resident's wound. At this time, the resident began having a second bowel movement. She removed her gloves, placed them on the bed, and left out of the room. She did not perform hand hygiene after removing her used gloves before exiting the room. She returned to the room, applied clean gloves, but did not perform hand hygiene. S4TNAgency proceeded to clean the resident's bowel movement, then removed her used gloves and applied clean gloves. She did not conduct hand hygiene between glove changes. S4TNAgency then placed the resident's clean dressing to the wound.On 02/24/2026 at 9:25 a.m., an interview was conducted with S4TNAgency. S4TNAgency confirmed that she did not bring hand sanitizer into Resident #2's room during the wound care observation. She confirmed that she did not conduct hand hygiene using hand sanitizer or wash her hands using soap and water between glove changes, and that she knew that she was supposed to sanitize or wash her hands between glove changes. S4TNAgency also confirmed that after cleansing the resident's wound, she did not change her gloves and proceeded to apply gentian violet to the resident's wound. S4TNAgency also confirmed that she placed soiled gloves on the resident's bed, and did not discard them in the trash after changing her gloves and should have.On 02/24/2026 at 11:55 a.m., another interview was conducted with S4TNAgency. She stated that she had been doing wound care for all residents for the last two weeks, and she was not trained on the facility's policies and/or procedures when she began doing treatments at the facility. She stated that she was not able to shadow or obtain direction from the nurse doing treatments prior to her, and she was not given any direction on how to complete the treatments or provide the wound care other than following the physician's orders. On 02/24/2026 at 12:05 p.m., an interview as conducted with S1Administrator. S1Administrator was asked who was responsible for ensuring agency staff was competent and trained on the facility's policies and procedures. She stated that the previous Director of Nursing was responsible for providing training on the facility's policies and procedures and ensuring agency staff had the required competencies to care for residents. S1Administrator was asked to provide evidence that S4TNAgency had competencies and was trained on the facility's policies and procedures being that she was providing treatments to the whole facility and had been for the last two weeks.The previous Director of Nursing was not available for interview at the time of the survey.On 02/24/2026 at 2:09 p.m., S1Administrator stated that there was no documented evidence that S4TNAgency was trained on the facility's policies and procedures, and no evidence that the facility ensured the she was competent to provide wound care for all residents at the facility.

Based on record review, observations, and interviews the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#1) of 3 sampled residents as evidenced by failing to ensure Resident #1 wore heel lift boots while in bed. Findings: Review of Resident #1's EHR (Electronic Health Record) revealed an admission date of 12/22/2005 and had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and type 2 diabetes. Review of Resident #1's care plan revealed the following goals and interventions in part: Potential for skin breakdown r/t (related to) decreased mobility and incontinence, dx (diagnosis) hemiplegia - Interventions: heel lift boots while in bed. Review of Resident #1's physician's orders revealed the following order dated 03/24/2025 that read: Heel lift boots while in bed every day shift. On 02/23/2026 at 2:50 p.m., an observation was made of Resident #1 in bed. The resident was not wearing heel lift boots at this time. On 02/24/2026 at 9:11 a.m., a second observation was made of Resident #1 in bed. The resident was not wearing heel lift boots at this time. On 02/24/2026 at 10:55 a.m., a third observation was made of Resident #1 in bed. The resident was not wearing heel lift boots at this time. S6CNA entered the resident's room. S6CNA was asked if the resident was supposed to have on heel lift boots while in bed. She stated that she really did not know if he was supposed to have them on and did not know where they were in the room. On 02/24/2026 at 11:00 a.m., an interview was conducted with S7LPN who stated she was the resident's nurse for this shift. S7LPN was asked if Resident #1 was supposed to be wearing heel lift boots while in bed, and she stated she was not very familiar with his care because she was not normally assigned to the resident. Resident #1's orders were reviewed with S7LPN. She confirmed that the resident had an order for heel lift boots while in bed and further confirmed that he should have had them on, but they were not.

Based on policy review, interviews and record reviews, the facility failed to file a grievance for 1 (Resident #2) out of 10 (#1-#9 and #R1) sampled residents.Findings:Review of the facility's policy and procedure titled, Grievances/Complaints, Filing, with a revised date of April 2017 revealed, in part: Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care not furnished.Grievances and/or complaints may be submitted orally or in writing.Upon receipt of a grievance and/or complaint, the Grievance officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.Review of Resident #2's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses, but were not limited to, end stage renal disease, dependence on renal dialysis, type 2 diabetes and atrial fibrillation. On 08/27/2025 at 9:52 a.m., a phone interview was conducted with Resident #2's appointed representative. She reported Resident #2 called her and told her he fell while in his wheelchair on the lift of the van prior to leaving the facility for his scheduled dialysis on Saturday morning 06/21/2025. Resident #2's representative stated she was really, really upset because the facility hadn't notified her until the night of 06/21/2025. She stated she went to the facility on Monday morning, 06/23/2025 and spoke to S1DON (Director of Nursing) in person about her concerns.Review of the facility's grievance log from June 2025 until August 25, 2025 failed to include a grievance filed for Resident #2.On 08/27/2025 at 3:40 p.m., an interview was conducted with S1DON. She confirmed she did speak with Resident #2's appointed representative in person on Monday 06/23/2025. S1DON verified Resident #2's representative was upset that she was not notified of the accident involving Resident #2 and the van lift prior to the resident's scheduled dialysis on Saturday 06/21/2025. S1DON denied filing a grievance.

Based on policy review, interviews and record reviews, the facility failed to ensure staff provide care and services that meet professional standards of quality as evidenced by failing to perform chest compressions immediately to a resident requiring cardiopulmonary resuscitation (CPR) for 1 (#5) resident out of 10 (#1-#9 and #R1) sampled residents.Findings:Review of Resident #5's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction (Stroke), weakness, jaw pain, hyperlipidemia, type 2 diabetes mellitus without complications and hypertension. Review of Resident #5's June 2025 physician's orders revealed an order date of 09/25/2024 for full code status.Review of the facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, with a revised date of April 2016, revealed in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), for victims of sudden cardiac arrest.Preparation for CPR. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material.Emergency Procedure-Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: .d. Initiate the basic life support sequence (BLS) of events. 2. The BLS sequence of event is referred to as C-A-B (chest compression, airway, breathing). 3. Chest compressions: a. following initial assessment, begin CPR with chest compressions.d. Minimize interruptions in chest compressions.6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest.Review of the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care revealed in part:.Increased focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is performed in all resuscitation attempts. According to an American Heart Association Journal (https://doi.org/10.1161/CIR.0000000000000916), AHA implemented updates to Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care in 2020, which incorporated the importance of minimizing interruptions in chest compressions and ensuring chest compressions provided are of adequate rate and depth. CPR is the single-most important intervention for a patient in cardiac arrest, and chest compressions should be provided promptly. Chest compressions are the most critical component of CPR, and a chest compression-only approach is appropriate if lay rescuers are untrained or unwilling to provide respirations.Review of Resident #5's nursing progress notes revealed an entry dated 06/02/2025 at 7:50 a.m. per S3LPN (Licensed Practical Nurse) read in part: Called into Resident's bedside by CNA (Certified Nursing Assistant) passing food tray. Resident located in bed, nonresponsive and nonreactive to verbal or tactile stimuli. No movements were present. Nonreactive pupil reflex. Grunting breath sounds present. No pulse present. Resident's chart clarified full code. Code Blue initiated. Began CPR at 7:57 a.m. Emergency Medical Services (EMS) arrived at 8:10 a.m. Resident expired on 06/02/2025 at 8:48 a.m.Review of EMS' Pre-Hospital Care Report Summary dated 06/02/2025 revealed the following:Call Received at 07:56:19, EMS Dispatched at 07:56:26, EMS en route at 07:56:31 and arrived on scene at 08:05:55. EMS made contact with Resident #5 at 08:08:55. Chief compliant (primary) was Cardiac Arrest and provider impression was Cardiac Arrest. EMS initiated Protocol 1: Asystole / PEA Protocol. EMS assessment revealed Resident #5 was apneic (breathing had stopped), skin was pale in color and was unresponsive which was not normal for the resident. On 08/26/2025 at 4:06 p.m., an interview was conducted with S7WC (Ward Clerk) who confirmed she was working on the morning of 06/02/2025. S7WC explained S6CNA asked S7WC to go with her because Resident #5 was not herself. S7WC reported Resident #5 was observed sitting up, kind of slouched in bed, not responding and her eyes were closed. S7WC stated she exited the resident's room and called 911. S7WC stated S1DON (Director of Nursing) started chest compressions when S1DON arrived to the facility around 8:00 a.m. on 06/02/2025.On 08/26/2025 at 4:12 p.m., an interview was conducted with S6CNA. S6CNA confirmed she was assigned to Resident #5 on the day shift on 06/02/2025. S6CNA explained she was picking up breakfast trays and she went into Resident #5‘s room and observed Resident #5 in her bed and her eyes were open but Resident #5 was not responding. Then S6CNA called S7WC and S3LPN to observe Resident #5. S3LPN then notified S1DON who was on her way to work. S1DON started CPR when she arrived to the facility on [DATE] around 8:00 a.m.On 08/26/2025 at 4:26 p.m., an interview was conducted with S3LPN. S3LPN confirmed she was assigned to Resident #5 on the day shift on 06/02/2025. She explained she was called to Resident #5's room by S6CNA because S6CNA reported Resident #5 was breathing weird and was not acting like herself. S3LPN stated when she went to Resident #5's room, she observed the resident kind of slouched in her bed. S3LPN attempted to arouse Resident #5, but the resident was not responsive. S3LPN reported that she did not start chest compressions immediately. S3LPN explained S7WC called 911 and S1DON started CPR when she arrived to the facility around 8:00 a.m. On 08/27/2025 at 1:42 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON explained S3LPN notified her via text message on 06/02/2025 at 7:52 a.m. that Resident #5 was unresponsive, had labored breathing, and pupils were not reactive. S1DON instructed S3LPN to call 911 and start CPR-chest compressions. S1DON further explained she arrived to the facility on [DATE] at 8:00 a.m. and immediately went to Resident #5's room and performed a sternal rub with no resident response. S1DON then hollered for S7WC to call 911 and then S1DON started chest compressions. S1DON verified S6CNA and S3LPN were CPR certified and should have started CPR immediately after discovering Resident #5 was unresponsive.

Based on policy review, interviews and record reviews, the facility failed to ensure staff maintained current CPR certification for 1 (S3LPN-Licensed Practical Nurse) of 3 (S3LPN, S5LPN and S6CNA-Certified Nursing Assistant) personnel records reviewed.Findings: Review of the facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, with a revised date of [DATE], revealed in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), for victims of sudden cardiac arrest.Preparation for CPR 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material. On [DATE] at 4:26 p.m., an interview was conducted with S3LPN who stated she had BLS certification.A review of S3LPN's personnel record revealed her BLS certification expired 05/2025 but was not renewed until [DATE].On [DATE] at 3:40 p.m., an interview and review of S3LPN's BLS certification records was conducted with S1DON (Director of Nursing). S1DON confirmed S3LPN's BLS certification had lapsed and should have been renewed in 05/2025, but was not.

Based on record review and interviews, the facility failed to ensure that a resident's physician and responsible party were immediately notified when the resident was injured for 1 (Resident #2) of 10 (#1-#9 and #R1) sampled residents. Findings:Review of the facility's policy with a review date of 01/01/2024 titled, Accidents and Incidents - Investigating and Reporting read in part, Policy Interpretation and Implementation, 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom.Review of Resident #2's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, end stage renal disease, dependence on renal dialysis, type 2 diabetes and atrial fibrillation. Review of the facility's Incident Report dated 06/21/2025 revealed Resident #2 had an incident described as a fall during staff assist on 06/21/2025 at 7:00 a.m. Further review of the facility's incident report revealed the wrong physician and wrong responsible party were notified on 06/21/2025.On 08/25/2025 at 7:27 a.m., a phone interview was conducted with S4LPN (Licensed Practical Nurse). She stated that on the morning of 06/21/2025, she recalled the fall incident involving Resident #2 and the facility's van driver. S4LPN confirmed she did not immediately notify the resident's responsible party because she believed she had 72 hours to notify the resident's family and physician. On 08/27/2025 at 4:30 p.m., an interview was conducted with S1DON (Director of Nursing) and S2ADM (Administrator). Both confirmed they were familiar with the staff assisted fall involving Resident #2 and the facility van on 06/21/2025. Both verified S4LPN failed to notify the correct physician and the resident's responsible party.

Based on record review and interview, the provider failed to implement the plan of care by not following physician orders to obtain laboratory testing as ordered for 1 (#2) out of 3 (#1, #2, #3) sampled residents.Review of Resident #2's medical record revealed his most recent readmission to the facility was on 02/04/2025 with diagnoses which included: essential hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia, and hyperlipidemia. Review of Resident #2's order summary report revealed laboratory orders dated 02/25/2025 for the following: Lipid panel q (every) 6 months (June/December); and PSA (Prostate Specific Antigen) and urine for microalbumin yearly (June). Further review of Resident #2's medical record failed to reveal evidence a Lipid panel, PSA and urine for microalbumin were obtained during the month of June.On 07/29/2025 at 10:30 a.m., an interview and record review of physician orders and laboratory testing results was conducted with S1DON (Director of Nursing). She confirmed Resident #2 had orders to obtain a Lipid panel every 6 months (June/December), and a PSA and urine for microalbumin yearly (June). She reviewed the file for laboratory results and confirmed those tests were not obtained as ordered.

Based on observation, record review, and interview, the facility failed to ensure residents that were unable to carry out activities of daily living received personal hygiene (incontinent care) per their care plan for 1 (#1) out of 3 (#1-#3) sampled residents. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypertension, and copd (chronic obstructive pulmonary disease). Review of the resident's annual MDS (Minimum Data Set) dated 06/11/2025 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 for being cognitively intact. Further review of the annual MDS revealed the resident had limited ROM (Range of Motion) on one side; used a wheelchair for mobility device; was dependent for toileting and personal hygiene. The resident was dependent for mobility. The resident was assessed to be incontinent for bowel and bladder. Review of the resident's care plan revealed that it addressed alteration in elimination related to bowel and bladder incontinence and to check every 2 hours for dryness and assist with personal care. On 07/28/2025 at 9:30 a.m., the resident was observed sitting up in wheelchair in the dayroom for an activity. On 07/28/2025 at 10:45 a.m., the resident was observed participating in activities in the dayroom. On 07/28/2025 at 11:00 a.m., the resident was observed sitting up in her wheelchair in the dayroom after activities. S4CNA (Certified Nursing Assistant) was then observed bringing the resident to the dining room for lunch. There was no observation of staff bringing the resident back to her room for incontinent care prior to lunch. On 07/28/2025 at 12:15 p.m., S5CNA and S6CNA were observed transferring the resident from her wheelchair to the bed with the use of the lifter with 2 person assist. The resident's pants were observed to be soaking wet when resident was lowered down in bed. S5CNA and S6CNA both confirmed the resident's pants was soaking wet. S6CNA stated the resident should have been toileted every 2 hours to ensure the resident was not wet. S6CNA stated she cleaned and changed the resident around 6:30 a.m. or 7:00 a.m. and that she did not change the resident again until now after lunch, which was approximately over 5 hours ago. On 07/28/2025 at 4:15 p.m., an interview was conducted with S1DON (Director of Nurses). S1DON stated the residents should be checked or rounded on every 2 hours and as needed for incontinent episodes. S1DON stated that checking for incontinent episodes requires the CNAs to bring the resident back to their room in order to check for incontinent episodes. On 07/29/2025 at 8:15 a.m., an interview was conducted with S3CNAS (Certified Nursing Assistant Supervisor). S3CNAS stated the CNAs should be toileting Resident #1 every 2 hours and that means the resident should be brought to her room and put in bed with the use of the lifter and incontinent care be provided. S3CNAS confirmed S5CNA and S6CNA informed her that the resident was not brought to her room for incontinent care that morning and was brought after lunch and at that time the resident was soaking wet.

Based on observation, record review, and interview, the facility failed to ensure the resident was receiving continuous oxygen as ordered for 1 (#1) out of 3 (#1-#3) sampled residents.Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypertension, and copd (chronic obstructive pulmonary disease).Review of the resident's annual MDS (Minimum Data Set) dated 06/11/2025 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 for being cognitively intact. Review of the resident's care plan revealed that it addressed the resident was at risk for edema and sob (shortness of breath) related to copd. Interventions included administer respiratory therapy treatments, assess for signs and symptoms of respiratory distress, and oxygen as ordered.Review of the resident's current physician's orders revealed an order for oxygen at 2L/NC (two liters nasal cannula) continuously to keep sats (oxygen saturation) greater than 92% for hypoxia. The order was started on 07/22/2025.Review of the resident's nurse's note dated 07/28/2025 at 11:00 a.m. revealed, Resident observed in dining room with no oxygen on per n/c as ordered.On 07/28/2025 at 9:30 a.m., the resident was observed sitting up in wheelchair in the dayroom for an activity. An oxygen tank was observed inside the oxygen tank holder that was attached to the back of the resident's wheelchair. The oxygen was not in use during this observation. On 07/28/2025 at 10:45 a.m., the resident was observed participating in activities in the dayroom. The resident was not using oxygen during this observation.On 07/28/2025 at 11:00 a.m., the resident was observed being brought to the dining room for lunch by S4CNA (Certified Nursing Assistant). The oxygen tank was observed inside the tank holder that was attached on the back of the resident's wheelchair. S4CNA was asked if the resident used oxygen. S4CNA responded that she did not know if the resident used oxygen. The resident was not using oxygen during this observation.On 07/28/2025 at 11:05 a.m., an observation and interview were conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed the oxygen tank was inside the tank holder on the back of the resident's wheelchair. S2LPN checked the oxygen tank and verified it was empty. On 07/28/2025 at 11:10 a.m., S2LPN reviewed the resident's physician's orders and confirmed the resident had orders for continuous oxygen at 2 liters per nasal cannula. S2LPN confirmed the resident was not receiving continuous oxygen as ordered.On 07/28/2025 at 4:15 p.m., an interview was conducted with S1DON (Director of Nursing) and she confirmed the resident should have had continuous oxygen in use per the physician's orders.

Based on observations and interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 87. Findings: On 05/06/2025 at 8:35 A.M., an observation of the daily posted staffing information revealed a date of 05/05/2025 with a census of 90 residents. On 05/08/2025 at 8:15 A.M., a second observation of the daily posted staffing information revealed a date of 05/05/2025 with a census of 90 residents. On 05/08/2025 at 10:50 A.M., an interview was conducted with S11AC (Administration Clerical). She confirmed that the staffing information posted daily included information from the day before. The staffing information with a date of 05/05/2025 including staffing information and census from 05/04/2025. She stated the information had always been posted with the previous day's information, and not the current date.

Based on record review and interview the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1(133) out of 5 (103, 150 ,94, 27) residents who were wanderers. This failed practice occurred when hall A was left unattended. As a result on [DATE] at 4:10 PM Resident #133 was placed in an immediate jeopardy situation when he left the building and wandered outside to the facility's parking lot after S2 CNA left hall A unattended to help S3 CNA with another resident on an adjacent hall. He was found past the facility's designated smoking area which is 25 feet away from the door that the resident used to exit the facility. Resident #133 was found nonresponsive with an open head wound on the right side of his forehead in the facility's parking lot. S4 LPN found the resident as a visitor to the facility initiated CPR (Cardiopulmonary Resuscitation) and an ambulance was called. On [DATE] Resident #133's hospital notes were reviewed. According to the hospitals radiology report the resident sustained [REDACTED]. The resident was placed on a respirator and admitted to the intensive care unit. The Immediate Jeopardy was lifted for Resident #133 on [DATE] at 4:45PM when he was taken to the hospital via ambulance. The Immediate Jeopardy remained in place for 11 other residents residing in the facility who were identified as wanders until [DATE] at 11:30 AM when the facility presented an acceptable plan of removal. The deficient practice remained at a Level III of Actual Harm. The facility's plan of removal included: Immediately, additional nursing staff (X2) has been placed for the entire facility to ensure their sole job will be to monitor the facility to ensure wandering residents do not exit the building unsupervised. These staff members have been in-serviced on [DATE] and have taken their position immediately at their post and have been instructed that they are not to leave their post (hall) for any reason without reporting to the Quality Assurance Nursing Staff and /or their staff nurse at their respective station and to follow the same protocol when they return to their post. This protocol will allow another staff member to monitor that specific location so the location is monitored at all times. This protocol is being followed twenty-four (24) hours per day, seven (7) days a week. A log has been created and is being utilized by the Quality Assurance staff in order to track staff on the hall and at all times. All employees were in-serviced on the same as of [DATE]th 2015 at 10:00 AM. The Director of Nurses and/or designee will monitor daily to ensure this protocol is being followed. Any further issues will be brought to the Quality Assurance Committee for review and action." Findings: On [DATE] the resident's Minimum Data Sheet dated [DATE] was reviewed. It stated the resident had [DIAGNOSES REDACTED]. Under the section titled Behavior the resident was coded as 1 which means the resident had verbal behavioral symptoms towards others and under the section for wandering the resident was coded as 3 which means the behavior of that type occurred daily. On the same day the resident's care plan was reviewed. Included in the care plan was a problem onset of having to "wear a wander guard device due to my risk and/or potential for elopement. The approach for this problem onset was, "Place resident in area where constant observation is possible. In addition, a form entitled Evangeline Oaks Elopement consent form dated [DATE] stated, "Res attempted to elope from facility expresses desire to be home. Able to redirect by staff." On [DATE] Resident #133's hospital notes were reviewed. According to the hospitals radiology report the resident sustained [REDACTED]. The resident was placed on the respirator and admitted to the intensive care unit. On [DATE] the facility's incident and accident report was reviewed. It revealed on [DATE] at 4:10 PM, "noted door alarm going off, this nurse went out of back door at end of hall a) and noted resident laying on right side with merry walker laying on side of (word missing), noted resident non-responsive, unhooked merry walker straps and with assist times 1 assessed noted head injury open wound to right side of forehead, no pulse noted, no respirations noted." On the same document under the title Immediate Actions Taken: CPR (Cardiopulmonary Resuscitation) initiated while waiting on DNR (Do Not Resuscitate) status and an ambulance to be called. On [DATE] at 10:30 AM S2 CNA was interviewed. She stated, "I was the CNA down hall B when resident #133 left the building. I was down that hall with another CNA helping her take care of a resident on that hall in room A. I did not hear the alarm go off. If I'm on another hallway I can't hear the alarm and when I'm more than halfway down hall A I can't hear the alarm. When I got out of the room I went to see what's going on. When I found out resident #133 was on the ground I went to get him a blanket and I then brought the crash cart to them. S4LPN and another nurse that does not work here were doing Cardio Pulmonary Resuscitation. He had a gash in his head." When asked about the resident's behavior the CNA stated, "He was aggressive. He would never sit down even when he was hurting. He would say that he was trying to get out. He was going to the doors to try to leave since he came." When the CNA was asked the reason she was alone on the hall she stated, "We are 2 CNA's on each hall. We each take a 15 minute break. When S1 CNA was on her break it leaves only one CNA. When she comes back I take my break. We usually start taking our breaks at 4:00 PM so there's 30 minutes that there's only one CNA on the hall." When asked if she had told anyone she was leaving the hall unattended she stated, "No, I didn't tell anyone I was leaving the hallway." On [DATE] at10:38 AM S1 CNA was interviewed, She stated, "I was working on the back of A hall. I was on break when that happened. We are left by ourselves when the other CNA's are on break." When asked about the resident's behaviors S1 CNA stated, "His behavior that day was normal for him. He's a little combative. He's active and tries to get out of bed. He was in his merry walker that day. I did not hear an alarm go off from the break room. When I'm on my hall I can't hear the alarm when I'm in a room with the door closed." On [DATE] at 11:00 AM S6CNA was interviewed. She stated, "He tries to elope all the time. We always watch the wanderers more. He was in area C walking around. I redirected him to area D. The ward clerk was at the station I don't remember who else was there. I wanted to keep him where we can watch him closer. Later I saw them doing CPR and I came back into the building." When asked about his behaviors the CNA stated, "In his case he's fast. He has gone through doors many times. We were always able to get to him. Sometimes he swung at us but we were always able to get him back in. His behavior was normal for him that day." On [DATE] at11:30 AM S4 LPN was interviewed. She stated, "I was his nurse. I was in the medication room for a few minutes. I heard the alarm after leaving the med room. I rushed to the end of the hallway. When I got outside I saw resident #133 was on the ground. I went to him. He wasn't responding. He wasn't breathing, he had no pulse and no blood pressure. A family member who was visiting their family was outside with me and the family member initiated CPR. I told a CNA to get the crash cart and call the ambulance." When asked about when she heard alarm S4LPN stated, "I was walking toward the hall when I heard the alarm. I did not hear the alarm at the nurse's station. I was closer to the hall when I first heard the alarm. When I got there I saw resident #133 had an open wound to his head." When asked about his behavior that day the nurse stated, "I saw him a few minutes before it happened. He wandered all the time. He tried to leave all the time." On [DATE] at 12:00 PM S7 CNA Supervisor was interviewed she stated, "The CNA's do team work if one CNA is busy they will help the other CNA. I would expect the CNA to ask someone to watch the hall before leaving a hall unattended." When asked about the residents' behavior she stated, "His behaviors were constantly in motion. As long as someone was with him he was ok but when he wasn ' t constantly looked after he was on his way to a door. At times his cognition was better than others. If he was walking he was going toward a door to get out. He wasn't trying to get out when he first got here but after a while he was trying to leave. That's why they put the wander guard." On [DATE] at1:30 PM S5DON was interviewed. She stated, "there is no one specific person that looks after wanderers. Everyone knows to keep an extra eye out for wanderers with wander guards. There's no set policy. Everyone just knows they have to help each other. On [DATE] the facility's nurses notes were reviewed. It revealed the incident happened at 4:10 PM. At 4:13 PM it was noted the ambulance was called and was in route. The ambulance arrived at 4:20 PM and left with the resident for the hospital at 4:45 PM. According to the hospitals radiology report the resident sustained [REDACTED]. The resident was placed on a respirator and admitted to the intensive care unit. According to the nurses notes on [DATE] at 11:43 PM S8 LPN was informed by the hospital that the resident died after being taken off his ventilator at family's request.

Based on record review and interview the facility's Administrator failed to ensure a resident received adequate supervision to prevent accidents by failing to have enough supervision down hall A. As a result of this failure 1 (#133) out of 5 (#103, #150 ,#94, #27, #133) wandering resident left the building and wandered outside Resident #133 was in immediate jeopardy on [DATE] at 4:10 PM when S2 CNA left hall A unattended to help S3 CNA with another resident on an adjacent hall. Resident #133 wandered out of the end of hall A and into the facility parking lot. He was found nonresponsive with an open wound on the right side of his forehead in the facility's parking lot which was approximately 40 to 50 feet away from the exit. S4 LPN found the resident and initiated CPR (Cardiopulmonary Resuscitation) and an ambulance was called. According to hospital records resident #133 sustained a fracture to C-1 and C-2 of his neck. A review of the facility's nurses notes on [DATE] revealed S8 received a call from the local hospital that the resident died after being taken off his respirator at family request. Findings: On [DATE] the resident's Minimum Data Sheet dated [DATE] was reviewed. It stated the resident had [DIAGNOSES REDACTED]. Under the section titled Behavior the resident was coded as 1 which means the resident had verbal behavioral symptoms towards others and under the section for wandering the resident was coded as 3 which means the behavior of that type occurred daily. On the same day the resident's care plan was reviewed. Included in the care plan was a problem onset of having to "wear a wonder guard device due to my risk and/or potential for elopement. The approach for this problem onset was, "Place resident in area where constant observation is possible. In addition, a form entitled Evangeline Oaks Elopement consent form dated [DATE] stated, "Res attempted to elope from facility expresses desire to be home. Able to redirect by staff." On [DATE] the facility's incident and accident report was reviewed. It revealed on [DATE] at 4:10 PM, "noted door alarm going off, this nurse went out of back door at end of hall A and noted resident laying on right side with merry walker laying on side of (word missing), noted resident non-responsive, unhooked merry walker straps and with assist times 1 assessed noted head injury open wound to right side of forehead, no pulse noted, no respirations noted." On [DATE] at 10:30 AM S2 CNA was interviewed. She stated, "I was the CNA down the hall when resident #1 left the building. I was down B hall with another CNA helping her take care of a resident on that hall in room A. I did not hear the alarm go off. If I'm on another hallway I can't hear the alarm and when I'm more than halfway down the hall I can't hear the alarm. When I got out of the room I went to see what's going on. When I found out resident #133 was on the ground I went to get him a blanket and I then brought the crash cart to them. S4LPN and another nurse that does not work here were doing CPR. He had a gash in his head." When asked about the resident's behavior the CNA stated, "He was aggressive. He would never sit down even when he was hurting. He would say that he was trying to get out. He was going to the doors to try to leave since he came." On [DATE] at 12:00 PM S7 CNA Supervisor was interviewed she stated, "The CNA's do teamwork work if one CNA is busy they will help the other CNA. I would expect the CNA to ask someone to watch the hall before leaving a hall unattended." When asked, the CNA Supervisor stated there was a form that the CNA's are supposed to fill out stating when they go on break and when they return and did not know the a) hall was unattended. A review of this form was done on [DATE]. The form dated [DATE] Saturday showed there was no one who signed in or out of a) hall that day. On [DATE] at 1:30 PM S5 DON was interviewed she stated, There is no one specific person that looks after wanderers. Everyone knows to keep an extra eye out for wanderers with wander guards. There's no set policy. Everyone just knows they have to help each other."

Based on observation, interview and record review, the facility failed to maintain a quality assessment and assurance committtee that identified issues and implemented appropriate plans of action to correct deficiencies as evidenced by failing to identify 5 sets of exit double doors that did not alarm when opened in 4 of 9 areas designated as Catch All Alarm exit doors. (2 sets in the Smoking Room, 1 on the Burgandy Hall (Cross Hall near the Laundry), 1 in the TV Room/Living Room Orange Station and 1 at the end of the Orange Hall) FINDINGS: A tour of the facility's exit/entry doors was conducted on 9/7/12 at 10:18 am, along with S5, Maintenance Supervisor and S6, Housekeeping. S5, Maintenance Supervisor stated that he performed the checks on all of the facility doors, both the Wander Guard Doors and the Catch All Doors once a day and that the weekend maintenance workers performed the checks in his absence. An observation was made on 9/7/12 at 10:26 am of the Smoke Room across from the Blue Nurse's Station with 9 residents inside smoking and no staff were in the room upon entry. 2 sets of double doors were located that opened to the outside front porch of the facility. S5, Maintenance Supervisor demonstrated the use of the doors by opening all 4 doors one at a time. The Right side of each double door (2 doors) did not close completely after opening and upon resetting the alarm system the doors did not activate the audible alarm when he reopened them. S5, Maintenance Supervisor confirmed that the 2 Right sided doors in the room did not properly sound the audible alarm when opening and he stated that the door jams would need to be adjusted to allow the doors to close completely after opening each time. S5, Maintenance Supervisor also stated that the wiring contacts located on the top of each door for the alarm system were rusted and were not working properly. S5, Maintenance Supervisor stated that residents could potentially leave the facility through these doors without the alarm system working properly and that these doors exited to the front porch, parking lot and the street in front of the facility. An interview was conducted with S7, LPN on 9/7/12 at 10:36 am who pointed out that there were 9 residents seated in the smoking room at this time. She stated that 4 of the 9 residents seated in the Smoke Room at this time would be able to leave the room to go outside on their own either ambulating or with the use of their wheelchairs. S9, LPN denied that any of the residents in the room smoking were wanderers. A demonstration by S8, Feeding Aide on 9/7/12 at 10:41 am, after his entry into the Smoke Room, which revealed that the Right sided doors did not alarm even after the 5 seconds that he allowed between reopening the doors. S8, Feeding Aide stated that maybe there was a 5 second delay between the alarms but stated that the doors were still not alarming even after he audible waiting counting to 5 outloud in the present of 2 surveyors. A redemonstration by S1, Administrator on 9/7/12 at 10:50 revealed that both double doors on the Right side of the Smoking Room did not alarm each and every time that he opened and reopened them. S1, Administrator denied knowledge of any problems with the alarm system prior to this time. An observation was made on 9/7/12 at 11:00 am of the double doors facing the laundry and maintenance departments on the Burgandy Hall. An observation was made of S5, Maintenance Supervisor opening the Right side door and there was no audible alarm. S5, Maintenance Supervisor opened and closed the Right door 3 times and the alarm sounded 1 of the 3 times. S5, Maintenance Supervisor and S6, Housekeeping both confirmed that the door did not alarm 2 of the 3 times that it was opened. S5, Maintenance Supervisor stated that these doors were catch all doors and should have alarmed each and every time that they were opened. Both S5, Maintenance Supervisor and S6, Housekeeping denied knowledge that the doors had a 5 second reset button and that staff would have needed to wait until the reset button was activated to walk away. An observation was made in the Television Room across from the Orange Nurse's Station on 9/7/12 at 11:20 am. 2 sets of Double Doors were observed and a demonstration by S5, Maintenance Supervisor revealed that the Left side double doors were locked. An additional demonstration of the Right side double doors revealed that the Left door did not alarm when S5, Maintenance Supervisor opened it. S5, Maintenance Supervisor stated that the doors were not closing properly between openeing and that perhaps that is why they were not alarming each time that they were opened. S5, Maintenance Supervisor stated that the maintenance department was responsible for adjusting the doors and door jams. During the interview, the door alarm was noted to alarm twice without opening and S5, Maintenance Supervisor and S6, Housekeeping confirmed that the door alarmed without anyone touching it. An observation was made on 9/7/12 at 11:35 am, of S5, Maintenance Supervisor demonstrating the opening of the double doors at the end of the Orange Hall. The Left side of the double door did not alarm the first time that he opened it. S5, Maintenance Supervisor confirmed that the Left door did not alarm the first time that he opened it and stated that this was a catch all door and should have alarmed each time that it was opened. S5, Maintenance Supervisor stated that all of the doors throughout the facility would need to be readjusted and that the wiring system in the Smoke Room would need to be replaced in order for the doors to function properly. S5, Maintenance Supervisor denied knowledge of any issues with the door alarms prior to this time. A review of the facility's training policy for Catch All Doors and Wander Guards Doors revealed that the catch all door alarms should make an audible sound when the doors are opened

Based on observation, interview, and record review, the facility failed to develop a system to identify quality deficiencies by failing to: 1) identify that staff were not educated or knowledgeable on the operation and/or testing of the facility's wander guard system to protect the residents from elopement from the facility; 2) have staff available to monitor the doors that had the wanderguard system in place that were identified as not functioning properly or to have an effective system for monitoring/supervising residents from elopement from the facility as evidenced by Resident #123's elopement from the facility on 10/1/11, Resident #37's elopement on 1/1/12, and Resident #58's elopement on 4/15/12. 3) identify staff were not investigating and/or reporting the elopements of Resident #123, Resident #37, or Resident #58. The provider failed to have staff that was properly educated on the functioning and operation/testing of the wander guard system. The facility's administration failed to effectively identify and put into place corrective measures to ensure that the facility's wandering residents were protected from elopement from the facility after identifying on 10/1/11 that the wander guard system was not functioning properly. The facility failed to develop and implement an appropriate plan of action for the non-functioning wander guard system after 10/1/11 and failed to ensure that the staff in the facility was knowledgeable of the proper working, testing, and functioning of the wander guard system. The Immediate Jeopardy situation began on 10/1/11 when resident # 123 eloped from the facility without the facility staff's knowledge. On 10/1/11, resident #123 exited the facility and placed herself in the back of a van belonging to visiting musicians who were at the facility for an activity on 10/1/11. The resident hid in the back of the visitor's van among the musical instruments. Band members discovered Resident #123 in the back of the van when the van arrived in another town about 9 miles from the facility. One of the band members contacted the resident's son to notify him that his mother had been found in the back of the van. The son called the nursing home to notify them that his mother had been found in the back of the musician's van and that she was unharmed. Upon Resident #123 ' s return to the facility, her wander guard bracelet was tested in the front entrance to the facility. The front door alarm did not sound when Resident # 123 passed through the front door. No new interventions were put into place to prevent resident #123 from eloping from the facility after it was noted that the wander guard alarm system was not working correctly on 10/1/11. All of the confused, wandering residents (#112, #52, #66, #133, #123, #144, #37, #58, #26, #82 and #7) were in immediate jeopardy on 10/1/11 when the facility failed to implement a system of supervision to prevent elopement from the facility when facility staff became aware that the wander guard alarm system was not working correctly. On 1/1/12, Resident #37 had his wander guard Bracelet changed after it was determined on the previous evening the resident's wander guard wasn't working when resident got out of the facility's doors x 2. The facility had knowledge that the new bracelet worked on the door in the TV room, but did not work on the back door at the end of the green hall. ON 4/15/12 AT 8:00 A.M., Resident #38 was found walking down a road by the facility heading to a local flea market. The resident was found 0.5 miles from the facility. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85, who was identified by the facility as a wanderer, was observed standing one hall over from the propped opened door. The (DON) confirmed that she had not in-serviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wander-guard system to ensure that it was functioning properly prior to team exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. Findings: The facility's wander guard policy was provided by the facility on 6/26/12 by the facility. Wander guard Policy- All resident at the facility who tends to wander will have a wander guard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wander guards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wander guard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wander guard monitoring binder. Resident# 123 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The review of the Elopement Risk assessment dated [DATE] revealed elopement attempt reported. Continue wander guard and every one hour check. Assessment of 3/27/12 revealed resident at risk for elopement. Wander guard in use to alert staff of resident's attempt to leave. On 6/19/12 assessment revealed wander guard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing home) per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wander guard going off when resident left. Notified D.O.N. ( ____ ) of incident. Nurse ' s notes dated 10/1/11 6:20 pm. revealed resident returned to N.H. accompanied by son without complaints in good condition. tested wander guard hallway on Gold Hall and alarm working and smoke room worked. tested wander guard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12, at 8:35 a.m., an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the residents son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the residents son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I brought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6-27-12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wander guard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that the wander guard system was not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I'm not sure which one it was. He stated that all exit doors have the wander guard system in place with one of two different type of systems being used which are a push button release system and a catch all type system. When asked if he was aware of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement, there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wander guard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed the incident report dated 10/1/11 with the administrator which revealed a resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. S24 administrator was asked if this incident was discussed at the monthly QA meeting and he stated yes, they addressed it at their daily meetings but he was unable to say what interventions were put into place at that time. He stated, "I would have talked to the DON/ADON and made sure they communicated to the staff." When questioned as to what he put into place as an administrator, he stated he could not tell us for sure but he knew he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, "They are supposed to". On 6-27-12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wander guards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNAs and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all residents with wander guards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn't fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wander guard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. Resident # 85 On 6/25/12 at 10:38 a.m., Resident # 85 ' s daughter was interviewed in Stage I of the survey process. She stated that her mother has a wander-guard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wander guard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident were again brought to the wander guard door alarm at the end of the brown hall. The alarm did not go off as the resident approached the door. S4DON stated that the alarm would go off as the resident approached the wander guard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work were the alarms on the patio and the front door of the facility. The wander guard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whole new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keeping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initialed the MAR indicated [REDACTED]. She was not aware of the battery life of the bracelet and had not been told of the time frame that it needed to be changed. The is the only way she would know if the bracelet was working would be when the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. Survey team and DON proceeded to check all of the bracelets on the wandering residents in the facility. The wanderers in the facility had their wander guard bracelets checked by the survey team at various doors in the facility that had the wander guard system in place. A total of 11 residents were identified as wanderers. Four of the 11 residents that were checked did not cause the system to alarm. Resident #66's wander guard did not work on the Gold/Brown Hall exit door. Resident #52's wander guard did not work on the patio exit door, Resident # 133's wander guard did not work on the green hall exit door. Resident #144's wander guard did not work on the green hall exit door. These 4 residents wander guard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wander guard system the following residents were found to have eloped from the facility. Resident #37 Resident #37 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was performed on the resident on 12/6/11 revealed wander guard intact. Elopement attempt reported. On 2/28/12 wander guard intact; no elopement attempts noted. 5/22/12 wander guard in use; no attempts made at elopement. List of wanderers requested from the facility and the resident was listed on the list by the facility as being a wanderer. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wander guard applied to left arm. The previous one wasn't working when resident left out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. Maintenance Supervisor was notified that the doors weren ' t alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. "As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside." On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am, that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and placed it on the green hall and made it work. S7 Maintenance Supervisor reported that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and send it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility ' s wander guard policy was provided on 6-26-12. Wander guard Policy: All residents at the facility who tend to wander will have a wander guard put in place and monitored Q (every) shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNAs will check wander guards Q shift for placement and functions, nurses will document on MAR (medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wander guard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wander guard monitoring binder. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no"; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, Delusions, Hallucinations, Anxiety Disorder, Depression, [MEDICAL CONDITION], and [MEDICAL CONDITION])? The response to this question was marked " no". The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58's Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58's Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58's elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___'s answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. When questioned as to how they monitor the functioning of the wander guard system, S4DON presented to the surveyor a factory handout of the wander guard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident, etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with SS17 Maintenance Supervisor was conducted and he stated that the system within the facility to protect wanderers is called wander guard but it has two different types of systems monitoring that are compatible with each other. The facility uses a "catch all " type system on some doors which means that anyone who goes in or out of the door will set off the alarm. It works by breaking the seal of the door which causes the alarm to go off. It has to be turned off by entering a code into a side panel that the staff has. The residents do not know the code so if the alarm sounds and is immediately turned off, and then we are aware it was a staff member. If it doesn ' t go off then the staff is alerted that they need to go and see who is attempting to exit the building. The other type of system that is used by the facility is a "push button recessed" system. This device works strictly off of the wander guard bracelets antenna signal and will not go off by a resident approaching the door. The resident has to physically go through the door or break the closed door seal to set off the alarm. The facility provided a list of wander guard devices by hallways and there were 6 push button recessed types and 7 catch all types listed by the facility On 6/28/12, an observation while touring the facility at 5:15am revealed that the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door had a wander guard alert system. The door had a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 who was identified by the facility as a wanderer was observed standing one hall over from the opened door. It was observed that the door remained opened from 5:15 am until 6:10 am when the surveyor went to the conference room at 6:30 am it was noted the patio door was closed. On 6/28/12 at 11:00 am, an interview was conducted with S4DON. She was informed of the surveyors finding the patio door on the private hall left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. She confirmed that Resident #85 was a wanderer in the facility and stated that she could have walked out of the patio door that was left open. On 6/26/12 at 2:45 pm an investigation of the facility's Wander Guard System was initiated. Resident #85 was escorted with the staff member S5LPN to the wander guard alarm at the end of the blue hall. S5LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and Resident #85 were brought to the wander guard doors at the end of the brown hall. The alarm did not go off as Resident #85 approached the door. S4DON stated that the alarm would go off as the resident wearing a wander guard bracelet approached the wander guard sensors. S4DON then stated the alarms did not work. She stated "some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work." She further stated that the only alarms that did work were the alarms on the patio door and the front door of the facility. The wander guard alarm on the brown hall doors and the blue hall doors did not activate and this was confirmed by S4DON. She stated that the facility got a price for a whole new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keeping an eye on the residents to increase the supervision. We are working on getting the system to work." Residents wearing the wander guard bracelets were checked by the surveyors at various exterior doors in the facility that had the wander guard system in place. A total of 11 residents were

Based on record reviews, observations and interviews, the facility administration failed to have a system of supervision and monitoring in place to prevent the confused, wandering residents from eloping from the facility. The facililty failed to maintain a properly functioning wander guard system to assist in alerting staff when a confused wandering resident eloped from the facility. The facility failed to: 1) Have staff that was properly educated on the functioning and operation/testing of the wander guard system. 2) Identity and implement a system of direct supervision and monitoring interventions of confused wandering residents to prevent the confused, wandering residents from eloping from the facility without staff knowledge on 10/1/2011 after the facility becoming aware the wander guard door alarm system was not functioning properly. 3) Develop and implement an appropriate plan of action to repair the wander guard system on 10/1/11 when the facility became aware that a resident wearing a wander guard bracelet exited the facility through the front door and the door alarm did not alarm 4) Have a system of monitoring in place to ensure the wander guard bracelets were tested and replaced as directed by the manufacturer 5) Have a system of in place to monitor the wander guard door alarms to ensure the alarms functioned correctly after a resident wearing a wander guard bracelet exited the facility through the front door and the alarm did not sound. 6) Identify resident elopement incidents as reportable to the state. The Immediate Jeopardy situation began at 10/1/11 when resident #123 eloped from the facility without the faciity staff's knowledge. On 10/1/11 resident #123 exited the facility and placed self in the back of a van belonging to visiting musicians who were at the facility for an activity. The resident hid in the back of the visitor ' s van among the musical instruments. Band members discovered Resident #123 in the back of the van when the van arrived in another town about 9 miles from the facility. One of the band members contacted the residents son to notify him that his mother had been found in the back of the van. The son called the nursing home to notify them that his mother had been found in the back of the musician ' s van and that she was unharmed. Upon Resident #123 ' s return to the facility, her wander guard bracelet was tested in the front entrance to the facility. The front door alarm did not sound when Resident # 123 passed through the front door. No new interventions were put into place to prevent resident #123 from eloping from the facility after it was noted that the wander guard alarm system was not working correctly on 10/1/11. All of the confused, wandering residents (#112, #52, #66, #133, #123, #144, #37, #58, #26, #82 and #7) were in immediate jeopardy on 10/1/11 when the facility failed to implement a system of supervision to prevent elopement from the facility when facility staff became aware that the wander guard alarm system was not working correctly. On 1/1/12, Resident #37 had his wander guard Bracelet changed after it was determined on the previous evening the resident's wander guard wasn't working when resident got out of the facility's doors x 2. The facility had knowledge that the new bracelet worked on the door in the TV room, but did not work on the back door at the end of the green hall. ON 4/15/12 AT 8:00 A.M., Resident #38 was found walking down a road by the facility heading to a local flea market. The resident was found 0.5 miles from the facility. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85, who was identified by the facility as a wanderer, was observed standing one hall over from the propped opened door. The (DON) confirmed that she had not in-serviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wander-guard system to ensure that it was functioning properly prior to team exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. The immediate jeopardy was lifted on 7/2/12 at 2:26 p.m.when the wander guard technician repaired and replaced the defective systems. Citation remains at a second level pattern. Findings: The facilty's wander guard policy was provided by the facility on 6/26/12. Wander Guard Policy--All residents at the facility who tend to wander will have a wander guard put in place and monitored Q (every) shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wanderguards Q-shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon reurn for placement and function of wander guard and nurses will document in nurses notes. 3. Monthy checks will be logged by charge nurse into wander guard monitoring binder. The administration of the facility failed to have staff that was properly educated on the functioning and operation/testing of the wander guard system. The facility's administration failed to effectively identify and put into place corrective measures to ensure that the facility ' s wandering residents were protected from elopement from the facility after identifying on 10/1/11 that the wander guard system was not functioning properly. The facility failed to develop and implement an appropriate plan of action for the non-functioning wander guard system after 10/1/11 and failed to ensure that the staff in the facility was knowledgeable of the proper working, testing, and functioning of the wander guard system. The immediate jeopardy situation began on 10/1/11 when the resident eloped from the facility and remains in place due to the facility not ensuring that the wander guard system in the facility is properly working and that the staff is trained on the proper functioning /testing of the system. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wandergaurd alert system which required that the door be closed to function properly as the alrm is set off by a break in the sensor. Resident #85 which was identified by the facility as a wander was observd standing one hall over from the opened door. The facility (DON) confirmed that she had not inserviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facililty did not have a technical support technician arrive at the facility to check their current wanderguard system to ensure that it was functioning properly prior to our exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. On 7/2/12 at 2:26 p.m. the immediate jeopardy was lifted when the wander guard technician repaired and replaced the defective systems. Citation remains at a second level potential for harm. Findings: On 6/25/12 at 10:38 am the resident # 85 daughter was interviewed in Stage I of the survey process. She stated that her mother has a wanderguard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wanderguard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident was again brought to the wanderguard at the end of the brown hall. The alarm did not go off as the resident approached he door. S4DON stated that the alarm would go off as the resident approached the wangerguard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work was the alarms on the padio and the front of the facility. The wanderguard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whold new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initiated the MAR indicated [REDACTED]. She was not aware of the battery life of the bracklet and had not been told of the time frame that it needed to be changed. This is the only way she would know if the braclet was working would be the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. The team then proceeded to check all of the bracelets on the wandering residents in the facility. The wanders in the facility had their wandergaurd bracelets checks by the surveyors at various doors in the facility that had the wanderguard system in place. A total of 11 residents were identified as wanders. 4 of the 11 residents that were checked did not alarm. Resident #66's wanderguard did not work on the Gold/Brown Hall, Resident #52 's wanderguard did not work on the padio door, Resident # 133's wanderguard did not work on the green hall, Resident #144's wanderguard did not work on the green hall. These 4 residents wanderguard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wanderguard system the following residents eloped from the facility. 1. Resident #37. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was preformed on the resident on 12/6/11 revealed wanderguard intact. Elopement attempt reported. On 2/28/12 wanderguard intact; no elopement attempts noted. 5/22/12 wanderguard in use; no attempts made at elopement. List of wanders requested from the facility and the resident was listed on the list by the facility as being a wander. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wanderguard applied to left arm. The previous one wasn't working when resident let out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. _____ _____ Maintenance Supervisor notified that the doors wasn't alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside. On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and and placed it on the green hall and made it work. S7 Maintenance Supervisor that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and sent it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility's wanderguard policy was provided by the facility on 6/26/12 by the facility. Wanderguard Policy- All resident at the facility who tends to wander will have a wanderguard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wanderguards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wanderguard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wanderguard monitoring binder. 2. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no" ; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, [MEDICAL CONDITION], Hallucinations, Anxiety Disorder, Depression, [MEDICAL CONDITION], and [MEDICAL CONDITION])? The response to this question was marked "no" . The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58 ' s Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58 ' s Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses ' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58 ' s elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___ 's answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. 3. Resident #123. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Elopement Risk assessment dated [DATE] elopement attempt reported. Continue wanderguard and every one hour check. 3/27/12 resident at risk for elopement. Wanderguard in use to alert staff of resident's attempt to leave. 6/19/12 revealed wanderguard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing home) per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wanderguard going off when resident left. Notified D.O.N. ( ____ ) of incident. 10/1/11 6:20 pm Resident returned to N.H. accompanied by son without complaints in good condition. tested wanderguard hallway on Gold Hall and alarm working and smoke room worked. tested wanderguard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12 at 8:35 am, an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the resident's son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the resident's son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I bought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6/27/12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wanderguard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that he his wanderguard system as not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I ' m not sure which one it was. He stated that all exit doors have the wanderguard system in place in which one of two different type of systems are being used which are a push button release system and a catch all type system. When asked if he was aware of of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement , there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wanderguard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed incident report with the administrator which revealed apparently resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. Once this incident occurred, did you discuss it at your monthly QA meeting? S24Administrator stated yes they addressed it at their daily meetings but can ' t tell you what interventions were put into place at that time. He stated,"I would have talked to the DON/ADON and make sure they communicated to the staff." When questioned as to what he put into place as an administrator and he stated he could not tell us for sure but he knows he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, " They are suppose to " . On 6/27/12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wanderguards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNA ' s and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all resident with wanderguards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn ' t fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wanderguard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them.. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. When questioned as to how they monitor the functioning of the wanderguard system, S4DON presented to the surveyor a factory handout of the wanderguard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident,etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with S17 Maintenance Supervisor was conducted On 6-26-12 at 5:30 pm, an interview with SS17 Maintenance Supervisor was conducted and he stated that the system within the facility to protect wanderers is called wander guard but it has two different types of systems monitoring that are compatible with each other. The facility uses a "catch all " type system on some doors which means that anyone who goes in or out of the door will set off the alarm. It works by breaking the seal of the door which causes the alarm to go off. It has to be turned off by entering a code into a side panel that the staff has. The residents do not know the code so if the alarm sounds and is immediately turned off, and then we are aware it was a staff member. If it doesn ' t go off then the staff is alerted that they need to go and see who is attempting to exit the building. The other type of system that is used by the facility is a "push button recessed" system. This device works strictly off of the wander guard bracelets antenna signal and will not go off by a resident approaching the door. The resident has to physically go through the door or break the closed door seal to set off the alarm. The facility provided a list of wander guard devices by hallways and there were 6 push button recessed types and 7 catch all types listed by the facility On 6/28/12, an observation while touring the facility at 5:15am revealed that the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the do

Based on record reviews, observations and interviews, the facility administration failed to have a system of supervision and monitoring in place to prevent the confused, wandering residents from eloping from the facility. The facililty failed to maintain a properly functioning wander guard system to assist in alerting staff when a confused wandering resident eloped from the facility. The facility failed to 1.Have staff that was properly educatd on the functioning and operation/testing of the wander guard system. 2) Identity and implement a system of direct supervision and monitoring interventions of confused wandering residents to prevent the confused, wandering residents from eloping from the facility without staff knowledge on 10/1/2011 after the facility becoming aware the wander guard door alarm system was not functioning properly. 3) Develop and implement an appropriate plan of action to repair the wander guard system on 10/1/11 when the facility became aware that a resident wearing a wander guard bracelet exited the facility through the front door and the door alarm did not alarm 4) Have a system of monitoring in place to ensure the wander guard bracelets were tested and replaced as directed by the manufacturer 5) Have a system of in place to monitor the wander guard door alarms to ensure the alarms functioned correctly after a resident wearing a wander guard bracelet exited the facility through the front door and the alarm did not sound. 6. Identify resident elopement incidents as reportable to the state. The Immediate Jeopardy situation began at 10/1/11 when resident #123 eloped from the facility without the faciity staff's knowledge. On 10/1/11 resident #123 exited the facility and placed self in the back of a van belonging to visiting musicians who were at the facility for an activity. The resident hid in the back of the visitor ' s van among the musical instruments. Band members discovered Resident #123 in the back of the van when the van arrived in another town about 9 miles from the facility. One of the band members contacted the residents son to notify him that his mother had been found in the back of the van. The son called the nursing home to notify them that his mother had been found in the back of the musician ' s van and that she was unharmed. Upon Resident #123 ' s return to the facility, her wander guard bracelet was tested in the front entrance to the facility. The front door alarm did not sound when Resident # 123 passed through the front door. No new interventions were put into place to prevent resident #123 from eloping from the facility after it was noted that the wander guard alarm system was not working correctly on 10/1/11. All of the confused, wandering residents (#112, #52, #66, #133, #123, #144, #37, #58, #26, #82 and #7) were in immediate jeopardy on 10/1/11 when the facility failed to implement a system of supervision to prevent elopement from the facility when facility staff became aware that the wander guard alarm system was not working correctly. On 1/1/12, Resident #37 had his wander guard Bracelet changed after it was determined on the previous evening the resident's wander guard wasn't working when resident got out of the facility's doors x 2. The facility had knowledge that the new bracelet worked on the door in the TV room, but did not work on the back door at the end of the green hall. ON 4/15/12 AT 8:00 A.M., Resident #38 was found walking down a road by the facility heading to a local flea market. The resident was found 0.5 miles from the facility. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85, who was identified by the facility as a wanderer, was observed standing one hall over from the propped opened door. The (DON) confirmed that she had not in-serviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wander-guard system to ensure that it was functioning properly prior to team exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. Findings: The facilty's wander guard policy was provided by the facility on 6/26/12. Wander Guard Policy--All residents at the facility who tend to wander will have a wander guard put in place and monitored Q (every) shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wanderguards Q-shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon reurn for placement and function of wander guard and nurses will document in nurses notes. 3. Monthy checks will be logged by charge nurse into wander guard monitoring binder. The administration of the facility failed to have staff that was properly educated on the functioning and operation/testing of the wander guard system. The facility's administration failed to effectively identify and put into place corrective measures to ensure that the facility ' s wandering residents were protected from elopement from the facility after identifying on 10/1/11 that the wander guard system was not functioning properly. The facility failed to develop and implement an appropriate plan of action for the non-functioning wander guard system after 10/1/11 and failed to ensure that the staff in the facility was knowledgeable of the proper working, testing, and functioning of the wander guard system. The immediate jeopardy situation began on 10/1/11 when the resident eloped from the facility and remains in place due to the facility not ensuring that the wander guard system in the facility is properly working and that the staff is trained on the proper functioning /testing of the system. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wandergaurd alert system which required that the door be closed to function properly as the alrm is set off by a break in the sensor. Resident #85 which was identified by the facility as a wander was observd standing one hall over from the opened door. The facility (DON) confirmed that she had not inserviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facililty did not have a technical support technician arrive at the facility to check their current wanderguard system to ensure that it was functioning properly prior to our exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. Findings: On 6/25/12 at 10:38 am the resident # 85 daughter was interviewed in Stage I of the survey process. She stated that her mother has a wanderguard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wanderguard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident was again brought to the wanderguard at the end of the brown hall. The alarm did not go off as the resident approached he door. S4DON stated that the alarm would go off as the resident approached the wangerguard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work was the alarms on the padio and the front of the facility. The wanderguard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whold new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initiated the MAR indicated [REDACTED]. She was not aware of the battery life of the bracklet and had not been told of the time frame that it needed to be changed. This is the only way she would know if the braclet was working would be the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. The team then proceeded to check all of the bracelets on the wandering residents in the facility. The wanders in the facility had their wandergaurd bracelets checks by the surveyors at various doors in the facility that had the wanderguard system in place. A total of 11 residents were identified as wanders. 4 of the 11 residents that were checked did not alarm. Resident #66's wanderguard did not work on the Gold/Brown Hall, Resident #52 's wanderguard did not work on the padio door, Resident # 133's wanderguard did not work on the green hall, Resident #144's wanderguard did not work on the green hall. These 4 residents wanderguard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wanderguard system the following residents eloped from the facility. 1. Resident #37. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was preformed on the resident on 12/6/11 revealed wanderguard intact. Elopement attempt reported. On 2/28/12 wanderguard intact; no elopement attempts noted. 5/22/12 wanderguard in use; no attempts made at elopement. List of wanders requested from the facility and the resident was listed on the list by the facility as being a wander. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wanderguard applied to left arm. The previous one wasn't working when resident let out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. _____ _____ Maintenance Supervisor notified that the doors wasn't alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside. On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and and placed it on the green hall and made it work. S7 Maintenance Supervisor that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and sent it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility's wanderguard policy was provided by the facility on 6/26/12 by the facility. Wanderguard Policy- All resident at the facility who tends to wander will have a wanderguard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wanderguards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wanderguard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wanderguard monitoring binder. 2. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no" ; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, [MEDICAL CONDITION], Hallucinations, Anxiety Disorder, Depression, [MEDICAL CONDITION], and [MEDICAL CONDITION])? The response to this question was marked "no" . The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58 ' s Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58 ' s Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses ' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58 ' s elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___ 's answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. 3. Resident #123. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Elopement Risk assessment dated [DATE] elopement attempt reported. Continue wanderguard and every one hour check. 3/27/12 resident at risk for elopement. Wanderguard in use to alert staff of resident's attempt to leave. 6/19/12 revealed wanderguard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing h)ome per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wanderguard going off when resident left. Notified D.O.N. ( ____ ) of incident. 10/1/11 6:20 pm Resident returned to N.H. accompanied by son without complaints in good condition. tested wanderguard hallway on Gold Hall and alarm working and smoke room worked. tested wanderguard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12 at 8:35 am, an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the resident's son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the resident's son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I bought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6/27/12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wanderguard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that he his wanderguard system as not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I ' m not sure which one it was. He stated that all exit doors have the wanderguard system in place in which one of two different type of systems are being used which are a push button release system and a catch all type system. When asked if he was aware of of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement , there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wanderguard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed incident report with the administrator which revealed apparently resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. Once this incident occurred, did you discuss it at your monthly QA meeting? S24Administrator stated yes they addressed it at their daily meetings but can ' t tell you what interventions were put into place at that time. He stated,"I would have talked to the DON/ADON and make sure they communicated to the staff." When questioned as to what he put into place as an administrator and he stated he could not tell us for sure but he knows he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, " They are suppose to " . On 6/27/12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wanderguards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNA ' s and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all resident with wanderguards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn ' t fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wanderguard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them.. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. When questioned as to how they monitor the functioning of the wanderguard system, S4DON presented to the surveyor a factory handout of the wanderguard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident,etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with S17 Maintenance Supervisor was conducted

Based on record reviews, observations and interviews, the facility failed to have: 1. nursing staff that was properly educated on the functioning and operation/testing of the wander guard system to protect the residents from elopement from the facility 2. staff available to monitor the doors that had the wanderguard system in place that was not functioning properly or monitoring of the residents that eloped through the facility's doors which was evident by: 1. The Director of Nursing incorrectly informing the surveyor that the wanderguard system would alarm on the wandering residents as they approached the door with the wanderguard sensors. The alarm did not function until the residents with the wanderguard bracelet activated the sensor on the door and went through the door. 2. Resident # 123 eloped on 10/1/11 from the facility without the staff ' s knowledge. The resident was allowed to have access and leave the facility ' s premises. She was later discovered in the visitor ' s van in a local town Louisiana, 9 miles away from the facility. The resident ' s son was called by the visitor and the son then called the facility and notified the facility of the resident not being in the facility. 3. Resident #37 after a review of the nurse's notes on 1/1/12 revealed that the resident had his wanderguard changed after on the previous evening the resident's wanderguard wasn't working when resident got out of the facility's doors x 2 the previous evening. The new alarm worked on door in the TV room but not the back door at the end of the green hall. 4. Resident #58 on 4/15/12 at 8:00 am was found outside of the facility walking down a road by the facility heading to a local flea market. The resident was found .5 miles from the facility. The facility ' s administration failed to effectively identify and put into place corrective measures to ensure that the facility ' s wandering residents were protected by the nursing staff from elopement from the facility after identifying on 10/1/11 that the wander guard system was not functioning properly. The facility failed to develop and implement an appropriate plan of action for the non-functioning wander guard system after 10/1/11 and failed to ensure that the staff in the facility was knowledgeable of the proper working, testing, and functioning of the wander guard system. The immediate jeopardy situation began on 10/1/11 when the resident eloped from the facility and remains in place due to the facility not ensuring that the wander guard system in the facility is properly working and that the staff is trained on the proper functioning /testing of the system. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15 am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wanderguard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 which was identified by the facility as a wander was observed standing one hall over from the opened door. The facility (DON) confirmed that she had not inserviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wanderguard system to ensure that it was functioning properly prior to our exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. On 7/2/12 at 2:46 pm, after a review of the facility's plan of removal #3 by state office, the immediate jeopardy was lifted and placed at a level K due to the facility's not placing interventions or monitoring in place since Resident #123 eloped on 10/1/11 from the facility and for the elopement of Resident # 37 on 1/1/12 and Resident #58 elopement on 4/15/12 . The immediate jeopardy was lifted on 7/2/12 at 2:26 p.m.when the wander guard technician repaired and replaced the defective systems. Citation remains at a second level pattern. Findings: On 6/25/12 at 10:38 am the resident # 85 daughter was interviewed in Stage I of the survey process. She stated that her mother has a wanderguard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wanderguard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident was again brought to the wanderguard at the end of the brown hall. The alarm did not go off as the resident approached he door. S4DON stated that the alarm would go off as the resident approached the wanderguard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work was the alarms on the patio and the front of the facility. The wanderguard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whole new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keeping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initiated the MAR indicated [REDACTED]. She was not aware of the battery life of the bracelet and had not been told of the time frame that it needed to be changed. This is the only way she would know if the bracelet was working would be the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. The team then proceeded to check all of the bracelets on the wandering residents in the facility. The wanders in the facility had their Sondergaard bracelets checks by the surveyors at various doors in the facility that had the wanderguard system in place. A total of 11 residents were identified as wanders. 4 of the 11 residents that were checked did not alarm. Resident #66's wanderguard did not work on the Gold/Brown Hall, Resident #52 's wanderguard did not work on the patio door, Resident # 133's wanderguard did not work on the green hall, Resident #144's wanderguard did not work on the green hall. These 4 residents wanderguard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wanderguard system the following residents eloped from the facility. 1. Resident #37. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was preformed on the resident on 12/6/11 revealed wanderguard intact. Elopement attempt reported. On 2/28/12 wanderguard intact; no elopement attempts noted. 5/22/12 wanderguard in use; no attempts made at elopement. List of wanders requested from the facility and the resident was listed on the list by the facility as being a wander. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wanderguard applied to left arm. The previous one wasn't working when resident let out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. _____ _____ Maintenance Supervisor notified that the doors wasn't alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside. On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and and placed it on the green hall and made it work. S7 Maintenance Supervisor that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and sent it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility's wanderguard policy was provided by the facility on 6/26/12 by the facility. Wanderguard Policy- All resident at the facility who tends to wander will have a wanderguard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wanderguards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wanderguard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wanderguard monitoring binder. 2. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no" ; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, Delusions, Hallucinations, Anxiety Disorder, Depression, [MEDICAL CONDITION], and [MEDICAL CONDITION])? The response to this question was marked "no" . The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58 ' s Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58 ' s Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses ' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58 ' s elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___ 's answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. 3. Resident #123. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Elopement Risk assessment dated [DATE] elopement attempt reported. Continue wanderguard and every one hour check. 3/27/12 resident at risk for elopement. Wanderguard in use to alert staff of resident's attempt to leave. 6/19/12 revealed wanderguard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing h)ome per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wanderguard going off when resident left. Notified D.O.N. ( ____ ) of incident. 10/1/11 6:20 pm Resident returned to N.H. accompanied by son without complaints in good condition. tested wanderguard hallway on Gold Hall and alarm working and smoke room worked. tested wanderguard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12 at 8:35 am, an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the resident's son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the resident's son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I bought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6-27-12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wanderguard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that he his wanderguard system as not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I ' m not sure which one it was. He stated that all exit doors have the wanderguard system in place in which one of two different type of systems are being used which are a push button release system and a catch all type system. When asked if he was aware of of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement , there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wanderguard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed incident report with the administrator which revealed apparently resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. Once this incident occurred, did you discuss it at your monthly QA meeting? S24Administrator stated yes they addressed it at their daily meetings but can ' t tell you what interventions were put into place at that time. He stated,"I would have talked to the DON/ADON and make sure they communicated to the staff." When questioned as to what he put into place as an administrator and he stated he could not tell us for sure but he knows he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, " They are suppose to " . On 6-27-12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wanderguards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNA ' s and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all resident with wanderguards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn ' t fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wanderguard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. When questioned as to how they monitor the functioning of the wanderguard system, S4DON presented to the surveyor a factory handout of the wanderguard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident,etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with S17 Maintenance Supervisor was conducted and he stated that the system within the facility to protect wanderers is called wanderguard but it has two different types of systems monitoring that are compatible with each other. The facility uses a " catch all " type system on some doors which means that anyone who goes in or out of the door will set off the alarm. It works by breaking the seal of the door which causes the alarm to go off. It has to be turned off by entering a code into a side panel that the staff has. The residents do not know the code so if the alarm sounds and is immediately turned off, than we are aware it was a staff member. If it doesn ' t goes off than the staff is alerted that they need to go and see who is attempting to exit the building. The other type of system that is used by the facility is a " push button recessed " system. This device works strictly off of the wanderguard bracelets antenna signal and will not go off by a resident approaching the door. The resident has to physically go through the door or break the closed door seal to set off the alarm. The facility provided a list of wanderguard devices by hallways and there were 6 push button recessed types and 7 catch all types listed by the facility. On 6/28/12 An observation while touring the facility at 5:15am revealed that the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door had a wanderguard alert system. The door had a wanderguard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 which was identified by the facility as a wander was observed standing one hall over from the opened door. It was observed that the door remained opened from 5:15 am until 6:10 am when the surveyor went to the conference room at 6:30 am it was noted the patio door was closed. On 6/28/12 at 11:00 am, an interview was conducted with S4DON. She was informed of the surveyors finding the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. She confirmed that Resident #85 was a wanderer in the facility and stated that she could have walked out of the patio door that was left open.

Based on record reviews, observations and interviews, the facility failed to have: 1. nursing staff that was properly educated on the functioning and operation/testing of the wander guard system to protect the residents from elopement from the facility 2. staff available to monitor the doors that had the wanderguard system in place that was not functioning properly or monitoring of the residents that eloped through the facility's doors which was evident by: 1. The Director of Nursing incorrectly informing the surveyor that the wanderguard system would alarm on the wandering residents as they approached the door with the wanderguard sensors. The alarm did not function until the residents with the wanderguard bracelet activated the sensor on the door and went through the door. 2. Resident # 123 eloped on 10/1/11 from the facility without the staff ' s knowledge. The resident was allowed to have access and leave the facility ' s premises. She was later discovered in the visitor ' s van in a local town Louisiana, 9 miles away from the facility. The resident ' s son was called by the visitor and the son then called the facility and notified the facility of the resident not being in the facility. 3. Resident #37 after a review of the nurse's notes on 1/1/12 revealed that the resident had his wanderguard changed after on the previous evening the resident's wanderguard wasn't working when resident got out of the facility's doors x 2 the previous evening. The new alarm worked on door in the TV room but not the back door at the end of the green hall. 4. Resident #58 on 4/15/12 at 8:00 am was found outside of the facility walking down a road by the facility heading to a local flea market. The resident was found .5 miles from the facility. The facility ' s administration failed to effectively identify and put into place corrective measures to ensure that the facility ' s wandering residents were protected by the nursing staff from elopement from the facility after identifying on 10/1/11 that the wander guard system was not functioning properly. The facility failed to develop and implement an appropriate plan of action for the non-functioning wander guard system after 10/1/11 and failed to ensure that the staff in the facility was knowledgeable of the proper working, testing, and functioning of the wander guard system. The immediate jeopardy situation began on 10/1/11 when the resident eloped from the facility and remains in place due to the facility not ensuring that the wander guard system in the facility is properly working and that the staff is trained on the proper functioning /testing of the system. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15 am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wanderguard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 which was identified by the facility as a wander was observed standing one hall over from the opened door. The facility (DON) confirmed that she had not inserviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wanderguard system to ensure that it was functioning properly prior to our exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. On 7/2/12 at 2:46 pm, after a review of the facility's plan of removal #3 by state office, the immediate jeopardy was lifted and placed at a level K due to the facility's not placing interventions or monitoring in place since Resident #123 eloped on 10/1/11 from the facility and for the elopement of Resident # 37 on 1/1/12 and Resident #58 elopement on 4/15/12 . Findings: On 6/25/12 at 10:38 am the resident # 85 daughter was interviewed in Stage I of the survey process. She stated that her mother has a wanderguard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wanderguard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident was again brought to the wanderguard at the end of the brown hall. The alarm did not go off as the resident approached he door. S4DON stated that the alarm would go off as the resident approached the wanderguard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work was the alarms on the patio and the front of the facility. The wanderguard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whole new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keeping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initiated the MAR indicated [REDACTED]. She was not aware of the battery life of the bracelet and had not been told of the time frame that it needed to be changed. This is the only way she would know if the bracelet was working would be the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. The team then proceeded to check all of the bracelets on the wandering residents in the facility. The wanders in the facility had their Sondergaard bracelets checks by the surveyors at various doors in the facility that had the wanderguard system in place. A total of 11 residents were identified as wanders. 4 of the 11 residents that were checked did not alarm. Resident #66's wanderguard did not work on the Gold/Brown Hall, Resident #52 's wanderguard did not work on the patio door, Resident # 133's wanderguard did not work on the green hall, Resident #144's wanderguard did not work on the green hall. These 4 residents wanderguard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wanderguard system the following residents eloped from the facility. 1. Resident #37. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was preformed on the resident on 12/6/11 revealed wanderguard intact. Elopement attempt reported. On 2/28/12 wanderguard intact; no elopement attempts noted. 5/22/12 wanderguard in use; no attempts made at elopement. List of wanders requested from the facility and the resident was listed on the list by the facility as being a wander. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wanderguard applied to left arm. The previous one wasn't working when resident let out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. _____ _____ Maintenance Supervisor notified that the doors wasn't alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside. On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and and placed it on the green hall and made it work. S7 Maintenance Supervisor that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and sent it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility's wanderguard policy was provided by the facility on 6/26/12 by the facility. Wanderguard Policy- All resident at the facility who tends to wander will have a wanderguard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wanderguards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wanderguard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wanderguard monitoring binder. 2. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no" ; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, [MEDICAL CONDITION], Hallucinations, Anxiety Disorder, Depression, [MEDICAL CONDITION], and [MEDICAL CONDITION])? The response to this question was marked "no" . The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58 ' s Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58 ' s Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses ' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58 ' s elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___ 's answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. 3. Resident #123. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Elopement Risk assessment dated [DATE] elopement attempt reported. Continue wanderguard and every one hour check. 3/27/12 resident at risk for elopement. Wanderguard in use to alert staff of resident's attempt to leave. 6/19/12 revealed wanderguard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing h)ome per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wanderguard going off when resident left. Notified D.O.N. ( ____ ) of incident. 10/1/11 6:20 pm Resident returned to N.H. accompanied by son without complaints in good condition. tested wanderguard hallway on Gold Hall and alarm working and smoke room worked. tested wanderguard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12 at 8:35 am, an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the resident's son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the resident's son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I bought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6-27-12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wanderguard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that he his wanderguard system as not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I ' m not sure which one it was. He stated that all exit doors have the wanderguard system in place in which one of two different type of systems are being used which are a push button release system and a catch all type system. When asked if he was aware of of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement , there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wanderguard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed incident report with the administrator which revealed apparently resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. Once this incident occurred, did you discuss it at your monthly QA meeting? S24Administrator stated yes they addressed it at their daily meetings but can ' t tell you what interventions were put into place at that time. He stated,"I would have talked to the DON/ADON and make sure they communicated to the staff." When questioned as to what he put into place as an administrator and he stated he could not tell us for sure but he knows he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, " They are suppose to " . On 6-27-12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wanderguards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNA ' s and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all resident with wanderguards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn ' t fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wanderguard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. When questioned as to how they monitor the functioning of the wanderguard system, S4DON presented to the surveyor a factory handout of the wanderguard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident,etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with S17 Maintenance Supervisor was conducted and he stated that the system within the facility to protect wanderers is called wanderguard but it has two different types of systems monitoring that are compatible with each other. The facility uses a " catch all " type system on some doors which means that anyone who goes in or out of the door will set off the alarm. It works by breaking the seal of the door which causes the alarm to go off. It has to be turned off by entering a code into a side panel that the staff has. The residents do not know the code so if the alarm sounds and is immediately turned off, than we are aware it was a staff member. If it doesn ' t goes off than the staff is alerted that they need to go and see who is attempting to exit the building. The other type of system that is used by the facility is a " push button recessed " system. This device works strictly off of the wanderguard bracelets antenna signal and will not go off by a resident approaching the door. The resident has to physically go through the door or break the closed door seal to set off the alarm. The facility provided a list of wanderguard devices by hallways and there were 6 push button recessed types and 7 catch all types listed by the facility. On 6/28/12 An observation while touring the facility at 5:15am revealed that the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door had a wanderguard alert system. The door had a wanderguard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 which was identified by the facility as a wander was observed standing one hall over from the opened door. It was observed that the door remained opened from 5:15 am until 6:10 am when the surveyor went to the conference room at 6:30 am it was noted the patio door was closed. On 6/28/12 at 11:00 am, an interview was conducted with S4DON. She was informed of the surveyors finding the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. She confirmed that Resident #85 was a wanderer in the facility and stated that she could have walked out of the patio door that was left open.

Based on record reviews, observations and interviews, the facility failed to have a system of supervision and monitoring in place to prevent confused, wandering residents from eloping from the facility after becoming knowledgeable that the wander guard alarm system was not functioning correctly on 10/1/11 for 3 (37, 58, and 123) confused, wandering residents out of a total of 11 (#112, #52, #66, #133, #123, #144, #37, #58, #26, #85, #7) residents identified as wanderers by the facility. Three of the 11 residents that were checked did not cause the wander guard system to alarm. The facility failed to: 1) have staff that was properly educated on the functioning and operation/testing of the wander guard system. 2) Identity and implement a system of direct supervision and monitoring interventions of confused wandering residents to prevent the confused, wandering residents from eloping from the facility without staff knowledge after 10/1/2011 after the facility becoming aware the wander guard door alarm system was not functioning properly on 10/1/2011. 3) Develop and implement an appropriate plan of action to repair the wander guard system on 10/1/11 when the facility became aware that a resident wearing a wander guard bracelet exited the facility through the front door and the door alarm did not alarm ON 10/1/11 4) Have a system of monitoring in place to ensure the wander guard bracelets were tested and replaced as directed by the manufacturer 5) Have a system of in place to monitor the wander guard door alarms to ensure the alarms functioned correctly after a resident wearing a wander guard bracelet exited the facility through the front door and the alarm did not sound. The Immediate Jeopardy situation began on 10/1/11 when resident # 123 eloped from the facility without the facility staff's knowledge. On 10/1/11, resident #123 exited the facility and placed herself in the back of a van belonging to visiting musicians who were at the facility for an activity on 10/1/11. The resident hid in the back of the visitor's van among the musical instruments. Band members discovered Resident #123 in the back of the van when the van arrived in another town about 9 miles from the facility. One of the band members contacted the resident's son to notify him that his mother had been found in the back of the van. The son called the nursing home to notify them that his mother had been found in the back of the musician's van and that she was unharmed. Upon Resident #123 ' s return to the facility, her wander guard bracelet was tested in the front entrance to the facility. The front door alarm did not sound when Resident # 123 passed through the front door. No new interventions were put into place to prevent resident #123 from eloping from the facility after it was noted that the wander guard alarm system was not working correctly on 10/1/11. All of the confused, wandering residents (#112, #52, #66, #133, #123, #144, #37, #58, #26, #82 and #7) were in immediate jeopardy on 10/1/11 when the facility failed to implement a system of supervision to prevent elopement from the facility when facility staff became aware that the wander guard alarm system was not working correctly. On 1/1/12, Resident #37 had his wander guard Bracelet changed after it was determined on the previous evening the resident's wander guard wasn't working when resident got out of the facility's doors x 2. The facility had knowledge that the new bracelet worked on the door in the TV room, but did not work on the back door at the end of the green hall. ON 4/15/12 AT 8:00 A.M., Resident #38 was found walking down a road by the facility heading to a local flea market. The resident was found 0.5 miles from the facility. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85, who was identified by the facility as a wanderer, was observed standing one hall over from the propped opened door. The (DON) confirmed that she had not in-serviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wander-guard system to ensure that it was functioning properly prior to team exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. Findings: The facility's wander guard policy was provided by the facility on 6/26/12 by the facility. Wander guard Policy- All resident at the facility who tends to wander will have a wander guard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wander guards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wander guard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wander guard monitoring binder. Resident# 123 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The review of the Elopement Risk assessment dated [DATE] revealed elopement attempt reported. Continue wander guard and every one hour check. Assessment of 3/27/12 revealed resident at risk for elopement. Wander guard in use to alert staff of resident's attempt to leave. On 6/19/12 assessment revealed wander guard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing home) per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wander guard going off when resident left. Notified D.O.N. ( ____ ) of incident. Nurse ' s notes dated 10/1/11 6:20 pm. revealed resident returned to N.H. accompanied by son without complaints in good condition. tested wander guard hallway on Gold Hall and alarm working and smoke room worked. tested wander guard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12, at 8:35 a.m., an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the residents son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the residents son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I brought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6-27-12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wander guard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that the wander guard system was not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I'm not sure which one it was. He stated that all exit doors have the wander guard system in place with one of two different type of systems being used which are a push button release system and a catch all type system. When asked if he was aware of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement, there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wander guard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed the incident report dated 10/1/11 with the administrator which revealed a resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. S24 administrator was asked if this incident was discussed at the monthly QA meeting and he stated yes, they addressed it at their daily meetings but he was unable to say what interventions were put into place at that time. He stated, "I would have talked to the DON/ADON and made sure they communicated to the staff." When questioned as to what he put into place as an administrator, he stated he could not tell us for sure but he knew he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, "They are supposed to". On 6-27-12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wander guards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNAs and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all residents with wander guards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn't fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wander guard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. Resident # 85 On 6/25/12 at 10:38 a.m., Resident # 85 ' s daughter was interviewed in Stage I of the survey process. She stated that her mother has a wander-guard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wander guard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident were again brought to the wander guard door alarm at the end of the brown hall. The alarm did not go off as the resident approached the door. S4DON stated that the alarm would go off as the resident approached the wander guard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work were the alarms on the patio and the front door of the facility. The wander guard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whole new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keeping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initialed the MAR stating that the wander guard bracelet was in place. She was not aware of the battery life of the bracelet and had not been told of the time frame that it needed to be changed. The is the only way she would know if the bracelet was working would be when the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. Survey team and DON proceeded to check all of the bracelets on the wandering residents in the facility. The wanderers in the facility had their wander guard bracelets checked by the survey team at various doors in the facility that had the wander guard system in place. A total of 11 residents were identified as wanderers. Four of the 11 residents that were checked did not cause the system to alarm. Resident #66's wander guard did not work on the Gold/Brown Hall exit door. Resident #52's wander guard did not work on the patio exit door, Resident # 133's wander guard did not work on the green hall exit door. Resident #144's wander guard did not work on the green hall exit door. These 4 residents wander guard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wander guard system the following residents were found to have eloped from the facility. Resident #37 Resident #37 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was performed on the resident on 12/6/11 revealed wander guard intact. Elopement attempt reported. On 2/28/12 wander guard intact; no elopement attempts noted. 5/22/12 wander guard in use; no attempts made at elopement. List of wanderers requested from the facility and the resident was listed on the list by the facility as being a wanderer. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wander guard applied to left arm. The previous one wasn't working when resident left out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. Maintenance Supervisor was notified that the doors weren ' t alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. "As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside." On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am, that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and placed it on the green hall and made it work. S7 Maintenance Supervisor reported that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and send it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility ' s wander guard policy was provided on 6-26-12. Wander guard Policy: All residents at the facility who tend to wander will have a wander guard put in place and monitored Q (every) shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNAs will check wander guards Q shift for placement and functions, nurses will document on MAR (medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wander guard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wander guard monitoring binder. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no"; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, Delusions, Hallucinations, Anxiety Disorder, Depression, Manic Depression, and Schizophrenia)? The response to this question was marked " no". The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58's Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58's Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58's elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___'s answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. When questioned as to how they monitor the functioning of the wander guard system, S4DON presented to the surveyor a factory handout of the wander guard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident, etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with SS17 Maintenance Supervisor was conducted and he stated that the system within the facility to protect wanderers is called wander guard but it has two different types of systems monitoring that are compatible with each other. The facility uses a "catch all " type system on some doors which means that anyone who goes in or out of the door will set off the alarm. It works by breaking the seal of the door which causes the alarm to go off. It has to be turned off by entering a code into a side panel that the staff has. The residents do not know the code so if the alarm sounds and is immediately turned off, and then we are aware it was a staff member. If it doesn ' t go off then the staff is alerted that they need to go and see who is attempting to exit the building. The other type of system that is used by the facility is a "push button recessed" system. This device works strictly off of the wander guard bracelets antenna signal and will not go off by a resident approaching the door. The resident has to physically go through the door or break the closed door seal to set off the alarm. The facility provided a list of wander guard devices by hallways and there were 6 push button recessed types and 7 catch all types listed by the facility On 6/28/12, an observation while touring the facility at 5:15am revealed that the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door had a wander guard alert system. The door had a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 who was identified by the facility as a wanderer was observed standing one hall over from the opened door. It was observed that the door remained opened from 5:15 am until 6:10 am when the surveyor went to the conference room at 6:30 am it was noted the patio door was closed. On 6/28/12 at 11:00 am, an interview was conducted with S4DON. She was informed of the surveyors finding the patio door on the private hall left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. She confirmed that Resident #85 was a wanderer in the facility and stated that she could have walked out of the patio door that was left open.

Based on record reviews, observations and interviews, the facility failed to have a system of supervision and monitoring in place to prevent confused, wandering residents from eloping from the facility after becoming knowledgeable that the wander guard alarm system was not functioning correctly on 10/1/11 for 3 (37, 58, and 123) confused, wandering residents out of a total of 11 (#112, #52, #66, #133, #123, #144, #37, #58, #26, #85, #7) residents identified as wanderers by the facility. Three of the 11 residents that were checked did not cause the wander guard system to alarm. The facility failed to: 1) have staff that was properly educated on the functioning and operation/testing of the wander guard system. 2) Identity and implement a system of direct supervision and monitoring interventions of confused wandering residents to prevent the confused, wandering residents from eloping from the facility without staff knowledge after 10/1/2011 after the facility becoming aware the wander guard door alarm system was not functioning properly on 10/1/2011. 3) Develop and implement an appropriate plan of action to repair the wander guard system on 10/1/11 when the facility became aware that a resident wearing a wander guard bracelet exited the facility through the front door and the door alarm did not alarm ON 10/1/11 4) Have a system of monitoring in place to ensure the wander guard bracelets were tested and replaced as directed by the manufacturer 5) Have a system of in place to monitor the wander guard door alarms to ensure the alarms functioned correctly after a resident wearing a wander guard bracelet exited the facility through the front door and the alarm did not sound. The Immediate Jeopardy situation began on 10/1/11 when resident # 123 eloped from the facility without the facility staff's knowledge. On 10/1/11, resident #123 exited the facility and placed herself in the back of a van belonging to visiting musicians who were at the facility for an activity on 10/1/11. The resident hid in the back of the visitor's van among the musical instruments. Band members discovered Resident #123 in the back of the van when the van arrived in another town about 9 miles from the facility. One of the band members contacted the resident's son to notify him that his mother had been found in the back of the van. The son called the nursing home to notify them that his mother had been found in the back of the musician's van and that she was unharmed. Upon Resident #123 ' s return to the facility, her wander guard bracelet was tested in the front entrance to the facility. The front door alarm did not sound when Resident # 123 passed through the front door. No new interventions were put into place to prevent resident #123 from eloping from the facility after it was noted that the wander guard alarm system was not working correctly on 10/1/11. All of the confused, wandering residents (#112, #52, #66, #133, #123, #144, #37, #58, #26, #82 and #7) were in immediate jeopardy on 10/1/11 when the facility failed to implement a system of supervision to prevent elopement from the facility when facility staff became aware that the wander guard alarm system was not working correctly. On 1/1/12, Resident #37 had his wander guard Bracelet changed after it was determined on the previous evening the resident's wander guard wasn't working when resident got out of the facility's doors x 2. The facility had knowledge that the new bracelet worked on the door in the TV room, but did not work on the back door at the end of the green hall. ON 4/15/12 AT 8:00 A.M., Resident #38 was found walking down a road by the facility heading to a local flea market. The resident was found 0.5 miles from the facility. The administrator was informed of the Immediate Jeopardy situation on 6/27/12 at 12:13 pm. The plan of removal was received on 6/28/12 at 8:18 am and was rejected. On 6/28/12, during an observation while touring the facility at 5:15am, the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door has a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85, who was identified by the facility as a wanderer, was observed standing one hall over from the propped opened door. The (DON) confirmed that she had not in-serviced her night staff on the new measures (Plan of Removal) for the immediate jeopardy. The second plan of removal was submitted on 6/29/12 and was rejected. The facility did not have a technical support technician arrive at the facility to check their current wander-guard system to ensure that it was functioning properly prior to team exiting the facility. On 6/29/12 at 4:00 pm the survey team exited the facility with the immediate jeopardy remaining in place. The immediate jeopardy was lifted on 7/2/12 at 2:26 p.m.when the wander guard technician repaired and replaced the defective systems. Citation remains at a second level pattern. Findings: The facility's wander guard policy was provided by the facility on 6/26/12 by the facility. Wander guard Policy- All resident at the facility who tends to wander will have a wander guard put in place and monitored Q(every)-shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNA's will check wander guards Q-Shift for placement and functions, nurses will document on MAR (Medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wander guard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wander guard monitoring binder. Resident# 123 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The review of the Elopement Risk assessment dated [DATE] revealed elopement attempt reported. Continue wander guard and every one hour check. Assessment of 3/27/12 revealed resident at risk for elopement. Wander guard in use to alert staff of resident's attempt to leave. On 6/19/12 assessment revealed wander guard in use to alert staff to resident's attempt to leave. Care plan reviewed and revealed that the resident is care planned for Potential for injury, related to potential to wander out of the facility - 10/1/11 left out of the facility. Nurse's Notes dated 10/1/11 at 5:15 pm revealed call in N.H.( nursing home) per resident's son - states Mom in a local town found in van (back of). Musicians were here earlier in cafeteria for activity and resident placed self in back of vehicle, stated resident did know band member. Son stated would visit with her and return back to the N.H. No indication of wander guard going off when resident left. Notified D.O.N. ( ____ ) of incident. Nurse ' s notes dated 10/1/11 6:20 pm. revealed resident returned to N.H. accompanied by son without complaints in good condition. tested wander guard hallway on Gold Hall and alarm working and smoke room worked. tested wander guard in front entrance and did not alarm when resident passed thru; did register (alarm) however when facing to enter alarm picks up on right hand. Meds given allowed to smoke 2 cigarettes and placed in room in bed. On 6/27/12, at 8:35 a.m., an interview with S22LPN/MDS was conducted and Resident #123's clinical record was reviewed to confirm what she had documented. She stated there were people that Resident #123 knew from her home town and S22LPN/MDS was told by the residents son that the resident hid in the back of the visitor's van amongst the instruments and when they got to a local town, the visitors opened the back doors of the van and noticed Resident #123 amongst the instruments. The visitor then contacted Resident #123's son. S22LPN/MDS stated she was passing medications in the cafeteria at the time of the incident and to her knowledge does not recall the system going off and she stated this is the only time that she knew of her getting out of the facility. S22LPN/MDS stated "when the residents son returned her to the facility, I decided to check the wander guard. First, I bought her to the brown hall and that door worked. When I asked her how she left, she told me she went through the front doors. I decided to test her alarm at the front door and her bracelet was on her right arm. When I bought her out of the front door into the patio area her bracelet did not alarm. When I brought her back into the facility the alarm did go off. It would not pick up the bracelet on her right arm so I put one on her left arm for the duration of the shift and that took care of the problem. I did make her go through the door again and it alarmed both times her going in and out of the facility. When I called the DON, she told me to just monitor her and when maintenance comes in tomorrow he will check it. I am not aware of anyone else leaving." Again S22 LPN/MDS confirmed that she tested the door on the brown hall where the resident lives and to the best of her knowledge the wander guard was intact and it was working. She stated usually bracelets are checked once a day or once a shift-not sure how they check them other than they bring the resident to the door. On 6-27-12 at 10:40 am, an interview was conducted with S24Administrator. During an interview with the administrator, it was asked by the surveyor if the administrator was aware of the wander guard system and how it works in his facility. The Administrator stated yes. When asked if he could explain how the system works, he then stated: residents are placed with a bracelet and the resident has to go through the door to make the alarm go off. When asked if he was aware that the wander guard system was not functioning properly, he stated no that they had a problem earlier and have purchased three new sensors and replaced the sensors on the main front door, patio door on the private hall and on one other door but I'm not sure which one it was. He stated that all exit doors have the wander guard system in place with one of two different type of systems being used which are a push button release system and a catch all type system. When asked if he was aware of an elopement of Resident #123 on 10-1-11 he stated yes. When asked if he could explain to us what happened at the time of this situation, the Administrator stated that on the day of the elopement, there was a band playing for the facility from the area that the resident lived prior to entering the facility. Apparently she got one of the band members to bring her to a local town and they called her son to tell him she was there. When asked if the wander guard system was working on that day, he stated that someone checked it out and it was still working. The surveyor reviewed the incident report dated 10/1/11 with the administrator which revealed a resident left through the front door of the facility and hid amongst the band equipment in the van and members were not aware she was there until they got to a local town. At that time, she let them know she was there and at that time she asked them to call her son. When questioned as to if he was aware of the fact that she eloped through the front door, he stated what could of happened is she walked out with some other people and even though it may have alarmed if the office staff didn't see her, they may have just shut off the alarm. S24 administrator was asked if this incident was discussed at the monthly QA meeting and he stated yes, they addressed it at their daily meetings but he was unable to say what interventions were put into place at that time. He stated, "I would have talked to the DON/ADON and made sure they communicated to the staff." When questioned as to what he put into place as an administrator, he stated he could not tell us for sure but he knew he would have made sure maintenance was aware of the issue so that the system could be checked. When the administrator was asked if it was the procedure for the staff to check to see if a resident had left the building prior to turning off an alarm, he stated, "They are supposed to". On 6-27-12 at 9:15 am, an interview with S4DON was conducted and the incident report of the resident's elopement was reviewed. S4DON was asked what she put into effect with the supervision of the wandering residents in the facility that had wander guards and she stated, Q (every) 1 hour visual checks to be sure residents were in the facility. These checks were to be done by CNAs and nurses and I informed the staff about this. The surveyor confirmed that q 1 hour checks were started after the resident eloped and all residents with wander guards had visual q 1 hour checks initiated on MARs. When questioned as to why they didn't fill out an Otis report, S4DON stated that at the time they were working on the abuse issues and it just slipped past us. S4DON stated that prior to resident elopement, they were not aware of any problems with the wander guard system. S4DON stated that S27ADON does all of the Otis reports. These are generated from the incident reports he receives after he does his part and I do review all of them. Again, S4DON was asked if an Otis report was generated and she stated no. S4DON stated that evidently they both overlooked this because they were so busy with working on abuse issues and just didn't realize it had not been done. Resident # 85 On 6/25/12 at 10:38 a.m., Resident # 85 ' s daughter was interviewed in Stage I of the survey process. She stated that her mother has a wander-guard system in place and that when she would take her out on pass, the alarm does not alarm. On 6/26/12 at 2:45 pm an investigation of the facility wander guard system was started. Resident #85 was escorted with the staff member S5LPN to the wander guard alarm at the end of the blue hall. The LPN stated that the alarm would go off when the resident got close to the doors. The alarm did not go off. At 3:10 pm, S4DON and the resident were again brought to the wander guard door alarm at the end of the brown hall. The alarm did not go off as the resident approached the door. S4DON stated that the alarm would go off as the resident approached the wander guard sensors. S4DON then stated the alarms do not work. She stated that some of them work and some of them don't. This is the system we put into place to protect the residents and it does not work. She further stated that the only alarms that did work were the alarms on the patio and the front door of the facility. The wander guard on the brown and the blue halls did not activate and this was confirmed by the S4DON. She stated that the facility got a price for a whole new system and needed a new system. S4DON stated, "We've been changing the unit boxes on the halls. We've been doing it one by one. The staff has been keeping an eye on the residents to increase the supervision. We are working on getting the system to work." On 6/26/11 at 5:55 pm an interview was conducted with S19 LPN and she stated that she initialed the MAR stating that the wander guard bracelet was in place. She was not aware of the battery life of the bracelet and had not been told of the time frame that it needed to be changed. The is the only way she would know if the bracelet was working would be when the resident attempted to leave the facility. A list of the wandering residents was requested from the DON. Survey team and DON proceeded to check all of the bracelets on the wandering residents in the facility. The wanderers in the facility had their wander guard bracelets checked by the survey team at various doors in the facility that had the wander guard system in place. A total of 11 residents were identified as wanderers. Four of the 11 residents that were checked did not cause the system to alarm. Resident #66's wander guard did not work on the Gold/Brown Hall exit door. Resident #52's wander guard did not work on the patio exit door, Resident # 133's wander guard did not work on the green hall exit door. Resident #144's wander guard did not work on the green hall exit door. These 4 residents wander guard bracelet did not alarm when they went through the above listed doors. During the investigation of the facility's non-functioning wander guard system the following residents were found to have eloped from the facility. Resident #37 Resident #37 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An Elopement assessment was performed on the resident on 12/6/11 revealed wander guard intact. Elopement attempt reported. On 2/28/12 wander guard intact; no elopement attempts noted. 5/22/12 wander guard in use; no attempts made at elopement. List of wanderers requested from the facility and the resident was listed on the list by the facility as being a wanderer. On 6/28/12 a review of the resident's chart was made. The Nurse's Notes dated 1/1/12 revealed the following," New wander guard applied to left arm. The previous one wasn't working when resident left out of the doors x 2 last pm. The new alarm worked on door in the TV room but not the back door at the end of the green hall. Maintenance Supervisor was notified that the doors weren ' t alarming when resident approached the doors." This note was signed by S19LPN. On 6/27/12 at 1:48 pm an interview was conducted with S18CNA/Ward Clerk. She stated that Resident #37 was near the smoke room at the blue station. "As I recall, the staff on the other side called me at the orange station and told me that he was seen outside of the facility in the front parking lot. I had never known him to go outside before but he would talk about it. The staff told me that he was alone in the parking lot. The resident was really adamant that day about looking for his car and he wanted to leave. I'm absolutely sure that I got a call from the blue station telling me about the resident being outside." On 6/27/12 at 3:50 pm, an interview with S11CNA was conducted and she stated that she observed the resident outside of the facility. She stated that it was about in early May in the afternoon when she saw him in the parking lot of the facility. She stated that she told the nurse and he was going through the door on the green hall. On 6/28/12 at 3:49 pm, an interview with S17 Maintenance Supervisor was conducted and he was asked about the incident on 1/1/12 when the nurse reported to him that the resident had left out of the facility and the alarm on the green hall door was not working. He stated that door alarm was not working and referred to his log of the maintenance done in the facility at that time. The log was reviewed and revealed that on 1/2/12 one unit in the facility was not working. He stated that he thought this was the green unit but had stated on 6/27/12 at 11:45 am, that it was the burgundy hall was not working. He could not confirm which unit in the facility was not functioning. On the Weekly Wander Guard Inspection form the unit on the burgundy hall was replaced on 3/12/12, the unit on the private hall was replaced on 3/19/12 and the unit in the lobby was replaced on 3/26/12. There was no documentation of the unit on the green hall being replaced. During the interview, S17 Maintenance Supervisor stated that he thinks that he used parts from another unit and placed it on the green hall and made it work. S7 Maintenance Supervisor reported that he knew "that the resident had eloped from the facility in January. He stated that the facility went all these weeks with the units not working because the facility did not let me purchase new equipment so I could not do anything about the alarm not working. He stated, in February I submitted a request for a new system and the facility did not approve the request. I requested a new system because the present system does not work. He stated the Administrator asked me to get the quotes for a new system due to the system being old and not working properly. I had to order 3 new units instead to fix the current system. He further stated, between you and me, it was not fixing the system it was just a get by." On 6/28/12 at 3:20 pm an interview was conducted with the S4DON and S27ADON and the Administrator of the facility. S4DON was asked to read the Nurse's Notes entry on 1/1/12 and the entry revealed that the resident did elope out of the facility 2 times on the previous evening. When S4DON was asked if she was aware of this incident she stated that she knew about the resident leaving out of the facility in January. S4DON was asked for the incident report concerning the incident and she stated that she did not fill out an incident report. The S4DON was asked for an OTIS report of this incident and she stated that she did not fill out an OTIS report and send it to the state. On 6/29/12, S27ADON presented the facility policy for Critical Incident Reporting Policies and Procedures and stated this is what the facility follows. He confirmed that in the policy elopement is considered a reportable incident to the state. The facility ' s wander guard policy was provided on 6-26-12. Wander guard Policy: All residents at the facility who tend to wander will have a wander guard put in place and monitored Q (every) shift. On a monthly basis, batteries will be checked by charge nurse. 1. Nurses and CNAs will check wander guards Q shift for placement and functions, nurses will document on MAR (medication Administration Record). 2. Residents leaving facility for any length of time will be check upon return for placement and function of wander guard and nurses will document in nurses notes. 3. Monthly checks will be logged by charge nurse into wander guard monitoring binder. Resident #58. A review of Resident #58's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. An observation of Resident #58 on 6/28/12 at 2:30 pm revealed he was ambulatory throughout the facility. He was not wearing a wander guard bracelet during this observation. Resident #58's initial Elopement Risk assessment dated [DATE] read: 1) is the resident cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficit or disoriented all the time)? The response to this question was marked "no"; 2) Does the resident have a pertinent diagnosis (i.e., Dementia, OBS, Alzheimer's, Delusions, Hallucinations, Anxiety Disorder, Depression, Manic Depression, and Schizophrenia)? The response to this question was marked " no". The Summary/Conclusions/Recommendations indicated Resident #58 was not an elopement risk. Further review of Resident #58's Elopement Risk Assessment form revealed S1LPN/MDS documented " Resident not at risk for elopement " on 1/10/12 and S22LPN/MDS documented " no attempts at elopement " on 4/3/12. As of 6/28/12 at 10:15 am, there were no other entries documented on Resident #58's Elopement Risk Assessment form. Further review of Resident #58's clinical record revealed an entry on his Nurses' Notes dated 4/15/12, timed 8:00 am, which read: Resident #58 left the property and was headed down to the flea market. Found resident on the corner of Arceneaux Road and Potier Road. Talked resident into coming back. When resident arrived on the property he was yelling at another resident. Attempted to redirect resident into the building but he continued to walk towards the other resident. Resident charged at the other resident but was stopped by staff. Calling S4DON to inform her of what occurred. Left message at 8:45 am. An entry timed 2:50 pm read: S4DON returned phone call and said to write an incident report. These entries were signed by S32LPN. On 6/28/12 at 10:30 am, an interview was conducted with S24 ADM, S4 DON, and S27 ADON. S4DON confirmed elopement was considered to be any resident leaving the facility without staff knowledge that the resident has left. S24 ADM, S4 DON, and S27 ADON were asked if they had knowledge of any residents, including residents assessed to be at risk of elopement and residents not considered to be at risk of elopement, S4 DON stated the only residents that had eloped from this facility in the past year were Resident #123 and Resident #37. According to S4 DON, she had not known that Resident #37 had eloped from this facility until the survey team began investigating this elopement. S4DON and S27ADON confirmed that they should have known about the incident with Resident #37, but had not. S4 DON was again asked if there had been any other residents that had eloped from this facility, she replied no. S4DON was asked to review Resident #58's Nurses' Notes dated 4/15/12, timed 8:00 am and 2:50 pm. After reading these entries, S4 DON confirmed that she was aware Resident #58 had eloped from this facility on 4/15/12 and she told the nurse to complete an incident report. S27ADON then confirmed he had been aware that Resident #58 had left the facility without staff knowledge of him leaving on 4/15/12. S27ADON confirmed he had reviewed Resident #58 ' s incident report, dated 4/15/12, but had not completed an OTIS Report. S27ADON stated he was not aware that OTIS Reports should be completed for elopements; therefore, he had not completed Resident #123, Resident #37, or Resident #58. S24 ADM denied knowledge of Resident #58's elopement on 4/15/12. S4 DON confirmed Resident #58's elopement risk was not reassessed after the elopement on 4/15/12. When asked if Resident #58's elopement risk should have been reassessed after his elopement on 4/15/12, S24ADM replied "absolutely Resident #58 should have been reassessed in a timely manner with interventions put in place to protect and supervise him." S24 ADM verified there was a break in this facility's system regarding communication and quality assurance. The facility's I & A Reporting Form, dated 4/15/12, read: "Resident #58 was seen by another resident leaving the property. Resident #58 was at the corner of Arceneaux Road and Potier Road. I got in my car and drove down to get the resident. I asked the resident to get in my car so we could go back to the facility. Resident #58 got in my car and said he wanted to go to the Flea Market. Once back on the property, Resident #58 was very upset. He began yelling at another resident for telling and then he charged at the other resident. Myself and other staff members had to physically pull the resident in the other direction. Called Dr.____ at 3:05 pm to inform him about the resident leaving the property. Left a message with Dr.___'s answering service. Called resident's sister/responsible party and left a message for her to call at 3:00 pm. Intervention-told resident he needs to let the ward clerk know because he needs to be signed out." According to this report, the incident occurred at 8:00 am and Resident #58's condition before the incident was described as "normal". This form was signed by S32 LPN on 4/15/12, S4DON on 4/18/12, and S24 ADM (not dated). On 6/28/12 at 1:45 p.m., S7 SSD stated she had known about Resident #58 eloping from the facility on 4/15/12. S7 SSD stated he was attempting to walk a few miles to get to the flea market, but another resident noticed him walking on the street. She stated he was found on the corner of Potier Road and Arceneaux Road, which was approximately 0.5 miles away from the facility. S7 SSD revealed it had probably taken him almost 15 minutes to get that far before staff found him. During interview on 6/28/12 at 2:20 p.m., S36 SSD stated she did not recall discussing elopement as an area that needed quality assurance at the quarterly QA meetings, nor did she recall discussing any issues or problems with the wander guard system. S36 SSD confirmed she was aware of Resident # 58 eloping from the facility on 4/15/12. When questioned as to how they monitor the functioning of the wander guard system, S4DON presented to the surveyor a factory handout of the wander guard and read from the handout that the staff was to, use sensor, stand xxx feet front entrance, point sensor toward resident, etc. S4 DON was asked if this was what was being done and she stated no. S27 ADON looked at material and stated this is old material and not sure if this is what is being done by maintenance. He stated he would have to check with maintenance supervisor but I know he uses something. When S4DON was questioned as to how they monitor who has actually attempted to leave the facility or how many times they have attempted to leave the facility, she stated they have nothing in place for this and doesn't believe there is a way to monitor this. On 6-26-12 at 5:30 pm, an interview with SS17 Maintenance Supervisor was conducted and he stated that the system within the facility to protect wanderers is called wander guard but it has two different types of systems monitoring that are compatible with each other. The facility uses a "catch all " type system on some doors which means that anyone who goes in or out of the door will set off the alarm. It works by breaking the seal of the door which causes the alarm to go off. It has to be turned off by entering a code into a side panel that the staff has. The residents do not know the code so if the alarm sounds and is immediately turned off, and then we are aware it was a staff member. If it doesn ' t go off then the staff is alerted that they need to go and see who is attempting to exit the building. The other type of system that is used by the facility is a "push button recessed" system. This device works strictly off of the wander guard bracelets antenna signal and will not go off by a resident approaching the door. The resident has to physically go through the door or break the closed door seal to set off the alarm. The facility provided a list of wander guard devices by hallways and there were 6 push button recessed types and 7 catch all types listed by the facility On 6/28/12, an observation while touring the facility at 5:15am revealed that the patio door on the private hall was left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. This door had a wander guard alert system. The door had a wander guard alert system which required that the door be closed to function properly as the alarm is set off by a break in the sensor. Resident #85 who was identified by the facility as a wanderer was observed standing one hall over from the opened door. It was observed that the door remained opened from 5:15 am until 6:10 am when the surveyor went to the conference room at 6:30 am it was noted the patio door was closed. On 6/28/12 at 11:00 am, an interview was conducted with S4DON. She was informed of the surveyors finding the patio door on the private hall left ajar with a cone shaped yellow floor wet sign in between the door preventing the door from closing. She confirmed that Resident #85 was a wanderer in the facility and stated that she could have walked out of the patio door that was left open.

Based on record review and interview, the facility failed to provide necessary care to a resident to maintain her highest practicable physical well-being by failing to provide care which would have prevented the condition of the resident deteriorating for 1 of 6 sampled residents (#6). The resident ' s last bowel movement was on 7/7/11. The facility failed to administer medications after Resident #6 did not have a bowel movement for more than three days, and failed to notify the physician after the resident did not have a bowel movement after four days. Resident #6 became impacted and on 7/11/11, she began to vomit and a bowel impaction was manually removed from her rectum. Findings: Resident #6: A review was conducted of Resident #6 ' s record and revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of the Accumulative [DIAGNOSES REDACTED]. Further review of the resident ' s record revealed that she had become a hospice patient on 6/17/2010. A review of the physician's order [REDACTED]. following orders for Constipation: (If no BM in 3 days). The facility ' s Routine Physician ' s Standing Orders were in effect upon Resident #6 ' s admit of 10/17/2008. A. Milk of Magnesia 30cc PO or PEG Q HS B. If no results in 24 hours use Fleets enema or 1 [MEDICATION NAME] suppository C. If still no BM, check for fecal impaction and follow with 2nd Fleets enema * Notify MD if no BM or further problems A review of the July 2011 Nursing Care Sheet in Resident #6 's chart revealed an area in which bowel movements were charted by the CNAs (Certified Nursing Assistant). Bowel movements can be documented as N- Normal, D- Diarrhea, or C- Constipated. The resident ' s bowel movements are charted during three shifts during one day. These shifts are from 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. A bowel movement of "N" (normal) was charted on 7/7/11 during the 3:00-11:00 p.m. shift. From the 11:00 p.m. -7:00 a.m. shift on 7/7/11 until the 7:00 a.m. -3:00 p.m. shift on 7/14/11, all bowel movements were recorded as "O" (none). A review of the July 2011 Medication Administration Record (MAR) for Resident #6, which was copied on 7/19/11, failed to reveal that the Physician ' s Standing Orders for Milk of Magnesia had been administered after the resident did not have a bowel movement for more than 3 days, between 7/7/11 and 7/11/11. A review of the Nurses' Notes revealed an entry dated 7/11/11 at 5pm. It revealed that S6LPN documented that a suppository had been administered after a fecal exam and a large BM was noted and was round, brown, formed. Further review of Resident #6's chart revealed a hospice Nursing Clinical Note dated 7/12/11 was conducted and revealed that Resident #6's last bowel movement had been 7/7/11 and that the nursing home staff removed an impaction from the resident earlier that day. An interview was conducted with S1DON on 7/19/11 at 9:45am. She reviewed the Nursing Care Sheet for July 2011 and verified that the Resident #6 had a bowel movement on 7/7/11 then not again until 7/14/11. She stated that she would have expected the facility to follow the physician's orders [REDACTED]. S1DON reviewed the resident's July 2011 MAR and confirmed that no medication had been administered as per the standing orders for Resident #6's lack of bowel movements. She further stated that the facility did not follow the physician's orders [REDACTED]. She stated that this may have resulted in Resident #6 becoming impacted. She stated that the hospice nurse and the physician had not been notified of the resident ' s condition and further stated that they should have been notified about the resident not having bowel movements for more than 3 days An interview was conducted with S1DON on 7/19/11 at 10:45am. She stated that if a resident had not had a bowel movement in three days and was vomiting, the resident should be assessed for a bowel impaction. She further stated that this assessment would be critical if the resident had a history of [REDACTED].#6's chart, dated 7/11/11 which stated that the resident was vomiting green fluid and undigested food. She stated that she was the nurse that had written that entry. She continued to review the nurse ' s notes in Resident #6's chart and stated that there was no nursing assessment by the nursing home staff, of Resident #6's bowel sounds or impaction, in her chart for the period of 7/7/11 through 7/11/11. S1DON further stated that she did not notify the physician nor the hospice nurse of the resident ' s vomiting because she thought it was just a single episode. S1DON further stated that she was not aware that Resident #6's last bowel movement was on 7/7/11when the resident was vomiting on 7/11/11. S1DON stated that she did not refer to the Nursing Care Sheet to assess when Resident #6's last bowel movement had been documented, during the vomiting episode. An interview was conducted with Resident #6 on 7/20/11 at 9:00 a.m. She confirmed that she didn't "poo" (have a bowel movement) for more than 3 days. She stated that it hurt and she told the workers it hurt and they gave her pain medicine. She stated that she couldn't "poo", and she started to get "sick of the stomach and I started throwing up" She further stated " I couldn't eat before I throwed up because my stomach felt sick. I throwed up a lot. My daughter was with me when I throwed up. The workers came and cleaned me up because I was all messed up." She further stated " The workers came to take the hard stuff out of me and it hurt when they took it out. Oh yes it hurt a lot when they took it out of me". She further stated " I had pain before when I couldn't poo and the workers gave me medicine for the hurting. After the workers took out the hard poo poo I didn't have any more pain." An interview was conducted with S6LPN on 7/20/11 at10:20 a.m. She presented additional nurse ' s notes that were not found in Resident #6 ' s chart. She stated that these notes were from the " Private Hall Binder " where documentation should be done for Resident #6. She further stated that there is a binder for each hall which holds nurses notes for the residents on that hall. She stated that the charting is to be done on the nurses notes in these binders, but sometimes the new nurses forget and they chart directly in the residents ' binders. She stated that when this document is full it is placed in the resident's binder. She reviewed Resident #6's nurse's notes from the "Private Hall Binder" and stated that on 7/11/11 at 5:00 p.m., she documented that she had "noted" a large bowel. She confirmed that the resident had been impacted, and that between 4:00 p.m. and 5:00 p.m., on 7/11/11 she removed a small to medium impaction of bowel. She further stated that she had not contacted the resident's physician regarding lack of bowel movements, removal of the impaction or that the resident had experienced vomiting because she thought that the hospice nurse would be responsible for that. An interview was conducted with S1DON on 7/20/11 at 12:30 p.m. She stated that all the nurses are supposed to be charting on the nurses notes in the appropriate binder which is housed at the nurses' station and not directly on the nurses notes in the residents' binders. She reviewed the nurse's notes for Resident #6 from the "Private Hall Binder". She stated that she had forgotten about these nurse's notes. She would not reply when she was asked why she had not documented her provision of care to Resident #6 when she was vomiting on 7/11/11 on these nurse's notes rather than directly in the resident's chart. S1DON reviewed the hospice notes in Resident #6's chart and confirmed that an impaction had been removed from the resident on 7/11/11.

Based on record review and interview the facility failed to keep a resident from harm by: A) Not appropriately lifting the resident into the facility's van which resulted in hitting the resident's right foot causing a broken right knee. B) Not Immediately reporting to staff an injury which caused pain to the residnet. On 7/18/11 resident #4's record was reviewed. It revealed that the resident had an incident and accident report dated 7/9/11 at 2:00 pm.. The time of the incident was listed as 2:00 pm when the facility was informed by the family that the resident's knee was swollen and hurting. There is no documentation of the actual time of the incident. There is mention in one witness statement of a phone call from the family at 12:30 on 7/9/11 asking if the resident had fallen, as he was complaining about the knee.In the emergency room Report, the time of the incident was listed as "10:30 am ?" as if they were not sure of the exact time. The report stated that a member of the resident's family called the nursing home at 2:00 PM and stated that the "resident had swelling to the right knee with redness". The report also stated that the resident arrived at the nursing home at 2:50 PM and the assessment on the report stated "Resident assessed per nurse, right knee slightly swollen. Ice pack in place. Tylenol 1 Gram given for pain." According to the report the resident was experiencing pain at a level 7 out of 10. An interview with the resident was attempted but he was unable to be understood. A witness statement dated 7/8/11 (?) with no time listed, from (S3) CNA/van driver stated "When I put (resident #4) on the lifter gate to put in the truck his right foot hit the lifter gate lightly. I put ice on the right knee for the swelling. " The nurses' note concerning the incident, dated 7/9/11 at 2:50 pm states: "Resident right knee slightly swollen. Ice pack in place. Resident complains of pain when right leg is moved Acetaminophen 500 milligrams X2 given for pain. Resident put back to bed and made comfortable using lifter and right leg up on pillow. " At 3:00 PM the nurse's notes continued, stating that the nurse practitioner was called and told of the incident. The nurse practitioner ordered to continue with ice packs to help keep swelling down and to x-ray right knee on Monday. ( 2 days later). (S2)ADON was notified. Family was notified. At 8:15 PM the resident ' s nurses notes stated that the family was at the nursing home visiting. The family requested that the resident be sent to the hospital because the knee was swelling more and the knee was warm to touch. The nurse called the nurse practitioner and the resident was sent out to the hospital. On 7/19/11 at 1:30 PM records from the hospital the resident was sent to were reviewed. The final impression from the x-ray was acute right knee fracture. On 7/19/11 at 2:30 PM (S1) DON stated " I got witness statements from the 2 ladies (S3)CNA/driver and (S4)CNA .( S3) stated she did not notice the knee when she was loading him. She was trying to put the gerichair in the van. (S3) can/van driver is no longer employed here. The policy for reporting incidents and accidents is getting statements and getting information about the accident. (S3) should have filled out an incident report before she left the building because she knew she hit the resident ' s foot. That way the resident could have been assessed before leaving in the van. I think the resident broke his knee when she bumped his foot because #4 ' s feet are contracted inward and she bumped the knee and caused the fracture. She should have told us when she first bumped the foot. They are trained to report when something happens not to wait and see what happens then report it. "

Based on record review and interviews, the facility failed to provide the necessary care and services to a resident to attain his highest practicable physical well-being a. by failing to initiate a PT/OT Evaluation at the time of admit for a resident who had been assessed at being at high risk for falls and assessed as having a balance problem and an unsteady gait related to generalized weakness and b. by failing to have a system in place to adequately evaluate a resident for the need of PT/OT services after the resident had 4 documented falls for 1 of 4 residents reviewed for falls in a sample of 5 residents in a facility with a census of 159. #2 Findings: a). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His Statement of Medical Status dated 5-5-11 revealed he was oriented x2 and had no vision in his left eye, his ambulation was unstable and he exhibited gait difficulty. His admitting assessment at the facility dated 5-17-11 revealed he was alert but confused and needed limited assistance with transfers, walking, dressing and grooming. He also used a wheelchair. Further review revealed he had been transferred from a hospital in north Louisiana to the facility on [DATE]. A side rail assessment done on 5-17-11 revealed the resident's balance and gait was unsteady due to generalized weakness. Review of #2's Preliminary Care Plan dated 5-17-11 revealed that one of his 'Problems' was 'Potential for falls/injury R/T falls D/T unsteady balance and gait'. The 'Goal' was as follows, 'Call bell in reach' and 'Notify MD and RP of all incidents and accidents'. Under the area listed as 'Interventions' read to have PT, OT, ST to screen initially and quarterly and make necessary recommendations. Review was done of #2's discharge summary from the north LA hospital dated 5-3-11. Within the summary the physician wrote that PT and OT were consulted for assessment and evaluation while on the floor, who recommended discharge to home with outpatient PT. (It was learned later that #2 was not discharged on [DATE] but instead on 5-17-11) Review of a Progress Note from the same hospital dated 5-16-11 read to continue PT and OT however the admitting orders to the facility on [DATE] did not have any orders to continue or evaluate for PT and OT. An interview was held with #S1LPN/MDS on 6-1-11 at 10:40 a.m. She stated she did a fall assessment on #2 when he was admitted . The stated that #2 had impaired vision, needed assist with bowel and bladder and had an unsteady gait but ambulated. She stated she also did a siderail assessment on admit and determined that #2 had his balance and gait impaired and an unsteady gait. An interview was held with #S3LPN on 6-2-11 at 9:05 a.m. She stated that she was the admitting nurse when #2 came in to the facility. She stated that she had not seen the progress note or hospital discharge summary which read to continue PT/OT so this was never clarified. An interview was held with #S4ADON on 6-2-11 at 9:20 a.m. He stated that had not seen the progress note or hospital discharge summary which read to continue PT/OT so this was never clarified. An interview was held with #S2PT Rehab Coordinator on 6-1-11 at 9:30 a.m.- He stated that he was not aware that #2 had been assessed as exhibiting unsteady balance and gait due to generalized weakness. Stated Physical Therapy Screens were done if the physician ordered or if the facility's I/A reports indicated that a resident needed PT or OT. On 6-2-11 at 11:35 a.m. an interview was again held with #S2PT Rehab Coordinator. At this time he was shown the hospital progress note dated 5-16-11 which read to continue PT/OT. He stated if he had been aware of the progress note he would have followed up on it. He stated in the future he thought he would try to put a fall team together to prevent anyone from falling through the cracks. b.) Review of #2's records revealed that #2 had 1 fall on 5-18-11(which read that #2 stated he got weak and went down to his knees), 2 falls on 5-22-11 and 1 fall on 5-25-11(which read that #2 claimed he fell trying to get in his bed). There were no injuries from any of the four falls. During an interview with #S2PT Rehab Coordinator on 6-2-11 at 11:35 a.m., he stated that he was told that the resident's falls were not related to balance problems but instead related to his refusals to use the call light. He stated that he did not actually evaluate the resident and that Physical Therapy Screens were done if the physician ordered or if the facility's I/A reports indicated that a resident needed PT/OT. He stated that on 5-25-11 a Physical Therapy Screen was done by reading #2's I/A reports and that PT did not visibly evaluate #2. He stated that after reading the I/A reports, nothing in the reports indicated he needed to evaluate the resident at that time because the I/A reports read that his falls were mostly attributed to #2's refusals to use the call light. He did state that he thought the facility should provide more information other than the I/A reports. S2 was asked to read #2's I/A reports. After reading the I/A report dated 5/18/11, he stated that the I/A reports on 5-18-11 and 5-25-11 could have indicated a need for PT/OT services. He stated that it appeared #2 "fell through the cracks" and that a better system was needed.

Based on record review and interview, the facility failed to provide necessary care to a resident to maintain her highest practicable physical well-being by failing to provide care which would have prevented the condition of the resident deteriorating for 1 of 6 sampled residents (#6). The resident ' s last bowel movement was on 7/7/11. The facility failed to administer medications after Resident #6 did not have a bowel movement for more than three days, and failed to notify the physician after the resident did not have a bowel movement after four days. Resident #6 became impacted and on 7/11/11, she began to vomit and a bowel impaction was manually removed from her rectum. Findings: Resident #6: A review was conducted of Resident #6 ' s record and revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of the Accumulative [DIAGNOSES REDACTED]. Further review of the resident ' s record revealed that she had become a hospice patient on 6/17/2010. A review of the physician's order [REDACTED]. following orders for Constipation: (If no BM in 3 days). The facility ' s Routine Physician ' s Standing Orders were in effect upon Resident #6 ' s admit of 10/17/2008. A. Milk of Magnesia 30cc PO or PEG Q HS B. If no results in 24 hours use Fleets enema or 1 [MEDICATION NAME] suppository C. If still no BM, check for fecal impaction and follow with 2nd Fleets enema * Notify MD if no BM or further problems A review of the July 2011 Nursing Care Sheet in Resident #6 's chart revealed an area in which bowel movements were charted by the CNAs (Certified Nursing Assistant). Bowel movements can be documented as N- Normal, D- Diarrhea, or C- Constipated. The resident ' s bowel movements are charted during three shifts during one day. These shifts are from 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. A bowel movement of "N" (normal) was charted on 7/7/11 during the 3:00-11:00 p.m. shift. From the 11:00 p.m. -7:00 a.m. shift on 7/7/11 until the 7:00 a.m. -3:00 p.m. shift on 7/14/11, all bowel movements were recorded as "O" (none). A review of the July 2011 Medication Administration Record (MAR) for Resident #6, which was copied on 7/19/11, failed to reveal that the Physician ' s Standing Orders for Milk of Magnesia had been administered after the resident did not have a bowel movement for more than 3 days, between 7/7/11 and 7/11/11. A review of the Nurses' Notes revealed an entry dated 7/11/11 at 5pm. It revealed that S6LPN documented that a suppository had been administered after a fecal exam and a large BM was noted and was round, brown, formed. Further review of Resident #6's chart revealed a hospice Nursing Clinical Note dated 7/12/11 was conducted and revealed that Resident #6's last bowel movement had been 7/7/11 and that the nursing home staff removed an impaction from the resident earlier that day. An interview was conducted with S1DON on 7/19/11 at 9:45am. She reviewed the Nursing Care Sheet for July 2011 and verified that the Resident #6 had a bowel movement on 7/7/11 then not again until 7/14/11. She stated that she would have expected the facility to follow the physician's orders [REDACTED]. S1DON reviewed the resident's July 2011 MAR and confirmed that no medication had been administered as per the standing orders for Resident #6's lack of bowel movements. She further stated that the facility did not follow the physician's orders [REDACTED]. She stated that this may have resulted in Resident #6 becoming impacted. She stated that the hospice nurse and the physician had not been notified of the resident ' s condition and further stated that they should have been notified about the resident not having bowel movements for more than 3 days An interview was conducted with S1DON on 7/19/11 at 10:45am. She stated that if a resident had not had a bowel movement in three days and was vomiting, the resident should be assessed for a bowel impaction. She further stated that this assessment would be critical if the resident had a history of [REDACTED].#6's chart, dated 7/11/11 which stated that the resident was vomiting green fluid and undigested food. She stated that she was the nurse that had written that entry. She continued to review the nurse ' s notes in Resident #6's chart and stated that there was no nursing assessment by the nursing home staff, of Resident #6's bowel sounds or impaction, in her chart for the period of 7/7/11 through 7/11/11. S1DON further stated that she did not notify the physician nor the hospice nurse of the resident ' s vomiting because she thought it was just a single episode. S1DON further stated that she was not aware that Resident #6's last bowel movement was on 7/7/11when the resident was vomiting on 7/11/11. S1DON stated that she did not refer to the Nursing Care Sheet to assess when Resident #6's last bowel movement had been documented, during the vomiting episode. An interview was conducted with Resident #6 on 7/20/11 at 9:00 a.m. She confirmed that she didn't "poo" (have a bowel movement) for more than 3 days. She stated that it hurt and she told the workers it hurt and they gave her pain medicine. She stated that she couldn't "poo", and she started to get "sick of the stomach and I started throwing up" She further stated " I couldn't eat before I throwed up because my stomach felt sick. I throwed up a lot. My daughter was with me when I throwed up. The workers came and cleaned me up because I was all messed up." She further stated " The workers came to take the hard stuff out of me and it hurt when they took it out. Oh yes it hurt a lot when they took it out of me". She further stated " I had pain before when I couldn't poo and the workers gave me medicine for the hurting. After the workers took out the hard poo poo I didn't have any more pain." An interview was conducted with S6LPN on 7/20/11 at10:20 a.m. She presented additional nurse ' s notes that were not found in Resident #6 ' s chart. She stated that these notes were from the " Private Hall Binder " where documentation should be done for Resident #6. She further stated that there is a binder for each hall which holds nurses notes for the residents on that hall. She stated that the charting is to be done on the nurses notes in these binders, but sometimes the new nurses forget and they chart directly in the residents ' binders. She stated that when this document is full it is placed in the resident's binder. She reviewed Resident #6's nurse's notes from the "Private Hall Binder" and stated that on 7/11/11 at 5:00 p.m., she documented that she had "noted" a large bowel. She confirmed that the resident had been impacted, and that between 4:00 p.m. and 5:00 p.m., on 7/11/11 she removed a small to medium impaction of bowel. She further stated that she had not contacted the resident's physician regarding lack of bowel movements, removal of the impaction or that the resident had experienced vomiting because she thought that the hospice nurse would be responsible for that. An interview was conducted with S1DON on 7/20/11 at 12:30 p.m. She stated that all the nurses are supposed to be charting on the nurses notes in the appropriate binder which is housed at the nurses' station and not directly on the nurses notes in the residents' binders. She reviewed the nurse's notes for Resident #6 from the "Private Hall Binder". She stated that she had forgotten about these nurse's notes. She would not reply when she was asked why she had not documented her provision of care to Resident #6 when she was vomiting on 7/11/11 on these nurse's notes rather than directly in the resident's chart. S1DON reviewed the hospice notes in Resident #6's chart and confirmed that an impaction had been removed from the resident on 7/11/11.

Based on interview and record review , the facility failed to ensure each resident received adequate supervision and use of assistive devices to prevent accidents by failing to transfer a resident (#3) with a lifter and by failing to adequately perform a 2 person assist transfer resulting in Resident #3 sustaining comminuted spiral fractures of the right distal tibia and fibula, requiring surgical placement of an intramedullary rod for 1 of 6 sampled residents reviewed for 2 person assist transfers. (#3) Findings: Resident #3 (R #3): A review of Resident #3's clinical record revealed she is an [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #3's MDS dated [DATE] reveals a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two + persons physical assist. A review of Resident #3's MDS dated [DATE] reveals a BIMS score of 14, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two+ persons physical assist. An observation of Resident #3 on 5/24/11 at 2:20 pm revealed Resident #3 lying in bed, watching television. The lifter pad was draped on Resident #3's wheelchair. Resident #3 was awake, alert, and oriented. During an interview with Resident #3 at this time, she stated that she had been living at this facility for several years. Resident #3 stated that since December (2010) she was unable to walk because she was too weak. Resident #3 also stated that recently she had an accident and broke her right leg. Resident #3 stated she had surgery at the end of April and a rod was placed in her right leg. Resident #3 denies pain at this time and stated " they give me pain medicine around the clock so that I don ' t have much pain, but the pain medicine makes me drowsy at times. " When asked how the staff transfers her, Resident#3 stated that they use the lift. When asked how long staff had been using the lift, Resident #3 stated that since she broke her leg, the staff had been using the lift for every transfer. When asked how staff transferred her before she broke her leg, Resident#3 stated " mostly they used the lift, but some of the girls transferred me without the lift. " When asked if staff had used the lift to transfer her when she broke her leg, Resident #3 replied " no " . Resident #3 further stated that a CNA got her up for bingo without the lift so when she was ready to get back in bed that evening, the CNAs brought the lifter into the room, but there was no pad underneath her so they could not use the lifter. Resident #3 stated that when the CNAs were helping her back to bed, she heard a pop and knew her leg was broken. Resident #3 further stated that she has been unable to stand or put any weight on her right leg since it was broken. During an interview on 5/24/11 at 2:35 pm, S2 LPN stated that Resident #3 had been a 2 person transfer with the Hoyer lift since her return to the facility after a hospitalization in December, 2010. S2 LPN stated that prior to the December hospitalization , Resident #3 was able to ambulate. She further stated that Resident #3's family had purchased a lifter pad to ensure that there was always a pad available for their mother's safety. During an interview on 5/24/11 at 3:00 pm, S1 DON stated it was a nursing judgment as to whether or not to use the Hoyer lift during the 2 person transfer of residents. When asked how the CNA's were informed of which residents they were to transfer with the lift, she stated that the MDS staff was notified when it was assessed that a resident should be transferred with the lift and then the MDS staff added this to the care plan. She further stated that S8, CNA Supervisor is notified of the names of residents who should be transferred with the Hoyer lift and then S8 CNA Supervisor communicates this information to the CNA staff. S1, DON confirmed that Resident #3 was a 2 person transfer with the Hoyer lift and all staff should have been aware of this. S1, DON further stated there was a form in the CNA's Flow sheet Binder of residents who were 2 person assist transfers. A review of the CNA Flow sheet Binder revealed a form titled "Two Person Assist With & Without Lifter". Resident #3's name was on this form with "(L)" typed after Resident #3 ' s name. During an interview on 5/25/11 at 8:35 am, S1 DON confirmed that the "(L)" identified Resident #3 as a 2 person transfer with the lifter. A review of the facility's I & A Reporting Form for Resident #3 dated 4/15/11, timed 6:20 pm reads: " Called to room per CNA. Res (resident) sitting on side of bed with legs dangling. CNA stated that while she and another CNA were putting res to bed, during the turning of res a cracking sound was heard from R (right) lower leg. Res denies pain or discomfort to R lower leg at this time. No redness, break to skin or obvious deformity noted to extremity. Resident's R lower leg supported per nurse while CNA x 2 turned res from sitting position to lying position. Leg supported by pillow while in bed. 8:35 pm X-Ray results of comminuted spiral fracture of the distal tibia and fibular diaphysis without significant foreshadowing. There is a slight varus angulation seen on the ankle views. Called in to nurse. ... ... for Dr ....., called and made aware. NON Send to ER for evaluation. Daughter here and aware. States that she will meet her there. Ambulance called and made aware of need for transport. Report called in to ER. 9:05 pm Resident out of facility via ambulance per stretcher. Completed by: S2 LPN. These findings were confirmed in an interview with S2 LPN on 5/24/11 at 3:30 pm. When asked why Resident #3 was transferred from the wheelchair to the bed without the use of the lift as per Resident #3's plan of care, S2 LPN stated that the lifter pad was not underneath Resident #3 while she was sitting in the wheelchair because on the afternoon of 4/15/11, S10 CNA transferred Resident #3 from the bed to the wheelchair for bingo without the lift. When asked the name of the other CNA who performed this transfer with S10 CNA, S2 LPN stated that she thought S10 CNA transferred Resident #3 alone. S2 LPN confirmed that Resident #3 should have been transferred by 2 people with the Hoyer lift. S2 LPN stated that when it was time to put Resident #3 back in the bed, the 2 CNA's were unable to use the lift because the lifter pad was not underneath Resident #3, as it should have been. S2 LPN confirmed that S3 CNA and S5 CNA were the 2 CNA's performing the transfer when Resident #3's right lower leg was fractured. S2 LPN denied being made aware by S10 CNA that no lift pad was available for Resident#3, nor that she had transferred Resident#3 alone. When S2 LPN was asked if she was informed by S3CNA or S5CNA that there was no lift pad underneath Resident #3 prior to transferring the resident from the wheelchair to the bed, S2LPN denied knowledge of the transfer until after that CNAs heard the cracking sound and S2LPN was called to the room to assess Resident #3. A review of Resident #3's Care Plan for impaired physical mobility reads: Problem: Physical Mobility Impaired R/T debility and unsteadiness with transitions; Problems onset: 12/22/2010; Approaches: ... ... ... ... ....Transfer with 2 person assist and lifter ... ... ... ... ... During an interview on 5/24/11 at 3:45 pm, S9 MDS/LPN confirmed that Resident #3 was a 2 person physical assist transfer with a lifter since 12/22/2010. S9 MDS/LPN further stated that it was a nursing judgment to use the pad and lifter and the CNA staff requested it for Resident #3 due to her size and inability to assist in transfers. She confirmed that according to Resident #3's plan of care, all CNA staff should have been using the lifter for Resident #3 during all transfers since her return from the hospital in December, 2010. A review of Resident #3's X-Ray Impression dated 4/15/11, timed 7:54 pm and 8:00 pm reads: 1. Comminuted spiral fracture of the distal tibia and fibular diaphysis without significant foreshortening. There is slight varus angulation seen on the ankle views. 2. Severe degenerative changes are seen of the right knee. There is no proximal fibular fracture seen. 3. Pes planus deformity of the longitudinal arch of the foot. During an interview on 5/24/11 at 4:15 pm, S5 CNA confirmed that she was in the room with Resident #3 on 4/15/11 when her right leg was fractured. S5 CNA stated that she was asked by S3 CNA to assist in transferring Resident #3 from her wheelchair to her bed around 6:00 pm on 4/15/11. S5 CNA confirmed that Resident #3 was a 2 person transfer with the lift, but stated when she and S3 CNA brought the lift to Resident #3 ' s room for the transfer, they noticed that there was no lifter pad underneath Resident #3. S5 CNA stated that Resident #3 must have been transferred from the bed to the wheelchair without the lift. S5 CNA confirmed that if a resident was already in a wheelchair without the lifter pad positioned underneath the resident, then the resident could not be transferred back to bed with the lift. S5 CNA stated that she and S3 CNA had to transfer Resident #3 to bed without the lift and while attempting to transfer Resident #3, Resident #3's leg got stuck underneath S3 CNA's leg and a popping sound was heard. S5 CNA confirmed that neither she nor S3 CNA informed the nurse that Resident #3 was in the wheelchair without the lifter pad or that they were going to attempt to transfer Resident #3 without the lift. S5 CNA confirmed that S2LPN was not called until the popping sound was heard. During an interview on 5/25/11 at 9:45 am, S8 CNA Supervisor confirmed that Resident #3 was a 2 person transfer with the Hoyer lift. S8 CNA Supervisor stated that she had informed all CNA staff that they must use the lift to transfer Resident #3. S8 CNA Supervisor confirmed that she had no documentation of inservices regarding the 2 person transfer with the Hoyer lift for Resident #3 prior to the 4/15/11 incident, which resulted in the fracture of Resident # 3's right leg. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA was assigned to Resident #3 and S10 CNA transferred Resident #3 from the bed to the wheelchair without the assistance of another CNA or the Hoyer lift. S8 CNA Supervisor further stated that when Resident #3 was ready to be transferred back to bed, the other shift of CNA staff was at work. She stated that S3 CNA and S5 CNA transferred Resident #3 to bed without the lift because there was no lifter pad under Resident #3. S8 CNA Supervisor further stated that she was told by S3 CNA that when she pivoted with Resident #3 during the transfer, S3 CNA heard a cracking sound. S8 CNA Supervisor stated that she spoke with S10 CNA after the incident on 4/15/11 and asked her why she transferred Resident #3 from the bed to the wheelchair without the lift and S10 CNA told her there was no lift pad available and Resident #3 had told her she could stand for a little while to get in the wheelchair. S8 CNA Supervisor stated that Resident #3's family had purchased a lifter pad for Resident #3, but the family had taken it home to be washed. S8 CNA Supervisor further stated that S10 CNA should have used one of the facility's lifter pads, as there are extra pads for the Hoyer lift available. S8 CNA Supervisor stated that on 4/18/11, S10 CNA was counseled regarding the improper transfer of Resident #3 on 4/15/11 without the lifter pad. S8 CNA Supervisor stated that S3 CNA and S5 CNA were also counseled on 4/18/11 for the improper transfer of Resident #3, which occurred on 4/15/11. S8 CNA Supervisor stated that S10 CNA had resigned from facility. During an interview on 5/25/11 at 10:00 am, S1 DON confirmed that R #3 was assessed as a 2 person transfer with the Hoyer lift and S10 CNA should have transferred R #3 from the bed to the wheelchair with the use of another CNA and the Hoyer lift on 4/15/11. S1 DON further stated that because Resident #3 was initially transferred to the wheelchair without the lift on 4/15/11, S3 CNA and S5 CNA were unable to use the Hoyer lift to transfer Resident #3 from the wheelchair to the bed because the lifter pad was not underneath Resident #3. S1 DON stated she was not able to obtain a statement from S10 CNA regarding the incident because she had resigned and the contact phone numbers did not work. S1 DON confirmed that the fractures to Resident #3's right leg were the result of: 1) an improper transfer of Resident #3 by S10CNA because she failed to use the Hoyer lift and another staff member to initially transfer Resident #3 from the bed to the wheelchair and 2) an improper transfer of Resident #3 by S3 CNA and S5 CNA. During an interview on 5/25/11 at 10:50 pm, S1 DON confirmed that Resident#3 was on pain medication, Lortab, prior to the fractures, but the dosage and frequency of pain medication had increased since the fractures on 4/15/11. During an observation of Resident #3 sitting in her wheelchair in her room on 5/25/11 at 12:00 pm, she was crying and stated "I sometimes feel very sad and sorry for myself since I broke my leg. I feel like I am stuck in my room more and can't go to all the activities I used to go to." Resident #3 further stated that the reason she does not go to her normal activities anymore is because she takes more pain medication since she fractured her right leg and the pain medication makes her drowsy, keeping her in her room. A review of Resident #3's Resident Activities Progress Notes and Evaluation form dated 3/29/11, prior to the fractures that occurred on 4/15/11, reads: she attends activities 2/3 time awake participating in mass, rosary, ball toss, bands, parties, exercise, movies and television..........She takes a nap daily for approximately one hour before bingo....... Further review of this form reveals an entry for Resident #3 dated 4/28/11 which reads: returned from hospital. Visited. She is doing ok. Her son is here visiting, asking if she has pain states yes but will get better. Will revisit x 2 week until she can resume activities. Further review of this form reveals continuing entries of activities being provided to resident in her room dated from 5/3/11 to 5/24/11. During an interview on 5/25/11 at 1:25 pm, S3 CNA stated that the fractures to Resident #3's right lower leg happened on 4/15/11, around 6:00 pm. S3 CNA stated that she asked S5 CNA to help her transfer Resident #3 from her wheelchair to her bed and when they brought the Hoyer lift to Resident#3's room, they noticed that the lifter pad was not positioned underneath Resident #3. S3 CNA confirmed that Resident #3 was a 2 person transfer with the lift. S3 CNA further stated that since the lifter pad was not underneath Resident #3, she asked S5 CNA to help transfer Resident #3 from the wheelchair to the bed without the lift. S3 CNA confirmed that she did not consult Resident #3 ' s nurse to inform her that the lift pad was not placed underneath Resident #3 and that she would attempt to transfer R#3 from the wheelchair to the bed without the Hoyer lift. S3 CNA stated that S5 CNA was positioned on the outside and she was positioned on the inside. S3 CNA stated that when she (S3 CNA) went to turn, Resident #3's right leg got stuck in between her legs. S3 CNA stated that Resident #3's body did not turn when she (S3 CNA) pivoted and that is when she heard the popping sound. She stated that she thought it was Resident #3's ankle. She stated that she and S5CNA put Resident#3 on the bed and called the S2 LPN. S3 CNA stated that when S2 LPN came to examine Resident #3, she and S5 CNA helped Resident #3 lie down . S3 CNA stated that S2 LPN called for a portable XRAY and the report found that Resident #3 ' s right leg was broken and later required surgery to place a rod in Resident #3's right leg. S3 CNA confirmed that she attended 2 inservices on 3/4/11 and 4/18/11 and both of the inservices were given by S8 CNA Supervisor. S3 CNA stated that during the inservices, there was discussion and demonstration on the lifter and the pad, specifically how to work the lifter and apply the pad. S3 CNA stated that some of the CNA staff was able to demonstrate how to use the lift and the lifter pad or how to perform a 2 person transfer but all of the CNA's were not able to perform a return demonstration. She stated that S8 CNA Supervisor inserviced staff and watched some of the CNA's to make sure lifter was being used correctly. S3CNA denied training on what CNA staff should do if a lift pad is not available or what CNA staff should do if a resident needs to be transferred with the Hoyer lift but a lift pad is not positioned underneath the resident. A review of the following employee records failed to reveal documentation of competency regarding 2 person transfers or use of assistive devices, such as a lift, used to promote resident safety: S3 CNA date of hire: 11/25/09 S5 CNA date of hire: 9/15/10 S10 CNA date of hire: 9/27/10 During an interview with S8 CNA Supervisor on 5/25/11 at 11:30 am, she reviewed the employee files of S3 CNA, S5 CNA, and S10 CNA and confirmed that there was no documentation of competency in transferring skills or the use of the Hoyer lift. S8 CNA Supervisor stated that she does go into the resident's rooms with the CNA's and observes them doing transfers with and without the lift, but she does not document that they are competent in these skills and verified that she should document this competency. S8 CNA Supervisor further stated that all CNA staff was inserviced on the use of the lift and a proper 2 person transfer on 3/4/11 and 4/18/11, but she did not have documentation of return demonstrations. S8 CNA Supervisor stated that she is not sure which CNA's performed return demonstrations on 3/4/11 and which CNA's performed return demonstrations on 4/18/11. S8 CNA Supervisor further stated that to this date, not all of the CNA staff was able to perform return demonstrations of proper 2 person transfers with and without the lift nor did she have documentation of which CNA's had been able to perform return demonstrations. S8 CNA Supervisor confirmed that she did not discuss what the CNA staff should do if a lift pad is not available for a resident who is a 2 person assist with the lift because there should always be a lift pad available. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA performed an improper transfer for Resident #3 when she transferred Resident #3 without the use of the lift and without another CNA. S8 CNA Supervisor further confirmed that S3 CNA and S5 CNA failed to adequately perform a proper transfer for Resident #3 from her wheelchair to her bed on 4/15/11, which resulted in the fractures to Resident #3's right leg. S8 CNA Supervisor again confirmed that she should have documentation of competency in transfer skills and use of the Hoyer lift, but she does not. During an interview on 5/25/11 at 11:50 am, S5 CNA confirmed that 2 inservices for the CNA staff were held, one in March and one in April. When shown the inservice sign in sheets dated 3/4/11 and 4/18/11, she confirmed that she did attend both inservices and S8 CNA Supervisor reviewed and demonstrated 2 person transfers and 2 person transfers with lifter at these inservices. S5 CNA stated that she was able to assist with a 2 person transfer at the 4/18/11 inservice, but not during the 3/4/11 inservice. When asked if all CNA staff was able to perform a return demonstration on 2 person transfers with and without the use of the Hoyer lift at either the 3/4/11 inservice or the 4/18/11 inservice, S5CNA stated that she did not think so. When asked if the CNA Supervisor discussed what should be done if a lift pad is not available in the future to transfer a resident who is deemed a 2 person transfer with the lift, she stated that she did not recall that being discussed at either inservices or when she was counseled after the incident with Resident #3. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S5CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA. Informed CNA if actions continue that she will be terminated. This form was signed by S8 CNA Supervisor and S5CNA. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S3 CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA Supervisor, QAA, and CNA. Informed CNA if actions continue she will be terminated. This form was signed by S8 CNA Supervisor and S3CNA. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S10 CNA; Problem-CNA didn't use the lifter pad on resident as required; Statement By Employee-There was no lifter pad available and resident ask to get out of be; Resolution of Problem or Action Taken-Informed CNA to always have a lifter pad for resident or she would have to stay in bed until one is available. Informed her if her actions continue it was result in (5) days suspension and CNA inserviced on using lifter/lifter pad. she will be terminated. This form was signed by S8 CNA Supervisor and S10CNA. A review of the inservices done on 3/4/11 and 4/18/11 and the Employee Counseling Forms completed on S3CNA, S5CNA and S10CNA failed to reveal documentation of the CNA staff being taught the importance of not making critical nursing judgments such as the decision to transfer a resident without the Hoyer lift when the resident is deemed a 2 person transfer with the Hoyer lift by the nursing staff.

Based on record review and interview the facility failed to keep a resident from harm by: A) Not appropriately lifting the resident into the facility's van which resulted in hitting the resident's right foot causing a broken right knee. B) Not Immediately reporting to staff an injury which caused pain to the residnet. On 7/18/11 resident #4's record was reviewed. It revealed that the resident had an incident and accident report dated 7/9/11 at 2:00 pm.. The time of the incident was listed as 2:00 pm when the facility was informed by the family that the resident's knee was swollen and hurting. There is no documentation of the actual time of the incident. There is mention in one witness statement of a phone call from the family at 12:30 on 7/9/11 asking if the resident had fallen, as he was complaining about the knee.In the emergency room Report, the time of the incident was listed as "10:30 am ?" as if they were not sure of the exact time. The report stated that a member of the resident's family called the nursing home at 2:00 PM and stated that the "resident had swelling to the right knee with redness". The report also stated that the resident arrived at the nursing home at 2:50 PM and the assessment on the report stated "Resident assessed per nurse, right knee slightly swollen. Ice pack in place. Tylenol 1 Gram given for pain." According to the report the resident was experiencing pain at a level 7 out of 10. An interview with the resident was attempted but he was unable to be understood. A witness statement dated 7/8/11 (?) with no time listed, from (S3) CNA/van driver stated "When I put (resident #4) on the lifter gate to put in the truck his right foot hit the lifter gate lightly. I put ice on the right knee for the swelling. " The nurses' note concerning the incident, dated 7/9/11 at 2:50 pm states: "Resident right knee slightly swollen. Ice pack in place. Resident complains of pain when right leg is moved Acetaminophen 500 milligrams X2 given for pain. Resident put back to bed and made comfortable using lifter and right leg up on pillow. " At 3:00 PM the nurse's notes continued, stating that the nurse practitioner was called and told of the incident. The nurse practitioner ordered to continue with ice packs to help keep swelling down and to x-ray right knee on Monday. ( 2 days later). (S2)ADON was notified. Family was notified. At 8:15 PM the resident ' s nurses notes stated that the family was at the nursing home visiting. The family requested that the resident be sent to the hospital because the knee was swelling more and the knee was warm to touch. The nurse called the nurse practitioner and the resident was sent out to the hospital. On 7/19/11 at 1:30 PM records from the hospital the resident was sent to were reviewed. The final impression from the x-ray was acute right knee fracture. On 7/19/11 at 2:30 PM (S1) DON stated " I got witness statements from the 2 ladies (S3)CNA/driver and (S4)CNA .( S3) stated she did not notice the knee when she was loading him. She was trying to put the gerichair in the van. (S3) can/van driver is no longer employed here. The policy for reporting incidents and accidents is getting statements and getting information about the accident. (S3) should have filled out an incident report before she left the building because she knew she hit the resident ' s foot. That way the resident could have been assessed before leaving in the van. I think the resident broke his knee when she bumped his foot because #4 ' s feet are contracted inward and she bumped the knee and caused the fracture. She should have told us when she first bumped the foot. They are trained to report when something happens not to wait and see what happens then report it. "

Based on interview and record review, the facility failed to have documentation of CNA competency to perform a proper 2 person transfer which resulted in Resident #3 sustaining comminuted spiral fractures of the distal tibia and fibula requiring surgical placement of an intramedullary rod for 1 of 6 sampled residents reviewed for 2 person transfers. (#3) Findings: A review of the following employee records failed to reveal documentation of competency regarding 2 person transfers or the use of assistive devices, such as a lift, used to promote resident safety: S3 CNA date of hire: 11/25/09 S5 CNA date of hire: 9/15/10 S10 CNA date of hire: 9/27/10 During an interview with S8 CNA Supervisor on 5/25/11 at 11:30 am, she reviewed the employee files of S3 CNA, S5 CNA, and S10 CNA and confirmed that there was no documentation of competency in transferring skills or the use of the Hoyer lift. S8 CNA Supervisor stated that she does go into the resident's rooms with the CNA's and observes them doing transfers with and without the lift, but she does not document that they are competent in these skills and she should document this competency. S8 CNA Supervisor further stated that all CNA staff was inserviced on the use of the lift and a proper 2 person transfer on 3/4/11 and 4/18/11, but she did not have documentation of return demonstrations. S8 CNA Supervisor stated that she is not sure which CNA's performed return demonstrations on 3/4/11 and which CNA's performed return demonstrations on 4/18/11. S8 CNA Supervisor further stated that to this date, not all of the CNA staff was able to perform return demonstrations of proper 2 person transfers with and without the lift nor did she have documentation of which CNA's had been able to perform return demonstrations. S8 CNA Supervisor confirmed that she did not discuss what the CNA staff should do if a lift pad is not available for a resident who is a 2 person assist with the lift because there should always be a lift pad available. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA performed an improper transfer for Resident #3 when she transferred Resident #3 without the use of the lift and without another CNA. S8 CNA Supervisor further confirmed that S3 CNA and S5 CNA failed to adequately perform a proper transfer for Resident #3 from her wheelchair to her bed on 4/15/11, which resulted in the fractures to Resident #3's right leg. S8 CNA Supervisor again confirmed that she should have documentation of competency in transfer skills and use of the Hoyer lift, but she does not. During an interview on 5/25/11 at 11:44 am, S8 CNA Supervisor confirmed that S4CNA was hired on 4/28/11. S8 CNA Supervisor stated that for the in-service done on 4/18/11, S4CNA was not employed by the facility yet. S8CNA Supervisor confirmed that S4CNA's name was on the 4/18/11 Inservice sign in sheet and stated that the signature on the sign in sheet was not S4CNA ' s. S8 CNA Supervisor stated that she did not know how S4CNA's name got on the sign in sheet. S8 CNA Supervisor stated that she did an in-service with S4CNA showing her how to transfer with the lifter but does not have any documentation of the training or of a return demonstration. A review of the inservices done on 3/4/11 and 4/18/11 and the Employee Counseling Forms completed on S3CNA, S5CNA and S10CNA failed to reveal documentation of the CNA staff being taught the importance of not making critical nursing judgments such as the decision to transfer a resident without the Hoyer lift when the resident is deemed a 2 person transfer with the Hoyer lift by the nursing staff. During an interview on 5/25/11 at 11:50 am, S5 CNA confirmed that 2 inservices for the CNA staff were held, one in March and one in April. When shown the inservice sign in sheets dated 3/4/11 and 4/18/11, she confirmed that she did attend both inservices and S8 CNA Supervisor reviewed and demonstrated 2 person transfers and 2 person transfers with lifter at these inservices. S5 CNA stated that she was able to assist with a 2 person transfer at the 4/18/11 inservice, but not during the 3/4/11 inservice. When asked if all CNA staff was able to perform a return demonstration on 2 person transfers with and without the use of the Hoyer lift at either the 3/4/11 inservice or the 4/18/11 inservice, S5CNA stated that she did not think so. When asked if the CNA Supervisor discussed what should be done if a lift pad is not available in the future to transfer a resident who is deemed a 2 person transfer with the lift, she stated that she did not recall that being discussed at either inservices or when she was counseled after the incident with Resident #3. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S5CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA. Informed CNA if actions continue that she will be terminated. This form was signed by S8 CNA Supervisor and S5CNA. During an interview on 5/24/11 at 3:00 pm, S1 DON stated it was a nursing judgment as to whether or not to use the Hoyer lift during the 2 person transfer of residents. When asked how the CNA's were informed of which residents they were to transfer with the lift, she stated that the MDS staff was notified when it was assessed that a resident should be transferred with the lift and then the MDS staff added this to the care plan. She further stated that S8, CNA Supervisor is notified of the names of residents who should be transferred with the Hoyer lift and then S8 CNA Supervisor communicates this information to the CNA staff. S1, DON confirmed that Resident #3 was a 2 person transfer with the Hoyer lift and all staff should have been aware of this. S1, DON further stated there was a form in the CNA's Flow sheet Binder of residents who were 2 person assist transfers. A review of the CNA Flow sheet Binder revealed a form titled "Two Person Assist With & Without Lifter". Resident #3's name was on this form with "(L)" typed after Resident #3 ' s name. During an interview on 5/25/11 at 8:35 am, S1 DON confirmed that the "(L)" identified Resident #3 as a 2 person transfer with the lifter. A review of Resident #3's clinical record revealed she is an [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #3's MDS dated [DATE] reveals a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two + persons physical assist. A review of Resident #3's MDS dated [DATE] reveals a BIMS score of 14, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two+ persons physical assist. An observation of Resident #3 on 5/24/11 at 2:20 pm revealed Resident #3 lying in bed, watching television. The lifter pad was draped on Resident #3 ' s wheelchair. Resident #3 was awake, alert, and oriented. During an interview with Resident #3 at this time, she stated that she had been living at this facility for several years. Resident #3 stated that since December (2010) she was unable to walk because she was too weak. Resident #3 also stated that recently she had an accident and broke her right leg . Resident #3 stated she had surgery at the end of April and a rod was placed in her right leg. Resident #3 denies pain at this time and stated " they give me pain medicine around the clock so that I don ' t have much pain, but the pain medicine makes me drowsy at times. " When asked how the staff transfers her, Resident#3 stated that they use the lift. When asked how long staff had been using the lift, Resident #3 stated that since she broke her leg, the staff had been using the lift for every transfer. When asked how staff transferred her before she broke her leg, Resident#3 stated " mostly they used the lift, but some of the girls transferred me without the lift. " When asked if staff had used the lift to transfer her when she broke her leg, Resident #3 replied " no " . Resident #3 further stated that a CNA got her up for bingo without the lift so when she was ready to get back in bed that evening, the CNA's brought the lifter into the room, but there was no pad underneath her so they could not use the lifter. Resident #3 stated that when the CNA's were helping her back to bed, she heard a pop and knew her leg was broken. Resident #3 further stated that she has been unable to stand or put any weight on her right leg since it was broken. During an interview on 5/24/11 at 2:35 pm, S2 LPN stated that Resident #3 had been a 2 person transfer with the Hoyer lift since her return to the facility after a hospitalization in December, 2010. S2 LPN stated that prior to the December hospitalization , Resident #3 was able to ambulate. She further stated that Resident #3's family had purchased a lifter pad to ensure that there was always a pad available for their mother's safety. A review of the facility's I & A Reporting Form for Resident #3 dated 4/15/11, timed 6:20 pm reads: " Called to room per CNA. Res (resident) sitting on side of bed with legs dangling. CNA stated that while she and another CNA were putting res to bed, during the turning of res a cracking sound was heard from R (right) lower leg. Res denies pain or discomfort to R lower leg at this time. No redness, break to skin or obvious deformity noted to extremity. Resident's R lower leg supported per nurse while CNA x 2 turned res from sitting position to lying position. Leg supported by pillow while in bed. 8:35 pm X-Ray results of comminuted spiral [MEDICAL CONDITION] tibia and fibular diaphysis without significant foreshadowing. There is a slight varus angulation seen on the ankle views. Called in to nurse. ... ... for Dr ....., called and made aware. NON Send to ER for evaluation. Daughter here and aware. States that she will meet her there. Ambulance called and made aware of need for transport. Report called in to ER. 9:05 pm Resident out of facility via ambulance per stretcher. Completed by: S2 LPN. These findings were confirmed in an interview with S2 LPN on 5/24/11 at 3:30 pm. When asked why Resident #3 was transferred from the wheelchair to the bed without the use of the lift as per Resident #3's plan of care, S2 LPN stated that the lifter pad was not underneath Resident #3 while she was sitting in the wheelchair because on the afternoon of 4/15/11, S10 CNA transferred Resident #3 from the bed to the wheelchair for bingo without the lift. When asked the name of the other CNA who performed this transfer with S10 CNA, S2 LPN stated that she thought S10 CNA transferred Resident #3 alone. S2 LPN confirmed that Resident #3 should have been transferred by 2 people with the Hoyer lift. S2 LPN stated that when it was time to put Resident #3 back in the bed, the 2 CNA's were unable to use the lift because the lifter pad was not underneath Resident #3, as it should have been. S2 LPN confirmed that S3 CNA and S5 CNA were the 2 CNA's performing the transfer when Resident #3's right lower leg was fractured. S2 LPN denied being made aware by S10 CNA that no lift pad was available for Resident#3, nor that she had transferred Resident#3 alone. When S2 LPN was asked if she was informed by S3CNA or S5CNA that there was no lift pad underneath Resident #3 prior to transferring the resident from the wheelchair to the bed, S2LPN denied knowledge of the transfer until after that CNA's heard the cracking sound and S2LPN was called to the room to assess Resident #3. A review of Resident #3's Care Plan for impaired physical mobility reads: Problem: Physical Mobility Impaired R/T debility and unsteadiness with transitions; Problems onset: 12/22/2010; Approaches: ... ... ... ... ....Transfer with 2 person assist and lifter ... ... ... ... ... During an interview on 5/24/11 at 3:45 pm, S9 MDS/LPN confirmed that Resident #3 was a 2 person physical assist transfer with a lifter since 12/22/2010. S9 MDS/LPN further stated that it was a nursing judgment to use the pad and lifter and the CNA staff requested it for Resident #3 due to her size and inability to assist in transfers. She confirmed that according to Resident #3's plan of care, all CNA staff should have been using the lifter for Resident #3 during all transfers since her return from the hospital in December, 2010. A review of Resident #3's X-Ray Impression dated 4/15/11, timed 7:54 pm and 8:00 pm reads: 1. Comminuted spiral [MEDICAL CONDITION] tibia and fibular diaphysis without significant foreshortening. There is slight varus angulation seen on the ankle views. 2. Severe [MEDICAL CONDITION] changes are seen of the right knee. There is no proximal fibular fracture seen. 3. Pes planus deformity of the longitudinal arch of the foot. During an interview on 5/24/11 at 4:15 pm, S5 CNA confirmed that she was in the room with Resident #3 on 4/15/11 when her right leg was fractured. S5 CNA stated that she was asked by S3 CNA to assist in transferring Resident #3 from her wheelchair to her bed around 6:00 pm on 4/15/11. S5 CNA confirmed that Resident #3 was a 2 person transfer with the lift, but stated when she and S3 CNA brought the lift to Resident #3 ' s room for the transfer, they noticed that there was no lifter pad underneath Resident #3. S5 CNA stated that Resident #3 must have been transferred from the bed to the wheelchair without the lift. S5 CNA confirmed that if a resident was already in a wheelchair without the lifter pad positioned underneath the resident, then the resident could not be transferred back to bed with the lift. S5 CNA stated that she and S3 CNA had to transfer Resident #3 to bed without the lift and while attempting to transfer Resident #3, Resident #3 ' s leg got stuck underneath S3 CNA ' s leg and a popping sound was heard. S5 CNA confirmed that neither she nor S3 CNA informed the nurse that Resident #3 was in the wheelchair without the lifter pad or that they were going to attempt to transfer Resident #3 without the lift. S5 CNA stated that S2LPN was not called until the popping sound was heard. During an interview on 5/25/11 at 9:45 am, S8 CNA Supervisor confirmed that Resident #3 was a 2 person transfer with the Hoyer lift. S8 CNA Supervisor stated that she had informed all CNA staff that they must use the lift to transfer Resident #3. S8 CNA Supervisor confirmed that she had no documentation of inservices regarding the 2 person transfer with the Hoyer lift for Resident #3 prior to the 4/15/11 incident, which resulted in the fracture of Resident # 3's right leg. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA was assigned to Resident #3 and S10 CNA transferred Resident #3 from the bed to the wheelchair without the assistance of another CNA or the Hoyer lift. S8 CNA Supervisor further stated that when Resident #3 was ready to be transferred back to bed, the other shift of CNA staff was at work. She stated that S3 CNA and S5 CNA transferred Resident #3 to bed without the lift because there was no lifter pad under Resident #3. S8 CNA Supervisor further stated that she was told by S3 CNA that when she pivoted with Resident #3 during the transfer, S3 CNA heard a cracking sound. S8 CNA Supervisor stated that she spoke with S10 CNA after the incident on 4/15/11 and asked her why she transferred Resident #3 from the bed to the wheelchair without the lift and S10 CNA told her there was no lift pad available and Resident #3 had told her she could stand for a little while to get in the wheelchair. S8 CNA Supervisor stated that Resident #3's family had purchased a lifter pad for Resident #3, but the family had taken it home to be washed. S8 CNA Supervisor further stated that S10 CNA should have used one of the facility's lifter pads, as there are extra pads for the Hoyer lift available. S8 CNA Supervisor stated that on 4/18/11, S10 CNA was counseled regarding the improper transfer of Resident #3 on 4/15/11 without the lifter pad. S8 CNA Supervisor stated that S3 CNA and S5 CNA were also counseled on 4/18/11 for the improper transfer of Resident #3, which occurred on 4/15/11. S8 CNA Supervisor stated that S10 CNA had resigned from facility. During an interview on 5/25/11 at 10:00 am, S1 DON confirmed that Resident #3 was assessed as a 2 person transfer with the Hoyer lift and S10 CNA should have transferred Resident #3 from the bed to the wheelchair with the use of another CNA and the Hoyer lift on 4/15/11. S1 DON further stated that because Resident #3 was initially transferred to the wheelchair without the lift on 4/15/11, S3 CNA and S5 CNA were unable to use the Hoyer lift to transfer Resident #3 from the wheelchair to the bed because the lifter pad was not underneath Resident #3. S1 DON stated she was not able to obtain a statement from S10 CNA regarding the incident because she had resigned and the contact phone numbers did not work. S1 DON confirmed that the fractures to Resident #3's right leg were the result of: 1) an improper transfer of Resident #3 by S10CNA because she failed to use the Hoyer lift and another staff member to initially transfer Resident #3 from the bed to the wheelchair and 2) an improper transfer of Resident #3 by S3 CNA and S5 CNA. During an interview on 5/25/11 at 1:25 pm, , S3 CNA stated that the fractures to Resident #3's right lower leg happened on 4/15/11, around 6:00 pm. S3 CNA stated that she asked S5 CNA to help her transfer Resident #3 from her wheelchair to her bed and when they brought the Hoyer lift to Resident#3's room , they noticed that the lifter pad was not positioned underneath Resident #3. S3 CNA confirmed that Resident #3 was a 2 person transfer with the lift. S3 CNA further stated that since the lifter pad was not underneath Resident #3, she asked S5 CNA to help transfer Resident #3 from the wheelchair to the bed without the lift. S3 CNA confirmed that she did not consult Resident #3 ' s nurse to inform her that the lift pad was not placed underneath Resident #3 and that she would attempt to transfer R#3 from the wheelchair to the bed without the Hoyer lift. S3 CNA stated that S5 CNA was positioned on the outside and she was positioned on the inside. S3 CNA stated that when she (S3 CNA) went to turn, Resident #3's right leg got stuck in between her legs. S3 CNA stated that Resident #3's body did not turn when she (S3 CNA) pivoted and that is when she heard the popping sound. She stated that she thought it was Resident #3's ankle. She stated that she and S5CNA put Resident#3 on the bed and called the nurse. S3 CNA stated that when S2 LPN came to examine Resident #3, she and S5 CNA helped Resident #3 lie down . S3 CNA stated that S2 LPN called for a portable XRAY and the report found that Resident #3 ' s right leg was broken and later required surgery to place a rod in Resident #3's right leg. S3 CNA confirmed that she attended 2 inservices on 3/4/11 and 4/18/11 and both of the inservices were given by S8 CNA Supervisor. S3 CNA stated that during the inservices, there was discussion and demonstration on the lifter and the pad, specifically how to work the lifter and apply the pad. S3 CNA stated that some of the CNA staff was able to demonstrate how to use the lift and the lifter pad or how to perform a 2 person transfer but all of the CNA's were not able to demonstrate. She stated that S8 CNA Supervisor inserviced staff and watched some of the CNA's to make sure lifter was being used correctly. S3CNA denied training on what CNA staff should do if a lift pad is not available or what CNA staff should do if a resident needs to be transferred with the Hoyer lift but a lift pad is not positioned underneath the resident. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S3 CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA Supervisor, QAA, and CNA. Informed CNA if actions continue she will be terminated. This form was signed by S8 CNA Supervisor and S3CNA. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S10 CNA; Problem-CNA didn't use the lifter pad on resident as required; Statement By Employee-There was no lifter pad available and resident ask to get out of be; Resolution of Problem or Action Taken-Informed CNA to always have a lifter pad for resident or she would have to stay in bed until one is available. Informed her if her actions continue it was result in (5) days suspension and CNA inserviced on using lifter/lifter pad. she will be terminated. This form was signed by S8 CNA Supervisor and S10CNA.

Based on record review and interview the facility failed to ensure that personnel were properly trained by not training the CNA/van driver to properly lift and strap a resident in the facility's van for 1 of 6 sampled residents. Findings: On 7/18/11 resident #4 ' s record was reviewed. It revealed that the resident had an incident and accident report dated 7/9/11. The report stated that a member of the resident ' s family called the nursing home at 2:00 PM and stated that the "resident had swelling to the right knee with redness". A witness statement from (S3) LPN/van driver stated that "When I put resident #4 on the lifter gate to put in the truck his right foot hit against the lifter gate lightly I put ice on the right knee for the swelling". On 7/19/11 at 2:30 PM (S1) DON stated "I got witness statements from the 2 ladies (S3)CNA/driver and (S4)CNA .( S3) stated she did not notice the knee when she was loading him. She was trying to put the gerichair in the van. (S3) can/van driver is no longer employed here. The policy for reporting incidents and accidents is getting statements and getting information about the accident. (S3) should have filled out an incident report before she left the building because she knew she hit the resident ' s foot. That way the resident could have been assessed before leaving in the van. I think the resident broke his knee when she bumped his foot because #4 ' s feet are contracted inward and she bumped the knee and caused the fracture. She should have told us when she first bumped the foot. They are trained to report when something happens not to wait and see what happens then report it. "

Based on interview and record review, the facility failed to have documentation of CNA competency to perform a proper 2 person transfer which resulted in Resident #3 sustaining comminuted spiral fractures of the distal tibia and fibula requiring surgical placement of an intramedullary rod for 1 of 6 sampled residents reviewed for 2 person transfers. (#3) Findings: A review of the following employee records failed to reveal documentation of competency regarding 2 person transfers or the use of assistive devices, such as a lift, used to promote resident safety: S3 CNA date of hire: 11/25/09 S5 CNA date of hire: 9/15/10 S10 CNA date of hire: 9/27/10 During an interview with S8 CNA Supervisor on 5/25/11 at 11:30 am, she reviewed the employee files of S3 CNA, S5 CNA, and S10 CNA and confirmed that there was no documentation of competency in transferring skills or the use of the Hoyer lift. S8 CNA Supervisor stated that she does go into the resident's rooms with the CNA's and observes them doing transfers with and without the lift, but she does not document that they are competent in these skills and she should document this competency. S8 CNA Supervisor further stated that all CNA staff was inserviced on the use of the lift and a proper 2 person transfer on 3/4/11 and 4/18/11, but she did not have documentation of return demonstrations. S8 CNA Supervisor stated that she is not sure which CNA's performed return demonstrations on 3/4/11 and which CNA's performed return demonstrations on 4/18/11. S8 CNA Supervisor further stated that to this date, not all of the CNA staff was able to perform return demonstrations of proper 2 person transfers with and without the lift nor did she have documentation of which CNA's had been able to perform return demonstrations. S8 CNA Supervisor confirmed that she did not discuss what the CNA staff should do if a lift pad is not available for a resident who is a 2 person assist with the lift because there should always be a lift pad available. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA performed an improper transfer for Resident #3 when she transferred Resident #3 without the use of the lift and without another CNA. S8 CNA Supervisor further confirmed that S3 CNA and S5 CNA failed to adequately perform a proper transfer for Resident #3 from her wheelchair to her bed on 4/15/11, which resulted in the fractures to Resident #3's right leg. S8 CNA Supervisor again confirmed that she should have documentation of competency in transfer skills and use of the Hoyer lift, but she does not. During an interview on 5/25/11 at 11:44 am, S8 CNA Supervisor confirmed that S4CNA was hired on 4/28/11. S8 CNA Supervisor stated that for the in-service done on 4/18/11, S4CNA was not employed by the facility yet. S8CNA Supervisor confirmed that S4CNA's name was on the 4/18/11 Inservice sign in sheet and stated that the signature on the sign in sheet was not S4CNA ' s. S8 CNA Supervisor stated that she did not know how S4CNA's name got on the sign in sheet. S8 CNA Supervisor stated that she did an in-service with S4CNA showing her how to transfer with the lifter but does not have any documentation of the training or of a return demonstration. A review of the inservices done on 3/4/11 and 4/18/11 and the Employee Counseling Forms completed on S3CNA, S5CNA and S10CNA failed to reveal documentation of the CNA staff being taught the importance of not making critical nursing judgments such as the decision to transfer a resident without the Hoyer lift when the resident is deemed a 2 person transfer with the Hoyer lift by the nursing staff. During an interview on 5/25/11 at 11:50 am, S5 CNA confirmed that 2 inservices for the CNA staff were held, one in March and one in April. When shown the inservice sign in sheets dated 3/4/11 and 4/18/11, she confirmed that she did attend both inservices and S8 CNA Supervisor reviewed and demonstrated 2 person transfers and 2 person transfers with lifter at these inservices. S5 CNA stated that she was able to assist with a 2 person transfer at the 4/18/11 inservice, but not during the 3/4/11 inservice. When asked if all CNA staff was able to perform a return demonstration on 2 person transfers with and without the use of the Hoyer lift at either the 3/4/11 inservice or the 4/18/11 inservice, S5CNA stated that she did not think so. When asked if the CNA Supervisor discussed what should be done if a lift pad is not available in the future to transfer a resident who is deemed a 2 person transfer with the lift, she stated that she did not recall that being discussed at either inservices or when she was counseled after the incident with Resident #3. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S5CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA. Informed CNA if actions continue that she will be terminated. This form was signed by S8 CNA Supervisor and S5CNA. During an interview on 5/24/11 at 3:00 pm, S1 DON stated it was a nursing judgment as to whether or not to use the Hoyer lift during the 2 person transfer of residents. When asked how the CNA's were informed of which residents they were to transfer with the lift, she stated that the MDS staff was notified when it was assessed that a resident should be transferred with the lift and then the MDS staff added this to the care plan. She further stated that S8, CNA Supervisor is notified of the names of residents who should be transferred with the Hoyer lift and then S8 CNA Supervisor communicates this information to the CNA staff. S1, DON confirmed that Resident #3 was a 2 person transfer with the Hoyer lift and all staff should have been aware of this. S1, DON further stated there was a form in the CNA's Flow sheet Binder of residents who were 2 person assist transfers. A review of the CNA Flow sheet Binder revealed a form titled "Two Person Assist With & Without Lifter". Resident #3's name was on this form with "(L)" typed after Resident #3 ' s name. During an interview on 5/25/11 at 8:35 am, S1 DON confirmed that the "(L)" identified Resident #3 as a 2 person transfer with the lifter. A review of Resident #3's clinical record revealed she is an [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #3's MDS dated [DATE] reveals a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two + persons physical assist. A review of Resident #3's MDS dated [DATE] reveals a BIMS score of 14, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two+ persons physical assist. An observation of Resident #3 on 5/24/11 at 2:20 pm revealed Resident #3 lying in bed, watching television. The lifter pad was draped on Resident #3 ' s wheelchair. Resident #3 was awake, alert, and oriented. During an interview with Resident #3 at this time, she stated that she had been living at this facility for several years. Resident #3 stated that since December (2010) she was unable to walk because she was too weak. Resident #3 also stated that recently she had an accident and broke her right leg . Resident #3 stated she had surgery at the end of April and a rod was placed in her right leg. Resident #3 denies pain at this time and stated " they give me pain medicine around the clock so that I don ' t have much pain, but the pain medicine makes me drowsy at times. " When asked how the staff transfers her, Resident#3 stated that they use the lift. When asked how long staff had been using the lift, Resident #3 stated that since she broke her leg, the staff had been using the lift for every transfer. When asked how staff transferred her before she broke her leg, Resident#3 stated " mostly they used the lift, but some of the girls transferred me without the lift. " When asked if staff had used the lift to transfer her when she broke her leg, Resident #3 replied " no " . Resident #3 further stated that a CNA got her up for bingo without the lift so when she was ready to get back in bed that evening, the CNA's brought the lifter into the room, but there was no pad underneath her so they could not use the lifter. Resident #3 stated that when the CNA's were helping her back to bed, she heard a pop and knew her leg was broken. Resident #3 further stated that she has been unable to stand or put any weight on her right leg since it was broken. During an interview on 5/24/11 at 2:35 pm, S2 LPN stated that Resident #3 had been a 2 person transfer with the Hoyer lift since her return to the facility after a hospitalization in December, 2010. S2 LPN stated that prior to the December hospitalization , Resident #3 was able to ambulate. She further stated that Resident #3's family had purchased a lifter pad to ensure that there was always a pad available for their mother's safety. A review of the facility's I & A Reporting Form for Resident #3 dated 4/15/11, timed 6:20 pm reads: " Called to room per CNA. Res (resident) sitting on side of bed with legs dangling. CNA stated that while she and another CNA were putting res to bed, during the turning of res a cracking sound was heard from R (right) lower leg. Res denies pain or discomfort to R lower leg at this time. No redness, break to skin or obvious deformity noted to extremity. Resident's R lower leg supported per nurse while CNA x 2 turned res from sitting position to lying position. Leg supported by pillow while in bed. 8:35 pm X-Ray results of comminuted spiral [MEDICAL CONDITION] tibia and fibular diaphysis without significant foreshadowing. There is a slight varus angulation seen on the ankle views. Called in to nurse. ... ... for Dr ....., called and made aware. NON Send to ER for evaluation. Daughter here and aware. States that she will meet her there. Ambulance called and made aware of need for transport. Report called in to ER. 9:05 pm Resident out of facility via ambulance per stretcher. Completed by: S2 LPN. These findings were confirmed in an interview with S2 LPN on 5/24/11 at 3:30 pm. When asked why Resident #3 was transferred from the wheelchair to the bed without the use of the lift as per Resident #3's plan of care, S2 LPN stated that the lifter pad was not underneath Resident #3 while she was sitting in the wheelchair because on the afternoon of 4/15/11, S10 CNA transferred Resident #3 from the bed to the wheelchair for bingo without the lift. When asked the name of the other CNA who performed this transfer with S10 CNA, S2 LPN stated that she thought S10 CNA transferred Resident #3 alone. S2 LPN confirmed that Resident #3 should have been transferred by 2 people with the Hoyer lift. S2 LPN stated that when it was time to put Resident #3 back in the bed, the 2 CNA's were unable to use the lift because the lifter pad was not underneath Resident #3, as it should have been. S2 LPN confirmed that S3 CNA and S5 CNA were the 2 CNA's performing the transfer when Resident #3's right lower leg was fractured. S2 LPN denied being made aware by S10 CNA that no lift pad was available for Resident#3, nor that she had transferred Resident#3 alone. When S2 LPN was asked if she was informed by S3CNA or S5CNA that there was no lift pad underneath Resident #3 prior to transferring the resident from the wheelchair to the bed, S2LPN denied knowledge of the transfer until after that CNA's heard the cracking sound and S2LPN was called to the room to assess Resident #3. A review of Resident #3's Care Plan for impaired physical mobility reads: Problem: Physical Mobility Impaired R/T debility and unsteadiness with transitions; Problems onset: 12/22/2010; Approaches: ... ... ... ... ....Transfer with 2 person assist and lifter ... ... ... ... ... During an interview on 5/24/11 at 3:45 pm, S9 MDS/LPN confirmed that Resident #3 was a 2 person physical assist transfer with a lifter since 12/22/2010. S9 MDS/LPN further stated that it was a nursing judgment to use the pad and lifter and the CNA staff requested it for Resident #3 due to her size and inability to assist in transfers. She confirmed that according to Resident #3's plan of care, all CNA staff should have been using the lifter for Resident #3 during all transfers since her return from the hospital in December, 2010. A review of Resident #3's X-Ray Impression dated 4/15/11, timed 7:54 pm and 8:00 pm reads: 1. Comminuted spiral [MEDICAL CONDITION] tibia and fibular diaphysis without significant foreshortening. There is slight varus angulation seen on the ankle views. 2. Severe [MEDICAL CONDITION] changes are seen of the right knee. There is no proximal fibular fracture seen. 3. Pes planus deformity of the longitudinal arch of the foot. During an interview on 5/24/11 at 4:15 pm, S5 CNA confirmed that she was in the room with Resident #3 on 4/15/11 when her right leg was fractured. S5 CNA stated that she was asked by S3 CNA to assist in transferring Resident #3 from her wheelchair to her bed around 6:00 pm on 4/15/11. S5 CNA confirmed that Resident #3 was a 2 person transfer with the lift, but stated when she and S3 CNA brought the lift to Resident #3 ' s room for the transfer, they noticed that there was no lifter pad underneath Resident #3. S5 CNA stated that Resident #3 must have been transferred from the bed to the wheelchair without the lift. S5 CNA confirmed that if a resident was already in a wheelchair without the lifter pad positioned underneath the resident, then the resident could not be transferred back to bed with the lift. S5 CNA stated that she and S3 CNA had to transfer Resident #3 to bed without the lift and while attempting to transfer Resident #3, Resident #3 ' s leg got stuck underneath S3 CNA ' s leg and a popping sound was heard. S5 CNA confirmed that neither she nor S3 CNA informed the nurse that Resident #3 was in the wheelchair without the lifter pad or that they were going to attempt to transfer Resident #3 without the lift. S5 CNA stated that S2LPN was not called until the popping sound was heard. During an interview on 5/25/11 at 9:45 am, S8 CNA Supervisor confirmed that Resident #3 was a 2 person transfer with the Hoyer lift. S8 CNA Supervisor stated that she had informed all CNA staff that they must use the lift to transfer Resident #3. S8 CNA Supervisor confirmed that she had no documentation of inservices regarding the 2 person transfer with the Hoyer lift for Resident #3 prior to the 4/15/11 incident, which resulted in the fracture of Resident # 3's right leg. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA was assigned to Resident #3 and S10 CNA transferred Resident #3 from the bed to the wheelchair without the assistance of another CNA or the Hoyer lift. S8 CNA Supervisor further stated that when Resident #3 was ready to be transferred back to bed, the other shift of CNA staff was at work. She stated that S3 CNA and S5 CNA transferred Resident #3 to bed without the lift because there was no lifter pad under Resident #3. S8 CNA Supervisor further stated that she was told by S3 CNA that when she pivoted with Resident #3 during the transfer, S3 CNA heard a cracking sound. S8 CNA Supervisor stated that she spoke with S10 CNA after the incident on 4/15/11 and asked her why she transferred Resident #3 from the bed to the wheelchair without the lift and S10 CNA told her there was no lift pad available and Resident #3 had told her she could stand for a little while to get in the wheelchair. S8 CNA Supervisor stated that Resident #3's family had purchased a lifter pad for Resident #3, but the family had taken it home to be washed. S8 CNA Supervisor further stated that S10 CNA should have used one of the facility's lifter pads, as there are extra pads for the Hoyer lift available. S8 CNA Supervisor stated that on 4/18/11, S10 CNA was counseled regarding the improper transfer of Resident #3 on 4/15/11 without the lifter pad. S8 CNA Supervisor stated that S3 CNA and S5 CNA were also counseled on 4/18/11 for the improper transfer of Resident #3, which occurred on 4/15/11. S8 CNA Supervisor stated that S10 CNA had resigned from facility. During an interview on 5/25/11 at 10:00 am, S1 DON confirmed that Resident #3 was assessed as a 2 person transfer with the Hoyer lift and S10 CNA should have transferred Resident #3 from the bed to the wheelchair with the use of another CNA and the Hoyer lift on 4/15/11. S1 DON further stated that because Resident #3 was initially transferred to the wheelchair without the lift on 4/15/11, S3 CNA and S5 CNA were unable to use the Hoyer lift to transfer Resident #3 from the wheelchair to the bed because the lifter pad was not underneath Resident #3. S1 DON stated she was not able to obtain a statement from S10 CNA regarding the incident because she had resigned and the contact phone numbers did not work. S1 DON confirmed that the fractures to Resident #3's right leg were the result of: 1) an improper transfer of Resident #3 by S10CNA because she failed to use the Hoyer lift and another staff member to initially transfer Resident #3 from the bed to the wheelchair and 2) an improper transfer of Resident #3 by S3 CNA and S5 CNA. During an interview on 5/25/11 at 1:25 pm, , S3 CNA stated that the fractures to Resident #3's right lower leg happened on 4/15/11, around 6:00 pm. S3 CNA stated that she asked S5 CNA to help her transfer Resident #3 from her wheelchair to her bed and when they brought the Hoyer lift to Resident#3's room , they noticed that the lifter pad was not positioned underneath Resident #3. S3 CNA confirmed that Resident #3 was a 2 person transfer with the lift. S3 CNA further stated that since the lifter pad was not underneath Resident #3, she asked S5 CNA to help transfer Resident #3 from the wheelchair to the bed without the lift. S3 CNA confirmed that she did not consult Resident #3 ' s nurse to inform her that the lift pad was not placed underneath Resident #3 and that she would attempt to transfer R#3 from the wheelchair to the bed without the Hoyer lift. S3 CNA stated that S5 CNA was positioned on the outside and she was positioned on the inside. S3 CNA stated that when she (S3 CNA) went to turn, Resident #3's right leg got stuck in between her legs. S3 CNA stated that Resident #3's body did not turn when she (S3 CNA) pivoted and that is when she heard the popping sound. She stated that she thought it was Resident #3's ankle. She stated that she and S5CNA put Resident#3 on the bed and called the nurse. S3 CNA stated that when S2 LPN came to examine Resident #3, she and S5 CNA helped Resident #3 lie down . S3 CNA stated that S2 LPN called for a portable XRAY and the report found that Resident #3 ' s right leg was broken and later required surgery to place a rod in Resident #3's right leg. S3 CNA confirmed that she attended 2 inservices on 3/4/11 and 4/18/11 and both of the inservices were given by S8 CNA Supervisor. S3 CNA stated that during the inservices, there was discussion and demonstration on the lifter and the pad, specifically how to work the lifter and apply the pad. S3 CNA stated that some of the CNA staff was able to demonstrate how to use the lift and the lifter pad or how to perform a 2 person transfer but all of the CNA's were not able to demonstrate. She stated that S8 CNA Supervisor inserviced staff and watched some of the CNA's to make sure lifter was being used correctly. S3CNA denied training on what CNA staff should do if a lift pad is not available or what CNA staff should do if a resident needs to be transferred with the Hoyer lift but a lift pad is not positioned underneath the resident. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S3 CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA Supervisor, QAA, and CNA. Informed CNA if actions continue she will be terminated. This form was signed by S8 CNA Supervisor and S3CNA. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S10 CNA; Problem-CNA didn't use the lifter pad on resident as required; Statement By Employee-There was no lifter pad available and resident ask to get out of be; Resolution of Problem or Action Taken-Informed CNA to always have a lifter pad for resident or she would have to stay in bed until one is available. Informed her if her actions continue it was result in (5) days suspension and CNA inserviced on using lifter/lifter pad. she will be terminated. This form was signed by S8 CNA Supervisor and S10CNA.

Based on record review and interview the facility failed to ensure that personnel were properly trained by not training the CNA/van driver to properly lift and strap a resident in the facility's van for 1 of 6 sampled residents. Findings: On 7/18/11 resident #4 ' s record was reviewed. It revealed that the resident had an incident and accident report dated 7/9/11. The report stated that a member of the resident ' s family called the nursing home at 2:00 PM and stated that the " resident had swelling to the right knee with redness. A witness statement from (S3) LPN/van driver stated that " When I put resident #4 on the lifter gate to put in the truck his right foot hit against the lifter gate lightly I put ice on the right knee for the swelling. On 7/19/11 at 2:30 PM (S1) DON stated " I got witness statements from the 2 ladies (S3)CNA/driver and (S4)CNA .( S3) stated she did not notice the knee when she was loading him. She was trying to put the gerichair in the van. (S3) can/van driver is no longer employed here. The policy for reporting incidents and accidents is getting statements and getting information about the accident. (S3) should have filled out an incident report before she left the building because she knew she hit the resident ' s foot. That way the resident could have been assessed before leaving in the van. " " I think the resident broke his knee when she bumped his foot because #4 ' s feet are contracted inward and she bumped the knee and caused the fracture. She should have told us when she first bumped the foot. They are trained to report when something happens not to wait and see what happens then report it. "

Based on interview and record review , the facility failed to ensure each resident received adequate supervision and use of assistive devices to prevent accidents by failing to transfer a resident (#3) with a lifter and by failing to adequately perform a 2 person assist transfer resulting in Resident #3 sustaining comminuted spiral fractures of the right distal tibia and fibula, requiring surgical placement of an intramedullary rod for 1 of 6 sampled residents reviewed for 2 person assist transfers. (#3) Findings: Resident #3 (R #3): A review of Resident #3's clinical record revealed she is an [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #3's MDS dated [DATE] reveals a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two + persons physical assist. A review of Resident #3's MDS dated [DATE] reveals a BIMS score of 14, which indicates cognitively intact and Transfer ability is coded as 3/3, which is extensive assistance with two+ persons physical assist. An observation of Resident #3 on 5/24/11 at 2:20 pm revealed Resident #3 lying in bed, watching television. The lifter pad was draped on Resident #3's wheelchair. Resident #3 was awake, alert, and oriented. During an interview with Resident #3 at this time, she stated that she had been living at this facility for several years. Resident #3 stated that since December (2010) she was unable to walk because she was too weak. Resident #3 also stated that recently she had an accident and broke her right leg. Resident #3 stated she had surgery at the end of April and a rod was placed in her right leg. Resident #3 denies pain at this time and stated " they give me pain medicine around the clock so that I don ' t have much pain, but the pain medicine makes me drowsy at times. " When asked how the staff transfers her, Resident#3 stated that they use the lift. When asked how long staff had been using the lift, Resident #3 stated that since she broke her leg, the staff had been using the lift for every transfer. When asked how staff transferred her before she broke her leg, Resident#3 stated " mostly they used the lift, but some of the girls transferred me without the lift. " When asked if staff had used the lift to transfer her when she broke her leg, Resident #3 replied " no " . Resident #3 further stated that a CNA got her up for bingo without the lift so when she was ready to get back in bed that evening, the CNAs brought the lifter into the room, but there was no pad underneath her so they could not use the lifter. Resident #3 stated that when the CNAs were helping her back to bed, she heard a pop and knew her leg was broken. Resident #3 further stated that she has been unable to stand or put any weight on her right leg since it was broken. During an interview on 5/24/11 at 2:35 pm, S2 LPN stated that Resident #3 had been a 2 person transfer with the Hoyer lift since her return to the facility after a hospitalization in December, 2010. S2 LPN stated that prior to the December hospitalization , Resident #3 was able to ambulate. She further stated that Resident #3's family had purchased a lifter pad to ensure that there was always a pad available for their mother's safety. During an interview on 5/24/11 at 3:00 pm, S1 DON stated it was a nursing judgment as to whether or not to use the Hoyer lift during the 2 person transfer of residents. When asked how the CNA's were informed of which residents they were to transfer with the lift, she stated that the MDS staff was notified when it was assessed that a resident should be transferred with the lift and then the MDS staff added this to the care plan. She further stated that S8, CNA Supervisor is notified of the names of residents who should be transferred with the Hoyer lift and then S8 CNA Supervisor communicates this information to the CNA staff. S1, DON confirmed that Resident #3 was a 2 person transfer with the Hoyer lift and all staff should have been aware of this. S1, DON further stated there was a form in the CNA's Flow sheet Binder of residents who were 2 person assist transfers. A review of the CNA Flow sheet Binder revealed a form titled "Two Person Assist With & Without Lifter". Resident #3's name was on this form with "(L)" typed after Resident #3 ' s name. During an interview on 5/25/11 at 8:35 am, S1 DON confirmed that the "(L)" identified Resident #3 as a 2 person transfer with the lifter. A review of the facility's I & A Reporting Form for Resident #3 dated 4/15/11, timed 6:20 pm reads: " Called to room per CNA. Res (resident) sitting on side of bed with legs dangling. CNA stated that while she and another CNA were putting res to bed, during the turning of res a cracking sound was heard from R (right) lower leg. Res denies pain or discomfort to R lower leg at this time. No redness, break to skin or obvious deformity noted to extremity. Resident's R lower leg supported per nurse while CNA x 2 turned res from sitting position to lying position. Leg supported by pillow while in bed. 8:35 pm X-Ray results of comminuted spiral fracture of the distal tibia and fibular diaphysis without significant foreshadowing. There is a slight varus angulation seen on the ankle views. Called in to nurse. ... ... for Dr ....., called and made aware. NON Send to ER for evaluation. Daughter here and aware. States that she will meet her there. Ambulance called and made aware of need for transport. Report called in to ER. 9:05 pm Resident out of facility via ambulance per stretcher. Completed by: S2 LPN. These findings were confirmed in an interview with S2 LPN on 5/24/11 at 3:30 pm. When asked why Resident #3 was transferred from the wheelchair to the bed without the use of the lift as per Resident #3's plan of care, S2 LPN stated that the lifter pad was not underneath Resident #3 while she was sitting in the wheelchair because on the afternoon of 4/15/11, S10 CNA transferred Resident #3 from the bed to the wheelchair for bingo without the lift. When asked the name of the other CNA who performed this transfer with S10 CNA, S2 LPN stated that she thought S10 CNA transferred Resident #3 alone. S2 LPN confirmed that Resident #3 should have been transferred by 2 people with the Hoyer lift. S2 LPN stated that when it was time to put Resident #3 back in the bed, the 2 CNA's were unable to use the lift because the lifter pad was not underneath Resident #3, as it should have been. S2 LPN confirmed that S3 CNA and S5 CNA were the 2 CNA's performing the transfer when Resident #3's right lower leg was fractured. S2 LPN denied being made aware by S10 CNA that no lift pad was available for Resident#3, nor that she had transferred Resident#3 alone. When S2 LPN was asked if she was informed by S3CNA or S5CNA that there was no lift pad underneath Resident #3 prior to transferring the resident from the wheelchair to the bed, S2LPN denied knowledge of the transfer until after that CNAs heard the cracking sound and S2LPN was called to the room to assess Resident #3. A review of Resident #3's Care Plan for impaired physical mobility reads: Problem: Physical Mobility Impaired R/T debility and unsteadiness with transitions; Problems onset: 12/22/2010; Approaches: ... ... ... ... ....Transfer with 2 person assist and lifter ... ... ... ... ... During an interview on 5/24/11 at 3:45 pm, S9 MDS/LPN confirmed that Resident #3 was a 2 person physical assist transfer with a lifter since 12/22/2010. S9 MDS/LPN further stated that it was a nursing judgment to use the pad and lifter and the CNA staff requested it for Resident #3 due to her size and inability to assist in transfers. She confirmed that according to Resident #3's plan of care, all CNA staff should have been using the lifter for Resident #3 during all transfers since her return from the hospital in December, 2010. A review of Resident #3's X-Ray Impression dated 4/15/11, timed 7:54 pm and 8:00 pm reads: 1. Comminuted spiral fracture of the distal tibia and fibular diaphysis without significant foreshortening. There is slight varus angulation seen on the ankle views. 2. Severe degenerative changes are seen of the right knee. There is no proximal fibular fracture seen. 3. Pes planus deformity of the longitudinal arch of the foot. During an interview on 5/24/11 at 4:15 pm, S5 CNA confirmed that she was in the room with Resident #3 on 4/15/11 when her right leg was fractured. S5 CNA stated that she was asked by S3 CNA to assist in transferring Resident #3 from her wheelchair to her bed around 6:00 pm on 4/15/11. S5 CNA confirmed that Resident #3 was a 2 person transfer with the lift, but stated when she and S3 CNA brought the lift to Resident #3 ' s room for the transfer, they noticed that there was no lifter pad underneath Resident #3. S5 CNA stated that Resident #3 must have been transferred from the bed to the wheelchair without the lift. S5 CNA confirmed that if a resident was already in a wheelchair without the lifter pad positioned underneath the resident, then the resident could not be transferred back to bed with the lift. S5 CNA stated that she and S3 CNA had to transfer Resident #3 to bed without the lift and while attempting to transfer Resident #3, Resident #3's leg got stuck underneath S3 CNA's leg and a popping sound was heard. S5 CNA confirmed that neither she nor S3 CNA informed the nurse that Resident #3 was in the wheelchair without the lifter pad or that they were going to attempt to transfer Resident #3 without the lift. S5 CNA confirmed that S2LPN was not called until the popping sound was heard. During an interview on 5/25/11 at 9:45 am, S8 CNA Supervisor confirmed that Resident #3 was a 2 person transfer with the Hoyer lift. S8 CNA Supervisor stated that she had informed all CNA staff that they must use the lift to transfer Resident #3. S8 CNA Supervisor confirmed that she had no documentation of inservices regarding the 2 person transfer with the Hoyer lift for Resident #3 prior to the 4/15/11 incident, which resulted in the fracture of Resident # 3's right leg. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA was assigned to Resident #3 and S10 CNA transferred Resident #3 from the bed to the wheelchair without the assistance of another CNA or the Hoyer lift. S8 CNA Supervisor further stated that when Resident #3 was ready to be transferred back to bed, the other shift of CNA staff was at work. She stated that S3 CNA and S5 CNA transferred Resident #3 to bed without the lift because there was no lifter pad under Resident #3. S8 CNA Supervisor further stated that she was told by S3 CNA that when she pivoted with Resident #3 during the transfer, S3 CNA heard a cracking sound. S8 CNA Supervisor stated that she spoke with S10 CNA after the incident on 4/15/11 and asked her why she transferred Resident #3 from the bed to the wheelchair without the lift and S10 CNA told her there was no lift pad available and Resident #3 had told her she could stand for a little while to get in the wheelchair. S8 CNA Supervisor stated that Resident #3's family had purchased a lifter pad for Resident #3, but the family had taken it home to be washed. S8 CNA Supervisor further stated that S10 CNA should have used one of the facility's lifter pads, as there are extra pads for the Hoyer lift available. S8 CNA Supervisor stated that on 4/18/11, S10 CNA was counseled regarding the improper transfer of Resident #3 on 4/15/11 without the lifter pad. S8 CNA Supervisor stated that S3 CNA and S5 CNA were also counseled on 4/18/11 for the improper transfer of Resident #3, which occurred on 4/15/11. S8 CNA Supervisor stated that S10 CNA had resigned from facility. During an interview on 5/25/11 at 10:00 am, S1 DON confirmed that R #3 was assessed as a 2 person transfer with the Hoyer lift and S10 CNA should have transferred R #3 from the bed to the wheelchair with the use of another CNA and the Hoyer lift on 4/15/11. S1 DON further stated that because Resident #3 was initially transferred to the wheelchair without the lift on 4/15/11, S3 CNA and S5 CNA were unable to use the Hoyer lift to transfer Resident #3 from the wheelchair to the bed because the lifter pad was not underneath Resident #3. S1 DON stated she was not able to obtain a statement from S10 CNA regarding the incident because she had resigned and the contact phone numbers did not work. S1 DON confirmed that the fractures to Resident #3's right leg were the result of: 1) an improper transfer of Resident #3 by S10CNA because she failed to use the Hoyer lift and another staff member to initially transfer Resident #3 from the bed to the wheelchair and 2) an improper transfer of Resident #3 by S3 CNA and S5 CNA. During an interview on 5/25/11 at 10:50 pm, S1 DON confirmed that Resident#3 was on pain medication, Lortab, prior to the fractures, but the dosage and frequency of pain medication had increased since the fractures on 4/15/11. During an observation of Resident #3 sitting in her wheelchair in her room on 5/25/11 at 12:00 pm, she was crying and stated "I sometimes feel very sad and sorry for myself since I broke my leg. I feel like I am stuck in my room more and can't go to all the activities I used to go to." Resident #3 further stated that the reason she does not go to her normal activities anymore is because she takes more pain medication since she fractured her right leg and the pain medication makes her drowsy, keeping her in her room. A review of Resident #3's Resident Activities Progress Notes and Evaluation form dated 3/29/11, prior to the fractures that occurred on 4/15/11, reads: she attends activities 2/3 time awake participating in mass, rosary, ball toss, bands, parties, exercise, movies and television..........She takes a nap daily for approximately one hour before bingo....... Further review of this form reveals an entry for Resident #3 dated 4/28/11 which reads: returned from hospital. Visited. She is doing ok. Her son is here visiting, asking if she has pain states yes but will get better. Will revisit x 2 week until she can resume activities. Further review of this form reveals continuing entries of activities being provided to resident in her room dated from 5/3/11 to 5/24/11. During an interview on 5/25/11 at 1:25 pm, S3 CNA stated that the fractures to Resident #3's right lower leg happened on 4/15/11, around 6:00 pm. S3 CNA stated that she asked S5 CNA to help her transfer Resident #3 from her wheelchair to her bed and when they brought the Hoyer lift to Resident#3's room, they noticed that the lifter pad was not positioned underneath Resident #3. S3 CNA confirmed that Resident #3 was a 2 person transfer with the lift. S3 CNA further stated that since the lifter pad was not underneath Resident #3, she asked S5 CNA to help transfer Resident #3 from the wheelchair to the bed without the lift. S3 CNA confirmed that she did not consult Resident #3 ' s nurse to inform her that the lift pad was not placed underneath Resident #3 and that she would attempt to transfer R#3 from the wheelchair to the bed without the Hoyer lift. S3 CNA stated that S5 CNA was positioned on the outside and she was positioned on the inside. S3 CNA stated that when she (S3 CNA) went to turn, Resident #3's right leg got stuck in between her legs. S3 CNA stated that Resident #3's body did not turn when she (S3 CNA) pivoted and that is when she heard the popping sound. She stated that she thought it was Resident #3's ankle. She stated that she and S5CNA put Resident#3 on the bed and called the S2 LPN. S3 CNA stated that when S2 LPN came to examine Resident #3, she and S5 CNA helped Resident #3 lie down . S3 CNA stated that S2 LPN called for a portable XRAY and the report found that Resident #3 ' s right leg was broken and later required surgery to place a rod in Resident #3's right leg. S3 CNA confirmed that she attended 2 inservices on 3/4/11 and 4/18/11 and both of the inservices were given by S8 CNA Supervisor. S3 CNA stated that during the inservices, there was discussion and demonstration on the lifter and the pad, specifically how to work the lifter and apply the pad. S3 CNA stated that some of the CNA staff was able to demonstrate how to use the lift and the lifter pad or how to perform a 2 person transfer but all of the CNA's were not able to perform a return demonstration. She stated that S8 CNA Supervisor inserviced staff and watched some of the CNA's to make sure lifter was being used correctly. S3CNA denied training on what CNA staff should do if a lift pad is not available or what CNA staff should do if a resident needs to be transferred with the Hoyer lift but a lift pad is not positioned underneath the resident. A review of the following employee records failed to reveal documentation of competency regarding 2 person transfers or use of assistive devices, such as a lift, used to promote resident safety: S3 CNA date of hire: 11/25/09 S5 CNA date of hire: 9/15/10 S10 CNA date of hire: 9/27/10 During an interview with S8 CNA Supervisor on 5/25/11 at 11:30 am, she reviewed the employee files of S3 CNA, S5 CNA, and S10 CNA and confirmed that there was no documentation of competency in transferring skills or the use of the Hoyer lift. S8 CNA Supervisor stated that she does go into the resident's rooms with the CNA's and observes them doing transfers with and without the lift, but she does not document that they are competent in these skills and verified that she should document this competency. S8 CNA Supervisor further stated that all CNA staff was inserviced on the use of the lift and a proper 2 person transfer on 3/4/11 and 4/18/11, but she did not have documentation of return demonstrations. S8 CNA Supervisor stated that she is not sure which CNA's performed return demonstrations on 3/4/11 and which CNA's performed return demonstrations on 4/18/11. S8 CNA Supervisor further stated that to this date, not all of the CNA staff was able to perform return demonstrations of proper 2 person transfers with and without the lift nor did she have documentation of which CNA's had been able to perform return demonstrations. S8 CNA Supervisor confirmed that she did not discuss what the CNA staff should do if a lift pad is not available for a resident who is a 2 person assist with the lift because there should always be a lift pad available. S8 CNA Supervisor confirmed that on 4/15/11, S10 CNA performed an improper transfer for Resident #3 when she transferred Resident #3 without the use of the lift and without another CNA. S8 CNA Supervisor further confirmed that S3 CNA and S5 CNA failed to adequately perform a proper transfer for Resident #3 from her wheelchair to her bed on 4/15/11, which resulted in the fractures to Resident #3's right leg. S8 CNA Supervisor again confirmed that she should have documentation of competency in transfer skills and use of the Hoyer lift, but she does not. During an interview on 5/25/11 at 11:50 am, S5 CNA confirmed that 2 inservices for the CNA staff were held, one in March and one in April. When shown the inservice sign in sheets dated 3/4/11 and 4/18/11, she confirmed that she did attend both inservices and S8 CNA Supervisor reviewed and demonstrated 2 person transfers and 2 person transfers with lifter at these inservices. S5 CNA stated that she was able to assist with a 2 person transfer at the 4/18/11 inservice, but not during the 3/4/11 inservice. When asked if all CNA staff was able to perform a return demonstration on 2 person transfers with and without the use of the Hoyer lift at either the 3/4/11 inservice or the 4/18/11 inservice, S5CNA stated that she did not think so. When asked if the CNA Supervisor discussed what should be done if a lift pad is not available in the future to transfer a resident who is deemed a 2 person transfer with the lift, she stated that she did not recall that being discussed at either inservices or when she was counseled after the incident with Resident #3. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S5CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA. Informed CNA if actions continue that she will be terminated. This form was signed by S8 CNA Supervisor and S5CNA. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S3 CNA; Problem-Improper transfer on resident by CNA; Statement By Employee-I was inserviced and a demonstration was done by CNA Supervisor, QAA, and myself with 2 person transfer and 2 person transfer with lifter; Resolution of Problem or Action Taken-Inservice CNA on 2 person transfer and 2 person transfer with lifter. A demonstration was done by CNA Supervisor, QAA, and CNA. Informed CNA if actions continue she will be terminated. This form was signed by S8 CNA Supervisor and S3CNA. A review of the Employee Counseling Form dated 4/18/11 reads: Employee-S10 CNA; Problem-CNA didn't use the lifter pad on resident as required; Statement By Employee-There was no lifter pad available and resident ask to get out of be; Resolution of Problem or Action Taken-Informed CNA to always have a lifter pad for resident or she would have to stay in bed until one is available. Informed her if her actions continue it was result in (5) days suspension and CNA inserviced on using lifter/lifter pad. she will be terminated. This form was signed by S8 CNA Supervisor and S10CNA. A review of the inservices done on 3/4/11 and 4/18/11 and the Employee Counseling Forms completed on S3CNA, S5CNA and S10CNA failed to reveal documentation of the CNA staff being taught the importance of not making critical nursing judgments such as the decision to transfer a resident without the Hoyer lift when the resident is deemed a 2 person transfer with the Hoyer lift by the nursing staff.

Based on record review and interview the facility failed to keep a resident from harm by: A) Not appropriately lifting the resident into the facility's van which resulted in hitting the resident's right foot causing a broken right knee. B) Not Immediately reporting to staff an injury which caused pain to the residnet. On 7/18/11 resident #4's record was reviewed. It revealed that the resident had an incident and accident report dated 7/9/11 at 2:00 pm.. The time of the incident was listed as 2:00 pm when the facility was informed by the family that the resident's knee was swollen and hurting. There is no documentation of the actual time of the incident. There is mention in one witness statement of a phone call from the family at 12:30 on 7/9/11 asking if the resident had fallen, as he was complaining about the knee.In the emergency room Report, the time of the incident was listed as "10:30 am ?" as if they were not sure of the exact time. The report stated that a member of the resident's family called the nursing home at 2:00 PM and stated that the "resident had swelling to the right knee with redness". The report also stated that the resident arrived at the nursing home at 2:50 PM and the assessment on the report stated "Resident assessed per nurse, right knee slightly swollen. Ice pack in place. Tylenol 1 Gram given for pain." According to the report the resident was experiencing pain at a level 7 out of 10. An interview with the resident was attempted but he was unable to be understood. A witness statement dated 7/8/11 (?) with no time listed, from (S3) CNA/van driver stated "When I put (resident #4) on the lifter gate to put in the truck his right foot hit the lifter gate lightly. I put ice on the right knee for the swelling. " The nurses' note concerning the incident, dated 7/9/11 at 2:50 pm states: "Resident right knee slightly swollen. Ice pack in place. Resident complains of pain when right leg is moved Acetaminophen 500 milligrams X2 given for pain. Resident put back to bed and made comfortable using lifter and right leg up on pillow. " At 3:00 PM the nurse's notes continued, stating that the nurse practitioner was called and told of the incident. The nurse practitioner ordered to continue with ice packs to help keep swelling down and to x-ray right knee on Monday. ( 2 days later). (S2)ADON was notified. Family was notified. At 8:15 PM the resident ' s nurses notes stated that the family was at the nursing home visiting. The family requested that the resident be sent to the hospital because the knee was swelling more and the knee was warm to touch. The nurse called the nurse practitioner and the resident was sent out to the hospital. On 7/19/11 at 1:30 PM records from the hospital the resident was sent to were reviewed. The final impression from the x-ray was acute right knee fracture. On 7/19/11 at 2:30 PM (S1) DON stated " I got witness statements from the 2 ladies (S3)CNA/driver and (S4)CNA .( S3) stated she did not notice the knee when she was loading him. She was trying to put the gerichair in the van. (S3) can/van driver is no longer employed here. The policy for reporting incidents and accidents is getting statements and getting information about the accident. (S3) should have filled out an incident report before she left the building because she knew she hit the resident ' s foot. That way the resident could have been assessed before leaving in the van. I think the resident broke his knee when she bumped his foot because #4 ' s feet are contracted inward and she bumped the knee and caused the fracture. She should have told us when she first bumped the foot. They are trained to report when something happens not to wait and see what happens then report it. "

Based on interview and record review the facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (#110) reviewed for pain in the Stage 2 sample of 31 residents. The facility failed to assess the resident's pain and implement the identified approaches in the plan of care. Findings: Resident #110 On 03/29/2011 at 10:01 a.m., the resident was interviewed and stated that she had back surgery in 1989 and has back pain. She stated that she has medication for her back pain that she has to request. Stated that the staff bring the medication when she asks for it and it eases the pain, but the medication does not relieve the pain. Review of the MAR (Medication Administration Record) for March, 2011 revealed that pain assessment was initialed every shift. Review of the MAR revealed that [MEDICATION NAME] 37.5 mg. one every 6 hours as needed for pain was noted and that the resident had only received one dose on 03/28/11. Review of the back side of the MAR revealed that [MEDICATION NAME] was given on 03/28/11 at 12:45 p.m. for complaint of back pain. The code indicated that at 1:45 p.m. the medication was effective. Review of the February MAR revealed that the resident received [MEDICATION NAME] 37.5 mg. on 02/25/11 and 02/26/11. Review of the back of the MAR revealed no documented evidence of a pain assessment or an assessment of the effectiveness of the medication. Review of the nurses notes for 02/25/11 and 02/26/11 revealed no documented evidence of any pain assessments nor was there any documentation of an assessment of the effectiveness of the medication. Review of the physician's orders [REDACTED]. [MEDICATION NAME] was not found on the March orders but was noted as telephone order on 02/16/11. Review of the record revealed no documented evidence of a pain assessment of the causative or relieving factors, the character of the pain, the history of the pain, or any non-pharmacologic measures to relieve pain. On 03/20/11 at 9:20 a.m. S7LPN who was assigned to the resident was interviewed. When asked if the resident complained of pain, she stated not very often. When asked what was the procedure for the assessment and documentation of pain, she stated that they chart the medication on the MAR and the response on the back of the MAR. When asked where an assessment of the intensity, causative or relieving factors would be documented, she stated in the nurse's notes. She stated that they ask the resident if they have pain when they make rounds and ask if they want anything for pain. Review of the nurses notes revealed no entries for 03/28/11. Review of the record revealed no documented evidence of an assessment of the resident's pain. Review of the resident's care plan revealed that the potential for pain related to generalized aches and pains was identified as a problem on 12/01/10. The following approaches were identified: Assess location, frequency, duration and intensity of pain. Document assessment. Report increased pain trend to physician. Attempt non-pharmacologic pain relief measures such as repositioning, back rubs. Document effectiveness. Administer pain meds as ordered per MD. Notify MD if pain is not tolerable. Pain Scale 0-10. Review of the record revealed no documented evidence that any non-pharmacologic pain relief measures were attempted and there was no documented evidence that a pain scale was used. On 03/30/11 at 9:45 a.m., the resident was interviewed and stated that she did not have pain today. When asked how often she experienced pain, she stated a couple of times a week. She stated that she does ask for pain medication when she needs it and the staff bring it. When asked if any non-medication measures had been tried by the staff such as a back rub, she stated no. On 03/30/11 at 11:22 a.m., S20CNA was interviewed and stated that the resident has reported pain and it is usually early in the morning when she gets up. Stated that she reports the resident's complaint of pain to the nurse. She stated that she goes ahead with her routine because the resident complained of pain a couple of times a week. She stated that on some days she doesn't want to get up and on those days she gets her a breakfast tray in her room. She stated that she has not been instructed on any measures other than reporting pain to the nurse. On 03/30/11 at 12:35 p.m., S7LPN was interviewed and reviewed the resident's record. She verified that there was no documentation of a pain assessment on the record. She verified that she was the nurse that administered the pain medication on 02/25/11 and 02/16/11 and verified that she had not documented an assessment or effectiveness of the pain. On 03/30/11 at 2:50 p.m., S21LPN MDS nurse was interviewed. She stated that the MDS nurses assessed the resident's pain quarterly. She stated that when they do the assessment they asked the resident if they have had pain in last 5 days. She stated if the resident has not had pain in the last 5 days, the pain assessment part is over. She stated that she does look in the MARs to see if any medication was given. After reviewing the care plan, she verified the above approaches and stated that the nurse assigned to the resident was responsible for assessing the resident's pain. After reviewing the nurses notes, she found documentation on 01/18/11 by the MDS nurse that resident denied pain in last 5 days. On 03/30/11 at 3:06 p.m., S7LPN was interviewed. After reviewing the resident's care plan, she verified the above approaches for the resident's pain. She verified that the pain scale had not been utilized for the last 3 times the resident requested pain medication. She verified that the frequency, duration and intensity of the resident's pain had not been documented for the last 3 times the resident requested pain medication. She stated that she has suggested to the resident that changing her position may help the pain, but verified that that was not documented. She verified that there was no documented evidence that any non-pharmacologic approaches had been attempted. She verified that there was no documented evidence of any assessment of contributory or relieving factors. Review of the facility's policy and procedure entitled Administering Pain Medication, revealed the following: Obtain subjective information from the resident: Location, Pain Intensity, Pain quality, Onset and Duration, Aggravating factors, Alleviating factors, and accompanying symptoms. Evaluate the effectiveness of non-pharmacologic interventions. The following information should be recorded in the resident's medical record: 1. Subjective evidence of pain. 2. Objective evidence of pain. 3. Condition of the pain site, if appropriate. 4. The drug name, dose, time, date, and route of administration. 5. There resident's response to the medication. On 04/01/11 at 11:45 a.m., S2DON was interviewed. After reviewing the resident's record, she verified that there was no documented evidence of any pain assessment. She verified that the resident had received pain medication and the nurse had not documented the effectiveness of the pain medication on February 25 and 26, 2011. She verified that the facility's policy was for the nurse to document an assessment of the resident's pain and the effectiveness of any medication administered.

Based on record review and interview, the facility failed to provide necessary care to a resident to maintain her highest practicable physical well-being by failing to provide care which would have prevented the condition of the resident deteriorating for 1 of 6 sampled residents (#6). The resident ' s last bowel movement was on 7/7/11. The facility failed to administer medications after Resident #6 did not have a bowel movement for more than three days, and failed to notify the physician after the resident did not have a bowel movement after four days. Resident #6 became impacted and on 7/11/11, she began to vomit and a bowel impaction was manually removed from her rectum. Findings: Resident #6: A review was conducted of Resident #6 ' s record and revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of the Accumulative [DIAGNOSES REDACTED]. Further review of the resident ' s record revealed that she had become a hospice patient on 6/17/2010. A review of the physician's order [REDACTED]. following orders for Constipation: (If no BM in 3 days). The facility ' s Routine Physician ' s Standing Orders were in effect upon Resident #6 ' s admit of 10/17/2008. A. Milk of Magnesia 30cc PO or PEG Q HS B. If no results in 24 hours use Fleets enema or 1 [MEDICATION NAME] suppository C. If still no BM, check for fecal impaction and follow with 2nd Fleets enema * Notify MD if no BM or further problems A review of the July 2011 Nursing Care Sheet in Resident #6 's chart revealed an area in which bowel movements were charted by the CNAs (Certified Nursing Assistant). Bowel movements can be documented as N- Normal, D- Diarrhea, or C- Constipated. The resident ' s bowel movements are charted during three shifts during one day. These shifts are from 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. A bowel movement of "N" (normal) was charted on 7/7/11 during the 3:00-11:00 p.m. shift. From the 11:00 p.m. -7:00 a.m. shift on 7/7/11 until the 7:00 a.m. -3:00 p.m. shift on 7/14/11, all bowel movements were recorded as "O" (none). A review of the July 2011 Medication Administration Record (MAR) for Resident #6, which was copied on 7/19/11, failed to reveal that the Physician ' s Standing Orders for Milk of Magnesia had been administered after the resident did not have a bowel movement for more than 3 days, between 7/7/11 and 7/11/11. A review of the Nurses' Notes revealed an entry dated 7/11/11 at 5pm. It revealed that S6LPN documented that a suppository had been administered after a fecal exam and a large BM was noted and was round, brown, formed. Further review of Resident #6's chart revealed a hospice Nursing Clinical Note dated 7/12/11 was conducted and revealed that Resident #6's last bowel movement had been 7/7/11 and that the nursing home staff removed an impaction from the resident earlier that day. An interview was conducted with S1DON on 7/19/11 at 9:45am. She reviewed the Nursing Care Sheet for July 2011 and verified that the Resident #6 had a bowel movement on 7/7/11 then not again until 7/14/11. She stated that she would have expected the facility to follow the physician's orders [REDACTED]. S1DON reviewed the resident's July 2011 MAR and confirmed that no medication had been administered as per the standing orders for Resident #6's lack of bowel movements. She further stated that the facility did not follow the physician's orders [REDACTED]. She stated that this may have resulted in Resident #6 becoming impacted. She stated that the hospice nurse and the physician had not been notified of the resident ' s condition and further stated that they should have been notified about the resident not having bowel movements for more than 3 days An interview was conducted with S1DON on 7/19/11 at 10:45am. She stated that if a resident had not had a bowel movement in three days and was vomiting, the resident should be assessed for a bowel impaction. She further stated that this assessment would be critical if the resident had a history of [REDACTED].#6's chart, dated 7/11/11 which stated that the resident was vomiting green fluid and undigested food. She stated that she was the nurse that had written that entry. She continued to review the nurse ' s notes in Resident #6's chart and stated that there was no nursing assessment by the nursing home staff, of Resident #6's bowel sounds or impaction, in her chart for the period of 7/7/11 through 7/11/11. S1DON further stated that she did not notify the physician nor the hospice nurse of the resident ' s vomiting because she thought it was just a single episode. S1DON further stated that she was not aware that Resident #6's last bowel movement was on 7/7/11when the resident was vomiting on 7/11/11. S1DON stated that she did not refer to the Nursing Care Sheet to assess when Resident #6's last bowel movement had been documented, during the vomiting episode. An interview was conducted with Resident #6 on 7/20/11 at 9:00 a.m. She confirmed that she didn't "poo" (have a bowel movement) for more than 3 days. She stated that it hurt and she told the workers it hurt and they gave her pain medicine. She stated that she couldn't "poo", and she started to get "sick of the stomach and I started throwing up" She further stated " I couldn't eat before I throwed up because my stomach felt sick. I throwed up a lot. My daughter was with me when I throwed up. The workers came and cleaned me up because I was all messed up." She further stated " The workers came to take the hard stuff out of me and it hurt when they took it out. Oh yes it hurt a lot when they took it out of me". She further stated " I had pain before when I couldn't poo and the workers gave me medicine for the hurting. After the workers took out the hard poo poo I didn't have any more pain." An interview was conducted with S6LPN on 7/20/11 at10:20 a.m. She presented additional nurse ' s notes that were not found in Resident #6 ' s chart. She stated that these notes were from the " Private Hall Binder " where documentation should be done for Resident #6. She further stated that there is a binder for each hall which holds nurses notes for the residents on that hall. She stated that the charting is to be done on the nurses notes in these binders, but sometimes the new nurses forget and they chart directly in the residents ' binders. She stated that when this document is full it is placed in the resident's binder. She reviewed Resident #6's nurse's notes from the "Private Hall Binder" and stated that on 7/11/11 at 5:00 p.m., she documented that she had "noted" a large bowel. She confirmed that the resident had been impacted, and that between 4:00 p.m. and 5:00 p.m., on 7/11/11 she removed a small to medium impaction of bowel. She further stated that she had not contacted the resident's physician regarding lack of bowel movements, removal of the impaction or that the resident had experienced vomiting because she thought that the hospice nurse would be responsible for that. An interview was conducted with S1DON on 7/20/11 at 12:30 p.m. She stated that all the nurses are supposed to be charting on the nurses notes in the appropriate binder which is housed at the nurses' station and not directly on the nurses notes in the residents' binders. She reviewed the nurse's notes for Resident #6 from the "Private Hall Binder". She stated that she had forgotten about these nurse's notes. She would not reply when she was asked why she had not documented her provision of care to Resident #6 when she was vomiting on 7/11/11 on these nurse's notes rather than directly in the resident's chart. S1DON reviewed the hospice notes in Resident #6's chart and confirmed that an impaction had been removed from the resident on 7/11/11.

I. Based on observation and staff interview, the facility failed to ensure that the resident environment remained free of accident hazards by failing to ensure residents did not have access to medications and razors, and sharps containers were disposed of when full. The deficient practice had the potential to effect 150 residents currently residing in the facility as documented on the Resident Census and Condition report. Findings: On 04/01/11 at 11:00 a.m., an observation was made on the 400 private hall. A blue pill was noted on the floor in the hall between the hopper room/restroom and room 409. At 11:05 a.m., S9LPN assigned to that hall, was interviewed. She verified that there was a blue pill on the floor in the hall. She picked up the pill and stated that it was Glipizide. Observation of the pill revealed the name was on the pill and was Glipizide. On 04/01/11 at 1:57 p.m., S9LPN stated that she had reviewed the MARs on the hall where the Glipizide was found and several residents were on this medication. She stated that some doses were given at 6 am and some were given at 8 am. 04/01/11 at 3:29 p.m., an observation was made with S26 Maintenance Supervisor. An unlocked cabinet in the shower room called Orange Side Women's Shower Room was noted to have a bag of opened razors in the cabinet. S26 Maintenance verified the razors were in the cabinet and stated that the cabinet was supposed to be locked. The door to the room was observed to be propped open. The cabinet was observed to have a lock on it, but it was not locked. The sharps container was also noted to be filled above the fill line. S26 stated that the sharps container was filled past the full line and should have been replaced. S26 stated that the sharps container was full of razor blades. On 04/01/11 at 3:40 p.m., an observation was made with S26 Maintenance Supervisor in the Orange Side Men's bathroom. The sharps container was noted to be filled over the fill line. S26 stated the sharps container was filled with razors and should be changed when the full line is reached. II. Based on record reviews and interviews the facility failed to identify and correct possible accident hazards by failing to investigate the cause and/or circumstances surrounding a fall for 2 of 3 residents (#140 and #149) reviewed out of a total Stage 2 sampled size of 31. Findings: Resident #140 Resident #140 was a [AGE] year old female admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 2/27/11 at 2:45pm revealed S16LPN documented the resident was resting in bed with side rails up times two. A Certified Nurse Assistant (CNA) heard a noise, went into the resident's room and found the resident on the floor next to the bed. An assessment was done by S16LPN and the resident was found to be without injury. Review of the facility's investigation form, The Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form, completed for the resident's fall on 2/27/11 revealed a statement stating the resident attempted to get out of bed without assistance, lost balance and fell to floor. Attached to the investigation form was a duplicate copy of The Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form and a copy of the nurse's notes for 2/27/11. No investigation into how the resident fell , causative factors, nor witness statements accompanied the report. An interview was conducted on 3/30/11 at 11:04 am with S16LPN. When asked about the resident's fall on 2/27/11, S16LPN stated the resident scooted to the end of the bed and got out. An interview was conducted on 4/1/11 at 4:35pm with S2DON. When asked about the investigation process after a fall, S2DON stated The Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form is completed. She further stated witness statements are taken to discover details surrounding of the fall including any causative factors. S2DON was asked to review The Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Form completed for Resident #140's fall on 2/27/11 to determine the cause of the fall. After reviewing the form, S2DON stated she wasn't sure how the resident fell . She verified no witness statements as well as no causative actions were done during the investigation. Resident #149: On 3/28/11 at 1:40p.m. an interview was conducted with resident #149. The resident stated that she fell at the entrance of the building on 3/7/11 when she was exiting the facility with a friend. She stated that she did not know why she fell . She stated that she fell face down, chipped her front tooth and broke her arm. On 3/31/11 at 2:26p.m. an interview was conducted with S11LPN, MDS Nurse. She reviewed resident #149's current care plan with goal date of 6/7/11. She stated that the resident fell in the parking lot when she was going out on pass. She stated that we understood that she was getting into a car with a friend and not staff when she fell . S11LPN, MDS Nurse verified that she was unaware of the circumstances or cause of the resident's fall on 3/7/11. A review of the nurses notes dated 3/7/11, 10:00a.m. revealed the following: Summonded outside to front parking lot, resident found on ground in prone position with nose bleed, states she tripped hitting her nose and falling face first, complained right shoulder pain, arm guarded. Assisted resident to sitting position and then into wheelchair. 10:15a.m. Transferred to hospital. On 4/1/11 at 4:19p.m. an interview was conducted with S2DON. She provided the surveyor with a copy of the facility's Incident Report, dated 3/7/11 regarding resident #149's fall. She stated that she thought the Incident Report was the investigation of the fall. She stated that resident #149 was outside in front of the building, getting into a friend's car, when she fell . She verified that the causative factors surrounding resident #149's fall on 3/7/11 were not investigated.