Every finding on record at Focused Care at Clarksville

Based on observation, interview, and record review, the facility failed to ensure residents assessments accurately reflected the resident's status for 3 of 15 residents (Residents #7, #8 and #36) reviewed for accuracy of assessments. 1. The facility failed to accurately complete the MDS assessment to indicate Resident #7's PASRR status was positive. 2. The facility failed to accurately complete the MDS assessment to indicate Resident #8's tobacco use.3. The facility failed to accurately complete the MDS assessment to indicate Resident #36's PASRR status was positive. These failures could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of Resident #7's face sheet, dated 02/24/2026, indicated a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #7 had diagnoses which included anxiety and major depressive disorder. Record review of Resident #7's physician orders, dated 02/2026, indicated diagnoses of major depressive disorder and anxiety. Record review of Resident #7's significant change MDS assessment, dated 10/14/2025, indicated Resident #7 was not marked for current PASRR positive during the assessment period. The assessment indicated Resident #7 had a BIMS score of 15, which indicated intact cognition. Record review of Resident #7's care plan, with a target date of 03/22/2026, indicated Resident #7 was PASRR positive status for mental illness related to anxiety and depression requiring a recent psychiatric inpatient stay. Record review of an undated list of PASRR positive residents provided by the facility indicated Resident #7 was PASRR positive and refused services. 2. Record review of Resident #8's face sheet, dated 02/23/2026, indicated a [AGE] year-old female, admitted [DATE] and readmitted [DATE]. Resident #8 had a diagnosis which included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #8's annual MDS assessment, dated 04/29/2025, indicated Resident #8 was not marked for current tobacco use during the assessment period. The assessment indicated Resident #8 had a BIMS score of 12, which indicated moderately impaired cognition with a diagnosis of chronic obstructive pulmonary disease. Record review of Resident #8's care plan, with a target date of 03/22/2026, indicated Resident #8 was a smoker with interventions that included facility staff would keep all lighters and resident would participate in supervised smoking breaks. Record review of a Safe Smoking Assessment, dated 04/28/2025, indicated Resident #8 required direct supervision while smoking and all smoking materials be kept at the nurse's station. During an observation and interview on 02/23/2026 at 9:45 a.m., Resident #8 was sitting on her bedside. Resident #8 said she smoked daily; the staff kept her smoking supplies and monitored her during smoking times. Resident #8 said she was aware of the smoking times. During an observation and interview on 02/24/2026 at 1:11 p.m., Resident #8 was observed smoking, a staff member was observed lighting the cigarette and provided smoking supplies and monitored the resident during the smoking episode. Resident #8 said she smoked daily and had smoked daily since her admission to the facility but may try to quit soon. During an interview on 02/25/2026 at 10:05 a.m., LVN A said she was providing care for Resident #8 today and she smoked cigarettes daily. LVN A said the staff kept Resident #8's smoking supplies, lit her cigarettes and monitored her during smoking episodes. She said the MDS Nurse was responsible for all MDSs in the facility. 3. Record review of a face sheet dated 02/24/26 indicated Resident #36 was a [AGE] year-old male admitted on [DATE]. His diagnoses included schizophrenia (a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), psychotic disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) with hallucinations (belief or altered reality that is persistently held despite evidence or agreement to the contrary), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of a PASRR Level 1 Screening dated 08/19/25 indicated Resident #36 was discharged from a psychiatric hospital. The form was marked no for dementia as a primary diagnosis and yes for Mental Illness. Record review of a LMHA letter dated 08/20/25 indicated Resident #36 did meet criteria for mental illness and qualified for special services. Record review of an annual MDS assessment dated [DATE] for Resident #36 indicated for A1500: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked no. During an observation and interview on 02/23/26 at Resident#36 was in bed watching TV. He said he's had a headache since he bruised his brain in 1976 and medications don't really help. He said he had no issues with his care. During an interview on 02/24/26 at 02:11 p.m. the DON said she was not real familiar with PASRR or MDS. She said she was not aware of what needed to be done if the MDS was incorrect when Resident #36's PASRR indicated he was positive and did meet criteria. She said she thought the MDS should reflect he was PASRR positive even though he refused services. During a phone interview and record review on 02/25/2026 at 10:55 a.m., the MDS Nurse said she was responsible for all MDSs completed in the facility and her back up that double checked random MDSs was the Clinical Reimbursement Nurse. She said the Clinical Reimbursement Nurse was not available for interview. The MDS Nurse said she was educated on the completion of MDSs. She said Resident #8's MDS, dated [DATE], was not completed by her but it should have been marked for smoking. She said Resident #8 smoked according to the Smoking Assessment on 4/28/25. She said it was overlooked at the annual MDS. The MDS Nurse said the resident's risk of an MDS not marked correctly was it could affect the residents care and needs and the resident's care plan. The MDS Nurse said Resident #7's MDS assessment dated [DATE] should have been coded positive for PASRR and they completed a modification after surveyor intervention. During an interview on 02/25/2026 at 10:45 a.m., the DON said the MDS Nurse was responsible for all MDS in the facility with the Clinical Reimbursement was the backup that double checked random MDSs. She said the MDS Nurse was educated on the completion of MDSs. The DON said the MDSs marked incorrectly were overlooked. She said she expected all MDSs in the facility to be correct and accurate. The DON said the resident risk of an MDS marked incorrectly was the MDS may not paint a good picture of residents and the care the residents needed. During an interview on 02/25/2026 at 11:00 a.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and was educated on the completion of MDSs. She said the Clinical Reimbursement was the backup to double check some MDSs for accuracy. The Administrator said the resident risk of an MDS not marked correctly was the MDS may not paint a good picture of the resident and resident's care. She said her expectation was all MDSs be correct and accurate. Record review of the facility's policy titled, Resident Assessment, revised 11/15/2023, indicated, . The purpose of this policy is to ensure accuracy and timeliness of MDS completion. 1. Each facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated .A1500: Preadmission Screening and Resident Review (PASRR). Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. .J1300: Current Tobacco Use coding . Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1. Yes. Coding Instructions, Code, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated .Guidelines for Determining When a Significant Change Should Result in Referral for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation: If an SCSA occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.5

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication rooms and 1 of 2 medication carts for 4 of 18 residents reviewed for pharmacy services (Resident #8, #42, #43 and #52). 1. The facility failed to perform an inventory of controlled substances of the medication cart upon transfer of keys between staff.2. The facility failed to ensure expired mediations were removed from all medication carts and medication rooms.These failures could place residents at increase risks of drug diversion and of receiving medications that were not at their intended potency and potential adverse reactions or side effects. 1. During an observation on 02/23/2026 at 09:05 a.m., MA B was observed rolling the medication cart into the medication room. MA B then informed LVN A she had a family emergency and needed to leave work. MA B handed her medication cart keys to LVN A and exited the facility. During an observation and interview on 02/23/2026 at 09:15 a.m., LVN A exited the medication room with a medication cart. She said the cart was the one that MA B was working on. LVN A said she received the keys from MA B and said the narcotics on the cart were not counted prior to MA B leaving. She said she knew they should have counted the narcotics between themselves, and due to the emergency, they failed to do so. During an interview on 02/23/2026 at 10:45 a.m., the DON said LVN A and MA B should have counted the narcotics prior to MA B leaving the facility. She said her expectations were for narcotics to be counted at every shift change and at any change of hands in between. She said staff were educated on counting narcotics in these situations. The DON said drug diversions and missing medications were potential negative outcomes for failure to count narcotics. During an interview on 02/24/2026 at 12:15 p.m., the administrator said anytime the medication carts changed between shifts or in emergency situations, the narcotics should be counted between staff who were responsible for the carts. She said failure to count narcotics on the carts could potentially result in drug diversion or missing medications. During an interview on 02/24/2026 at 2:20 p.m., MA B said she had a family emergency regarding her child and had to leave work. She said she handed the keys to her medication cart to LVN A prior to exiting the facility. MA B said she was trained to always count narcotics when taking control of the medication cart and when handing it off to the next shift, as well as during unusual circumstances. MA B said she was aware her responsibility was to have counted with LVN A prior to leaving the facility and she had failed to do so. MA B said potential risks were drug diversion and residents not receiving medications timely. 2. Record review of Resident #8's face sheet, dated 02/23/2026, indicated a [AGE] year-old female, admitted [DATE] and readmitted [DATE]. Resident #8 had a diagnosis which included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #8's annual MDS assessment, dated 04/29/2025, indicated Resident #8 was not marked for current tobacco use during the assessment period. The assessment indicated Resident #8 had a BIMS score of 12, which indicated moderately impaired cognition with a diagnosis of chronic obstructive pulmonary disease. Record review of Resident #8's care plan, with a target date of 03/22/2026, indicated Resident #8 was a smoker with interventions that included facility staff will keep all lighters and resident will participate in supervised smoking breaks. Record review of Resident #42's face sheet, dated 02/25/2026, indicated a [AGE] year-old female, admitted [DATE]. Resident #42 had diagnoses which included hypertension (high blood pressure) and heart failure (condition where the heart cannot pump enough blood and oxygen to support the body's needs.) Record review of Resident #42's quarterly MDS assessment, dated 12/05/2025, indicated Resident #42 had a BIMS score of 8, which indicated moderately impaired cognition with a diagnosis of hypertension and heart failure. Record review of Resident #42's care plan, with a target date of 04/02/2026, indicated Resident #42 was at risk of cardiac failure and heart failure and hypertension with interventions that included received medication as ordered. Record review of Resident #42's physician orders, dated 02/25/2026, indicated she was prescribed amlodipine 5 mg every day with a start date of 12/03/2023. Record review of Resident #43's face sheet, dated 02/25/2026, indicated an [AGE] year-old female, admitted [DATE]. Resident #43 had a diagnosis which included hypertension (high blood pressure) Record review of Resident #43's quarterly MDS assessment, dated 01/28/2026, indicated Resident #43 had a BIMS score of 3, which indicated severely impaired cognition with a diagnosis of hypertension. Record review of Resident #43's care plan, with a target date of 04/02/2026, indicated Resident #43 had a diagnosis of hypertension and interventions that included received medication as ordered. Record review of Resident #43's physician orders, dated 02/25/2026, indicated she was prescribed Diltiazem HCL 180 mg every day for hypertension with a start date of 03/18/2023. Record review of Resident #52's face sheet, dated 02/25/2026, indicated an [AGE] year-old female admitted [DATE]. Resident #52 had a diagnosis which included depression (a mood disorder characterized by persistent sadness, low energy and loss of interest in activities). Record review of Resident #52's admission MDS assessment, dated 01/28/2026, indicated Resident #52 had a BIMS score of 10, which indicated moderately impaired cognition with a diagnosis of depression. Record review of Resident #52's care plan, with a target date of 04/30/2026, indicated Resident #52 had a diagnosis of depression and interventions that included received medication as ordered. Record review of Resident #52's physician orders, dated 02/25/2026, indicated she was prescribed Venlafaxine HCL ER 180 mg every day for depression with a start date of 01/20/2025. During an observation and interview on 02/25/2026 at 8:58 a.m., Hall 400, 500, 600 MA cart with LVN C revealed 1 medication card with 15 of 30 pills (1/2 light blue/1/2 dark blue capsules) diltiazem CL 180 mg every day for blood pressure with a use by date of 12/24/2025 labeled for Resident #43. Also discovered was 1 medication card with 30 of 30 pills amlodipine 5 mg every day with a use by date of 05/02/2025 labeled for Resident #42. LVN C said the nurses and MA that gave medication off this medication cart were responsible for ensuring all expired medications were removed from the medication cart and placed in the medication destruction bin. She said she was giving medication off this medication cart today and was educated on removal of expired medication. LVN C said the DON was the backup that made random checks for expired medication on the medication carts. She said these expired medications were overlooked. LVN C said the resident risk of expired medication left on a medication cart was they may have decreased potency. She said she had not given any of the expired medication. During an observation and interview on 02/25/2026 at 9:40 a.m., the facility medication storage room with LVN D was discovered 1 full bottle and one bottle with 1/10 the ingredients of Guardian brand 13 oz Fiber powder both with an expiration date of January 2026. In a cubby labeled Resident #8 was discovered one box of Nicotine transdermal system patch (to help stop smoking) 14 mg delivered over 24 hours, 12 of 14 patches with an expiration date of April 2025 that was labeled Resident #8. In a cubby labeled for Resident #52 was 1 bottle of one a day vitamin with minerals 2/4 full of 60 tablets opened and with an expiration date of 11/2025 and 1 bottle of Venlafaxine HCL ER (antidepressant medication) 150 mg labeled to give 1 capsule per day for Resident #52 with an expiration date of 9/2025. The bottle included 14 of 90 pills. LVN D said all the nurses and MAs were responsible for ensuring all expired medication were removed from the medication room and stored in the medication destruction bin. She said the pharmacy consultant was a backup that double checked the medication room for expired medication monthly. She said the expired medications were overlooked. LVN D said all the nurses and MAs were educated on removal of expired medication from the medication room. She said the resident risk of expired medication not removed from the medication room was the medication could be used and be less effective as it should be. LVN D said the expired medications should have been removed from the medication room and disposed of in the medication destruction bin. During an interview on 02/25/2026 at 10:00 a.m., the DON said the nurses and MAs were all responsible and educated on ensuring all expired medication was removed from medication carts and the medication room and placed in the medication destruction bin. She said she was the back up to double check medication carts and the medication room for expired medication and did random checks monthly. She said the Pharmacy Consultant also did random checks monthly for the medication carts and medication room. She said the expired medications found were overlooked. The DON said the potential resident risk of expired medication not removed from the medication carts or medication room was they may not be as effective as should be. She said her expectation was the nurses and MAs checked and removed all expired medication from the medication carts and medication room and placed in the medication destruction bin. During an interview on 02/25/2026 at 10:15 a.m., the Administrator said the nurses and MA were all responsible and educated on ensuring expired medication was removed from the medication carts and the medication room and placed in the medication destruction bin. She said the DON was the back up to double check medication carts and the medication room for expired medication through random checks monthly. The Administrator said the expired medications were overlooked. She said the potential resident risk of expired medication not removed from the medication carts or medication room was the expired medication could be used and may not be as effective as should be. The Administrator said her expectation was staff remove all expired medication from the medication carts and medication room and placed in the medication destruction bin. During an interview on 02/25/2026 at 11:50 a.m., the Pharmacy Consultant said she did random checks monthly of a medication cart or the medication room and the Pharmacy Technician checked all the medication carts and medication room monthly for expired medications and then quarterly when the facility was not in their survey window. She said the expired medications were overlooked. The Pharmacy Consultant said the Pharmacy Technician should have pulled the expired medication from the medication carts and medication room for destruction. The Pharmacy Consultant said the resident risk of expired medication on the medication carts and in the medication room was the medications could be administered and not be as effective. During an attempted interview on 02/25/2026 at 12:15 p.m., the Pharmacy Technician message was left to return call with no response. Record review of the Monthly Consultant Pharmacist Report, dated 02/13/2026, indicated, .Medication Cart for Halls 100, 200, 300 was reviewed expired medication was removed with no medication labeling or dating concerns . Record review of a facility policy, revised 08/2020, titled, Preventing and Detecting Adverse Consequences and Medication Errors, indicated, . d. Checking the medication storage areas and the medication carts for proper storage and labeling of medications, cleanliness, and removal of expired medications. 7. No expired medication will be administered to a resident. 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. In order to safeguard the quality and stability of medications used within the facility, medications brought to the facility by other than the designated pharmacist or agent can be accepted only if there is a current order for use, the medication is in a proper container properly labeled, the medication has not expired, and the medication has been positively identified by the physician or pharmacist prior to use. The facility will have documentation that the identification has been made. Review of the Policy and Procedures - Pharmacy Services for Nursing Facilities, dated 08/2020, indicated the following.Policy: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures: 5. Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed: a) at each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections 2 of 2 residents observed for incontinent care (Residents #5 and #32), for 1 of 1 resident observed for wound care (Resident #5), and 1 of 1 resident for transfers (Resident #32). * CNA F and CNA G used gloves pulled from their pockets, CNA G touched clean items without hand hygiene between glove changes, CNA F did not do hand hygiene between glove changes, and CNA G did not wash her hands before leaving the room when they provided incontinent care and Hoyer lift transfer on Resident #32. * CNA F used gloves pulled from her pocket, LVN C used gloves pulled from CNA F's pocket, and when cleaning the wound LVN C did not do hand hygiene between glove changes when they provided incontinent care and wound care to Resident #5. These failures could place residents at risk for spread of infections or worsened infections. Findings included: 1. Record review of a face sheet dated 02/25/26 indicated Resident #32 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included kidney failure (condition where the kidney reaches advanced state of loss of function). Record review of the quarterly MDS dated [DATE] indicated Resident #32 was cognitively intact with a BIMS of 14 out 15. She was dependent on assistance with toileting. During an observation and interview on 02/23/2026 at 09:55 a.m. of incontinent care provided to Resident #32 by CNA F and CNA G. CNA F and CNA G had gloves in their pockets. After removing the dirty brief with feces, CNA G changed gloves with no hand hygiene between. A clean brief was placed and Resident #32 was transferred by Hoyer lift to wheelchair with CNA G not performing hand hygiene between glove changes. CNA F and CNA G were asked if they would have or should have done anything different and they said no. CNA G left Resident #32's room without washing her hands. During an interview on 02/24/26 at 10:12 a.m. CNA F was asked about the incontinent care provided to Resident #32 on 02/23/26 and she said they should have changed gloves with hand hygiene between. She said the hand washing she did after changing the dirty brief CNA G should have also done. She said staff should always wash their hands when entering and exiting a resident room. 2. Record review of a face sheet dated 02/25/26 indicated Resident #5 was a [AGE] year-old male readmitted on [DATE]. His diagnoses included malignant neoplasm (uncontrolled growth of cells) of the prostate (a gland in the male reproductive system) and paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body). Record review of the February 2026 physician orders for Resident #5 indicated he had an order dated 06/21/25 for Enhanced Barrier Precautions due to wound care requirements and indwelling device every shift Record review of the quarterly MDS dated [DATE] indicated Resident #5 had intact cognition with a BIMS of 13 out of 15. He required substantial/maximum assistance with toileting. He had an indwelling urinary catheter and was frequently incontinent of bowel. He had an unhealed stage 4 pressure ulcer. Record review of a care plan revised 02/23/36 indicated Resident #5 required substantial/maximum assistance with toileting, had an indwelling urinary catheter, was incontinent of bowel, had an unhealed stage 4 pressure ulcer, and was EBP due to catheter and wound. During an observation and interview on 02/24/2026 at 10:00 a.m. of incontinent care and wound care provided to Resident #5 by LVN C and CNA F. While providing incontinent care, CNA F pulled gloves from her pocket when changing gloves during incontinent care on the front of Resident #5. LVN C ran out of gloves during wound care and CNA F gave gloves from her pocket to LVN C to complete wound care. While cleaning the wound to the sacral area, LVN C utilized the gloves given to her by CNA F from her pocket and did not do hand hygiene between glove changes. CNA F said she thought she could put the gloves in her pocket. LVN C said she thought she used sanitizer between all of the glove changes. She said she did not realize she did not during a few of the changes. She said she ran out of gloves she had for wound care while assisting with incontinent care and did not think about the gloves being pulled out of CNA F's pocket. During an interview on 02/25/2026 at 10:20 a.m. the DON indicated staff should place gloves in a plastic bag to provide care to residents. She said she expected staff to wash their hands after cleaning a resident with a bowel movement and when they enter/exit a resident room. She said staff should always do hand hygiene between glove changes. She said they could spread infections to the residents or to other residents. During an interview on 02/25/2026 at 11:00 a.m., the Administrator said she expected staff to follow the policies on hand hygiene and glove use. Record review of a Hand Hygiene policy revised 10/24/22 indicated Policy:.1. You should always perform hand hygiene:.Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield/goggles), Before and after providing any type of care.2. You must perform hand hygiene (hand washing or the use of ABHR) after contact with bodily fluids, such as urine or blood, mucous membranes, such as the mouth or nose, and non-intact skin.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #36) reviewed for care plans. The facility failed to ensure that Resident #36's care plan addressed his PASRR positive status. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included:Record review of a face sheet dated 02/24/26 indicated Resident #36 was a [AGE] year-old male admitted on [DATE]. His diagnoses included schizophrenia (a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), psychotic disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) with hallucinations (belief or altered reality that is persistently held despite evidence or agreement to the contrary), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of a PASRR Level 1 Screening dated 08/19/25 indicated Resident #36 was discharged from a psychiatric hospital. The form was marked no for dementia as a primary diagnosis and yes for Mental Illness. Record review of a LMHA letter dated 08/20/25 indicated Resident #36 did meet criteria for mental illness and qualified for special services. Record review of the care plan revised 01/09/26 indicated Resident #36 had no care plan to address his PASRR positive status. During an observation and interview on 02/23/26 at Resident #36 was in bed watching TV. He said he's had a headache since he bruised his brain in 1976 and medications don't really help. He said he had no issues with his care. During an interview on 02/24/2026 at 02:11 p.m. the DON said she was familiarizing herself with care plans. She said Resident #36 should have a care plan indicating he was PASRR positive even though he refused services. During a phone interview and record review on 02/25/2026 at 10:55 a.m., the MDS Nurse said she was responsible for care plans completed in the facility. The MDS Nurse said she was educated on completion of care plans. She said Resident #36's care plan should have addressed his PASRR positive status. The MDS Nurse said the resident risk of an MDS not marked correctly was that it could affect the residents care and needs and the resident's care plan. During an interview on 02/25/2026 at 10:45 a.m., the DON said the MDS Nurse was responsible for all care plans in the facility. She said the MDS Nurse was educated on the completion of care plans. The DON said the resident risk of a care plan not addressing a resident's status may not paint a good picture of residents and the care the residents needed. During an Interview on 02/25/2026 at 11:00 a.m., the Administrator said the MDS Nurse was responsible for all care plans in the facility and was educated on completion of care plans. The Administrator said the resident risk of a care plan address all the resident needs may not paint a good picture of resident and resident's care. She said her expectation was all care plans be correct and accurate. Record review of a Comprehensive Care Plan Policy revised 04/25/21 indicated POLICY:Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS 3.0) and CAAS, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from residents' representatives, external partners PASRR, Hospice, Therapy, Clinicians and not as all-inclusive.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: for excessive duration) for 2 of 5 residents (Residents #5 and #32) reviewed for unnecessary medications. * The facility did not have a stop date for Resident #5's Methenamine Hippurate (antibiotic) * The facility did not have a stop date for Resident #32's Bactrim DS (antibiotic) These failures could place residents at risk for antibiotic resistance infections due to excessive use of antibiotics. Findings included:1. Record review of a face sheet dated 02/25/26 indicated Resident #5 was a [AGE] year-old male readmitted on [DATE]. His diagnoses included malignant neoplasm (uncontrolled growth of cells) of the prostate (a gland in the male reproductive system) and paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body). Record review of February 2026 physician orders for Resident #5 indicated he had an order dated 12/26/25 to receive Methenamine Hippurate Oral Tablet 1 GM 1 tablet by mouth two times a day for urinary antiseptics. There was no stop date on the order. Record review of a Physician Progress Notes dated 01/29/26 for Resident #5 indicated there was no documentation as for the reason for no stop date on the order. 2. Record review of a face sheet dated 02/25/26 indicated Resident #32 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included kidney failure (condition where the kidney reaches advanced state of loss of function). Record review of February 2026 physician orders for Resident #32 indicated she had an order dated 01/28/2026 to receive Bactrim DS Oral Tablet 800-160 mg (Sulfamethoxazole-Trimethoprim) 1 tablet by mouth one time a day for chronic UTIs. There was no stop date on the order. Record review of a Physician Progress Note dated 01/29/26 for Resident #32 indicated there was no documentation as for the reason for no stop date on the order. During an interview on 02/25/2026 at 09:05 a.m. IP indicated she thought the physician had ordered the antibiotic prophylactically (to prevent infection) for UTI. She indicated she did not see any notes from the physician about the antibiotic. She indicated she would reach out to request any documentation they may have. During an interview on 02/25/2026 at 10:20 a.m. the DON indicated she understood there should be documentation to support why an antibiotic would be given for an extended length of time as well as follow up/reviews of the residents. During an Interview on 02/25/2026 at 11:00 a.m., the Administrator indicated she expected staff and physicians to follow protocols regarding antibiotic orders. Record review of an Antibiotic Stewardship Program Policy revised 10/01/22 indicated POLICY:The Community has a formal Antibiotic Stewardship Program (ASP) to optimize the treatment of infections, reduce the risk of adverse events, including the development of antibiotic-resistant organisms and employs Community-wide system to monitor the appropriate use of antibiotics.ANTIBIOTIC STEWARDSHIP PROGRAM (ASP) CORE ELEMENTS: 1. Leadership Commitment to demonstrate support and commitment to safe and appropriate antibiotic use in the community.7. Resources and education are provided to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use. b. Licensed independent practitioners (LIPs) are provided written education, the Community Antibiotic Stewardship Program and appropriate prescribing protocols upon credentialing and as needed. At the discretion of the Administrator or Community Medical Director, LIPs may be reeducated or provided with additional educational materials to improve antibiotic prescribing practices.ANTIBIOTIC STEWARDSHIP TEAM:The Community has an Antibiotic Stewardship Team to implement and direct the Core Elements of the ASP. The Team includes but is not limited to the following: .2. Medical Director or another licensed independent practitioner: a. Provides or assists in the provision of prescribing practices for credentialed clinical providers b. Oversees adherence to antibiotic prescribing practices for credentialed providers and offers written feedback regarding prescribing practices and compliance with antibiotic use protocols, which may include: .iii. Prescription documentation: indication for use, dosage, duration. iv. Clinical justification for use of an antibiotic beyond initial duration ordered.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. * The facility did not ensure the gas stove was in safe operating condition. The two right burners would not ignite when the knobs were turned. This failure could place the residents at risk of a fire for not having safe operating equipment. Findings included:During an observation and interview on 02/23/2026 at 08:53 a.m. the stove's two right burners were not lighting when the knobs turned on. Observation indicated the pilot lights to the two burners were not lit. The DM said they had to be lit with a long lighter. The DM said the stove should light without using a lighter. He said having to light the stove with a lighter could cause an explosion possibly causing injuries to residents. Observation indicated there was no hissing sound of gas and no foul smell of gas coming from the burners. During an interview on 02/24/26 at 11:05 a.m. the DM said the MD had looked at the stove after surveyor saw it and it still had a problem but there was no gas coming out unless the knobs were turned on. He said someone was supposed to be coming today to repair it. During an Interview on 02/25/26 at 11:00 a.m., the Administrator said she expected kitchen equipment to be working correctly. She said due to the stove being gas it could cause a fire and possible injuries. During an interview and record review on 02/25/26 at 11:30 a.m. the DM said someone had come and repaired the stove. He showed surveyor an equipment repair receipt for the stove. Record review of a Preventative Maintenance and Repair of Equipment policy dated 04/2022 indicated POLICY:The facility Plant Operations personnel will perform monthly inspections of kitchen equipment to ensure proper care of equipment and reduce cost by providing preventative maintenance in a timely manner. Record review of the FDA Food Code 2022 accessed on 02/25/26 at https://www.fda.gov/food/retail-food-protection/fda-food-code 4-5 Maintenance and Operation4-501 Equipment4-501.11 Good Repair and Proper Adjustment.(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on observation, interview and record review, the facility failed to ensure the right to be free from Misappropriation of Resident Property for 6 of 18 residents (Resident #'s 1,2,3,4,5, and 6). 1.The facility failed to prevent the misappropriation of bottle of megace (Resident #1) and (Resident #4), card of Zofran (Resident #5) and (Resident #3), card of Pantoprazole (Resident #6), card of montelukast (no legible name), Nystatin, Xyzal (no legible name), card of Flexeril (no legible name), (CMA H) removed the medication from the nurses' cart, without authorization, for personal gain. 2. The facility failed to ensure that Resident #2 was not subject to financial misappropriation or exploitation from Housekeeper A from the time period 2/11/2025 to 2/17/2025. Housekeeper A accepted cash in the amount of $60 from Resident #2. The noncompliance was identified as PNC. The past noncompliance began on 2/11/25 and ended on 4/4/25. The facility had corrected the noncompliance before the investigation began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident funds and drug diversion. Findings Included: 1. Record review of Resident #1's Face Sheet dated 3-21-25 revealed a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of Alzheimer's (progressive disease that destroys memory and other important mental functions), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), type 2 diabetes mellitus with diabetic polyneuropathy (complication of diabetes mellitus (insulin resistance, with or without insulin deficiency that induces organ dysfunction) progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers) and essential hypertension (high blood pressure). Record review of Resident # 1's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 0 indicating Resident #1 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #1 was unable to voice any pain concerns. Record review of Resident #1's Care Plan dated 10-24-24 indicated Resident #1 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain: Location, Severity, on a scale of 1-10, type and frequency; discuss with resident factors that precipitate pain and what may reduce it; administer pain medications as ordered; discuss with resident the need to request pain medications before pain becomes severe; discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record Review orders dated 11/23/2024 indicated Resident #1 was prescribed Megace for weight loss. Record review of Resident #3's Face Sheet dated 3-21-25 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), cognitive communication deficit (the inability to think of the correct word), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), hypothyroidism (thyroid gland doesn't make enough thyroid hormone), GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure). Record review of Resident # 3's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 9 indicating Resident #3's cognition was moderately impaired. The pain assessment frequency indicated resident was occasionally in pain. Record review of Resident #3's Care Plan dated 10-24-24 indicated Resident #1 had potential for pain and was at risk for Injury from Decrease in ADLs. The care plan interventions included discuss with resident factors that precipitate pain and what may reduce it; Administer pain medications as ordered; Discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain; Monitor for potential side effects of pain medication and discuss with resident the need to request pain medications before pain becomes severe. Record Review orders dated 11/22/24 indicated Resident #3 was prescribed Zofran for nausea and vomiting. Record review of Resident #4's Face Sheet dated 3-21-25 revealed a 81-yer-old male who admitted to the facility on [DATE] with a primary diagnosis of hypotension (low blood pressure), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) and cognitive communication deficit (the inability to think of the correct word). Record review of Resident # 4's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 5 indicating Resident #1 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #4 did not have any pain concerns. Record review of Resident #4's Care Plan dated 3-12-25 indicated Resident #4 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain; Discuss with resident factors that precipitate pain and what may reduce it; Administer pain medications as ordered; Discuss with resident the need to request pain medications before pain becomes severe; Discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record Review orders dated 2/19/25 indicated Resident #4 was prescribed Megace for weight loss. Record Review orders dated 7/18/24 indicated was Resident #6 prescribed Pantoprazole for morning indigestion. Record review of Resident #5's Face Sheet dated 3-21-25 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to cognitive communication deficit (the inability to think of the correct word), GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining) and essential hypertension (high blood pressure). Record review of Resident # 5's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 5 indicating Resident #5 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #5 was did not indicate any pain concerns. Record review of Resident #5's Care Plan dated 6-21-24 indicated Resident #5 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain: Location, Severity, on a scale of 1-10, type and frequency; discuss with resident factors that precipitate pain and what may reduce it; administer pain medications as ordered; discuss with resident the need to request pain medications before pain becomes severe; discuss with physician that for maximum pain relief pain medication are best given. around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record Review orders dated 8/1/24 indicated Resident #5 was prescribed Zofran for nausea and vomiting. Record review of Resident #6's Face Sheet dated 3-21-25 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar and essential hypertension (high blood pressure). Record review of Resident # 6's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 0 indicating Resident #6 cognition was severe. The Pain Assessment Section of the MDS indicated Resident #6 was having pain frequently. Record review of Resident #6's Care Plan dated 9-9-24 indicated Resident #6 had potential for pain and was at risk for injury from decrease in ADLs. The care plan interventions included, assess characteristics of pain; discuss with resident factors that precipitate pain and what may reduce it; administer pain medications as ordered; discuss with resident the need to request pain medications before pain becomes severe; discuss with physician that for maximum pain relief pain medication are best given around the clock, with prns for breakthrough pain and monitor for potential side effects of pain medication. Record review of facility's in-service training dated 3/28/25 revealed 35 employees (12 LVN's, 20 CNA's, 8 RN's, 4 CMA's, 1 Administrator) were trained by the abuse coordinator on drug storage: all discontinued medication or medications to be destroyed. Record Review of intake investigation worksheet dated 3/28/25 at 10:00 a.m., Narrative of The Incident: Received phone call from investigator for confidential District Attorney's office. He said he was at CMA H's house and wanted to know if we were missing any meds because he had multiple drugs they had found there while searching the home. He named off multiple prescription drugs that were found. He named off the identified names that were former residents here with what drug their name was on. (He also had names that were not residents here). Actions and Notifications: CMA H's was suspended pending investigation. Dr was notified. Police Officer said he would get a police report number for us. All residents listed were deceased and no meds were narcotics that are counted. Resident #1-megace; Resident#4-Megace; Resident #5-Zofran; Resident#6-pantoprazole; Resident #3-Zofran. -Ombudsman notified. Record Review of typed note located inside the Provider investigation packet dated 3/28/25 at unknown time indicated, on 3/28/25 the Administrator received a phone call from investigator with confidential District Attorneys' office. He told me that he was at CMA H's house and wanted to know If she worked for us. I told him that she did work for us as a medication aide, and he asked if we had any medications missing. I told him that I was not aware of any medications that were missing. He said that he had found numerous cards and bottles of medications and wondered if she was getting them here. He told me that he had the following: 1. Bottle of megace with Resident #1's name, 2. Bottle of megace with Resident #4's name, 3. Card of Zofran with Resident #5's name, 4.Card of Zofran with Resident #3's name, 5. Card of Pantoprazole with Resident #6's name, 6. Card of montelukast with no legible name, 7. Nystatin with no legible name, 8. Xyzal with no name, 9. Card of Flexeril with no legible name, 10. Multiple OTCs, 11. One med with patient name someone else outside of the facility, 12. One med with patient name someone else's name. The Administrator wrote, I informed him that Resident #1, Resident #4, Resident #5, Resident #3 and Resident #6 were all previous patients here and all had passed away here. I told him that the medications would not be meds that we would count shift to shift as they were not narcotics, but that I could not recall any of these meds being an issue with not having with these patients and that I suspected that the meds were probably taken after they passed away. CMA H was arrested on 3/28/25 and therefore, suspended, pending outcome of this investigation. Medical Director was notified by DON. The pharmacist was notified by the DON. Results of the investigation indicated CMA H's was terminated for theft of medications. Ombudsman was notified by myself; Human Resources was notified of the allegation and previous disciplinary actions for attendance. The med carts were checked to ensure all current residents had their medications and there were no concerns found with meds being missing. A Narcotic count was done to ensure that all narcotic counts were correct and there were no concerns found. A list of current residents on the above meds was made and reviewed for any indications that they are not receiving their meds as ordered. There were no concerns noted by the DON. An in-service was conducted on clear bag policy and not having any personal bags in the med room. An additional in service was conducted on process to follow when drugs are discontinued or a resident pass away. Further investigation will be completed by DON in my absence. On 4/4/25 the investigation was completed, and CMA H was terminated. Record Review of the police incident report dated 3/28/25 at 11:11 am indicated, CMA H was facing multiple charges including 1. Possession of Controlled Substance, 2. Possession of Controlled Substance, 3. Forgery Financial Instrument, 4. Possession of Dangerous Drug and 5. Possession of Marijuana Record Review of in-services was reviewed on 5/20/25 at 10:22 a.m.; Ex Employee CMA H's was last in-service on abuse and neglect on 9/20/24. Record Review of the grievance log was reviewed on 5/20/25 at 10:35 a.m. and found no issues from December 2024 to May 2025. Record Review of the Drug and medication carts audits conducted by the Administrator and DON on 3/28/25 at 3:15 p.m., revealed all medications were accounted for. During an interview on 5/20/25 at 12:16 p.m., CMA B stated she had been employed since 2023. CMA B stated she had been in-service on misappropriation recently but did not know when her last in-service on misappropriation was last completed. CMA B stated it had not been too long ago since her last most recent in-service on misappropriation. CMA B stated she had never taken money from a resident. CMA B stated the abuse coordinator was the Administrator. CMA B stated if the medication was narcotics that she would let the DON take the medication off the cart. CMA B stated if the medication was not a narcotic then it's in a locked cabinet in the med room that the medication would be discarded in. CMA B stated the DON would discard the medication in the lock box. CMA B stated she had never logged or documented medication disposal. CMA B stated she was not sure if the DON documented medication disposal. CMA B stated the DON was responsible for removing and securing mediations that were no longer in use. CMA B stated the facility did not return medication to the pharmacy instead the medications would be disposed of at the facility. CMA B stated the designated area for disposing of medication would be the medication room. During an interview on 5/20/25 at 12:26 p.m., LVN C stated when a resident passed away or was discharged that medication was pulled from the cart. LVN C stated the nurses would pull the mediation from the carts. LVN C stated if the medication was a narcotic that she would get the DON who would be the one to remove the mediation off the carts. LVN C stated she would look at the count sheet, the nurses would make sure the count sheet was corrected and the DON would take the medication along with the count sheet and locked her office in her closet that was triple locked. LVN C stated if she found medication that were not labeled or appeared to be expired that she would put the medication in a destruction box located in the medication room. LVN C stated the designated area for medication disposal was the medication room. During an interview on 5/20/25 at 12:44 p.m., CNA E stated she had been employed at the facility for 5 or 6 years. CNA E stated she did not quite remember when her last in-service on abuse and neglect, but it might had been last month. CNA E stated she had so many in-services each month. CNA E stated she did not handle drug destruction or administering medication. During an interview on 5/20/25 at 12:48 p.m., CNA F stated she had been employed at the facility for 2 years. CNA F stated she was in serviced on misappropriation this month (May 2025). CNA F stated the Administrator was the abuse coordinator. CNA F stated the process for handling the medication that was not a narcotic was first she would put the medication inside a lock box in the medication room and let the DON know the medication was discarded in the locked cabinet. CNA F stated if the medication was a narcotic medication that she would count down the medication and write the number of pills left on the count sheet and let the DON know and the DON would remove the narcotic from off the carts. CNA F stated she did not return anything to the pharmacy instead the DON would dispose of the mediation at the facility. CNA F stated if she found medication that was not labeled or expired that she would let the DON know and have the DON to take the medication off the cart. CNA F stated the designated area for drug destruction was the medication room. During an interview on 5/20/25 at 1:03 p.m., LVN G stated she had been employed at the facility for 8 years. LVN G stated in-services on misappropriation was completed recently about a month ago. LVN G stated the abuse coordinator was the Administrator. LVN G stated she normal did not handle drug destruction. LVN G stated if a mediation had not been opened and needed to be returned to the pharmacy, then the pharmacy may pick up the medication. LVN G stated if the medication had been opened and was no longer needed by the resident that the medication would be destroyed by the DON. LVN G stated the DON destroyed medication at the facility. LVN G stated if she found mediation that were not labeled or expired that she gave medications to the DON. LVN G stated the medication room was the dedicated room for mediation disposal. LVN G stated the DON would be responsible for securing medication especially if it was a narcotic medication. During an observation and interview in the medication room on 5/21/25 at 11:30 a.m., with RN K the following were observed: Narcotics were locked in lock box located in the refrigerator; there was no observation of personal bags; there was a locked cabinet with a small hole at the top for placing non-narcotic medications inside for destruction. During an interview with RN K, RN K stated all expired or discontinued medication were to be given to the DON. RN K stated the med aide were to let the DON know that they had expired/discontinued medication and place the expired or discontinued medication inside the locked cabinet to be discarded by the DON. RN K stated the DON was the only person with the keys to the lock box for the narcotics. RN K stated there had never been a time when non-narcotic medication was placed on the countertop and not inside the locked cabinet. RN K stated in-services was last completed a few months ago on drug diversion. RN K stated the DON, and the charge nurses were the only one with the keys to non-narcotic locked cabinet locked in the medication room. During an interview on 5/21/25 at 12:00 p.m., the DON stated if the medication was not a narcotic then medication would go inside the lock cabinet under the counter. The DON stated once the medication was there then she would send the medication back for a possible refund and or to destroy the medication. The DON stated if the medication was a narcotic then she would get the medication off the cart. The DON stated when she received the medication, she verified the medication on the count sheet and lock up the medication in her file closet located in her room. The DON stated her file closet was triple locked. The DON stated herself and the charge nurses were responsible for removing and securing medications that are no longer in use. The DON stated she secured the drugs for resident that passed away or have been sent to the hospital by taking the medication out of the cart and putting the medication in the lock cabinet in the medication room. The DON stated she monitored the non-narcotic drug by conducting cart audit weekly. The DON stated during morning meeting if someone had passed away or was discharge, that she would go to the carts and pull the medications off the cart. The DON stated this process was the same for discontinued medications as well. The DON stated she kept a logbook for pharmacy for medication that were able to be returned to the pharmacy. The DON stated if there was medication that was not labeled or expired then the medication would go into the disposal lockbox. The DON stated she had not ever witnessed staff bringing bags into the medication room. The DON stated prior to this incident staff had been putting expired drugs on to the countertop and not inside the locked cabinet. The DON stated the process now was any drug that was not narcotic were to go inside the locked cabinet. The DON stated her and the ADON would follow up to make sure the medication was removed from the cart and placed in the locked cabinet. The DON stated the med aide, ADON, nurses and herself had a key to the medication room. The DON stated she had no clue regarding the medication found in CMA H's home was missing from the facility. The DON stated she check the medication room in the morning before the meeting and after the meeting she checked the carts to make sure everything was off and once a week she conducted audits. The DON stated it was important to ensure the medication was properly disposed of because the medication belonged to that resident, and it was important for safety. During an interview on 5/21/25 at 12:24 p.m., The Administrator stated the process for handling narcotics was that the narcotics stayed on the cart until the medication could be passed directly to the DON. The Administrator stated the process for handling non narcotics was the non-narcotics were to be placed in the locked cabinet for the DON to destroy. The Administrator stated the DON was responsible for removing and securing medications that were no longer in use. The Administrator stated she monitored the drugs at the facility by monitoring the drug destruction logs every month. The Administrator stated the facility was in the process of putting a camera inside the medication room. The Administrator stated in the past staff were not putting the expired or discontinued medication in the locked cabinet. The Administrator stated since the in-services on misappropriation that staff have gotten better with properly discarding the medications and no medications were found to be left on top of the countertop. The Administrator stated the drugs found in CMA H home were drugs that was on CMA H medication cart. The Administrator stated that she believed CMA H removed the medications from her medication cart and took the medications that she wanted and then put the medications that she did not want in the locked cabinet in the medication room. The Administrator stated the nursing staff had the keys to the medication room. The Administrator stated the DON had the keys to the locked cabinet in the medication room. The Administrator stated she conducted random checks on the medication carts. The Administrator stated she checked the narcotic medication quite a bit. The Administrator stated during her checks she made sure the residents were getting their medication and the medications were still at the facility. The Administrator stated to prevent this from happening again she conducted in services on drug destruction process, the facility will install a camera in the medication room, and she checked the medication room daily. The Administrator stated it was important for the medication to be disposed of properly so that no one who did not need them got ahold of the medications that they were not prescribed. The Administrator stated if staff found medication that was not labeled or was expired that the non-narcotic medication was to be discarded in the locked cabinet. The Administrator stated if the medication was a narcotic, it was to stay on the cart and was counted shift to shift until the medication could be personally handed off the DON. During an attempted phone call on 5/22/25 at 7:53 a.m., CMA H was unavailable for an interview; voicemail left for a return phone call. During a return phone call interview on 5/22/25 at 9:49 a.m., CMA H stated she was to dispose of medication that was expired or no longer in use in the locked cabinet in the medication room. CMA H stated if she did not have any money for her blood pressure medication and the resident was expired then she took the medication home that was to be discarded and take it home for herself. CMA H stated she was not allowed to take narcotics from the facility. CMA H stated the facility was not going to do anything but throw the medication away. CMA H stated every medication that was taken and found in her home was not a narcotic medication. CMA H stated she was in-service on misappropriation at another facility. CMA H stated the medication she took from the facility was just set on the countertop and she took the mediation off the top of the countertop and place in her personal bag. CMA H stated the medication was never in the lockbox. CMA H stated she had a personal clear bag in the medication room. CMA H stated multiple staff were bringing in personal bags and lunch bags inside the medication room. CMA H stated every employee took bags in the medication room. CMA H stated she had nothing else to add to this intake. 2. Record review of Resident #2's face sheet dated 05/20/2025 revealed the resident was a [AGE] year-old female admitted on [DATE]. The resident's diagnoses included: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), cognitive communication deficit (the inability to think of the correct word), dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining).) and essential hypertension (high blood pressure). Record review of Resident #2s admission MDS dated [DATE] revealed a BIMS score of 11, indicating the resident was moderately cognitively impaired. Record review of Resident #2's comprehensive care plan, accessed on 11/07/2024, revealed the Resident has impaired cognitive function or impaired thought processes; Res has cognitive loss (loss of memory, time sense and requires assistance with decision making) Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression Dementia. Interventions included Administer medications as ordered. Monitor/document for side effects and effectiveness; Cue, reorient and supervise as needed; Discuss concerns about confusion, disease process, NH placement with resident/family/caregivers) and Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Record Review of intake investigation worksheet dated 2/11/25 at 3: 45 p.m., indicated, Narrative of The Incident: Met with, RP of Resident #2, who said that Resident #2 said she had given a staff member some money to get her a vape to keep in her room but did not get the vape. I followed up & met with Resident #2 who said that she had given Housekeeper A in housekeeping some money to get her a vape and some other things, but that Housekeeper A is no longer here because of car trouble and I just chalk that one up to being stupid for giving her money. She could not recall how much money; however, the of Resident#2 report she told her $60; Actions and Notifications: Housekeeper A no longer works here. Self-terminated 1/14/25. Family and MD have been notified. $60 replaced. Pending report to confidential Police Department (waiting for them to come out and take report). Ombudsman notified. Record Review of the Provider investigation Report dated 2/11/25 at 4:36 p.m., indicated, of resident #2, met with admin on 2/11/25 and said that Resident #2 told her (Administrator) that she (Resident #2) gave some money to a staff member who is no longer here to get her some items but that she no longer works here and never got the items. Resident #2 said that she thought it was $60 but could not recall exactly or when it happened. Met with Resident #2 who told me (Administrator) that she had given money to Housekeeping A in housekeeping but said that something was wrong with her car and changed Jobs and has not been back. She (Resident #2) could not recall how much money she had given her (Housekeeper A). I (Administrator) told her that I (Administrator) was going to replace the money and she (Resident #2) said that she did not need it replaced but instead chalked it up as not trusting anyone to give money to for things. I (Administrator) told her that she (Resident #2) could give money to myself or to the activity director, but that I (Administrator) really preferred she not give it to anyone else to get items. She (Resident #2) agreed. Had her (Resident #2) sign that she (Resident #2) received $60, and it was given to her to keep. Life Satisfaction rounds were conducted with no further issues noted. Housekeeper A self-terminated on 1/14/25. She (Housekeeper A) had started work on 11/21/24. Have been unsuccessful in attempts to reach Housekeeper A for her statement. Record Review of written note by the Administrator dated from the Provider investigation report dated on 4/15/25 at unknown time indicated the Administrator received call from Housekeeper A, Saying that the police contacted Housekeeper A and she could be spending 2 years in jail. Housekeeper A said that she took the money-which she said was $40 and bought Resident #2 socks and laundry detergent and that she did bring them to her. Housekeeper A asked if she could bring $60 to us and it be taken care of that way. I told her that was between her and the police. Housekeeper A said she would contact them and then if okay, she would have her r bring us the money because she was now out of state. Record Review of in-services was reviewed on 5/20/25 at 10:22 a.m.; Ex Employee Housekeeping A was last in-service on abuse and neglect on 11/21/24. Record Review of the abuse and neglect policy was reviewed on 5/20/25 at 10:30 a.m. Record Review of the grievance log was reviewed on 5/20/25 at 10:35 a.m. and found no issues from December 2024 to May 2025. Record Review of personnel file for Ex-employee Housekeeper A reviewed on 5/20/25 at 10:44 a.m., revealed Housekeeper A self-terminated on 1/14/25. Record Review of the police Report dated, 2/14/25 at 2:00 p.m., the police report indicated on February 14, 2025, the Administrator came to the Police Department to make a report of a theft. This theft occurred the Nursing Facility, The Administrator informed the offer that Housekeeping A, a former employee at the nursing home received $60 from Resident #2, a resident. Housekeeping A was asked to pick up certain items for Resident #2 with the money she was given. Housekeeping A then left the employ of the nursing home and neither returned the money given nor brought Resident #2 the items requested. During an attempted phone interview with Resident #2 RP on 5/20/25 at 10:53 a.m., of resident #2 RP was unavailable to be reached by phone; voice message left for a return phone call. During an interview on 5/20/25 at 11:00 am Resident #2 stated she did not remember the employee's name who worked here, but [TRUNCATED]

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, and in that: 1) The facility failed to date all food items. 2) Dietary staff failed to dispose of expired foods items 3)The facility failed to ensure proper infection control measures when a resident self-served ice from the ice chest cooler located on Hall 2 on [DATE], [DATE] and [DATE]. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observation in the kitchen Refrigerator 1 of 3 on [DATE] at 9:56 a.m., the following was observed: -(1) gallon of 2 percent milk unopened expired on [DATE]. During observation in the kitchen Refrigerator 2 of 3 on [DATE] at 10:03 a.m., the following was observed: -(1) serving of hot sauce prep date of [DATE]. (expired) During observation in the kitchen on [DATE] at 10:17 a.m., the following were observed: -(1) 6-ounce container of pumpkin spice seasoning received on [DATE] had a use by date of [DATE]. -(1) 6-ounce container of ground ginger had an open date of [DATE] and a use by date of [DATE] -(1) container of frosted flakes had a prep date of [DATE] and no use by date. -(1) container of Raisin Bran Cereal had a prep date of [DATE] and no use by date. -(1) container of cheerios cereal had a prep date of [DATE] and no use by date. -(1) container of fruit loop cereal had a prep date of [DATE] and no use by date. During an interview and observation of the kitchen on [DATE] at 10:03 a.m., the Dietary Manager stated the hot sauce was good for a few months once prepped and the hot sauce should have been discarded from the refrigerator. The Dietary Manager stated the cereal should have had a use by date on the label. During an interview on [DATE] at 1:30 p.m., the dietary manager stated he had been the Dietary Manager for a year. The Dietary Manager stated the Administrator oversaw him. The Dietary Manager stated, Yes all food items in the kitchen were to be labeled, dated with receive date, open date and expiration date. The Dietary Manager stated the last in-service on expired foods was last completed a month ago. The Dietary Manager stated he conducted a walk thru in the kitchen daily. The Dietary Manager stated he was aware of the hot sauce and missing use by dates on the cereal. The Dietary Manager stated he was not aware of the expired milk found in the refrigerator. The Dietary Manager stated once food was prepared that the food item was good for a week or two. The Dietary Manager stated it was important to ensure staff were discarding expired foods so that the residents did not get sick. During an interview on [DATE] at 1:39 p.m., the Administrator stated she had been employed at the facility for [AGE] years. The Administrator stated she oversaw the Dietary Manager. The Administrator stated all food items in the kitchen were to be labeled, dated with receive date, open date, and expiration date. The Administrator stated she did not know when the last in-service on discarding expired food items was last completed. The Administrator stated walk throughs were conducted by her weekly in the kitchen. The Administrator stated she was not aware of the surveyor's findings in the kitchen prior to Survey. The Administrator stated it was important to ensure the dietary staff were discarding expired refrigerated foods so that the expired foods were not a hazard to the residents. Record Review of the Food Safety: Food storage policy revised on [DATE] indicated, all food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness; (6) Food removed from its original packaging will be labeled with the following: a. Receive Date, b. Open Date c. Contents in the Package; (9) Opened package or leftover food is to be tightly wrapped or covered in airtight, clean. containers. It should be labeled, dated with the opened or use by date. Do not keep leftovers in the refrigerator for more than 7 days. Record Review of FDA Food code dated 2022 indicated, ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. 3. During an observation on [DATE] at 10:32 AM, a resident was self-serving ice into two personal cups from the ice chest cooler located on Hall 2. During an observation on [DATE] at 10:45 AM, a resident was self-serving ice into two personal cups from the ice chest cooler located on Hall 2. During an observation on [DATE] at 10:42 AM, a resident was self-servicing ice into two personal cups from the ice chest cooler located on Hall 2. During an interview on [DATE] at 4:32 PM, RN C said the residents are given ice by the staff from the ice chest coolers located on Hall 2 and Hall 5. RN C said she had noticed residents self - serving ice from the ice chest coolers but had never thought of it as being cross-contamination until the surveyor interview. RN C said, they would not know if the resident had washed their hands so that could cause some infection control issues. During an interview on [DATE] at 04:35 PM, the ADON said she was not aware of any residents self-serving ice from the ice chest coolers. The ADON said the staff provided the ice and water to the residents every shift. The ADON said it was an infection control issue and could cause cross contamination for the residents to self-serve ice. The ADON said she was the infection control preventionist and responsible for ensuring the facility is following procedures to prevent the spread of infections. During an interview on [DATE] at 4:45 PM, the DON said she was not aware of residents getting their own ice for the coolers in the hallways. The DON said residents should not be allowed to self-serve ice from the hallway coolers because of the risk of cross contamination. During an interview [DATE] at 05:50 PM, the Administrator said she expected infection control policies to be followed by all the staff and all staff was responsible to ensure cross contamination was not occurring in the facility. The Administrator said the staff were responsible to ensure fresh ice was served to the residents. The Administrator said to decrease the chance of cross contamination residents should not self-service ice from the hallway coolers. Record review of the facility's policy titled Infection Control dated [DATE], indicated, the facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection

Based on observation, interview, and record review the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 2 residents (Resident #13) reviewed for accident hazards. The facility failed to ensure the cigarettes for Resident #13 were properly secured in the designated locked box behind the nurse's station. The facility failed to ensure Resident #13 was smoking with supervision when she was found outside in the smoking area on 12/04/24 smoking alone. These failures could place residents at risk for injuries. Findings included: Record review of Resident #13's face sheet dated 12/4/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses hemiplegia following a cerebral infarction (a stroke that causes one sided weakness or paralysis), diabetes mellitus (disease in which the body has difficulty controlling the blood sugar), depression, high blood pressure, and lack of coordination. Record review of Resident #13's admission MDS assessment dated [DATE] indicated she was able to make herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact, and she was a current tobacco user. Record review of Resident #13's care plan dated 11/11/2024 indicated she was a smoker and she would have supervised smoking privileges to minimize safety risks with interventions for Resident #13 to keep all lighters/matches with facility staff for safety and she would participate in supervised smoke breaks. Record review of Resident #13's safe smoking assessment dated [DATE] indicated she should be supervised as per facility policy and all smoking equipment would be left at the nursing station in a box. During an observation on 12/4/24 at 09:18 AM Resident #13 was found by surveyor outside in the designated smoking area alone smoking with a lit cigarette in her hand. Resident #13 said the staff were supposed to keep the cigarettes and lighters in a box at the nurse's station. She refused to tell surveyor who gave her the cigarette she had in her hand, nor would she tell who lit the cigarette. She said usually the staff would stay out there in the smoking area with the residents when they would smoke but she guessed the staff did not stay because she was smoking at a different time. During an interview on 12/04/24 at 04:20 PM The DON said when she went outside with Resident #13, Resident #13 had her cigarettes in her pocket. She said the resident handed her the cigarettes and refused to tell her who gave her the cigarettes. The DON said all the staff were responsible for ensuring the resident did not have smoking items on them and did not smoke at undesignated time, or unsupervised. She said the failure placed Resident #13 at risk of burns, safety risks, or respiratory problems. The DON said she had her sign a sheet saying she did not abide by the policy since this was her first time violating the rules. During an interview on 12/04/24 at 05:08 PM The Administrator said Resident #13 went out on pass with friends and family and she could not be 100% sure that she wouldn't have cigarettes. She said her expectation was for all smoking items to be in a locked box at the nursing station and she expected all the residents to turn the cigarettes and lighters in to be placed in the lock box when they would get them from outside of the facility. The Administrator said the failure placed a risk of Resident #13 not following the smoking policy. Record review of the undated facility policy Smoking Policy indicated: It is the policy of this community to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. 1. Smoking by residents is allowed outside in a designated, marked smoking areas .6. Residents will not be allowed to possess any lighters, cigarettes or other smoking material. 7. IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke .

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 19 residents reviewed for medication storage. (Resident #14). The facility failed to ensure Resident #14's vagisil maximum strength cream (used for vaginal itching), preparation H hemorrhoidal ointment (used for relief of swelling, burning, or pain from hemorrhoids), Asper creme lidocaine roll on (used for pain), fluticasone 50mcg nasal spray (used for allergies), and 2 bottles of Systane eye drops were stored and locked in an area not accessible to unauthorized staff, residents, or visitors. These failures could place residents at risk of injury. Findings included: Record review of Resident #14's face sheet dated 12/04/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses high blood pressure, arthritis, seasonal allergies, and abnormal posture. Record review of Resident #14's admission MDS assessment dated [DATE] indicated she was able to make herself understood and able to understand others. The MDS also indicated she had a BIMS score of 14 which meant she was cognitively intact. Record review of Resident #14's care plan dated 09/26/24 indicated her discharge had been determined to not be feasible based on resident and family request and need for ADL assistance and assistance with medication administration. The care plan also indicated Resident had impaired visual functioning and was at risk for a decrease in ADLs and injuries and she wears glasses with interventions for the staff to administer Systane eye drops at night. Record review of Resident #14's electronic medical record did not indicate Resident #14 had a self-administration assessment. Record review of Resident #14's order summary report dated 12/04/24 indicated she had orders for: 1. Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol (Ophth)) Instill 1 drop in both eyes at bedtime for Burning &irritation with a start date of 08/31/2024. The order summary did not indicate Resident #14 had an order for vagisil maximum strength cream, preparation H hemorrhoidal ointment, fluticasone nasal spray, nor asper creme lidocaine pain roll on. During an observation on 12/02/24 at 11:50 AM Resident #14 was sitting in her room in her wheelchair and had a bottle of fluticasone 50mcg allergy relief nose spray on her bedside table. Resident #14 said her family member brought it to her today. During an observation on 12/02/24 at 03:42 PM Resident #14 had a caddy sitting in her bathroom that had a container of vagisil maximum strength cream, preparation H hemorrhoidal ointment, and an asper creme lidocaine roll on container. During an observation on 12/03/24 at 08:51 AM Resident #14 continued to have the Vagisil maximum strength cream, preparation H hemorrhoidal ointment, and an asper creme lidocaine roll on container in her caddy in her bathroom. During an observation and interview on 12/04/24 at 10:23 AM CNA D walked in Resident #14's bathroom with surveyor and the vagisil maximum strength cream, preparation H hemorrhoidal ointment, and an asper creme lidocaine roll on container continued to be in Resident #14's caddy in her bathroom. CNA D said Resident #14 should not have the medications in her room, but resident was independent with her ADLs most of the time, so the CNAs do not always come into her bathroom. CNA D removed the medications from Resident #14's bathroom. CNA D said the failure placed Resident #14 at risk of self-medicating as well as wandering residents getting a hold of the medication. CNA D also found the bottle of fluticasone 50mcg allergy relief nose spray and 2 bottles of systane eye drops in Resident #14's dresser drawer. CNA D said all staff were responsible for ensuring no resident had medications in their rooms. During an interview on 12/04/24 at 04:56 PM the DON said her expectation was for all residents' medications to be locked in the proper location. She said they had sent letters out to the families to inform them of things that should not be brought into the facility and left with the residents. The DON said during rounds the staff should have found the medications being left out in Resident #14's room and bathroom. The DON said the failure placed Resident #14 at risk of self-treating and not fixing the problems she had. She said the failure could have also caused harm or injury for Resident #14 or any wandering residents that could get into the medications. During an interview on 12/04/24 at 05:04 PM The Administrator said she had sent out letters to the families of residents in the facility about hazardous items not to be left with residents, including medications. The Administrator said her expectation was for the medication to be stored in medication carts and medication rooms. She said all staff were responsible for ensuring that the medications were not in the residents' rooms. The Administrator said the failure placed staff at risk of not knowing what Resident #14 was taking and they could have possibly medicated her with medications that she could have had adverse reactions with. Record review of the facility policy Storage of Medications revised on 08-2024 indicated: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. I. General guidelines .2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Residents #17). 1.CNA A and CNA B failed to use enhanced barrier precautions by donning a gown when performing foley care on Resident #17 on 12/03/2024. 2.CNA A and CNA B failed to change their gloves after performing foley care on Resident #17 and touched the resident and clean surfaces on 12/03/2024. These failures could place residents at risk of exposure to communicable diseases, cross-contamination and infections. Findings included: Record review of the face sheet, dated 12/04/2024, revealed Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), type 2 diabetes (a long term condition where the body had trouble controlling blood sugar and using it for energy), hyperlipidemia (a condition where there are high levels of fat particles in the blood), and obstructive and reflux uropathy (a condition where urine flow is blocked with the urinary tract causing urine to back flow upward into the kidneys). Record review of the comprehensive MDS assessment, dated 10/28/2024, revealed Resident #17 had clear speech and was sometimes understood by staff. The MDS revealed Resident #17 was usually able to understand others. The MDS revealed Resident #17 had a BIMS score of 0, which indicated severe cognitive impairment. The MDS revealed Resident #17 was dependent on staff assistance for toilet hygiene and transfers. The MDS revealed Resident #17 had a foley catheter. Record review of Resident #17's orders summary dated 10/10/2024 indicated cleanse foley catheter insertion site with Thera Worx (hygiene protective barrier) to prevent urinary tract infections and provide foley care every shift. Record review of the comprehensive care plan, revised on 12/02/2024, revealed Resident #17 was on enhanced barrier precautions for indwelling catheter with the intervention of staff will gown and glove during high contact resident care. Record review of Resident #17's comprehensive care plan, revised on 10/10/2024, revealed resident had indwelling catheter and at risk for increased urinary tract infections with the intervention of monitor for signs and symptoms of infection. There was a sign posted regarding use of enhanced barrier protection and personal protection equipment was located in Resident #17's room. During an observation on 12/03/2024 at 4:09 PM, CNA A and CNA B entered Resident #17's room and donned gloves after washing their hands. CNA A and CNA B did not wear a gown for enhanced barrier protection. CNA B performed foley care for Resident #17. CNA A assisted CNA B. CNA A placed the foley catheter bag and tubing on the bed next to Resident #17's leg. CNA A unclamped the tubing from the leg stabilization device and held the tubing while CNA B performed foley care and placed the foley catheter bag below the bladder. CNA A and CNA B did not change their gloves. CNA A and CNA B touched Resident #17's clean brief, blanket and bed side table with the same gloves. After covering Resident #17 and adjusting the bed side table, CNA A and CNA B took off their gloves and washed her hands. During an interview on 12/04/2024 at 01:38 PM, CNA A said she should have used enhanced barrier precautions because Resident #17 had a foley. CNA A said she forgot to grab a gown when providing foley care for Resident #17 to prevent cross contaminations. CNA A said it was important to take dirty gloves off before touching anything clean to prevent spreading germs. She said staff had to take off their dirty gloves, wash their hands and re-glove, if needed. She said it was an infection control issue to touch items or residents with dirty gloves. She said she was trained and educated on enhanced barrier precautions and to remove her dirty gloves before touching anything clean and washing her hands to prevent infection. During an interview on 12/04/2024 at 04:22 PM, CNA B said she should have changed her gloves after the foley care when her gloves were dirty and before touching the resident's brief, blanket and bed side table. She said she was trained to change her gloves and clean her hands after foley care, and she did not because she was nervous. She said what she did was an infection control issue and could spread infection. CNA B said she failed to use enhanced barrier precautions by not utilizing a gown during foley care. CNA B said she is a new CNA and worked at the facility a short time (hire date of 11/21/2024). CNA B said she was assigned to work with a seasoned nurse until orientation completed. CNA B said she was not familiar with the residents on hall 2 and was nervous and realized afterwards the procedure was not done correctly. CNA B said she was aware and had been educated on all residents with foley care required enhanced barrier precautions to prevent the spread of germs and infections. During an interview on 12/04/2024 at 04:35 PM, the ADON said she was the Infection Preventionist. The ADON said it was her job to train, educate and complete skills check evaluations on the CNAs for foley care and enhanced barrier precautions to prevent the spread of infections in the facility. The ADON said it is her responsibility to monitor the staff through random checks, observations, and education to ensure infection control practices are being followed by staff. The ADON said she had started the position about 2 months ago and she had not completed any skill evaluations yet for any staff. The ADON said she was learning her position and would resume the evaluations in January 2025. The ADON said touching clean surfaces with dirty gloves could cause cross contamination of the clean area especially if someone else touched the dirty area with clean gloves or hands. She said the danger to the resident was infection, weight loss and an infection could require the resident to be on antibiotics. The ADON said enhanced barrier precautions should be used for all residents with a foley. The ADON said there were signs in the Resident's rooms to alert staff and the necessary supplies required for enhanced barrier protection such as gowns. During an interview on 12/04/2024 at 4:45 PM, the DON said she expected the staff to follow the procedures for foley care which included enhanced barrier precautions which required wearing the gown during foley care. The DON said infection control was vital for all staff to adhere to and prevent cross contamination. The DON said staff should never touch the residents or resident's items such as linens or reposition the residents with dirty gloves. She said to do that was cross-contamination which could spread infection or cause infection. She said she expected staff to go by their training and change their gloves after a dirty procedure and perform hand hygiene. She said dirty gloves should be changed and hand hygiene performed before going to a clean area. The DON stated she had performed skill evaluations for the staff while the ADON was training. The DON said CNA B was hired approximately three weeks ago and had not completed skills evaluation at this time. During an interview 12/04/2024 at 05:50 PM, the Administrator said she expected staff to follow best practices learned when obtaining their licensure. The Administrator said enhanced barrier precautions were important to protect the residents as well as the staff from infections and should be utilized with residents that had a foley. She said if a staff had dirty gloves on and touched a clean area it was cross-contamination and could possibly cause infection. The Administrator said she felt that CNA A and CNA B were nervous when the surveyor observed the care provided. Record review of a skills check off entitled CNA Skills Fair 2024 - Incontinent Care - Peri/Incontinent Care with Catheter - Male, dated 10/25/2024, indicated CNA A was competent in foley care. Record review of a skills check off entitled CNA Skills Fair 2024 indicated CNA B had not completed the skills check for foley care. Record review of the facility policy titled Enhanced Barrier Precautions, dated 04/01/2024, indicated: Enhanced Barrier Precautions are a CDC guidance to reduce the transmission of multi-drug resistant organisms in health care setting, including nursing homes .requires team members to wear a gown and gloves while performing high contact care who have open wounds or indwelling catheters. Record review of the facility's policy titled Catheters-Insertion and Care, dated 04/2021, indicated: It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications 3. wash hand, put on gloves 17. remove gloves and wash hands. 18. Leave resident in a comfortable position with call light within reach.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 19 residents (Resident #14) reviewed for physical environment. The facility failed to ensure Resident #14's bathroom toilet was functioning properly. The facility failed to ensure Resident #14's bathroom toilet was not briskly running or leaking water for her to use safely. This failure could place residents at-risk of falls and further injuries due to an unsafe environment. The findings were: Record review of Resident #14's face sheet dated 12/04/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses high blood pressure, arthritis, seasonal allergies, and abnormal posture. Record review of Resident #14's admission MDS assessment dated [DATE] indicated she was able to make herself understood and able to understand others. The MDS also indicated she had a BIMS score of 14 which meant she was cognitively intact. The MDS also indicated Resident #14 was always continent of bowel and bladder. Record review of Resident #14's care plan dated 09/26/24 indicated her discharge had been determined to not be feasible based on resident and family request and need for ADL assistance and assistance with medication administration. The care plan also indicated Resident had impaired visual functioning and was at risk for a decrease in ADLs and injuries and she wears glasses. Record review of the facility maintenance request book on 12/02/24 at 03:58 PM indicated there were no maintenance requests noted in the book for Resident #14 for September 2024, October 2024, nor November 2024. During an observation and interview on 12/02/24 at 03:42 PM Resident #14 was sitting in her room and she said she forgot to tell the surveyor about her toilet running and leaking since she admitted to the facility on [DATE]. Resident #14 said her toilet had been having problems since she admitted on [DATE] and she had told staff. The toilet in her room was briskly running water but there was no observation of water on the floor. During an interview on 12/02/24 at 04:03 PM the Maintenance Director said he was aware of the problem with Resident #14's toilet about 3 weeks prior to 12/02/24. The Maintenance Director said he did not have the problem in his maintenance book because he found the problem with Resident #14's toilet running water while he was making rounds to check water temperatures. The Maintenance Director said Resident #14's toilet flapper was not functioning, and he fixed it by replacing it at that time. The Maintenance Director said he would have normally documented in his book, but he did not on that occasion. He said he was not aware the toilet was not operating properly. During an observation on 12/04/24 at 10:35 AM Resident #14's toilet water was leaking on the floor from her toilet to her room. She had left the room, but someone had attempted to use paper towels to try to dry the water up and left paper towels on the floor in the leaking water. During an interview on 12/04/24 at 10:39 AM Community Cleanliness Provider E said he had never noticed the toilet leaking or running but he was not always scheduled to work on Resident #14's hallway. During an observation and interview on 12/04/24 at 10:44 AM Maintenance Director said he came back down to the room on the afternoon of 12/2/24 and checked Resident #14's toilet after he rebuilt (he removed the toilet and put it back together) the toilet and there were no problems with it running or leaking. He said he was responsible for ensuring the toilets in the facility were functioning properly, but he did not know it was leaking. The Maintenance Director said the leaking toilet placed Resident #14 at risk for slipping and falling. During an interview on 12/04/24 at 04:53 PM the DON said her expectation was for the toilet in Resident #14's room to be functional and not leaking. She said the Maintenance Director was responsible for ensuring that the toilet was fixed but all staff were responsible for ensuring all residents' toilets were functioning and reporting in the maintenance book when the toilets were not functioning. The DON said the failure placed Resident #14 at risk for falls. During an interview on 12/04/24 at 05:02 PM the Administrator said her expectation was for the residents' toilets functioning and running properly but she felt the leaking toilet was a different problem that was newly found. The Administrator said the Maintenance Director was responsible for all the maintenance and toilets in the facility. She said the failure placed Resident #14 at risk of injury. Record review of the facility policy Quality of Life-Homelike Environment revised May 2017 indicated: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment .

Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 3 (Resident # 1) residents reviewed for misappropriation of resident property. The facility failed to prevent a drug diversion (misappropriation) of Resident #1's-controlled medications on [DATE], Hydrocodone-Acetaminophen 7XXX,d+[DATE]MG (narcotic pain reliever), Hydrocodone-Acetaminophen,d+[DATE]MG, and Lorazepam (controlled anti-anxiety medication) 0.5 MG, after she expired on [DATE]. The medications were not found. The non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE] diagnoses of dysphagia (difficulty swallowing), myalgia (muscle pain), muscle wasting, lack of coordination, major depressive order (persistent feeling of sadness or loss of interest that can lead to an arrange of behavioral and physical symptoms), anxiety (mental disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), hypertension (high blood pressure), arthropathy (on going swelling and pain of joints). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and had the ability to understand others. The MDS indicated Resident #1 had a BIMS score of 09 which indicated a moderate cognitive impairment. The MDS indicated Resident #1 required maximal assistance with toilet use, bathing, bed mobility, transfer, and dressing, and extensive assistance for personal hygiene. The MDS indicated Resident #1 received setup/supervision assistance for eating. The MDS indicated Resident #1 received scheduled pain medication regimen and received 7 days of opioid (powerful pain-reducing medications) during the assessment period. The MDS assessment indicated Resident #1 received anti-anxiety medication. Record review of Resident #1's care plan dated [DATE] indicated Resident #1 was at risk for alteration of discomfort of musculoskeletal status limited range of motion (happens when swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age). Resident #1's care plan indicated she was at risk for anxiety (mental disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) related to cognitive deficit with the intervention to administer Lorazepam (medication used to relieve anxiety) as ordered. Record review of Resident #1's consolidated physician orders active as of [DATE] indicated the following orders: *Hydrocodone-Acetaminophen 7XXX,d+[DATE] MG give one tablet by mouth every 4 hours as needed for pain with an order start date of [DATE]. *Hydrocodone-Acetaminophen ,d+[DATE] MG give one tablet by mouth every 4 hours for pain with an order start date of [DATE]. *Lorazepam Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety, with a start date of [DATE]. Record review of Resident #1's MAR dated [DATE] - [DATE], indicated between this time Resident #1 received a total of: o 28 tablets of Hydrocodone-Acetaminophen 7.5mg-325mg, o 39 tablets of Hydrocodone-Acetaminophen ,d+[DATE]mg, o 20 tablets of Lorazepam 0.5mg. Record review of the Provider Investigation Report dated [DATE] indicated .incident date unknown. telephone call reporting drug diversion .alleged perpetrator .RN A stealing narcotics from the facility .denied .reporter stated received information from a reliable source .suspension of RN A pending investigation .reviewed all residents that RN A had given narcotic pain medications to from [DATE] to [DATE] .interviewed for any change in pain of residents and unexplained change in pain noted .during investigation the DON noted Resident #1's medications missing after compared to pharmacy manifest .reported to police interviews on all staff who had access to the medication carts associated with Resident 1's missing medications no one admitted to taking drugs or knew what happened to the missing medication .interview with RN A .offered drug screen positive for opiates .no confirmed perpetrator .RN A remained suspended until drug screen confirmed . investigation findings. Record review of staff schedules dated [DATE] - [DATE] indicated RN A had access to the two medication carts with Resident #1's routine and as needed Lorazepam and hydrocodone-acetaminophens. Record review of a progress note dated [DATE] at 12:36 AM indicated LVN D attempted to give Resident #1 pain medication (Resident was not swallowing, refused to open mouth and take medicine. Medication wasted with second nurse. Record review of the facility's pharmacy manifest (tracks the waste to final disposal) dated [DATE] indicated Resident #1 received: o 115 pills of Hydrocodone-Acetaminophen ,d+[DATE] MG- dispensed on [DATE], o 90 pills of Hydrocodone-Acetaminophen 7XXX,d+[DATE] MG- dispensed on [DATE], o 60 Lorazepam Tablet 0.5 MG dispensed on [DATE]. Record review of the local police department report dated [DATE] at 12:38 PM, indicated .RN A took a drug test and awaiting results, test showed positive for opiates but sent off for specifics. Resident #1 passed on (died ) [DATE] and Hydrocodone 10's, Hydrocodone 7.5's and Lorazepam came up missing. RN A was suspended on [DATE] . During an interview on [DATE] at 4:00 PM, the informant from the local police department, stated he could not reveal his reliable source of information regarding RN A stealing narcotics from the nursing facility. The informant from the local police department said he felt obligated to let the facility know this information because he would not want any resident to be in pain and go without medication. During an attempted phone interview on [DATE] at 4:30 PM, RN A did not answer the phone. During an attempted phone interview on [DATE] at 9:14 AM, RN A did not answer the phone. During an interview on [DATE] at 9:15 AM, LVN C said she had worked the night shift on [DATE], and she recalled the Hydrocodone ,d+[DATE] mg being on the cart. LVN C said she did not notice when the medication was no longer on the cart. LVN C said she had no discrepancies with the narcotic counts at the beginning or the end of her shifts. LVN C said routine procedure was to leave any discontinued medications on the medication cart and continue to count the medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and Controlled Drug Administration Record were taken to the DON and verified by the DON and the nurse or MA. The nurses arrived for their shift at 6 am and 10 pm but the MA's shift started at 8 am. LVN C said she had not had any issues with her narcotic counts matching. LVN C said the facility started counting and recording all the cards in the narcotic box at the beginning and end of the shift during the summer. During an attempted phone interview on [DATE] at 12.32 PM, RN A did not answer the phone. A voice message was left to return call and phone number given. During an attempted phone interview on [DATE] at 2:15 PM, RN A did not answer the phone. A voice message was left to return call and phone number given. During an interview on [DATE] at 3:32 PM, RN F said she had worked approximately 6 months at the facility as the 2 PM to 10 PM charge nurse. RN F said she had been educated on the abuse policy on several occasions. RN F denied any abuse within the facility. RN F said the routine procedure was to leave discontinued medications on the medication cart and continue to count the controlled medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and narcotic sign out sheets were taken to the DON and verified by the DON and nurse or MA. RN F said when she arrived for her shift, she ensured the narcotic count was correct by counting and recording all the cards in the narcotic box at the beginning and end of the shift and had been doing this for a few months now. RN F stated the oncoming nurse counts the medications while the off going shift nurse or MA verified totals on the Controlled Drug Administration Record. RN F said the nurse arrived at 6 am and 10 pm but the MAs arrived at 8 am. RN F said she had not had any issues with her narcotic counts matching. During an interview on [DATE] at 12:39 PM, MA B said she had been working at the facility for 1 and a half years and worked all the halls at some point and took over the routine medication cart. She said when she received the medication cart, the Controlled Drug Administration Record was correct, and she had not experienced any discrepancies. She said she could not recall when she last saw the medications for Resident #1 on the medication cart. MA B said over the last few months a new procedure was implemented and the facility started counting and recording the total amount of medication cards in stock in the narcotic locked box. MA B said she would leave any discontinued medications on the cart and continue to count the medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and the Controlled Drug Administration Record were taken to the DON and verified by the DON and the nurse or MA. She said the keys and medication cart passed through a lot of hands because the nurse arrived at 6 am and 10 pm but the MAs arrived at 8 am. She said the morning LVN passed off to the morning MA then the morning MA passed off to the night LVN, then the night LVN passed off to the morning LVN. MA B said she had not had any issues when she worked with her narcotic counts matching. She said when she arrived for her shift, the narcotic count was correct. During an interview on [DATE] at 1:48 PM, the ADON said she was assigned to halls 4,5, and 6 as the charge nurse on [DATE] for the 6AM to 2PM shift. The ADON said she did not experience any drug discrepancies during this time but could not recall if Resident #1's medications were still on the cart that morning or not during the narcotic count down. The ADON said now the facility counted the total amount of cards in the locked narcotic box prior to doing the narcotic count down where the oncoming nurse counts the medications back to the going off shift nurse. The ADON said the routine procedure was to leave any discontinued medications on the cart and continue to count the medications against the Controlled Drug Administration Record when the DON was not in the building. Once the DON was in the building, the medications and narcotic sign out sheets were taken to the DON and verified by the DON and the nurse or MA. The ADON said she had been educated on abuse, neglect and misappropriation on several occasions at the facility. During an interview on [DATE] at 2:33 PM, the DON said she had been employed by the facility for approximately 2 years. During the investigation regarding the allegation of misappropriation with RN A, the DON said she reconciliated the pharmacy manifest to the Controlled Drug Administration Record and found the discrepancy between Resident #1's medications because there was no Controlled Drug Administration Record to match the received medications. The DON said the facility implemented adding and subtracting the amount of blister packs of medications added or removed from the narcotic locked boxes. The DON said the pharmacy reconciliation was done monthly now also. The DON said she was too new and was not aware to reconcile the narcotic sheets against the pharmacy manifest until the incident. The DON said the staff had been educated on abuse-misappropriation and reporting, the new implemented narcotic count down per shift counting the card and adding or subtracting. Staff surveys were completed regarding concerns of any residents not getting pain medications, and legal obligation to report those concerns. The DON said resident surveys were completed regarding pain/comfort levels. The DON and Administrator performed chart audits on residents receiving opioids given by RN A and the pain assessment notes were reviewed. The DON said it was important to ensure there was not misappropriation of medications, so the residents received medications appropriately and did not experience pain and or discomfort. During an interview on [DATE] at 2:45 PM, the Administrator said the facility could not find the missing medications, so the facility did have a drug diversion. She said if the drug was not available in the facility's emergency medication kit, then there was a potential for the resident to miss a dose and experience pain. The Administrator said the staff had been educated on abuse-misappropriation and reporting, they had now implemented narcotic count down per shift (counting the card and adding or subtracting) staff surveys were completed regarding concerns of any residents not getting pain medication, and legal obligation to report those concerns. The Administrator said resident surveys were completed regarding pain/comfort levels. The DON and Administrator performed chart audits on residents receiving opioids given by RN A and the pain assessment notes were reviewed. The Administrator said the medications belonged to the residents. The administrator said RN A had denied the allegations of taking narcotics from the facility. The DON said RN A volunteered to take a drug test when confronted with the allegations by the Administrator. The Administrator said the initial drug screen was positive for opioids. The Administrator said RN A stated, I eat lots of poppy seeds and take tons of Benadryl which would cause the positive drug screen result. The DON stated RN A remained suspended from [DATE] - [DATE] while the facility awaited the results of the sent-out drug screen. On [DATE], RN A was allowed to return to work when the final drug screen results were returned negative. Record review of a facility's Abuse, dated [DATE] indicated . the purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, .misappropriation of resident property . The facility had corrected the noncompliance on [DATE] by the following: Suspension of RN A who the allegations involved for misappropriation. All staff educated by in-service on abuse and neglect/misappropriation and legal obligation of reporting of any suspicions per facility policy. Life Surveys completed on staff: (RN G, RN H, CNA K, CNA L). All staff educated by in-service on abuse, neglect, misappropriation and examples and legal obligation to report and suspicion of activity. Self-Report completed to Health and Human Services and the local police department. Audits completed on narcotic locked boxes on all medication carts (inspected cards and verified counts). Residents prescribed with opioids reviewed for unexplained pain concerns. Life Surveys completed on residents to measure of pain and comfort levels (Resident #4 and Resident #5) Audit Report for computer system for as needed medications reviewed for trends administrated by RN A for [DATE] - [DATE]. Reconciliation of Controlled Drug Administration Record to the Pharmacy Manifest completed monthly from [DATE] to present - reviewed. Record Review and interviews of sampled residents (Resident #2, Resident #3, and Resident #4) indicated no misappropriation of property occurred. Record Review of sign in sheet dated [DATE] of all staff educated on abuse, neglect, misappropriation and examples and legal obligation to report and suspicion of activity. Record Review of sign in sheet dated [DATE] of all licensed staff educated utilizing the new narcotic count sheets to be filled out at each shift count. Parts include (addition, subtracting, when and who) to be completed on the new sheet. All medications should match the controlled narcotic sheets prior to any staff leaving the building, no blank spaces on the narcotic sheets, and the electronic computer system MAR should reflect when a medication was given and match the controlled narcotic sheets. All licensed staff interviewed (MA B, LVN C, LVN D, LVN E, RN F) verbalized any allegation of abuse/misappropriation should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours and removing the alleged perpetrator from the victim or any potential victims immediately. They verbalized the implementation of the card counting of the blister packs of the medications added to the narcotic count at the beginning and ending of each shift by utilizing the new narcotic count sheet each shift, no staff can leave prior to a count not being correct. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE].

Based on observation, interview and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to protect Resident #1 from inappropriate sexual touching by Resident #2. This failure could place residents at risk of for psychosocial harm and a diminished quality of life. Findings included: 1. Record review of Resident #1's face sheet dated 10/04/24 indicated she was an [AGE] year-old female who readmitted to the facility on [DATE] with the diagnoses of dementia (loss of cognitive functioning), cognitive communication deficit (result in difficulty with thinking and how someone uses language), diabetes (a chronic condition that affects the way the body processes blood sugar), major depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act), high blood pressure, and facture of her left arm. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had a BIMS score of 3, which means she had severe cognitive impairment. The MDS also indicated Resident #1 required moderate assistance with transfers, bed mobility, and eating, and maximum assistants with toileting and bathing. The MDS indicated Resident #1 had delusions. Record review of Resident #1's care plan revised on 10/04/24 indicated she had a BIMS score of 3, impaired cognitive function, and impaired decision-making abilities. The care plan also indicated Resident #1 had an ADL self-care performance deficit and required extensive assistance of one staff for toileting and transfers. The care plan did not indicate Resident #1 had a reportable incident with another resident. Record review of Resident #1's nurse's note dated 10/4/2024 at 07:00 AM completed by LVN A indicated Incident Note Text: Resident was previously at nurses' station in wheelchair and received her insulin. When went to obtain her to go to dining room for breakfast, she was not there. Search of hallways per staff for location. Found resident in another room in bed with male resident. Assisted to wheelchair per staff and assessed for injuries. Resident teary and when ask if she was ok, she shook her head no. Assured her we were close by. Monitored closely . Record review of the visit note from the Facility Counseling MD dated 10/5/2024 at 11:16 AM indicated Resident #1 voiced no recollection of being with the male Resident #2 and exhibited no emotional distress. The plan was to continue to provide psychotherapy focused on reducing symptoms of depression, increasing overall sense of well-being, and self-care. 2. Record review of Resident #2's face sheet dated 10/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behaviors), high blood pressure, psychotic disorder (mental disorder characterized by a disconnection from reality), dementia (loss of cognitive functioning), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #2's quarterly MDS dated [DATE] indicated he had a BIMS score of 8 which means he had moderate cognitive impairment. The MDS also indicated he required supervision for bathing, and he was independent with eating, transverse, and bed. mobility The MDS did not indicate that he had any behaviors. Record review of Resident #2's care plan revised 10/4/2024 after the sexual incident, indicated he had a potential to have behaviors related to dementia, poor impulse control, and schizophrenia hallucinations. The care plan included interventions of 1 on 1 monitoring for sexual behaviors and psychiatric/psychogeriatric consult as indicated. The care plan did not include any behaviors prior to 10/4/2024. Record review of the Provider Investigation Report dated 10/04/24 at 7:00 AM, indicated a search found Resident #1 laying across the bed in Resident #2's room with her pants and brief down and her shirt pulled up. Resident #2 was next to her fully clothed leaned over Resident #1 with his mouth on Resident #1's breast. He stopped when the LVN A walked in. His affect was no different than his usual. Resident #1 was tearful. She was assisted to dress and come out of the room. The report indicated a head-to-toe assessment was completed with no skin issues, no redness, bruising, or pain noted to the perineal area. A psychological assessment was to be completed by the Facility Counseling MD on 10/5/2024 for Resident #1 and Resident #2. The report also noted that Resident #2 would be placed on 1 on 1 supervision. Record review of the visit note from the Facility Counseling MD dated 10/5/2024 at 12:15 PM indicated Resident #2 shared no recollection of the sexual event but said I must have been inappropriate and offered no other details. Resident #2 presented with a calm demeanor and exhibited no emotional distress. The plan was to continue to provide psychotherapy focused on reducing symptoms of depression, increasing overall sense of well-being, and self-care. Record review of the facility in-service dated 10/5/2024 indicated the staff were educated over dementia care and sexuality. Record review of the facility in-service dated 10/5/2024 indicated the staff were educated over abuse and neglect. Record review of the facility 15-minute activity checks dated 10/4/2024 - 10/5/2024 indicated there had continuously been a staff member 1 on 1 with the Resident #2. During an observation and interview on 10/05/24 at 11:30 AM, CNA C was sitting outside of Resident #2's room and said she was on 1 on 1 duty for observation of Resident #2. CNA C said she had been on duty 10/04/24 for the 2:00PM-10:00 PM shift and returned on 10/05/24 at 6:00 AM and she had relieved another CNA who worked from 10/04/24 at 10:00PM until 10/05/24 at 6:00 AM. She said Resident #2 had not had any sexual behaviors and she had never known him to have any. CNA C said she was notified of the incident but had not had an abuse and neglect in-service since the incident. During an observation and interview on 10/05/24 at 11:40 AM, Resident #2 was laying in his bed and said he did not recall a woman in his bed on yesterday 10/04/24, nor did he recall any incident. He said he thought he slept through breakfast 10/04/24. Resident #2 said he did not have any close friends, but he tried to be nice to everyone. During an observation and interview on 10/05/24 at 12:00 PM, Resident #1 was sitting in front of the nurse's station in her wheelchair. She was in a pleasant mood and denied anyone hurting her or touching her inappropriately. During an interview on 10/05/24 at 12:30 PM, the Facility Counseling MD said she had been seeing Resident #2 for 1-2 months. She said he had continued to get adjusted to nursing facility but had never spoken of any type of relationship at the facility. She said he had kept to himself. The Facility Counseling MD said Resident #2 was always alert and oriented to person and place but on 10/05/24 he was not and was very forgetful. He told her he must had been inappropriate but did not indicate what was done. During an interview on 10/05/24 at 1:00 PM, LVN A said on 10/04/24 at about 6:45 AM Resident #1 was sitting at the nurse's station and Resident #2 was sitting in the front lobby. She said 15 minutes later the staff were looking for Resident #1 to go to breakfast and she was not at the nurse's station. LVN A said she went down hall 400 while other staff searched other hallways and she found Resident #1 in the room of Resident #2 laying across the middle of his bed with her pants and brief at her knees and her shirt was up to her chin. She said Resident #2 had his mouth on Resident #1's breast and he was fully clothed. She said Resident #1 had her hands cupped over her perineal area. LVN A said once she knocked Resident #2 sat upright. LVN A said she asked Resident #1 if she was ok, and she shook her head no. She said when she asked Resident #1 if he touched her, she said yes and when she asked if Resident #2 did anything else she said no. LVN A said she assisted Resident #1 to put clothes on and removed her from Resident #2's room and placed Resident #2 on 1 to 1 observation. She said she notified the Administrator, the DON, Resident #1's son, and the doctor of the incident. During an observation and interview on 10/05/2024 at 1:30 PM Resident #2 was sitting in the front lobby with CNA C sitting with him. CNA C said he had no behaviors noted. During an interview on 10/05/24 at 4:11 PM, Resident #2 said he had short term memory problems, but he did now remember Resident #1 coming to his room. He said that was the first time she came in there. He said he assisted Resident #1 onto his bed because he did not have a chair in his room. Resident #2 said he had been friends with her, and he thought it was a mutual thing. He said to his recollection she did not tell him no or stop. He then said he had short term memory problems and did not remember anything else about the incident. During an interview on 10/05/24 at 4:23 PM, the DON said her expectation was for the incident of suspected sexual abuse to be immediately reported to the administrator, as it was, and she then followed up with her. The DON said when there was a resident in harms ways she would step in and ensure the residents were safe. She said CNAs were immediately placed on 1 on 1 with Resident #2 to ensure he did not get to do the sexual behavior again. The DON said that all staff were responsible for ensuring abuse was prevented but the administrator was the abuse coordinator. The failure of not preventing abuse placed residents at risk for trauma, pain, and emotional problems. During an interview on 10/05/24 at 4:30 PM, the Administrator said her expectation was for staff to report things right away and they did. She said all the staff were responsible for ensuring that no resident was subject to abuse and neglect. She said the failure placed a risk for emotional trauma and physical trauma. Record review of the facility's policy titled Abuse effective 02/01/2017 and last revised 01/01/23 indicated: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving residents, family members, or legal guardians, care taker, friends, or other individuals.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the facility's only kitchen The facility failed to ensure that kitchen staff appropriately restrained their hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: 1. During an observation on 10/30/2023 starting at 09:03 AM revealed: two dented cans of Campbell's Cream of Mushroom Soup in the kitchen pantry. the Cook was not wearing the hairnet appropriately to restrain the sides and back of hair. the Dishwasher was not wearing the hairnet appropriately to contain facial hair, approximately one half inch mustache. During an observation on 10/30/2023 at 09:11 AM, revealed the dishwasher was in the kitchen without a hairnet on appropriately. The dishwasher was not wearing a hair net to contain facial hair approximately one half inch mustache. During an observation on 10/30/2023 at 09:30 AM., revealed the Cook was in the kitchen without a hairnet on appropriately. The Cook's hair was sticking out the sides and the back of the hairnet. During an observation on 10/31/2023 at 09:30 AM, revealed the Cook was in the kitchen without a hairnet on appropriately. The Cook's hair was sticking out the sides and the back of the hairnet. During an interview on 10/30/2023 at 02:00 PM., the Cook said the hairnet should be worn appropriately by tucking all the hair inside the hairnet to prevent any type of cross contamination. During an attempted telephone interview on 10/31/2023 at 11:30 AM., the Dishwasher did not answer the phone. During an attempted telephone interview on 10/01/2023 at 02:30 PM., the Dishwasher did not answer the phone. During an interview on 10/31/2023 at 04:32 PM., the Dietary Manager said the damaged food cans should be separated from cans of food to be served. The Dietary Manager said all staff should wear hairnets that covered their hair appropriately while in the kitchen. The Dietary Manager said those items or important to keep the residents healthy and prevent cross contamination and food borne illness. During an interview on 11/02/2023 at 1:30 PM., the Administrator said that she expected the Dietary Manager to check behind the staff to ensure that the tasks to prevent infection and cross contamination and food borne illness were completed. Record Review of the Food Preparation and Service Policy with a revised date of April of 2022, indicated . all food purchased will be wholesome, manufactured, processed, and prepared in compliance with all state, federal and local laws, and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food born illness. 1. Food is delivered at the appropriate temperature and inspected prior to storage for signs of contamination. D. No dented cans. 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. 11. Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded.19. Safe food temperatures will be maintained at acceptable levels during food storage, preparation, holding, service, delivery, cooling and reheating

Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 3 of 20 residents (Residents #4, #16 and #24) reviewed for advanced directives. 1. The facility did not ensure Resident #4's OOH-DNR included the physician signature and physician date the document was signed. 2. The facility did not ensure Resident #16's OOH-DNR included the witness 2 signature, physician license number, and physician date the document was signed. 3. The facility did not ensure Resident #24's OOH-DNR included the witness 1 signature. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 05/24/2021. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #4 usually understood others and usually made herself understood. The assessment indicated Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Record review of the Resident #4's care plan, revised on 06/27/2022, indicated Resident #4 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #4's OOH-DNR form dated 10/10/2016 revealed a missing signature and date by the physician. 2. Record review of Resident #16's face sheet, dated 11/02/2023, indicated Resident #16 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Record review of Resident #16's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 09/24/2021. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #16 understood others and made himself understood. The assessment indicated Resident #16 had a BIMS score of 11, which indicated his cognition was moderately impaired. Record review of the Resident #16's care plan, revised on 10/15/2021, indicated Resident #16 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #16's OOH-DNR form dated 09/22/2021 revealed a missing witness 2 signature, physician license number, and physician date. 3. Record review of Resident #24's face sheet, dated 11/02/2023, indicated Resident #24 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. Record review of Resident #24's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 08/01/2023. Record review of the significant change in status MDS assessment dated [DATE], indicated Resident #24 understood others and made herself understood. The assessment indicated Resident #24 had a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of the Resident #24's care plan, revised on 08/13/2023, indicated Resident #24 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #24's OOH-DNR form dated 07/31/2023 revealed a missing witness 1 signature. During an interview and record review on 11/01/2023 at 1:25 p.m., the Director of Resident Support Services stated she was responsible for completing DNRs. After reviewing Resident #4's electronic medical record, the Director of Resident Support Services stated Resident #4 OOH-DNR was missing a signature and date by the physician. After Resident #16's electronic medical record, the Director of Resident Support Services stated Resident #16 OOH-DNR was missing witness 2 signature, physician license number, and physician date. After Resident #24's electronic medical record, the Director of Resident Support Services stated Resident #24 OOH-DNR was missing witness 1 signature. The Director of Resident Support Services stated she was responsible for overseeing and monitoring by weekly audits. The Director of Resident Support Services stated her last audit was on 10/07/2023. The Director of Resident Support Services stated during the audit she checked the resident code status, care plan, and door label to ensure it was updated in PCC. The Director of Resident Support Services stated during her audits she did not look at the physical documents to ensure it was completely filled out. The Director of Resident Support Services stated it was important to ensure DNRs were completed to respect their wishes. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she expected DNR's to be completely filled out, including signatures, dates, and physician license number. The Administrator stated the Director of Resident Support Services was responsible for overseeing and monitoring the DNR. The Administrator stated it was important to ensure the DNR's were completed because, legally the form stated it must have signatures, dates, and physician license number . Record review of the facility's policy titled; Advanced Directives, effective 04/2020 did not address advance directive completion.

46892 Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 6 of 20 residents (Resident #8, Resident #13, Resident #19, Resident #25, Resident #47, and Resident #52) reviewed for accidents and supervision. The facility did not ensure Resident #52 smoked in the designated smoking area while being supervised during the smoke break. The facility did not ensure PTA F used the gait belt appropriately while ambulating Resident #25. The facility failed to ensure the safety of Resident #13 by not moving the Resident to another location/bed prior to removing/working on the bed. The facility failed to properly store aerosol can with a labeled Lavender Scent Deodorizer Spray leaving them on Resident #47's dresser. The facility failed to properly store 3 air freshener sprays and 1 container of disinfectant wipes leaving them on the bottom shelf of a stand at the foot of the bed in Resident #8's room. The facility failed to properly store razors leaving them on top of Resident #19's dresser. These failures could place residents at an increased risk for injury. Findings included: 1. Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of sepsis, unspecified organism (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 currently used tobacco. Record review of the comprehensive care plan, initiated on 05/18/23, revealed Resident #52 smoked. The goals included: Resident will have supervised smoking privileges to minimize safety risks. The interventions included: Resident will smoke only in designated smoking area with access to appropriate smoking receptacles. Record review of Resident #52's Safe Smoking Assessment, dated 07/30/23, revealed The resident requires direct supervision while smoking. Record review of the list of designated smoking times and staff responsible for supervising the smoke break, undated, revealed housekeeping staff, dietary staff, and the Social Worker were responsible for supervising the designated smoking breaks. During an observation on 10/31/23 beginning at 3:01 PM, multiple residents were outside in the designated smoking area. The Social Worker was supervising the smoke break and was sitting in a metal chair in the designated smoking area. Resident #52 was sitting up in her wheelchair, outside the designated smoking area on the sidewalk near a grassy area and was approximately 20 feet from a large propane tank. Resident #52 was observed smoking a red-tipped cigarette and flicking her ashes on the ground. The propane tank was in the grass with a metal chain-link fence around it. There was a large sign that read PROPANE: No Smoking; No Open Flames. There were approximately 11 red-tipped cigarette butts in the grass where Resident #52 was sitting. During an observation and interview on 10/31/23 at 3:38 PM, the Administrator accompanied the surveyor into the smoking area. There were approximately 11 red-tipped cigarette butts in the grass approximately 20 feet away from the propane tank. The Administrator stated Resident #52 should not have been smoking outside the designated smoking area. The Administrator stated cigarette butts should not have been thrown on the ground or in the grass. The Administrator stated she would provide in-service education to the facility staff. During an interview on 10/31/23 beginning at 4:06 PM, Food Service Manager C stated she supervised smoke breaks some of the scheduled times. Food Service Manager C stated the residents stayed inside the black gate during smoking breaks, which indicated the designated smoking area. Food Service Manager C stated during the smoke breaks she supervised; no residents had smoked outside the designated smoking area near the propane tank. Food Service Manager C stated she stayed outside with the residents until they were finished smoking. During an interview on 10/31/23 beginning at 4:08 PM, Resident #52 stated she normally sat in the designated smoking area. Resident #52 stated she had been sitting outside the smoking area during the last few days because it was cold, and she wanted to sit in the sun. Resident #52 stated no staff members had attempted to encourage her to sit in the designated smoking area. During an interview on 10/31/23 beginning at 4:13 PM, Community Cleanliness Provider A stated she normally assisted residents to smoke during the 8:30 AM, 10:30 AM, and 1:15 PM smoke breaks. Community Cleanliness Provider A stated the residents normally sit under the covered patio with the black fence around it. Community Cleanliness Provider A stated she had not observed any residents or staff smoking outside the designated smoking area near the propane tank. During an interview on 10/31/23 beginning at 4:23 PM, the Social Worker stated she was responsible for supervising residents during the 3:00 PM smoke break. The Social Worker stated Resident #52 usually sat outside the designated smoking area because she wanted to sit in the sun, but she stated Resident #52 did not normally smoke. The Social Worker stated she had not noticed Resident #52 smoking outside the designated area during the 3:00 PM smoke break. The Social Worker stated an explosion or fire could have happened if residents smoked outside the designated smoking area and threw their cigarette butts on the ground. Record review of the Smoking policy, undated, revealed Smoking by residents is allowed outside in designated, marked smoking areas . The policy further revealed IDT will develop an individualized plan for .required supervision for residents who smoke. 2. Record review of the face sheet, dated 11/01/23, revealed Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema (complication of high blood sugar where blood vessels in the eye are damaged causing swelling), legal blindness (unable to see), unsteadiness of feet, difficulty in walking, ataxia (loss of coordination of voluntary muscle movements), and muscle wasting and atrophy (loss of muscle and muscle mass leading to its shrinking and weakening). Record review of the MDS assessment, dated 09/22/23, revealed Resident #25 had clear speech and was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #25 required an extensive, one-person assistance with transfers, walking, and dressing. The MDS revealed Resident #25 was not steady and only able to stabilize with staff assistance for walking, turning around, and moving from a seated to standing position. Record review of the comprehensive care plan, revised on 10/05/23, revealed Resident #25 had an ADL self-care performance deficit related to his disease processes. The interventions did not address walking. The interventions for transfers included: .requires extensive assistance by 2 staff to move between surfaces as necessary. During an observation on 10/30/23 beginning at 10:06 AM, PTA F assisted Resident #25 with walking down the hallway using his walker. Resident #25 had a gait belt around his upper body. The gait belt was loose, hanging low, and twisted in the middle of his back. PTA F was holding Resident #25's shorts to guide him. PTA F was not holding onto the gait belt. During an interview on 11/02/23 beginning at 8:56 AM, PTA D stated PTA F was not scheduled to work until 11/03/23. PTA D was unable to provide PTA F's phone number at the time of the interview. PTA D stated gait belts should have been placed below the ribs or above the breasts under the armpits depending on the person. PTA D stated the gait belt should have been snug but not too tight. PTA D stated Resident #25 was in between independent and contact guard assistance. PTA D stated Resident #25 required hands on assistance sometimes. PTA D stated staff should not hold onto residents' pants during transfers unless they were falling. PTA D stated if the clothing was loose then he would have held both the pants and the gait belt while walking the resident. PTA D stated the gait belt should not have been twisted when placed on the resident. PTA D stated it was important to ensure the gait belt was placed appropriately to prevent skin injury and potential falls. During an interview on 11/02/23 beginning at 9:28 AM, the Director of Rehab stated the gait belt should be applied around the waist snuggly. The Director of Rehab stated the gait belt should be snug but comfortable for the resident. The Director of Rehab stated the gait belt should not have been twisted, but flat against the residents clothing. The Director of Rehab stated staff should have been holding the gait belt while walking with a resident. The Director of Rehab stated she had only been in the director role for approximately six months and gait belt training had not been performed by the therapy department. The Director of Rehab stated it was important to ensure the gait belt was appropriately placed to prevent an injury to the resident. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to ensure the gait belt was used appropriately. The DON stated the gait belt should not have been twisted or applied loosely. The DON stated the staff should have held the gait belt while ambulating Resident #25. The DON stated gait belt training was provided at least annually and staff would have been retrained if issues were observed. The DON stated it was important to ensure staff was using gait belts appropriately for resident safety. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected therapy staff to follow their practices and procedures for appropriately applying the gait belt. The Administrator stated the therapy manager was responsible for monitoring to ensure gait belts were used appropriately. The Administrator stated it was important to ensure gait belts were used appropriately for resident safety. Record review of an e-mail, accessed on 11/06/23, revealed a statement from PTA D sent by the Administrator as additional evidence. The statement from PTA D revealed In reference to the tag . received for the gait training I performed with the resident in room [ROOM NUMBER]: I was holding onto the patient's shorts elastic waist band because his shorts are loose and the resident requested that I hold them up otherwise they (his shorts) would fall to the ground while ambulating which would impose a safety concern on its own as well as degrade the patient's inherent right to dignity as he would be exposed to the other residents in the hallway. Furthermore, on this topic, this resident is legally blind and requires the use of tactile cues for navigation in a dynamic environment, such as a hallway, and I am unable to provide the most optimum tactile cues by only holding onto the gait belt. Also, this resident typically does not require the constant use of Contact Guard Assistance (holding onto the gait belt) for gait training which would further explain why I was not directly holding onto the gait belt. The gait belt was merely placed on the resident because it is best practice for safety. Rarely, if ever, does this resident require the use of holding onto the gait belt for balance corrections. During a telephone interview on 11/06/23 beginning at 9:57 AM, PTA D stated Resident #25 did not normally use a gait belt. PTA D stated the gait belt was only applied for safety reasons. PTA D stated on 10/30/23 Resident #25 requested him to hold onto his shorts so they did not fall. PTA D stated Resident #25 did not request his shorts to be changed. PTA D stated the gait belt should have been applied snuggly but Resident #25 requested the gait belt not be tight. PTA D stated the gait belt should not have been twisted. PTA D stated it was important to ensure the gait belt was applied properly to prevent injury to the resident in case it needed to be used. Record review of the Safe Lifting and Movement of Residents policy, revised July 2017, revealed .this facility uses appropriate techniques and devices to lift and move residents. The policy did not address the proper use of a gait belt when assisting residents with ambulation. 3. Record review of Resident #13's face sheet, dated 11/01/2023, indicated an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS Resident Assessment and Care Screen indicated 09/18/2023 indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. During an observation on 10/31/2023 at 10:32 AM, the Maintenance Supervisor was lying on the floor with the front portion of his body under Resident #13's left side of bed. The Maintenance Supervisor had a tool in hand and working on the bed. Resident #13's bed was in high position. During an observation on 11/01/2023 at 4:32 PM, the right-side rail had been removed from Resident #13's bed. During an interview on 11/02/23 at 12:07 PM, the DON said usually we take the residents out of the bed to remove the assist rails. The DON said Resident #13 no longer used the rails for bed mobility since she has declined. The DON said the facility had recently gone through and did assessments to make sure the resident's qualified to have the assistance rails and more than likely that's what the maintenance supervisor was doing at that time. The DON said the Resident should not have been in the bed while the work was being done with the bed in high position and the maintenance supervisor under it. The DON said it was not safe for resident or the maintenance supervisor. During an interview on 11/02/2023 at 12:32 PM, the Maintenance Supervisor said he was tightening the rail on resident #13's bed. He said Resident #13 was left in the bed while he made the repairs because he was not disturbing her, and it was not a safety issue. The Maintenance Supervisor said it was the only way to do the repairs to his knowledge because the resident cannot get out of the bed as she is in the dying process. During an interview on 11/02/2023 at 01:30, the Administrator said they would not have move Resident #13 out of bed for the bedrail repairs because she is in the dying process and would not want to cause discomfort and pain. 4. Record review of Resident #47's face sheet, dated 11/01/2023, indicated a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Prostate (abnormal growth where cells divide uncontrollably and destroy bodily tissue), Secondary Malignant Neoplasm of other Parts of Nervous System, Acquired Absence of other Genital Organ (missing one or several genitals due to injury or operation), Paraplegia (paralysis of the lower body), other cord compression, essential Hypertension (high blood pressure), Neuromuscular Dysfunction of Bladder (lack of bladder control related the muscles and nerves do not work well together). Record review of the MDS Resident Assessment and Care Screen indicated 08/30/2023 indicated Resident #47 was able to make self-understood and understood others. The MDS assessment indicated Resident #47 had a BIMS score of 14, which indicated cognitively intact. The MDS assessment Indicated Resident #47 required limited assistance for bed mobility, dressing, and personal hygiene and extensive assistance for transfers and toilet use. During an observation and interview on 10/30/2023 at 1:08 PM, an aerosol can with a labeled Lavender Scent Deodorizer Spray was sitting on the dresser in Resident #47's room. Resident #47 said he had won the aerosol spray during a Bingo game. During an observation on 10/31/2023 at 09:10 AM, an aerosol can with a labeled Lavender Scent Deodorizer Spray was sitting on the dresser in Resident #47's room. 5. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, moderate, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (pain that lasts a long time and affects your mood, sleep, and daily living), and acute kidney failure (sudden and serious condition that affects your kidneys' ability to filter waste and fluid from your blood). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #8 had a BIMS score of 7, which indicated her cognition was severely impaired. During an observation on 10/30/2023 at 4:32 PM, Resident #8 had 3 air freshener sprays and 1 container of disinfectant wipes on the bottom shelf of the stand at the foot of her bed. All items were labeled keep out of reach of children. During an observation on 11/01/2023 at 9:18 AM, Resident #8 had 3 air freshener sprays and 1 container of disinfectant wipes on the bottom shelf of the stand at the foot of her bed. 6. Record review of Resident #19's Order Summary Report indicated he was [AGE] years old and admitted on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia (carbon dioxide level is abnormally high in the blood causing respiratory failure), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus with foot ulcer (high blood sugar levels in the blood with a foot wound). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #19 was able to make himself understood and understood others. The MDS assessment indicated Resident #19 had a BIMs score of 12, which indicated his cognition was moderately impaired. During an observation on 10/30/2023 at 10:37 AM, Resident #19 had razors on his bedside table. Resident #19 said his family member had provided them for him and the CNAs used them to shave him. During an observation on 11/01/2023 at 09:55 AM, Resident #19 had razors on his bedside table. During an interview on 11/01/2023 at 10:01 AM, LVN E said Resident #8 should not have air freshener sprays and disinfectant wipes in her room. LVN E said Resident #8's family must have [NAME] the items into Resident #8's rooms, and she had not noticed them in there. LVN E said all the staff were responsible for ensuring the residents rooms did not have room sprays and disinfectant wipes in them. LVN E said the residents were not supposed to have razors on the dresser. LVN E said she had not seen Resident #19 had razors on his dresser. LVN E said the CNAs should ensure they were not left in the room accessible to the residents. LVN E said it was important for the residents to not keep room sprays because they could be flammable, and it was a danger to the residents. LVN E said the residents should not have disinfectant wipes in their rooms because the residents could confuse them with wet wipes and use the wrong wipe and cause harm to themselves. LVN E said wandering and confused residents could go in the resident's room and harm themselves. LVN E said it was important for the razors to not be left on the resident's dresser because another resident could pick one up and cut themselves and for safety. LVN E said Resident #19 could shave himself without the staff knowing and cut himself and bleed for an extended period before the staff found out. During an interview on 11/01/2023 at 10:33 AM, the ADON said air freshener sprays and disinfectant wipes should not be in the residents' rooms. The ADON said razors were not allowed at the bedside. The ADON said she checked Resident #8's and Resident #19's rooms daily as part of her rounds and she had not noticed the room sprays, disinfectant wipes or razors. The ADON said it was important for the residents to not keep room sprays in their rooms so they would not get something in their eyes or drink something they were not supposed to for their safety. The ADON said it was important for the disinfectant wipes to not be in the residents' rooms because they have chemicals that could harm the residents. The ADON said it was important to not keep razors at the bedside because the residents could be on blood thinners and injure themselves and other residents that did need their hands on the razors could get a hold of them. During an interview on 11/02/2023 at 12:32 PM, the DON said she encouraged the residents to not have room sprays and disinfectant wipes in their rooms. The DON said if they did have them in their rooms these items should be stored somewhere safe and out of reach of other residents. The DON said Resident #8 should not have had room sprays and disinfectant wipes in her room. The DON said it was important for the room sprays and disinfectant wipes to be stored properly and out of reach of other residents for the resident's safety. The DON said she did not want a confused resident to get a hold of these items and hurt themselves. The DON said razors should not be left on top of the dresser. The DON said it was important for razors to be out of the reach of the residents because they could hurt themselves or others. The DON said it was all the staff's responsibility to keep room sprays, disinfectant wipes, and razors out of the residents reach for their safety. During an interview on 11/02/2023 at 1:33 PM, the Administrator said room sprays and disinfectant wipes were allowed in the rooms because it was the residents choice to keep them in their rooms. The Administrator said it was important for room sprays and disinfectant wipes to be out of reach of other residents because if they should not have it, they would not get it. The Administrator said residents were allowed to keep razors at the bedside if they were capable of keeping them. The Administrator said the razors at the bedside could pose a risk to other residents, but there were so many hazards that could be dangerous in the residents' rooms. The Administrator said all the staff were responsible for ensuring the residents environment was safe for them. During an interview on 11/02/2023 at 1:10 PM, the DON said she could not find a policy regarding accidents and hazards. 47006

Based on interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 3 of 20 residents (Residents #4, #9 and #24) reviewed for medical records. 1. The facility did not ensure Resident #4's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #4's side effects were adequately monitored regarding her antianxiety, antidepressant and antipsychotic medications. 2. The facility did not ensure Resident #9's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #9's side effects were adequately monitored regarding her antianxiety and antidepressant medications. 3. The facility did not ensure Resident #24's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #24's side effects were adequately monitored regarding her antianxiety medication. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included anxiety/major depressive disorder, and schizophrenia (mental condition involving a breakdown in the relation between though, emotion, and behavior). Record review of Resident #4's physician order summary report, dated 11/02/2023, indicated an active physician's order for: *Buspirone 5 mg 1 tablet three times a day for anxiety with a start date of 10/29/2021 *Duloxetine 20 mg 1 tablet daily for depression with a start date of 06/10/2022 *Risperidone 0.5 mg 1 tablet at bedtime for schizophrenia with a start date of 06/07/2023 Record review of the quarterly MDS dated [DATE], indicated Resident #4 usually understood others and usually made herself understood. The assessment indicated Resident #4 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #4 received antianxiety, antidepressants and antipsychotic medications during the 7 day look back period. Record review of the Resident #4's care plan, revised on 06/27/2022, indicated Resident #4 had a behavior related to schizophrenia and used an antianxiety and antidepressant medication. The care plan interventions included, administer Duloxetine as ordered by physician, monitor/document side effects/effectiveness every shift, administer antianxiety medication as ordered by physician, monitor for side effects/effectiveness every shift, and monitor behavior episodes and attempt to determine underlying cause. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. 2. Record review of Resident #9's face sheet, dated 11/02/2023, indicated Resident #9 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included major depressive and anxiety disorder. Record review of Resident #9's physician order summary report, dated 11/02/2023, indicated an active physician's order for: *Buspirone 10 mg 1 tablet by mouth two times a day for anxiety with a start date of 12/01/2021 * Citalopram Hydrobromide 10 mg 1 tablet by mouth daily for depression with a start date of 06/07/2022 *Trazadone 100 mg 1 tablet at bedtime for depression with a start date of 01/11/2022 Record review of Resident #9's annual MDS, dated [DATE], indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 had a BIMS score of 13, which indicated her cognition was intact. The assessment indicated Resident #9 received antianxiety and antidepressant medications during the 7 day look back period. Record review of Resident #9's care plan, revised on 06/17/2022 indicated Resident #9 used an antianxiety and antidepressant medication. The care plan interventions included, administer antidepressant and antianxiety medications as ordered by physician, and monitor/document side effects/effectiveness every shift. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. 3. Record review of Resident #24's face sheet, dated 11/02/2023, indicated Resident #24 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. The face sheet did not address the anxiety diagnosis. Record review of Resident #24's physician order summary report, dated 11/02/2023, indicated an active physician's order for: * Alprazolam 0.25 mg 1 tablet by mouth two times a day for anxiety with a start date of 08/03/2023 * Alprazolam 0.25 mg 1 tablet by mouth every 6 hours as needed for anxiety with a start date of 10/26/2023 Record review of the significant change in status MDS dated [DATE], indicated Resident #24 understood others and made herself understood. The assessment indicated Resident #24 had a BIMS score of 10, which indicated her cognition was moderately impaired. The assessment indicated Resident #9 received antianxiety medication during the 7 day look back period. Record review of the Resident #24's care plan, revised on 08/15/2023, indicated Resident #24 used an antianxiety medication. The care plan interventions included, administer antianxiety medication as ordered by physician, and monitor/document side effects/effectiveness every shift. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. During an interview on 11/01/2023 at 1:44 p.m., LVN E stated the charge nurses were responsible for monitoring/documenting behaviors and side effects in PCC (electronic medical record). LVN E stated psychotropic medications required to be monitored to ensure the medication was effective and to show whether or not the medication was required. LVN E stated if the resident was not having any behaviors, 0 should be documented or if the resident was exhibiting s/sx, 1, 2 or 3 should be documented. LVN E stated it was not appropriate to document NA to indicate if the resident was exhibiting side effects or behaviors. LVN E stated it was important to ensure there was not an error in documentation to prevent the medication from getting discontinued and putting the residents at risk for increased depression, anxiety, and psychotic episodes. LVN E stated the risk associated with error in documentation was extended problems such as tardive dyskinesia, N/V, rash and swelling. During an interview on 11/02/2023 at 9:11 a.m., the DON stated she expected the nurses to monitor for side effects and behaviors by properly documenting in the resident's chart. The DON stated the nurses should assessed the residents for side effects and behaviors for psychotic medications and chart if the resident was exhibiting side effects or behaviors such as panic attacks, yelling, screaming, or cursing. The DON stated if the resident was not exhibiting any s/sx the charge nurses were to document 0 which indicated no side effects/behaviors. The DON stated the monitoring should be 0,1, 2 or 3 and not NA to indicate side effects/behaviors. The DON stated she expected every shift to monitor and document for any side effects or behaviors. The DON stated there was not a consistent procedure for monitoring to ensure follow up for complete documentation. The DON stated it was important to monitor for side effects/behaviors to properly treat the resident and to ensure medication was effective. The DON stated the risk associated with error in documentation was residents not properly being treated for the psychotic medication. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she was referring to the DON regarding psychotropic medications documentation because she was responsible for monitoring that system. During an interview on 11/02/2023 at 11:57 a.m., the Regional MDS nurse stated there was not a policy and procedure regarding behavior monitoring.

Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 9 residents reviewed for insulin administration. (Resident #52) The facility did not ensure LVN P and RN Q administered Resident #52's Humalog (insulin lispro) KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 was taking insulin and an indication was noted. The MDS revealed Resident #52 received an insulin injection 3 out of 7 days during the look-back period. Record review of the comprehensive care plan, initiated on 04/27/23, revealed Resident #52 was at risk for complication related to diagnosis of type 2 diabetes mellitus. The interventions included: Diabetes medication as ordered by doctor. Record review of the order summary report, dated 10/31/23, revealed Resident #52 had the following orders: Insulin lispro injection - inject 5 units subcutaneously before meals and at bedtime for diabetes, which started on 10/08/23. Humalog KwikPen 100 units/ML - inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; notify MD if greater than 400 for orders, subcutaneously before meals and at bedtime for diabetes, which started on 10/11/23. Record review of the MAR, dated October 2023 and November 2023, revealed Resident #52 received insulin injections daily. Record review of the manufacturer's instructions titled Instruction for Use - Humalog KwikPen (insulin lispro) ., accessed on 11/01/23 at 3:09 PM, revealed Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. During an observation and interview on 10/31/23 beginning at 4:00 PM, LVN P was standing at her medication cart. LVN P stated she was going to perform a finger stick blood sugar check and administer insulin to Resident #52. LVN P prepared the finger stick blood sugar check and went into Resident #52's room. LVN P stuck Resident #52's finger and obtained a small amount of blood for the test. The result was 295. LVN P returned to the cart to prepare the insulin for Resident #52. LVN P took a Humalog KwikPen with Resident #52's name on it out of the medication cart. LVN P took the lid off the pen and opened the needle tip to apply to the pen. LVN P applied the needle and rotated the dial to 5 units. LVN P did not prime the pen (push through 2 units of insulin to remove air from the needle). LVN P administered 5 units of insulin to Resident #52's left lower quadrant of her abdomen. LVN P returned to the medication cart and realized she administered the incorrect amount of insulin. LVN P stated she should have administered 6 units of the Humalog KwikPen according to the sliding scale and then another 5 units of the insulin lispro pen. LVN P took the Humalog KwikPen and applied another needle tip. LVN P rotated the dial to 1 unit, to equal a total of 6 units. LVN P then obtained an insulin lispro pen with Resident #52's name on it from the medication cart. LVN P took the lid off the pen and opened the need tip to apply to the pen. LVN P applied the needle and rotated the dial to 5 units. LVN P did not prime either pen while preparing the insulin for administration. LVN P administered 1 unit of the Humalog KwikPen and 5 units of the insulin lispro pen to Resident #52's left lower quadrant of her abdomen. LVN P returned to the medication cart. LVN P stated she noticed Resident #52 had two different orders for insulin administration. LVN P stated Resident #52 received 5 units of insulin routinely and then received additional insulin based on the results of her finger stick blood sugar. LVN P stated Resident #52 had two different insulin pens on the medication cart, Humalog, and insulin lispro (the same medication). During an observation and interview on 11/01/23 beginning at 4:08 PM, RN Q was standing at her medication cart. RN Q stated she had obtained Resident #52's finger stick blood sugar and the result was 260. RN Q obtained the Humalog KwikPen with Resident #52's name on it from the medication cart. RN Q took the lid off the pen and opened the needle tip to apply to the pen. RN Q applied the needle and rotated the dial to 11 units. LVN P stated she combined the routinely ordered 5 units with the sliding scale requirement of 6 units to equal a total of 11 units. RN Q did not prime the pen (push through 2 units of insulin to remove air from the needle). RN Q stated she did not normally prime the insulin pen prior to administration. RN Q stated she was believed they were required to prime the insulin pen before the initial dose only. During an interview on 11/02/23 beginning at 9:45 AM, LVN P stated the process for administering an insulin injection was to look at the orders, find the correct pen with the resident's name on it, dial the pen to the correct amount and administer the insulin. LVN P stated she did not normally prime the insulin pen prior to each use. LVN P stated she would only have primed the pen if it was the initial use. LVN P stated she was unaware the manufacturer's instructions on the insulin pen required priming the pen before each use. LVN P stated she had received training in the past for the insulin pen, approximately 2011 or 2012. LVN P stated it was important to ensure the manufacturer's instructions were followed to ensure the residents received the accurate dosage of medication. LVN P stated if the accurate dose was not received, the diabetes could not have been managed. LVN P stated it could have made the blood sugars high or low. During an interview on 11/02/23 beginning at 9:56 AM, the Pharmacy Consultant stated an insulin pen should definitely have been primed prior to the first use. The Pharmacy Consultant stated if facility staff primed the insulin pen before each use, they would run out of the medication. The Pharmacy Consultant stated she was driving but she believed the manufacturer's instructions were to prime only before the initial dose. The Pharmacy Consultant stated it was important to prime the pen to ensure it was working correctly and the residents received the correct dose of insulin. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected the nursing staff to follow policy, procedure, and manufacturer's instructions when administering insulin pens. The DON stated training was provided for administering insulin approximately at the beginning of the year. The DON stated to her knowledge she did not recall that the training addressed using the insulin pen, only the insulin vials. The DON stated the nurse management was responsible for monitoring to ensure insulin was administered correctly to the residents. The DON stated it was monitored by random observations and during monthly visits by the pharmacy consultant. The DON stated it was important to ensure insulin was administered according to the manufacturer's instructions, so the residents received the correct dosage of insulin. The DON stated receiving the incorrect dosage of insulin could have caused the blood sugars to become high or low. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected nursing staff to follow manufacturer's instructions when administering the insulin pens. The Administrator stated the DON was responsible for monitoring to ensure the nursing staff administered insulin correctly. The Administrator stated it was important to ensure insulin was administered according to manufacturer's instructions because staff was supposed to do things the correct way. The Administrator stated there were procedures to follow. Record review of the Administration Procedures for All Medications policy, revised 08/2020, revealed .consult a drug reference, manufacturer package insert, or pharmacist for more information .

46892 Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 20 residents (Resident #8, Resident #9, and Resident #40) and 1 of 1 empty resident's room reviewed for drugs and biologicals. The facility failed to ensure Resident #8's Afrin (nasal spray medication) was stored properly. The facility failed to ensure Resident #40's Azelastine (nasal spray medication) was stored properly. The facility did not ensure a Plavix pill (antiplatelet) was stored in a locked container and original packaging. The facility did not ensure Resident #9's multivitamins, ear drops, and triple antibiotic ointment were properly safe and secured. These failures could place residents at risk of medication misuse and diversion. Findings included: 1. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, moderate, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (pain that lasts a long time and affects your mood, sleep, and daily living), and acute kidney failure (sudden and serious condition that affects your kidneys' ability to filter waste and fluid from your blood). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #8 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #8 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of the care plan with date initiated 09/14/2023 indicated Resident #8 had impaired cognitive function or impaired thought process to administer medications as ordered. Resident #8's care plan did not indicate she could self-administer medications. During an observation on 10/30/2023 at 4:32 PM, Resident #8 had Afrin nasal spray on her bedside dresser. During an observation on 11/01/2023 at 9:18 AM, Resident #8 had Afrin nasal spray on her bedside dresser. Record review of the Order Summary Report dated 10/31/2023 indicated Resident #8 did not have an order for Afrin. There was no order to indicate Resident #8 was able to self-administer medications. 2. Record review of a face sheet dated 11/02/2023 indicated Resident #40 was an [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia in other diseases classified elsewhere, moderate, other diagnosis without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ((loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #40 was able to make herself understood and understood others. The MDS assessment indicated Resident #40 had a BIMs score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #40 required supervision for bed mobility, dressing, and toilet use, and limited assistance with transfers and personal hygiene. Record review of the care plan with a target date of 11/11/2023 indicated Resident #40 had impaired cognitive function and loss of memory. Resident #40's care plan did not indicate she could self-administer medications. Record review of Resident #40's Order Summary Report dated 11/02/2023 indicated Resident #40 had an order for Azelastine solution 0.1% 1 spray in both nostrils two times a day with a start date of 09/16/2022. There was no order to indicate Resident #40 could self-administer medications. During an observation and interview on 10/30/2023 at 10:29 AM, Resident #40 had Azelastine on the dresser by her bed. Resident #40 said she used it sometimes when she got the snuffles. During an observation on 10/31/2023 at 9:19 AM, Resident #40 had Azelastine on the dresser by her bed. During an observation on 11/01/2023 at 9:55 AM, Resident #40 had Azelastine on the dresser by her bed. During an interview on 11/01/2023 at 10:07 AM, LVN E said the residents should not have nasal sprays at the bedside. LVN E said the nurses and management staff were responsible for ensuring the residents did not have nasal sprays at the bedside. LVN E said she was not aware Resident #8 and Resident #40 had nasal sprays on their dressers. LVN E said it was important for the residents not to keep medications at the bedside because the resident may not be in the state of mind to self-administer. LVN E said if the resident's mental capacity allowed for them to keep medications in the room, they would have to have a doctor's order. During an interview on 11/01/2023 at 10:33 AM, the ADON said the residents were not allowed to keep nasal sprays at the bedside because they were medications. The ADON said management staff performed daily rounds to check the residents' rooms. The ADON said she had done the rounds on Resident #8 and Resident #40, and she had not noticed they had nasal spray at their bedside. The ADON said it was important for the residents not to keep medications at their bedside because the medications had doses and the staff did not need to allow the residents to use the medication as often as they want, and medications required monitoring. During an interview on 11/02/2023 at 12:36 PM, the DON said Resident #8 should not have Afrin in her room, and Resident #40 should not have Azelastine in her room. The DON said those medications should be on the medication carts. The DON said she was not aware those medications were in the residents' rooms. The DON said the department heads, nurses, and CNAs were all responsible for ensuring the residents did not keep medications in their rooms. The DON said it was important for medications to be stored properly for the safety of the residents. During an interview on 11/02/2023 at 1:39 PM, the Administrator said for residents to have medications at the bedside they would have to be assessed for their ability to have it. The Administrator said the IDT was responsible for making sure if medications were at the bedside the residents were appropriately assessed. The Administrator said it was important for them to know if medications were at the resident's bedside because they needed to know what the residents were taking for the resident's safety. 3. During an observation and interview on 10/30/23 beginning at 11:18 AM, a small, round, light pink pill with the letters SG was observed on the ground next to the leg of a chair in an empty resident's room, room [ROOM NUMBER]. The Administrator was notified. The Administrator picked up the pill with a brown paper towel and stated she was going to notify the DON. During an observation and interview on 10/30/23 beginning at 11:33 AM, the DON showed the surveyor the back side of the small, round, light pink pill, which had the numbers 124. The DON stated she looked up the medication and determined it was a Plavix pill, which was an antiplatelet medication. During an interview on 11/01/23 beginning at 4:43 PM, the Director of Environmental Services stated empty rooms were deep cleaned when residents moved out of the room or left the facility. The Director of Environmental Services stated finding medication on the floor was not a common thing, but he had found medication on the floor. The Director of Environmental Services stated when medication was found on the floor, the process was to notify the charge nurse. The Director of Environmental Services stated the empty resident room on Hall 6 was deep cleaned and no medication was observed on the ground. The Director of Environmental Services stated it was important to ensure medication was not left on the floor to ensure medication was accounted for and to ensure the residents received all their medication. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she was unsure how the Plavix pill ended up on the ground in an empty resident room. The DON stated it could have been the last resident to occupy the room or possibly a family member's medication. The DON stated the empty room should have been deep cleaned after the resident moved out or went home. The DON stated she expected the housekeeping staff to ensure the rooms were deep cleaned. The DON stated she expected nursing staff to ensure all medication was administered to a resident. The DON stated she expected staff to notify the nurse if medication was found on the ground. The DON stated medication administration and storage was monitored by random observations and monthly by the pharmacy consultant. The DON stated it was important to ensure medications were properly administered and stored so residents could get the appropriate treatment and to protect other residents from taking medication that did not belong to them. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated there was no medication noticed on the ground the morning on 10/30/23 when she was getting the room ready for the survey team. The Administrator stated the room was cleaned and set up that morning. The Administrator stated she checked all areas including drawers, etc. before saying it was ready for use by the survey team. The Administrator stated the surveyor would have been the first to see the pill on the floor and report it to the facility. The Administrator stated it would not have been seen by anyone else to have been given the opportunity to address it. The Administrator stated if the medication did not belong to one of the surveyors, the only other explanation would have been the pill fell out of the chair after being moved. The Administrator stated it was important to ensure medication was not on the ground for resident safety. 4. Record review of Resident #9's face sheet, dated 11/02/2023, indicated Resident #9 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included cervical disc with myelopathy (an injury to the spinal cord due to severe compression that my resulted from trauma). Record review of Resident #9's annual MDS, dated [DATE], indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 had a BIMS score of 13, which indicated her cognition was intact. The MDS indicated Resident #9 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of Resident #9's care plan, revised on 06/17/2022 indicated Resident #9 had a memory loss, poor cognition and decreased sense of safety related to age progression and pain. The care plan intervention included, communicate with the resident/family/caregivers regarding residents' capabilities. During an observation and interview on 10/30/2023 at 9:56 a.m., Resident #9 was lying in bed. There was a bottle labeled equate ear drops on Resident #9's bedside table. There was a bottle labeled women's multivitamins and triple antibiotic ointment on her dresser. Resident #9 stated a family member brought those to her because her right ear was stopped up. Resident #9 stated I haven't started taking the vitamins. During an observation on 10/31/2023 at 2:37 p.m., Resident #9 was lying in bed. There was a bottle labeled equate ear drops on Resident #9 bedside table. There was a bottle labeled women's multivitamins and triple antibiotic ointment on her dresser. Record review of the physician order summary report dated 11/02/2023 did not indicate Resident #9 had an order for ear drops or triple antibiotic ointment. The physician order summary report indicated Resident #9 had an order for multivitamins with a start date 11/02/2023. During an observation on 11/01/2023 at 3:10 p.m., the DON removed the multivitamins, ear drops and triple antibiotic ointment and instructed Resident #9 that the facility needed to store the medications for safety. During an interview on 11/01/2023 at 4:22 p.m., the Director of Resident Support Services stated she conducted daily rounds for Hall 4 which included Resident #9. The Director of Resident Support Services stated she went in to check on the resident, make sure the room was clean and looked for OTC medications. The Director of Resident Support Services stated she completed rounds this week. The Director of Resident Support Services stated she did notice the ear drops, multivitamins and the triple antibiotic ointment. The Director of Resident Support Services stated she was not aware that Resident #9 could not have the medications at bedside. The Director of Resident Support Services stated it was important that medications were not at bedside because she could use too much, and it was also good for the nurses to keep track on when it was given. During an interview on 11/02/2023 at 9:11 a.m., the DON stated OTC medications were not allowed to be kept at bedside. The DON stated OTC medications were kept in the medication cart. The DON stated families were educated to bring medications to the charge nurse or herself so an order could be obtained and kept in the medication cart. The DON stated if the resident was having ear pain, the resident should have notified the charge nurse or herself so the doctor could be notified. The DON stated she monitored by daily rounds that was conducted by the department heads and nursing staff to oversee any OTC at the bedside. The DON stated it was important that medications were not left at bedside for the safety of other residents and the nursing staff would be aware of what the resident was actually taking. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated OTC medications were not allowed to be kept at bedside. The Administrator stated she expected all medications to be delivered and administered by staff if there was an order for it. The Administrator stated it was important that medications were not left at bedside, so the nursing staff was aware of what medications the residents were taking. Record review of the facility's policy Bedside Medication Storage revised in 08/2020, indicated .Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent) .1. A written order for the bedside storage of medication is present in the resident's medical record Record review of the Storage of Medications policy, dated 08/2020, revealed .provider pharmacy dispenses medications in containers that meet regulatory requirements .Medications are kept in these containers .Only those lawfully authorized to administer medications are permitted to access medications .all medications dispensed by the pharmacy are stored in pharmacy container with pharmacy label .medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart . Record review of the Administration Procedures for All Medications policy, dated 08/2020, revealed .Once removed from the package or container, unused or partial doses should be disposed of in accordance with the medication destruction policy . 47006

Based on interview and record review, the facility failed to consult with the physician for 1 of 5 residents reviewed for physician notification. (Resident #1) RN A did not notify the physician on [DATE] when Resident #1 exhibited a change in condition 3.5 hours prior to her death. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents with a change in condition at risk for complications and possible death. Findings included: The physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. An MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually understood others. The assessment indicated her cognition was severely impaired and she required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS indicated she was frequently incontinent of urine and bowel and had no falls during the assessment period. The care plan dated [DATE] indicated Resident #1 was at risk for falls and fractures due to decreased mobility. The interventions included to keep the call light within reach and encourage the resident to use it for assistance as needed and to follow the facility fall protocol. An incident report dated [DATE] at 2:10 p.m., indicated Resident #1 was found lying on her right side with her right arm under her in her bathroom. The incident report indicated the resident's wheelchair was across the room in front of her closet and she yelled out with pain in her left hip. The report indicated the physician was notified and an ambulance was called for transport to the emergency room (ER) for medical evaluation. The incident report was signed by LVN B. During an interview on [DATE] at 11:46 a.m., LVN B said on [DATE] at approximately 2:20 p.m., Resident #1 was found in her bathroom floor lying on her right side and she cried out in pain to her left hip. LVN B said she called for an ambulance and notified the physician of the fall and transport to the hospital for evaluation. LVN B said at approximately 4:30 p.m., the hospital called and said Resident #1 was ready to be transported back to the facility. She said the hospital staff said the resident had a contusion (bruise) to her right hip and no fracture. LVN B said she arranged transport for Resident #1 back to the facility prior to the end of her shift. LVN B said she reported Resident #1's fall, her symptoms and her transport back to the facility to the oncoming nurse, RN [NAME] LVN B said she left the facility before Resident #1 returned. An emergency department discharge summary dated [DATE] indicated the resident had a [DIAGNOSES REDACTED]. The summary indicated to resume all previous orders. A nursing note dated [DATE] at 6:30 p.m., indicated Resident #1 returned to the facility on [DATE] at 6:30 p.m., with orders to continue previous orders and a [DIAGNOSES REDACTED]. The note was signed by RN [NAME] A nursing note dated [DATE] at 8:30 p.m., indicated Resident #1 vomited a moderate amount of brown liquid. The note indicated Resident #1 kept complaining of being cold . and did not want to be moved in any way. The note did not indicate the physician was notified. The note was signed by RN [NAME] A nursing note dated [DATE] at 10:15 p.m., indicated Resident #1 vomited and her eyes rolled back, and she was unresponsive for a few seconds. The note indicated Resident #1 complained of being hot, her skin was cool and pale around her mouth and nose. The note indicated Resident #1 was restless and the nurse was unable to obtain a blood pressure and her pulse was weak and steady at 92 beats per minute. The note was signed by RN [NAME] The note did not indicate the physician was notified. A nursing note dated [DATE] at 11:45 p.m., indicated Resident #1 was assisted to sit up in a chair by her daughter. The note indicated Resident #1 said twice I have never felt this way before. The note indicated the nurse asked the resident's daughter to assist her back to bed and Resident #1 became still and unresponsive. The note indicated RN A was unable to obtain a blood pressure, pulse 89, temperature 95.6 and oxygen saturation was 62%. The nursing note indicated Resident #1 began agonal (struggling to breathe or gasping) breathing, pupils were set, and her time of death was [DATE] at 12:05 a.m. The note was signed by RN [NAME] A hospital fax report stamped received [DATE] at 9:13 a.m. of an x-ray Resident #1 received on [DATE] after her transport to the hospital, indicated she had a mildly displaced [MEDICAL CONDITION] superior and inferior pubic ramus at the symphysis (two or more breaks in the pelvic ring and the ends of the broken bones do not line up correctly). The report indicated no evidence of femur fracture. The report indicated Resident #1 was osteoporotic and the joint spaced and alignment were normal at the hips. During an interview on [DATE] at 8:35 a.m., RN A said on [DATE] she worked 4:30 p.m., to 6:00 a.m. She said she received information regarding Resident #1's fall, transport to the hospital and results of no fracture. RN A said at approximately 6:30 p.m., Resident #1 was back in the facility and her daughter was with her. She said the resident complained of pain on her left side when she was moved so they left her still on her back and she appeared to be comfortable. RN A said she assessed the resident and it appeared both hips were without bruising and no indication of a fracture. She said Resident #1 would not allow RN A to move her to her left side to look beneath her right hip because of pain. RN A said at approximately 8:30 p.m., Resident #1 vomited a brown substance. She said it was not a large amount and the resident denied nausea or pain. RN A said she called the hospital for a report of what was given to the resident in the emergency room and what test were completed. She said she spoke with the house supervisor and was told to send the request through fax. RN A said she was confused because the discharge form sent with Resident #1 from the hospital only contained a [DIAGNOSES REDACTED]. RN A said the resident continued to be in pain upon movement and she was concerned about her left hip. RN A said she did not give any medications to Resident #1 because she did not know what was given at the hospital. RN A said she sent the fax with the request to the hospital and she did not receive anything back during her shift. RN A said Resident #1 vomited again at approximately 10:15 p.m., and she became unresponsive for a few seconds then became lucid again and answered her questions. RN A said Resident #1 denied pain, was restless and her color was pale. She said the resident's skin was cool and clammy and she was unable to get a blood pressure. RN A said the resident's pulse was weak and steady at 92 beats per minute. She said Resident #1 complained of being hot, she put a fan in her room and a cool compress on her forehead. RN A said at approximately 10:15 p.m., Resident #1's daughter transferred her to a chair and the resident said, I have never felt this way before. RN A said the resident's daughter told her she thought her mother was dying. RN A said she assisted Resident #1 back in the bed and she became unresponsive and began agonal breaths. RN A said her oxygen saturation was 67% so she left the room to get oxygen and when she returned Resident #1 was expired. RN A said she was going to call the physician after she put the oxygen on the resident. RN A said she did everything she could, and the resident was a DNR, so she could not perform life saving measures. RN A said she did not think to call the physician prior to signs of impending death. During an interview on [DATE] at 9:04 a.m., Resident #1's daughter said on [DATE] at approximately 2:30 p.m., she received notification of the resident's transport to the hospital due to a fall and her complaints of left hip pain. She said she was with the resident in the emergency room and arrived with her back to the facility. Resident #1's daughter said the resident was not herself when she returned from the emergency room , and she was restless. The resident's daughter said she knew her mother was dying and there was nothing anyone could do but try to keep her comfortable. During an interview on [DATE] at 1:08 p.m., the DON said she expected the charge nurse to report any changes in condition to the physician. She said RN A was terminated because of the incident with Resident #1. The DON said all charge nurses had been in-serviced prior to the incident on when to report to the physician and have since been re-educated on changes in condition and when to notify the physician. During an interview on [DATE] at 1:40 p.m., the administrator said the charge nurses should follow the facility policies and procedures and report any changes in condition to the physician. A policy titled Changes in a Resident's Condition or Status with a revision date of (MONTH) (YEAR) .indicated . a significant change of condition is a major decline in the resident's status that impacts more than one area of the resident's health status .the nurse will notify the resident's physician when there has been a significant change in the resident's physical/emotional/mental condition . The surveyor determined the facility was in non-compliance from [DATE] to [DATE]. The facility took the following actions to correct the non-compliance: *An in-service dated [DATE] covering change of condition of a resident, physician notification, neglect and fall protocol was provided to nursing staff by the DON. *During interviews on [DATE], 4 LVNs were interviewed and indicated they received training prior to surveyor's entrance to evaluate a resident any time it was reported there was a change of condition and notify the physician immediately when a resident had a change in condition. *During interviews on [DATE], 4 CNAs were interviewed and indicated they received training prior to surveyor's entrance to notify the charge nurse immediately when a resident had a change of condition.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was individualized for resident care needs for 1 of 16 residents reviewed for care plans. (Resident #10) The facility did not update or revise Resident #10's care plan for falls. Resident #10 had a history of [REDACTED]. On [DATE] she sustained a hemorrhage at the base of her brain from a fall from her wheelchair, and on [DATE] she sustained a laceration to her forehead and fractured neck from a fall from bed. Resident #10 died in the hospital [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents identified as high fall risks at risk for injuries or death. Findings included: Consolidated physician orders [REDACTED].#10 was [AGE] years old, readmitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #10 usually made herself understood and usually understood others. She required extensive assistance with bed mobility and transfers requiring a two person assist. She was frequently incontinent of bowel and bladder. The assessment indicated she had falls prior to re-entry and two or more falls with no injury. A fall risk assessment dated [DATE] indicated Resident #10 had no history of falls in the past three (3) months. She was not able to perform the functions of gait/balance and was a high risk for falls. An undated care plan with problem onset of [DATE] indicated Resident #10 had poor safety awareness and was at risk for falls, with actual fall dates listed as: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The goal and target indicated Resident #10 would not experience any injuries related to falls and would be free of any falls through [DATE]. Approaches included .the hospitality aide would visit in afternoon for activities, refer to physical therapy for evaluation, reinforce teaching to use call light for assist with all transfers, nonslip socks/shoes, take to toilet after meals, do not leave in recliner unattended, assist with one staff for all ambulation, monitor for changes in condition that may warrant increased supervision, and notify physician, and use wheelchair for long distances . The incident/accident reports for Resident #10 included the following: *[DATE] at 10:15 p.m., Resident #10 was found on the floor beside her bed with her back against her bed. Actions taken: Made adequate and frequent visual checks. *[DATE] at 11:30 p.m., Resident #10 was found on the floor beside her bed. Actions taken: frequent visual checks and daughter-in-law will bring nonskid socks. *[DATE] at 9:30 p.m., Resident #10 was standing up from her wheelchair, lost her balance and fell against a bookshelf at the nurse station. CNA caught resident before falling any further. Actions taken: activity provided and toileted. *[DATE] at 8:40 p.m., a visitor heard Resident #10 yelling for help. She was found in the floor in front of her recliner not wearing nonskid socks and the floor was wet. Actions taken: assess for injuries. *[DATE] at 1:50 p.m., Resident #10 was found by CNA sitting in the floor beside her bed. Action taken: none. *[DATE] at 1:50 p.m., a CNA heard Resident #10 saying help lady and was found in the floor. No location was given. Action taken: assess resident. *[DATE] at 1:11 a.m., a CNA heard Resident #10 saying mama and she was found on the floor beside her bed in front of her recliner. Actions taken: pain and fall assessment completed and neuro checks started. *[DATE] at 2:32 a.m., a nurse heard Resident #10 talking and when she entered her room she was found on the floor beside her bed in front of the recliner. Actions taken: pain and fall assessment completed and neuro checks were started. *[DATE] at 10:45 p.m., a nurse witnessed Resident #10 slide off her bed onto the floor. Actions taken: pain assessment and fall assessment completed *[DATE] at 9:00 p.m., Resident #10 was at nurses' station being combative with staff and other residents, leaned forward to slap a staff member and fell out of her wheelchair hitting her head sustaining a laceration to her right brow and a hemorrhage at the base of her brain. Action taken: sent to emergency room . A nurse noted dated [DATE] at 11:27 p.m., indicated Resident #10 forgets she can't walk and lowering her bed to the floor may be safer for the resident with a fall mat at the bedside. The hospital records dated [DATE] indicated Resident #10 was admitted to the intensive care unit (ICU) status [REDACTED]. The history of her present illness indicated Resident #10 was involved in a fight at the nursing home and while hitting out at staff she fell and sustained a laceration over the right eyebrow. The report indicated Resident #10 was not a surgical candidate. An incident/accident report dated [DATE] at 2:20 a.m., a nurse heard Resident #10's bed alarm sounding and she was found on the floor beside her bed bleeding from her face and forehead. Resident #1 sustained a large laceration to her mid forehead, greater than 5 cm (centimeters) and top bridge of her nose approximately 3 cm. Action taken: head secured and left flat. The hospital records dated [DATE] indicated Resident #10 was admitted status [REDACTED]. During an interview on [DATE] at 2:35 p.m., LVN C said Resident #10 did have a history of falls. She said she did not recall any intervention being put into place. During an interview on [DATE] at 2:42 p.m., CNA E said she was not aware Resident #10 had a history of [REDACTED]. During an interview on [DATE] at 2:48 p.m., CNA G said Resident #10 had a history of [REDACTED]. During an interview on [DATE] at 9:19 a.m., LVN H said Resident #10 had a fall mat and had not had a bed alarm for very long, she could not recall how long. She said she did not have a low bed, a scoop mattress, or bolsters. During an interview on [DATE] at 9:25 a.m., LVN J said Resident #10 had a history of [REDACTED]. She said Resident #10 did not have a low bed. She said Resident #10 was on frequent monitoring, but there was no documentation of how often or who monitored. LVN J said nurses write physician orders [REDACTED]. During an interview on [DATE] at 9:25 a.m., the DON said Resident #10 had a fall mat and a bed alarm but could not recall how long she had them. She said she did not have bolsters, or a scoop mattress because she was afraid she would hurt herself climbing over it. She said orders were written for safety equipment and all interventions should be written on the care plan and updated accordingly. She said care cards were placed in the closets of residents' rooms for a quick reference as to what safety equipment a resident should have. The DON said nurses were responsible for making sure safety equipment was functioning and in place. She said the measures should be checked off on the TAR every shift. She said staff were doing frequent visual checks, but there was no documentation, and no other interventions were implemented. During an interview on [DATE] at 9:46 a.m., the MDS Coordinator said safety equipment required a written order and all interventions should be added to the care plan as needed. During an interview on [DATE] at 9:54 a.m., the ADON said Resident #10 had a fall mat and a bed alarm, she could not recall how long she had them. She said Resident #10 had a sitter for four hours a day, at different times of the day. She said she did not recall any other interventions to prevent Resident #10 from falling. She said orders should be written for interventions put into place. She said she could not find orders for any safety equipment for Resident #10. During an interview on [DATE] at 10:03 a.m., LVN K said Resident #10 had a fall mat and a bed alarm and no other interventions were initiated. She said the staff did a lot of visual monitoring for Resident #10 but there was no documentation of the monitoring. During an interview on [DATE] at 10:30 a.m., PTA L said therapy made the recommendation to make frequent checks on Resident #10 and did not recommend any other interventions. She said she did not have a low bed. During an interview on [DATE] at 11:03 a.m., the administrator said she could not find the in-service she conducted after Resident #10's fall on [DATE]. She said she documented in her investigation report to the state agency that she conducted an in-service on falls. During an interview on [DATE] at 11:51 a.m., Resident #10's sitter said the only safety equipment the resident had was a bed alarm and a fall mat. She said some days she had a fall mat and some days she did not. She said the facility did not initiate any other interventions for fall prevention During an interview on [DATE] at 12:05 p.m., the administrator said the facility did use low beds. During an interview on [DATE] at 1:50 p.m., the DON said there was no reason Resident #10 could not have used a low bed. During an interview on [DATE] at 1:51 p.m., the MDS Coordinator said physician orders [REDACTED]. She said it was her responsibility to update care plans and the care plan was updated when orders were written for interventions and also when an incident report was written. She said she did not see any orders for safety equipment and there were no interventions documented on the incident/accident reports and she said she did not update the care plan. During an interview on [DATE] at 2:27 p.m., the DON said she did not know if the MDS was correct or not regarding Resident #10's bed mobility. She said some days she could get out of bed on her own and other days she required a two person transfer. During an interview on [DATE] at 2:35 p.m., the administrator said there was no tool for frequent checks and there was no time on frequent checks. She said an order was not needed to initiate frequent checks. She said the facility did not do visual monitoring often and it was used for new residents and residents with behaviors. During an interview on [DATE] at 2:57 p.m., LVN H said Resident #10 was active at night. She said between the nurse and the CNA on duty they checked her every hour. LVN H said she did not document frequent checks, and documentation was often lacking due to patient care. LVN H said Resident #10 would get out of bed and fall straight to the floor. A Policy for Resident Incident and Visitor Accident Report policy revised on ,[DATE] indicated an incident report must be filled out by the person reporting the incident or the supervisor on the shift that the incident occurred. Pertinent documentation must be completed: incident witness form, incident report, nurse progress note .the charge nurse much immediately initiate and investigation to determine the circumstances of the incident/accident .documentation in the medical record: action taken to prevent a re-occurrence .the DON/designee completes the investigation follow up on the Investigation report form to come to a reasonable conclusion regarding the causative factors surrounding the incident and the actions necessary to prevent further incident/accidents .safety committee and QA committee will review the Incident/Accident trending log for discussion on how incidents/accidents may be prevented. A Fall Prevention Program revised on ,[DATE] indicated all residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of the assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A Policy For Prohibition of Abuse, Neglect, and Misappropriation of Property dated [DATE] indicated each resident has the right to be free from .neglect .The facility will prohibit neglect .neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The administrator and corporate nurse were notified on [DATE] at 3:12 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 4:55 p.m., and included: *Residents that have been identified through fall risk assessments with determination of high risk will immediately be reviewed by the IDT. This includes, nursing , rehab, activities, social services, MDS and restorative. Interventions, for prevention and reoccurrence of falls will be reviewed to determine effectiveness of approaches and interventions in place. A 60 days look back of all falls will be completed to determine trends for each resident affected. Completed today. *Care plans and care guide sheets will be updated to include specific plan and approaches for each resident affected. Completed today. *Staff inservice will be initiated immediately to include interventions and policy related to fall prevention program, by the regional nurse and regional director of operations. Facility will ensure that all staff has been inserviced prior to working their shift. CNA care guide sheets will be updated today to communicate specific resident needs. *Administration will determine comprehension of staff by test and verbal understanding. *MDS nurse has been inserviced on Fall Prevention care3 plans by the regional MDS nurse today. On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Interviews with 6 nurses, 8 CNAs, and 2 MAs who said they were in-serviced on fall prevention and implementing interventions. Care plans and care guide sheets were confirmed to have been updated. On [DATE] at 10:23 a.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 9:45 a.m., the administrator said 44 residents were at high risks for falls.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents reviewed for accidents. (Residents #10) Resident #10 had a history of [REDACTED]. On [DATE] she sustained a hemorrhage at the base of her brain from a fall from her wheelchair, and on [DATE] she sustained a laceration to her forehead and fractured neck from a fall from bed. Resident #10 died in the hospital [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents identified as high fall risks at risk for injuries or death. Findings included: 1.Consolidated physician orders [REDACTED].#10 was [AGE] years old, readmitted [DATE], with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #10 usually made herself understood and usually understood others. She required extensive assistance with bed mobility and transfers requiring a two person assist. She was frequently incontinent of bowel and bladder. The assessment indicated she had falls prior to admission. A fall risk assessment dated [DATE] indicated Resident #10 had no history of falls in the past three (3) months. She was not able to perform the functions of gait/balance and was a high risk for falls. An undated care plan with problem onset of [DATE] indicated Resident #10 had poor safety awareness and was at risk for falls, with actual fall dates listed as: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The goal and target indicated Resident #10 would not experience any injuries related to falls and would be free of any falls through [DATE]. Approaches included .the hospitality aide would visit in afternoon for activities, refer to physical therapy for evaluation, reinforce teaching to use call light for assist with all transfers, nonslip socks/shoes, take to toilet after meals, do not leave in recliner unattended, assist with one staff for all ambulation, monitor for changes in condition that may warrant increased supervision, and notify physician, and use wheelchair for long distances . The incident/accident reports for Resident #10 included the following: *[DATE] at 10:15 p.m., Resident #10 was found on the floor beside her bed with her back against her bed. Actions taken: Made adequate and frequent visual checks. *[DATE] at 11:30 p.m., Resident #10 was found on the floor beside her bed. Actions taken: frequent visual checks and daughter-in-law will bring nonskid socks. *[DATE] at 9:30 p.m., Resident #10 was standing up from her wheelchair, lost her balance and fell against a bookshelf at the nurse station. CNA caught resident before falling any further. Actions taken: activity provided and toileted. *[DATE] at 8:40 p.m., a visitor heard Resident #10 yelling for help. She was found in the floor in front of her recliner not wearing nonskid socks and the floor was wet. Actions taken: assess for injuries. *[DATE] at 1:50 p.m., Resident #10 was found by CNA sitting in the floor beside her bed. Action taken: none. *[DATE] at 1:50 p.m., a CNA heard Resident #10 saying help lady and was found in the floor. No location was given. Action taken: assess resident. *[DATE] at 1:11 a.m., a CNA heard Resident #10 saying mama and she was found on the floor beside her bed in front of her recliner. Actions taken: pain and fall assessment completed and neuro checks started. *[DATE] at 2:32 a.m., a nurse heard Resident #10 talking and when she entered her room she was found on the floor beside her bed in front of the recliner. Actions taken: pain and fall assessment completed and neuro checks were started. *[DATE] at 10:45 p.m., a nurse witnessed Resident #10 slide off her bed onto the floor. Actions taken: pain assessment and fall assessment completed *[DATE] at 9:00 p.m., Resident #10 was at nurses' station being combative with staff and other residents, leaned forward to slap a staff member and fell out of her wheelchair hitting her head sustaining a laceration to her right brow and a hemorrhage at the base of her brain. Action taken: sent to emergency room . The hospital records dated [DATE] indicated Resident #10 was admitted to the intensive care unit (ICU) status [REDACTED]. The history of her present illness indicated Resident #10 was involved in a fight at the nursing home and while hitting out at staff she fell and sustained a laceration over the right eyebrow. The report indicated Resident #10 was not a surgical candidate. A nurse noted dated [DATE] at 11:27 p.m., indicated Resident #10 . forgets she can't walk and lowering her bed to the floor may be safer for the resident with a fall mat at the bedside . An incident/accident report dated [DATE] at 2:20 a.m., a nurse heard Resident #10's bed alarm sounding and she was found on the floor beside her bed bleeding from her face and forehead. Resident #1 sustained a large laceration to her mid forehead, greater than 5 cm (centimeters) and top bridge of her nose approximately 3 cm. Action taken: head secured and left flat. The hospital records dated [DATE] indicated Resident #10 was admitted status [REDACTED]. The facility investigation report dated [DATE], indicated Resident #10 was placed on inpatient hospice at a local hospital and expired on [DATE]. During an interview on [DATE] at 2:35 p.m., LVN C said Resident #10 did have a history of falls. She said she did not recall any intervention being put into place. During an interview on [DATE] at 2:42 p.m., CNA E said she was not aware Resident #10 had a history of [REDACTED]. During an interview on [DATE] at 2:48 p.m., CNA G said Resident #10 had a history of [REDACTED]. During an interview on [DATE] at 9:19 a.m., LVN H said Resident #10 had a fall mat and had not had a bed alarm for very long, she could not recall how long. She said she did not have a low bed, a scoop mattress, or bolsters. During an interview on [DATE] at 9:25 a.m., LVN J said Resident #10 had a history of [REDACTED]. She said Resident #10 did not have a low bed. She said Resident #10 was on frequent monitoring, but there was no documentation of how often or who monitored. LVN J said nurses write physician orders [REDACTED]. During an interview on [DATE] at 9:25 a.m., the DON said Resident #10 had a fall mat and a bed alarm, but could not recall how long she had them. She said she did not have bolsters, or a scoop mattress because she was afraid she would hurt herself climbing over it. She said orders were written for safety equipment and all interventions should be written on the care plan and updated accordingly. She said care cards were placed in the closets of residents' rooms for a quick reference as to what safety equipment a resident should have. The DON said nurses were responsible for making sure safety equipment was functioning and in place. She said the measures should be checked off on the TAR every shift. She said staff were doing frequent visual checks, but there was no documentation, and no other interventions were implemented. During an interview on [DATE] at 9:46 a.m., the MDS Coordinator said safety equipment required a written order and all interventions should be added to the care plan as needed. During an interview on [DATE] at 9:54 a.m., the ADON said Resident #10 had a fall mat and a bed alarm, but could not recall how long she had them. She said Resident #10 had a sitter for four hours a day, at different times of the day. She said she did not recall any other interventions to prevent Resident #10 from falling. She said orders should be written for interventions put into place. She said she could not find orders for any safety equipment for Resident #10. During an interview on [DATE] at 11:51 a.m., Resident #10's sitter said the only safety equipment the resident had was a bed alarm and a fall mat. She said some days she had a fall mat and some days she did not. She said the facility did not initiate any other interventions for fall prevention During an interview on [DATE] at 10:03 a.m., LVN K said Resident #10 had a fall mat and a bed alarm and no other interventions were initiated. She said the staff did a lot of visual monitoring for Resident #10, but there was no documentation of the monitoring. During an interview on [DATE] at 10:30 a.m., PTA L said therapy made the recommendation to make frequent checks on Resident #10 and did not recommend any other interventions. She said she did not have a low bed. During an interview on [DATE] at 11:03 a.m., the administrator said she could not find the in-service she conducted after Resident #10's fall on [DATE]. She said she documented in her investigation report to the state agency that she conducted an in-service on falls. During an interview on [DATE] at 12:05 p.m., the administrator said the facility did use low beds. During an interview on [DATE] at 1:50 p.m., the DON said there was no reason Resident #10 could not have used a low bed. During an interview on [DATE] at 1:51 p.m., the MDS Coordinator said physician orders [REDACTED]. She said it was her responsibility to update care plans and the care plan was updated when orders were written for interventions and also when an incident report was written. She said she did not see any orders for safety equipment and there were no interventions documented on the incident/accident reports and she said she did not update the care plan. During an interview on [DATE] at 2:27 p.m., the DON said she did not know if the MDS was correct or not regarding Resident #10's bed mobility. She said some days she could get out of bed on her own and other days she required a two person transfer. During an interview on [DATE] at 2:35 p.m., the administrator said there was no tool for frequent checks and there was no time on frequent checks. She said an order was not needed to initiate frequent checks. She said the facility did not do visual monitoring often and it was used for new residents and residents with behaviors. During an interview on [DATE] at 2:57 p.m., LVN H said Resident #10 was active at night. She said between the nurse and the CNA on duty they checked her every hour. LVN H said she did not document frequent checks, and documentation was often lacking due to patient care. LVN H said Resident #10 would get out of bed and fall straight to the floor. A Fall Prevention Program revised on ,[DATE] indicated all residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of the assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A Policy for Resident Incident and Visitor Accident Report policy revised on ,[DATE] indicated an incident report must be filled out by the person reporting the incident or the supervisor on the shift that the incident occurred. Pertinent documentation must be completed: incident witness form, incident report, nurse progress note .the charge nurse much immediately initiate and investigation to determine the circumstances of the incident/accident .documentation in the medical record: action taken to prevent a re-occurrence .the DON/designee completes the investigation follow up on the Investigation report form to come to a reasonable conclusion regarding the causative factors surrounding the incident and the actions necessary to prevent further incident/accidents .safety committee and QA committee will review the Incident/Accident trending log for discussion on how incidents/accidents may be prevented. The administrator and corporate nurse were notified on [DATE] at 3:12 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 4:55 p.m., and included: *Residents that have been identified through fall risk assessments with determination of high risk will immediately be reviewed by the IDT. This includes, nursing , rehab, activities, social services, MDS and restorative. Interventions, for prevention and reoccurrence of falls will be reviewed to determine effectiveness of approaches and interventions in place. A 60 days look back of all falls will be completed to determine trends for each resident affected. Completed today. *Care plans and care guide sheets will be updated to include specific plan and approaches for each resident affected. Completed today. *Staff inservice will be initiated immediately to include interventions and policy related to fall prevention program, by the regional nurse and regional director of operations. Facility will ensure that all staff has been inserviced prior to working their shift. CNA care guide sheets will be updated today to communicate specific resident needs. *Administration will determine comprehension of staff by test and verbal understanding. *MDS nurse has been inserviced on Fall Prevention care3 plans by the regional MDS nurse today. On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Interviews with 6 nurses, 8 CNAs, and 2 MAs who said they were in-serviced on fall prevention and implementing interventions. Care plans and care guide sheets were confirmed to have been updated. On [DATE] at 10:23 a.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 9:45 a.m., the administrator said 44 residents were at high risks for falls.

Based on interview and record review the facility failed to consult the physician regarding elevated blood sugar levels for 1 of 4 residents reviewed with diabetes. (Resident #1) Resident #1 was a brittle diabetic (hard-to-control swings in blood glucose levels). The facility did not consult with the physician regarding: *accepatable parameters for the resident's blood sugars; *insulin orders for the amount and timing of administration when the resident's blood sugars exceeded acceptable limits; *correct instructions for administration of Resident #1's diabetic medication; and *from at [DATE] through [DATE] regarding nursing procedures for the resident's high blood sugars. Resident #1 was admitted to the hospital [DATE] in critical condition with [DIAGNOSES REDACTED]. Resident #1 died [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 5:54 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #1's hospitalization for diabetic ketoacidosis. An Immediate Jeopardy situation was identified on [DATE].The immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at pattern of actual harm due to the facility's need to develop a policy, train the nursing staff, and evaluate the effectiveness of the corrective systems. This failure could place 11 residents with diabetes at risk for not receiving timely medical evaluation and treatment. Findings included: Physician orders [REDACTED]. The orders required her to receive [MEDICATION NAME] 0.5 units per hour from midnight to 10 a.m., 0.6 units per hour from 10 a.m. to 10 p.m. and 0.4 units per hour from 10 p.m. to midnight. The orders indicated the insulin cartridge of [MEDICATION NAME] should be changed every 6 days. The orders required Resident #1 to receive finger stick blood sugar monitoring twice a day. Physician orders [REDACTED]. The orders indicated Resident #1's physician was to follow her care and provide adjustments for insulin pump management as needed. The section of the orders titled "General Parameters" indicated the high blood sugar allowable range was 120 to 350. The MDS dated [DATE] indicated Resident #1 always understood others, was always able to make herself understood, had adequate vision and was independent with all her ADLs. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #1 had diabetes and had "labile blood sugars". The care plan goal indicated Resdient 1's blood sugars would be below 120. Care plan interventions required staff to: *obtain finger stick blood sugars as ordered; *observe for signs and symptoms of low and high blood sugars; and *administer [MEDICATION NAME] per physician order. The careplan did not address when to consult with the physician regarding Resident #1's blood sugar. MARs dated [DATE] indicated Resident #1's blood sugar level was as follows: *[DATE] at 11:30 a.m. and 4:30 p.m. - "Hi" *[DATE] at 2:00 a.m. and 4:00 a.m. - blank *[DATE] at 11:30 a.m. - 437 *[DATE] at 7:30 p.m. - 474 *[DATE] at 2:00 a.m. - 369 *[DATE] at 7:30 p.m. - blank *[DATE] at 4:30 p.m. - 438 *[DATE] at 7:30 p.m. - 355 *[DATE] at 6:30 a.m. - 9:00 a.m., 11:30 a.m. and 2:00 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 6:30 a.m. and 4:30 p.m. - blank *[DATE] at 2:00 a.m. - 394 *[DATE] at 4:00 a.m. - 516 *[DATE] at 4:30 p.m. and 7:30 p.m. - blank The undated "Blood Glucose Monitoring System Guide" provided with the blood glucose machine used by the facility indicated a reading of "HI" meant the resident's blood sugar was greater than 600. The guide indicated the physician or healthcare professional should be notified immediately. MARs dated [DATE] indicated Resident #1's blood sugar level was as follows: *[DATE] at 4:00 a.m. - blank *[DATE] at 2:00 a.m. - 366, 4:30 p.m. - 386, and 2:00 a.m. - 488 *[DATE] at 4:00 a.m. - 396 *[DATE] at 4:30 p.m. and 7:30 p.m. - blank *[DATE] at 2:00 p.m. - blank and 4:30 p.m. - 437 *[DATE] at 4:30 p.m. - 448 and 7:30 p.m. - 364 *[DATE] at 2:00 a.m. - 388 and 4:30 p.m. - 440 *[DATE] at 4:30 p.m. - Hi and 7:30 p.m. - 374 *[DATE] at 2:00 a.m. - 509, 2:00 a.m. - 457, 4:30 p.m. and 7:30 p.m. - blank *[DATE] at 9:00 a.m. - blank and11:30 a.m. - 383 *[DATE] at 9:00 a.m. - blank,11:30 a.m. - 400, and 4:30 p.m. - 407 *[DATE] at 4:30 p.m. - 452 and 7:30 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 2:00 a.m. - 411, 4:30 p.m. - 376 and 2:00 p.m. blank *[DATE] at 2:00 a.m. - 414, 4:00 a.m. - 364, 9:00 a.m., 2:00 p.m. and 7:30 p.m. - blank, and 4:30 p.m. - 522 *[DATE] at 2:00 a.m. - 377; at 9:00 a.m., 2:00 p.m. and 7:30 p.m. - blank *[DATE] at 2:00 a.m. - 613, 4:00 a.m. - 521, 6:30 a.m. - 435 *[DATE] at 7:30 p.m. - blank *[DATE] at 2:00 a.m. - Hi at 4:00 a.m. - 600, 6:30 a.m. - 511, 9:00 a.m. - 364, and 2:00 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 11:30 a.m. - 396, and 2:00 p.m. - blank *[DATE] at 4:30 p.m. - 391, and 7:30 p.m. - blank *[DATE] at 2:00 a.m. - 501, 4:00 a.m. - 433, 6:30 a.m. - 360, 11:30 a.m. - Hi *[DATE] at 4:30 p.m. - Hi and 7:30 p.m. - 376 MARs dated [DATE] indicated Resident #1's blood sugar level was as follows: *[DATE] at 4:30 p.m. - 434 *[DATE] at 4:30 p.m. - 475 *[DATE] at 4:30 p.m. - blank *[DATE] at 4:30 p.m. - Hi *[DATE] at 6:30 p.m. - Hi, untimed - Hi and 4:30 p.m. - 507 *[DATE] at 6:30 a.m. - 397 *[DATE] at 4:30 p.m. - 499 *[DATE] at 4:30 p.m. - 389 *[DATE] at 6:30 a.m. - Hi *[DATE] at 6:30 a.m. - Hi and 4:30 p.m. - 468 Resident #1's nursing notes indicated the following: *,[DATE] to [DATE] - nothing documented; *[DATE] at 8:00 a.m. - orders were received to increase Resident #1's [MEDICATION NAME]; *,[DATE] to [DATE] - nothing documented regarding blood sugars; *[DATE] at 1:30 p.m. - "blood sugar 376 no complaints noted". *,[DATE] to ,[DATE] - nothing documented regarding blood sugars; *[DATE] - new orders were received to monitor Resident #1's blood sugars twice a day; *[DATE] - blood sugar stable; *,[DATE] to [DATE] - nothing documented; *[DATE] at 4:45 a.m. - blood sugar 489 *,[DATE] to [DATE] - nothing documented regarding blood sugars. During an interview on [DATE] at 10:20 a.m. LVN A said Resident #1's blood sugar level read "hi" she did not alter what she did for the resident. She said she did not always consult the physician for blood glucose reading higher than 400 because Resident #1 always ran high. She said she did not have parameters for Resident #1's blood sugar levels. During an interview on [DATE] at 10:32 a.m. LVN D said Resident #1's blood glucose level read "hi" she would administer Resident #1's regular scheduled [MEDICATION NAME]. She said she would not re-check the blood glucose reading. She said she did not always consult the physician and did not always document when she did consult the physician. During an interview on [DATE] at 11:09 a.m., LVN C said Resident #1 had an insulin pump that continuously administered insulin and she received a [MEDICATION NAME] dose of insulin three times a day. She said she was not sure what "hi" meant on the machine they used to check blood sugars but she thought it meant the resident's blood sugar was greater than 400. She said she did not consult with Resident #1's physician regarding her blood sugar after Resident #1 received the insulin pump. She said, "If I called the doctor every time her blood sugar was high, I would be calling him quite often." She said Resident #1 was very asymptomatic with regard to high blood sugar and she would not consult with the physician unless Resident #1 was symptomatic. During an interview on [DATE] at 12:25 p.m., LVN D said she thought a "hi" reading on the blood sugar machine meant the resident's blood sugar was greater than 500 but she wasn't sure. She said she had not received training regarding the machine used to check blood sugars. She said Resident #1 did not have parameter for consulting with the physician regarding her blood sugars after she received the insulin pump. She said after receiving the insulin Resident #1's "normal" blood sugars in the "mid 250's". She said a "hi" reading was unusual but she would not consult the physician until Resident #1's blood sugar had been high for ",[DATE] days". During an interview on [DATE] at 12:41 p.m., LVN A said a reading of "hi" on the blood sugar machine meant the resident's blood sugar could not be read by the machine. She said she thought it meant the resident's blood sugar was greater than 500. She said the only training she received regarding the blood sugar machine was a brief inservice by the supplier when they started using the machine. She said Resident #1's blood sugar had registered "hi" before when she checked but she could not remember if she had consulted with the physician regarding the reading. During an interview on [DATE] at 3:40 p.m. LVN B said Resident #1 did not have blood sugar parameters after she received the insulin pump. She said she would only consult the physician if resident #1's blood sugars ran high ,[DATE] days in a row. She said she thought a "hi" meant the resident's blood sugar was greater than 500. During an interview on [DATE] at 2:00 p.m., Resident #1's physician said Resident #1 had been a "brittle diabetic" for years. He said he admitted Resident #1 to the facility so she could get an insulin pump and stabilize her blood sugar levels. He said Resident #1 suffered from "autonomic nerve [MEDICAL CONDITION]" and was unaware of when her blood sugars were high or low. He said he "would definitely expect a call if Resident #1's blood sugar were greater than 400". He said his goal for Resident #1's blood sugar was 250. The "Obtaining a Fingerstick Glucose Level" policy dated [DATE] read, "Documentation 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on a sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc." During an interview on [DATE] at 12:57 p.m. the DON said they did not have a policy for reporting blood sugars. She said they would go by the physician orders [REDACTED]. She said Resident #1 received a pump because she was a "brittle diabetic". She said Resident #1 had blood sugar parameters to report prior to receiving her pump but not after. She said, in the absence of a physician order [REDACTED]. The facility routine order protocol dated [DATE] did not address consulting with the physician regarding blood sugar levels. During an interview on [DATE] at 12:57 p.m. the DON said, "I really don't know what I would report. I guess 350 - 400." Resident #1's nursing notes dated [DATE] indicated the following: *at 5:30 p.m., Resident #1 was non-responsive. Her respirations were labored. Staff were unable to obtain a blood pressure or oxygen saturation reading. *at 5:35 p.m., Resident #1 was not breathing and CPR was initiated by the EMS. *at 6:15 p.m., Resident #1 was transferred to the local hospital. An EMS transfer record dated [DATE] indicated Resident #1 was transferred from the facility in [MEDICAL CONDITION]. An emergency department workup dated [DATE] indicated Resident #1 was received from the nursing home unresponsive with agonal respirations (an abnormal pattern of breathing characterized by gasping and labored breathing). Her glucose level was 1102. The work-up indicated Resident #1 was transferred to a hospital that could provide a higher level of care. A hospital history and physical dated [DATE] indicated Resident #1 was admitted to the ICU on mechanical ventilator support and an IV insulin drip. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. The website, http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm, accessed [DATE], indicated diabetic ketoacidosis was a medical emergency and could lead to severe illness or death. Immediate Jeopardy The administrator was notified on [DATE] at 4:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:38 p.m. and included: *"On Nov. 7, 2012 Parameters for notification to MD by the Director of Nurses by written standing orders related to high and low results of fingerstick blood sugar tests were signed by the physicians and added to the fingerstick orders. All residents with diabetes will receive blood sugar monitoring. Parameters are to notify MD when blood sugar is less than 60 or greater than 400. These parameters are indicated in writing on the fingerstick order on the Treatment Administration record. In-service for Licensed Nurses is scheduled to be conducted on [DATE] by the ADON and prior to the next scheduled shift to work by the ADON and [DATE] by Nurse Practitioner and the Regional Clinical Specialist with a completion date for all licensed staff by [DATE]. *Diabetic residents that receive blood sugar monitoring will have their care plans updated with parameter notification to MD by [DATE]. *Licensed Nurses will receive In-service training on [DATE] by the ADON and prior to the next shift to work and on [DATE] by Nurse Practitioner and Regional Clinical Specialist with a completion date for all licensed staff by [DATE], related to that the nurse must provide the physician with accurate and complete information for incidents that occur. Incident reports must be completed and assessments must be completed for any incident. This information should include date and time, location, how, where, why and what possibly contributed to the occurrence of the incident. Assessment should include Vital signs, type of injury, description and location of pain, physical assessment of all areas of the body, and any treatment provided. They should not move a resident from the location of the incident until a complete and thorough assessment is done, and then only if it is safe to do so as to not cause further injury and only if the resident is not in pain. Physician and Responsible party notification of all incidents that occur must be done. Residents must also be assessed for changes of condition with physical assessment, vital signs, possible causative factors, and perform any testing such as blood sugars, urine dipsticks, Oxygen saturations that may pertain to their change of condition with a completion date for all licensed staff by [DATE]. *Licensed Nurses will receive In-service training on Nov. 8, 2012 by the ADON and prior to their next shift to work and on [DATE] by Nurse Practitioner and the Regional Clinical Specialist related to falsification of documentation. They will be informed that falsification of documentation and or falsification of any information pertaining to a resident in their care will be grounds for suspension, and possible termination and referral to the Board of Nurse Examiners, with a completion date for all licensed staff by [DATE]. *An In-service on [DATE] by the Administrator for the DON was conducted related to all incident reports must be investigated by the DON, and this should be completed within 3 days of the incident occurring. All incident reports will be brought to the morning meeting for review. If the DON needs assistance in the investigation they should contact the Regional Clinical Specialist. *If in the future this facility admits a resident with an insulin pump, or has a resident that requires an insulin pump, the following process will be followed: *The manufacturer of the pump will be contacted and requested to provide operational information and educational In-servicing to the licensed staff prior to the resident coming into the facility with the pump in place. The licensed staff will also receive In-servicing on signs and symptoms of hypo/[MEDICAL CONDITION] and reporting these to the MD. The Medical Director will oversee the resident for any complications that may occur. In the event he is not available, the protocol for managing the residents' blood sugars will be to disconnect the insulin pump, take blood sugar reading by fingerstick every 2 hours until further instructions received from the MD. In case of abnormal blood sugar readings the staff will follow the standing orders for sliding scale using Humalog insulin in the case of hyperglycemic results and D50 glucose tablets in the case of hypoglycemic results. " Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: *A copy of signed physician standing orders for reporting blood sugars was verified; *All diabetic resident's treatment administration records were checked for updated parameter notification and instruction; *All diabetic resident's clinical records were checked for updated care plans with parameter notification *Seven licensed nurses were interviewed to verify knowledge of inservice training received in relation to notification to physician and or responsible party following injury or change of condition, completion of assessments, incident reports and investigations, how to properly assess a resident following an injury or change of condition and falsification of documents *A copy of signed standing orders for protocol of insulin pumps was verified On [DATE] at 11:40 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm due to the facility's need to develop a policy, complete in-service training and evaluate the effectiveness of the corrective systems. A resident census list dated [DATE] indicated 11 residents had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibited neglect, for 1 of 9 residents reviewed for neglect. (Resident #1) Resident #1 was at risk for elopement and required supervision when outside. The facility did not: *provide supervision to prevent Resident #1 from leaving the facility. She was found across the highway in a ditch with fractures; *ensure the Wandergard system (a device that automatically locks doors and alarms when designated residents attempt to exit) was functional on 2 doors; *ensure staff were aware of which residents were exit seekers; *ensure 4 staff used correct protocol when the resident was found injured off of the facility property; *did not provide the hospital with correct information regarding the resident's incident; after being found in the ditch, 4 staff took the resident back to facility before they called EMS. On [DATE] Resident #1 was sent to the hospital and treated for [REDACTED]. The resident was taken back to the hospital and was admitted on [DATE]. Resident #1 died at the hospital on [DATE]. This failure contributed to Resident #1's elopement, injury, hospitalization and death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 5:54 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 4 residents who were at risk for elopement at risk for injury or death. Findings included: Physician orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 always understood others and was always able to make herself understood had adequate vision and was independent with all her ADLs. The MDS indicated Resident #1 had trouble sleeping, felt bad about herself or that she was a failure or had let herself or her family down for half or more of the days in the past two week period. The MDS indicated Resident #1 did not exhibit wandering behavior in the prior seven days. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #1 had a life long history of depression and was tearful at time. The care plan indicated the resident would be observed for changes in mood status and would be monitored for behavior at least every shift and the physician would be notified of any negative behavior. The care plan indicated Resident #1 had decreased vision and required assistance with ADLs and ambulation, supervision when smoking, and that she was at risk for elopement, wearing a Wanderguard bracelet to prevent unsupervised exits. Care plan interventions required staff to check Resident #1 frequently for wandering and remove her from unsafe situations. The wander data collection tool dated [DATE] was incomplete and did not indicate if Resident #1 was at risk for elopement. Nursing notes dated [DATE] indicated Resident #1 returned from being out on pass with her husband and began to exhibit exit seeking behaviors and/or behavior changes at the following times: *2:00 p.m. crying, exit seeking *3:18 p.m. verbally aggressive, cursing *3:40 p.m. exit seeking, difficult to redirect *4:10 p.m. exited facility *9:30 p.m. exit seeking *11:00 p.m. verbally aggressive, cursing, threats of physical violence, unable to calm *11:30 p.m. crying, verbally aggressive, cursing During an interview on [DATE] at 7:40 p.m. CNA K said on [DATE] at approximately 1:00 a.m. she was outside hall 400 when she saw Resident #1 exit through hall 400 door and go out alone to smoke. CNA K said at approximately 2:00 a.m. she went outside to the front of the facility with LVN N to take a break and heard someone in a loud voice say, "HEY." She said they saw Resident #1 across the highway sitting in the ditch flicking a cigarette lighter. CNA K said she went back to the facility to get a wheelchair and sheets. CNA K said they lifted Resident #1 with the sheets to the wheelchair and pushed her back across the highway and put her in the bed. She said she was unaware Resident #1 was an elopement risk. During an interview on [DATE] at 9:25 a.m. CNA M said on [DATE] at approximately 2:00 a.m. she went across the highway where Resident #1 was sitting in the grass in a ditch screaming and crying complaining of pain. CNA M said she helped RN L and LVN N put Resident #1 in the wheelchair by placing sheets under her to lift her into the wheelchair. CNA M said Resident #1 was taken back across the highway to the facility and put to bed. CNA M said residents and employees always used the exit on hall 400 to go outside to smoke. CNA M said she was not aware of residents who were at risk for elopement. CNA M said she only knew residents on halls 400, 500 and 600 where she worked and was not familiar with Resident #1 who resided on hall 200. She said the exit door on hall 400 would not close sometimes because it "got stuck". CNA M said she knew the alarm would sound if a resident wearing a Wanderguard bracelet tried to go outside, but she had not heard the alarm the night of Resident #1's incident. CNA M said the highway Resident #1 crossed was the major highway through the town. She said, "it is a very busy highway, with diesels and everything." During an observation on [DATE] at 9:00 a.m. the speed limit on the highway in front of the facility was 65 miles per hour. During an interview on [DATE] at 10:30 p.m. RN L said on [DATE] she was called on the phone by LVN N to get a pair of gloves and come outside. She said she went outside and observed Resident #1 sitting in the ditch on the opposite side of the highway from the facility. She said Resident #1 was unable to stand and she told CNA K to go get a wheelchair and two sheets. She said they placed the sheets under Resident #1 and lifted her into the wheelchair and pushed her across the highway to her room. She said earlier that night Resident #1 came to the nurse desk and asked for cigarettes and she told her to ask LVN N. She said the hall 400 exit door alarm by the laundry did not work. During an interview on [DATE] at 11:45 a.m., LVN C said after arriving to work [DATE] Resident #1 said she had fallen on some rocks. LVN C said Resident #1 seemed more drowsy than normal and her cognition was "not good". LVN C said Resident #1 wore an alarm on her ankle due to being an elopement risk and had to be supervised when she went out to smoke. LVN C said Resident #1 was often upset and she attempted to leave after being out on pass with her husband. She said Resident #1 had "recently" returned from an outing with her husband prior to the [DATE] incident. She said she had never been instructed regarding interventions to address Resident #1's behavior or elopement attempts. LVN C said she "recently" passed the facility while off duty and saw Resident #1 outside smoking without supervision but did not report it. LVN C said night shift charge nurses were responsible for checking batteries in Wanderguard bracelets weekly to assure they were functioning correctly. She said charge nurses were responsible for checking placement of the Wanderguard bracelets on residents every shift. During an interview on [DATE] at 1:30 p.m., CNA O said on [DATE] she was working alone on halls 100, 200 and 300. She said LVN N was the charge nurse for those halls. She said CNA K and CNA M were working on halls 400, 500 and 600 with RN L as the charge nurse. CNA O said at approximately 1:00 a.m. Resident #1 was walking from her room on Hall 200 and asked if she could go out to smoke. CNA O said she told Resident #1 to ask LVN N, who was at the nursing station. She said a few minutes later Resident #1 was headed toward hall 400 and told her LVN N said she could go out hall 400 to smoke. CNA O said she was not aware Resident #1 wore a Wanderguard bracelet and did not remember hearing the Wanderguard alarm that night. CNA O said at approximately 2:00 a.m. she was filling ice pitchers and noticed Resident #1 was not in her room. CNA O said a few minutes later LVN N, RN L and CNAs K and M came into the room with Resident #1 in a wheelchair. CNA O said Resident #1 screamed in pain and when touched shouted "that hurts". CNA O said when LVN N, RN L and CNA K and CNA M transferred Resident #1 from the wheelchair to the bed there was grass in the seat of the wheelchair. CNA O said when the EMTs transferred Resident #1 from her bed to the gurney; there was grass on the bed where Resident #1 was lying. CNA O said Resident #1 told the EMTs she was trying to run away and fell down outside. She said the DON and ADON had been working on the Wanderguard alarms a few days prior to the incident with Resident #1. CNA O said she was not aware of residents who were at risk for elopement or who wore Wanderguard bracelets. CNA O said it was common for Resident #1 and Resident #5 to be outside smoking together without staff present. CNA O said she was not aware of anyone who required supervision to smoke and she did not know how the Wanderguard system worked. During a phone interview on [DATE] at 6:02 p.m. LVN N denied allowing Resident #1 to go outside during her shift. She said she heard Resident #1 yelling and found her on the floor next to her bed complaining of pain to the shoulder, hip and knee. An incident/accident report dated [DATE] at 2:15 a.m., indicated LVN N heard Resident #1 yelling and entered her room and found her lying in the floor next to the bed on her left side. LVN N assessed Resident #1 and the resident was unable to move her upper extremities, and complained of her whole left side hurting. A witness statement dated [DATE] by the EMT indicated they were called to the facility on [DATE] for a fall in the early morning hours. He said when he went to Resident #1's room she was in pain and crying. He said he asked Resident #1 what happened. Resident #1 said she was trying to escape and tripped in the ditch outside, fell , and hurt her arm. He said Resident #1 indicated she wanted to go home. He said while transferring Resident #1 onto a cot he noticed grass in the bed and on Resident #1. While transferring Resident #1 she was crying and hollering in pain. He said no one at the facility gave him a report as to what happened. The emergency room record dated [DATE] at 4:00 a.m. indicated Resident #1 was received at the hospital after she had fallen and was found on the floor. The records indicated Resident #1 had a deformity of her shoulder and complained of pain in her left arm and both ankles. Radiology reports dated [DATE] indicated Resident #1 had a fractured left foot and left humerus (upper arm). A hospital history and physical dated [DATE] indicated Resident #1 returned to the hospital and was admitted to the ICU on mechanical ventilator support. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. During an observation and interview on [DATE] at 1:33 p.m. the exit door by the hall 400 employee time clock did not lock, when surveyor exited the door twice with a Wanderguard in hand. On the third attempt, the door locked and would not let surveyor exit. The maintenance supervisor said the door was supposed to lock when a person with a Wanderguard bracelet approached. He said if the exit doors were not shut properly, the doors would not lock. He said an employee could disable the lock, but not the alarm. He said he checked the Wanderguard bracelet batteries every week along with the doors and locks. He said if the Wanderguard bracelet battery was dead the doors would not lock and the alarm would not sound. During an interview on [DATE] at 7:40 p.m. CNA K said Resident #1 "often" went outside to smoke without supervision and she never heard an alarm go off when Resident #1 exited the building on [DATE]. During an interview on [DATE] at 3:00 p.m. housekeeper E said she did not know which residents were at risk for elopement. She said she was unaware of how to find out who was a risk for elopement. During an interview on [DATE] at 3:05 p.m., CNA P said he was not aware of residents who were at risk for elopement. CNA F said he had not been inserviced in the last ,[DATE] weeks on anything. CNA F said he would ask the charge nurse or look in the elopement book at the nursing station to find out who was at risk for elopement. During an interview on [DATE] at 3:15 p.m. CNA G said she identified residents at risk for elopement by looking for a Wanderguard bracelet on their ankles. She said she did not know where to look to find out who was at risk for elopement. She said unless someone told her who was at risk she would not know. During an interview on [DATE] at 3:30 p.m. CNA J said she was unaware of where to find who was at risk for elopement. She said if no one told her she would not know. During an interview on [DATE] at 4:15 p.m., CNA F said the exit door on hall 400 "often" did not close properly and would not lock when the Wanderguard bracelet activated the alarm. CNA F said Resident #1 was upset and attempted to leave after being out on pass with her husband. He said the resident had been out on pass with her husband a "few days" prior to the incident on [DATE]. He said he had never been trained regarding interventions to address Resident #1's behavior or elopement attempts. During an interview on [DATE] at 4:20 p.m., LVN B said Resident #1 often wandered and had to be chased when she got outside. LVN B said Resident #1 was often upset after being out on pass with her husband and would attempt to leave. She said Resident #1 had been out on pass with her husband a "few days" prior to the incident on [DATE]. She said she had never been trained regarding interventions to address Resident #1's behavior or elopement attempts. The undated elopement book located at the nursing station did not coincide with the list of residents who were elopement risk provided by the administrator on [DATE]. The elopement book included Resident #s 1, 2, 3, 4 and 6 and the list provided by the administrator included Resident #s 2, 3, 4 and 10. During an interview on [DATE] at 5:35 p.m. the DON said she felt LVN N, RN L and CNA K and CNA M did not give factual information in their reports of the incident with Resident #1. She said RN L told her during a phone interview Resident #1 was found across the highway in a ditch but later recanted her story during an interview in person with the DON and the regional clinical specialist. She said Resident #1 always had exit seeking behaviors after going out on pass with her husband. She said Resident #1 had been out on pass with her husband "a few days" prior to the incident on [DATE]. She said she never inserviced staff or put a plan into action regarding Resident #1's behaviors. The DON said Resident #1 wore a Wanderguard bracelet due to elopement attempts and she did not know how Resident #1 could have exited the facility without staff disarming the Wanderguard system. The DON said an elopement book was located at the nursing station and contained a list of residents who were at risk for elopement. She said the book was updated each time a resident was added or discharged and nursing staff were notified of any changed during report at shift change and the charge nurse notified the CNAs on duty. She said the elopement book must have not been updated, because it did not match the list provided by the administrator. She said Resident #1 was deceased , Resident #10 was no longer at risk for elopement, and those at risk for elopement included Resident #s 2, 3, 4, and 6. She said it was the responsibility of nurses on night shift to check batteries in Wanderguard bracelets weekly and to assure they were functioning properly. During an interview on [DATE] at 12:30 p.m., the administrator said they began investigating the conditions surrounding the [DATE] incident involving Resident #1 because staff gave conflicting statements. He said he felt LVN N provided false documentation and RN L, CNA K and CNA M gave false information in their statements and all had been terminated. He said based on the investigation, "all evidence shows the resident (Resident #1) was outside" when the incident occurred, but he did not know how she got out unless someone deactivated the door alarm. He said he changed the code on the alarm system following the incident and staff were in-serviced on requirements for residents who wore Wanderguard bracelets and instructed that any resident who wore a Wanderguard bracelet was not allowed to go out of the facility unsupervised. During an observation and interview on [DATE] at 12:40 p.m., the exit door on hall 300 was ajar and when approached with a Wanderguard bracelet device the door did not lock. The surveyor walked through the door and outside with the Wanderguard bracelet device in hand. The administrator was notified. The policy for prohibition of abuse, neglect and misappropriation of property dated [DATE] indicated: *All new and current employees would receive training and reinforcement on all aspects of the abuse prohibition program. The training was to include "appropriate interventions to deal with aggressive, stubborn residents, etc. and staff responsibility to immediately report any violations..." *Facility staff would immediately correct and intervene in reported or identified situation in which neglect was at risk for occurring. *The procedure for investigations would include notification of the physician, follow-up resolution and measures to prevent repeat incidents. *Any employee who became aware of an allegation of neglect would report the incident to a supervisor, DON or administrator immediately. *The facility quality assurance/improvement committee would analyze all occurrences to determine what change or changes were needed to the facility's policies and procedures to prevent further occurrences. The policy for resident elopement dated [DATE] indicated: *"it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. *all residents will be assessed for behaviors or conditions that may place them at risk for elopement. *all residents so identified will have these issues addressed in their individual care plans. *all staff is responsible to ensure resident safety *at no time shall the door alarm be turned off without continuous supervision of the exit door. The person responsible for turning off the alarm shall be responsible for resetting it and ensure that it is working properly. *Residents identified at risk for elopement will be reviewed by the interdisciplinary team to identify if the causative factors can be eliminated. If the causative factors cannot be eliminated, the team will develop and implement strategies to prevent elopement such as: location monitoring, structured activity programs, psychosocial interventions and evaluation of medication... *All staff shall be inserviced on: how to identify residents at risk for elopement; how to supervise, monitor and redirect the resident and what to do after the resident is recovered. *When a resident is found: if there is sign of injury, call for an ambulance. *if the resident appears unharmed, get the resident to safety and perform a complete assessment including but not limited to, vital signs, bead to toe assessment, mental status, etc. and document appropriately." The policy did not address what staff should do if the doors did not function properly when a resident with a Wanderguard bracelet approached. The undated "Wanderer Management and Monitoring System" policy included: *"Once a resident is admitted to the facility, Elopement Policy will be followed. *Use the "Elopement Risk Factor" form on all new admissions and quarterly if resident has been determined to be a wander risk. *Maintain a tracking system within your facility that indicates which resident has a signaling device, when it was placed on the resident and when it is due to expire. Binder to be kept at a central location to include resident pictures, Residents with Signaling Devices form, Weekly Checklist for Door modules form and may also include updated resident face sheets." The policy did not address what staff should do if the doors did not function properly when a resident with a Wanderguard bracelet approached. The Wanderguard Departure Alert System User Manual dated 2003 read: *pg. 15 "1. The system is designed such that the maximum opportunity for the monitor to " hear " the signal being transmitted by the signaling device, especially under interference conditions, is when the signaling device is worn on the resident's wrist. *Devices placed on the wrist are more readily visible so staff can check routinely to verify placement ...When a transmitter is placed on the ankle - which should not be done without specific instructions from (manufacture name removed), the transmitter cannot be visually checked because it is almost always hidden beneath trousers or stockings. As a result, a lost signaling device could go undetected." *pg. 20 "3. Staff must test signaling devices daily: otherwise device expiration or device failure may go undetected." The smoking policy dated [DATE] indicated "if a resident is deemed "unsafe", they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted and residents will be required to smoke with supervision only, according to schedule." Immediate Jeopardy The administrator and DON were notified on [DATE] at 6:20 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:33 p.m. and included: "Wander management tools (elopement assessments) are being completed for all residents by the ADON and MDS coordinator, to be completed by [DATE] Audit of all current residents at risk to wander to ensure bracelets are in place completed by ADON [DATE]. Verification that all bracelets currently on residents are functioning will be completed by DON [DATE] Elopement book will be updated by the DON with current list of all residents at risk to wander on [DATE] after wander management tools are completed Inservice for nursing staff by DON prior to their next shift to work and on [DATE] related to Wanderguard elopement book, location of book, list of residents at risk to wander, and the resident care guides (reference guide for CNAs) are to include information for elopement risk residents In-service for licensed nurses by DON prior to their next shift to work and on [DATE] on completing wander management tools in their entirety to include of the resident is or is not at risk to wander. Inservice for nursing staff by DON prior to their next shift and on [DATE] to communicate during shift change report of any new residents at risk to wander, or any changes in smoking habits and this will be updated on the resident care guides which are located in the resident rooms inside the closet door for reference In-service for staff by the Director of Nurses prior to their next shift to work and on [DATE] that absolutely no unsafe smokers are to be allowed to smoke unattended per facility policy. Audit of all residents who smoke to ensure their assessments are current and correct by social worker to be completed by [DATE]. Social Worker will complete a list of unsafe smokers and this list will be maintained by the social worker and will be posted by the social worker in nursing station, and in the nurses' treatment books and CNA ADL books. Maintenance manager completed a check of all exit doors on [DATE] to ensure that the departure alert system is functioning correctly. All doors are functioning correctly. In-service for staff by administrator prior to next shift worked and on [DATE] related to disarming alarm system and entering code to disarm alarm system. In-service by regional clinical specialist for Administrator and Director of Nurses on [DATE] on Wander Management and monitoring system protocol to include the policy, procedures for assessment of residents to determine risk for elopement, application of bracelet and monitoring of bracelet and door modules. Documentation of monitoring for placement and testing of bracelets, and of door modules. Forms to be completed to indicate process is completed. Signaling devices (bracelets) must be tested daily and door modules must be tested at least weekly on each shift. The charge nurses are to test the signaling devices and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: The Wander management tools (elopement assessments) were reviewed and had been completed for all residents in the facility. All residents identified to be at risk for elopement were observed to assure Wanderguard bracelets were in place and functioning properly. The elopement book was reviewed and had been updated with a list of all residents who were at risk to wander. Twelve CNAs were interviewed and said they had been inserviced prior to their next shift related to Wanderguard elopement book, location of book, list of residents at risk to wander, the resident care guides, procedures for unsafe smokers and procedures for door alarm system and using the code Seven nurses were interviewed and said they had been inserviced prior to their next shift related to Wanderguard elopement book, location of book, list of residents at risk to wander, the resident care guides, completion of management tools and communication procedures in relation to residents at risk to wander and smoking habits, procedures for unsafe smokers and procedures for door alarm system and using the code Smoking assessments were reviewed for all residents who smoked and none were evaluated as unsafe A check of all exit doors was completed to ensure the departure alert system was functioning correctly The administrator and the DON were interviewed and said they were in-serviced on the wander management and monitoring system protocol policy, procedures for assessment of residents, documentation of monitoring for placement and testing of bracelets, and of door modules. On [DATE] at 5:54 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the administrator dated [DATE] indicated 4 residents were at risk for elopement.

Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit neglect, for 1 of 9 residents reviewed for neglect. (Resident #1) Resident #1 was at risk for elopement & required supervision when outside. The facility did not: *provide supervision to prevent Resident #1 from leaving the facility. She was found across the highway in a ditch with fractures; *ensure the Wandergard system (a device that automatically locks doors and alarms when designated residents attempt to exit) was functional on 2 doors; *ensure staff were aware of which residents were exit seekers; *ensure 4 staff used correct protocol when the resident was found injured off of the facility property; *did not provide the hospital with correct information regarding the resident's incident; after being found in the ditch, 4 staff took the resident back to facility before they called EMS. On [DATE] Resident #1 was sent to the hospital and treated for [REDACTED]. The resident was taken back to the hospital and was admitted on [DATE]. Resident #1 died at the hospital on [DATE]. This failure contributed to Resident #1's elopement, injury, hospitalization and death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 5:54 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 4 residents who were at risk for elopement at risk for injury and death. Findings included: The policy for prohibition of abuse, neglect and misappropriation of property dated [DATE] indicated: *All new and current employees would receive training and reinforcement on all aspects of the abuse prohibition program. The training was to include "appropriate interventions to deal with aggressive, stubborn residents, etc. and staff responsibility to immediately report any violations..." *Facility staff would immediately correct and intervene in reported or identified situation in which neglect was at risk for occurring. *The procedure for investigations would include notification of the physician, follow-up resolution and measures to prevent repeat incidents. *Any employee who became aware of an allegation of neglect would report the incident to a supervisor, DON or administrator immediately. *The facility quality assurance/improvement committee would analyze all occurrences to determine what change or changes were needed to the facility's policies and procedures to prevent further occurrences. The policy for resident elopement dated [DATE] indicated: *"it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. *all residents will be assessed for behaviors or conditions that may place them at risk for elopement. *all residents so identified will have these issues addressed in their individual care plans. *all staff is responsible to ensure resident safety *at no time shall the door alarm be turned off without continuous supervision of the exit door. The person responsible for turning off the alarm shall be responsible for resetting it and ensure that it is working properly. *Residents identified at risk for elopement will be reviewed by the interdisciplinary team to identify if the causative factors can be eliminated. If the causative factors cannot be eliminated, the team will develop and implement strategies to prevent elopement such as: location monitoring, structured activity programs, psychosocial interventions and evaluation of medication... *All staff shall be inserviced on: how to identify residents at risk for elopement; how to supervise, monitor and redirect the resident and what to do after the resident is recovered. *When a resident is found: if there is sign of injury, call for an ambulance. *if the resident appears unharmed, get the resident to safety and perform a complete assessment including but not limited to, vital signs, bead to toe assessment, mental status, etc. and document appropriately." The policy did not address what staff should do if the doors did not function properly when a resident with a Wanderguard bracelet approached. The undated "Wanderer Management and Monitoring System" policy included: *"Once a resident is admitted to the facility, Elopement Policy will be followed. *Use the "Elopement Risk Factor" form on all new admissions and quarterly if resident has been determined to be a wander risk. *Maintain a tracking system within your facility that indicates which resident has a signaling device, when it was placed on the resident and when it is due to expire. Binder to be kept at a central location to include resident pictures, Residents with Signaling Devices form, Weekly Checklist for Door modules form and may also include updated resident face sheets." The policy did not address what staff should do if the doors did not function properly when a resident with a Wanderguard bracelet approached. The Wanderguard Departure Alert System User Manual dated 2003 read: *pg. 15 "1. The system is designed such that the maximum opportunity for the monitor to " hear " the signal being transmitted by the signaling device, especially under interference conditions, is when the signaling device is worn on the resident's wrist. *Devices placed on the wrist are more readily visible so staff can check routinely to verify placement ...When a transmitter is placed on the ankle - which should not be done without specific instructions from (manufacture name removed), the transmitter cannot be visually checked because it is almost always hidden beneath trousers or stockings. As a result, a lost signaling device could go undetected." *pg. 20 "3. Staff must test signaling devices daily: otherwise device expiration or device failure may go undetected." Physician orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 always understood others and was always able to make herself understood had adequate vision and was independent with all her ADLs. The MDS indicated Resident #1 had trouble sleeping, felt bad about herself or that she was a failure or had let herself or her family down for half or more of the days in the past two week period. The MDS indicated Resident #1 did not exhibit wandering behavior in the prior seven days. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #1 had a life long history of depression and was tearful at time. The care plan indicated the resident would be observed for changes in mood status and would be monitored for behavior at least every shift and the physician would be notified of any negative behavior. The care plan indicated Resident #1 had decreased vision and required assistance with ADLs and ambulation, supervision when smoking, and that she was at risk for elopement, wearing a Wanderguard bracelet to prevent unsupervised exits. Care plan interventions required staff to check Resident #1 frequently for wandering and remove her from unsafe situations. The wander data collection tool dated [DATE] was incomplete and did not indicate if Resident #1 was at risk for elopement. Nursing notes dated [DATE] indicated Resident #1 returned from being out on pass with her husband and began to exhibit exit seeking behaviors and/or behavior changes at the following times: *2:00 p.m. crying, exit seeking *3:18 p.m. verbally aggressive, cursing *3:40 p.m. exit seeking, difficult to redirect *4:10 p.m. exited facility *9:30 p.m. exit seeking *11:00 p.m. verbally aggressive, cursing, threats of physical violence, unable to calm *11:30 p.m. crying, verbally aggressive, cursing During an interview on [DATE] at 7:40 p.m. CNA K said on [DATE] at approximately 1:00 a.m. she was outside hall 400 when she saw Resident #1 exit through the hall 400 door and go out alone to smoke. CNA K said at approximately 2:00 a.m. she went outside to the front of the facility with LVN N to take a break and heard someone in a loud voice say, "HEY." She said they saw Resident #1 across the highway sitting in the ditch flicking a cigarette lighter. CNA K said she went back to the facility to get a wheelchair and sheets. CNA K said they lifted Resident #1 with the sheets to the wheelchair and pushed her back across the highway and put her in the bed. She said she was unaware Resident #1 was an elopement risk. During an interview on [DATE] at 9:25 a.m. CNA M said on [DATE] at approximately 2:00 a.m. she went across the highway where Resident #1 was sitting in the grass in a ditch screaming and crying complaining of pain. CNA M said she helped RN L and LVN N put Resident #1 in the wheelchair by placing sheets under her to lift her into the wheelchair. CNA M said Resident #1 was taken back across the highway to the facility and put to bed. CNA M said residents and employees always used the exit on hall 400 to go outside to smoke. CNA M said she was not aware of residents who were at risk for elopement. CNA M said she only knew residents on halls 400, 500 and 600 where she worked and was not familiar with Resident #1 who resided on hall 200. She said the exit door on hall 400 would not close sometimes because it "got stuck". CNA M said she knew the alarm would sound if a resident wearing a Wanderguard bracelet tried to go outside, but she had not heard the alarm the night of Resident #1's incident. CNA M said the highway Resident #1 crossed was the major highway through the town. She said, "it is a very busy highway, with diesels and everything." During an observation on [DATE] at 9:00 a.m. the speed limit on the highway in front of the facility was 65 miles per hour. During an interview on [DATE] at 10:30 p.m. RN L said on [DATE] she was called on the phone by LVN N to get a pair of gloves and come outside. She said she went outside and observed Resident #1 sitting in the ditch on the opposite side of the highway from the facility. She said Resident #1 was unable to stand and she told CNA K to go get a wheelchair and two sheets. She said they placed the sheets under Resident #1 and lifted her into the wheelchair and pushed her across the highway to her room. She said earlier that night Resident #1 came to the nurse desk and asked for cigarettes and she told her to ask LVN N. She said the hall 400 exit door alarm by the laundry did not work. During an interview on [DATE] at 11:45 a.m., LVN C said after arriving to work [DATE] Resident #1 said she had fallen on some rocks. LVN C said Resident #1 seemed more drowsy than normal and her cognition was "not good". LVN C said Resident #1 wore an alarm on her ankle due to being an elopement risk and had to be supervised when she went out to smoke. LVN C said Resident #1 was often upset and she attempted to leave after being out on pass with her husband. She said Resident #1 had "recently" returned from an outing with her husband prior to the [DATE] incident. She said she had never been instructed regarding interventions to address Resident #1's behavior or elopement attempts. LVN C said she "recently" passed the facility while off duty and saw Resident #1 outside smoking without supervision but did not report it. LVN C said night shift charge nurses were responsible for checking batteries in Wanderguard bracelets weekly to assure they were functioning correctly. She said charge nurses were responsible for checking placement of the Wanderguard bracelets on residents every shift. During an interview on [DATE] at 1:30 p.m., CNA O said on [DATE] she was working alone on halls 100, 200 and 300. She said LVN N was the charge nurse for those halls. She said CNA K and CNA M were working on halls 400, 500 and 600 with RN L as the charge nurse. CNA O said at approximately 1:00 a.m. Resident #1 was walking from her room on Hall 200 and asked if she could go out to smoke. CNA O said she told Resident #1 to ask LVN N, who was at the nursing station. She said a few minutes later Resident #1 was headed toward hall 400 and told her LVN N said she could go out hall 400 to smoke. CNA O said she was not aware Resident #1 wore a Wanderguard bracelet and did not remember hearing the Wanderguard alarm that night. CNA O said at approximately 2:00 a.m. she was filling ice pitchers and noticed Resident #1 was not in her room. CNA O said a few minutes later LVN N, RN L and CNAs K and M came into the room with Resident #1 in a wheelchair. CNA O said Resident #1 screamed in pain and when touched shouted "that hurts". CNA O said when LVN N, RN L and CNA K and CNA M transferred Resident #1 from the wheelchair to the bed there was grass in the seat of the wheelchair. CNA O said when the EMTs transferred Resident #1 from her bed to the gurney; there was grass on the bed where Resident #1 was lying. CNA O said Resident #1 told the EMTs she was trying to run away and fell down outside. She said the DON and ADON had been working on the Wanderguard alarms a few days prior to the incident with Resident #1. CNA O said she was not aware of residents who were at risk for elopement or who wore Wanderguard bracelets. CNA O said it was common for Resident #1 and Resident #5 to be outside smoking together without staff present. CNA O said she was not aware of anyone who required supervision to smoke and she did not know how the Wanderguard system worked. During a phone interview on [DATE] at 6:02 p.m. LVN N denied allowing Resident #1 to go outside during her shift. She said she heard Resident #1 yelling and found her on the floor next to her bed complaining of pain to the shoulder, hip and knee. An incident/accident report dated [DATE] at 2:15 a.m., indicated LVN N heard Resident #1 yelling and entered her room and found her lying in the floor next to the bed on her left side. LVN N assessed Resident #1 and the resident was unable to move her upper extremities, and complained of her whole left side hurting. A witness statement dated [DATE] by the EMT indicated they were called to the facility on [DATE] for a fall in the early morning hours. He said when he went to Resident #1's room she was in pain and crying. He said he asked Resident #1 what happened. Resident #1 said she was trying to escape and tripped in the ditch outside, fell , and hurt her arm. He said Resident #1 indicated she wanted to go home. He said while transferring Resident #1 onto a cot he noticed grass in the bed and on Resident #1. While transferring Resident #1 she was crying and hollering in pain. He said no one at the facility gave him a report as to what happened. The emergency room record dated [DATE] at 4:00 a.m. indicated Resident #1 was received at the hospital after she had fallen and was found on the floor. The records indicated Resident #1 had a deformity of her shoulder and complained of pain in her left arm and both ankles. Radiology reports dated [DATE] indicated Resident #1 had a fractured left foot and left humerus (upper arm). A hospital history and physical dated [DATE] indicated Resident #1 was sent back to the hospital and admitted to the ICU on mechanical ventilator support. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. During an observation and interview on [DATE] at 1:33 p.m. the exit door by the hall 400 employee time clock did not lock, when surveyor exited the door twice with a Wanderguard in hand. On the third attempt, the door locked and would not let surveyor exit. The maintenance supervisor said the door was supposed to lock when a person with a Wanderguard bracelet approached. He said if the exit doors were not shut properly, the doors would not lock. He said an employee could disable the lock, but not the alarm. He said he checked the Wanderguard bracelet batteries every week along with the doors and locks. He said if the Wanderguard bracelet battery was dead the doors would not lock and the alarm would not sound. During an interview on [DATE] at 7:40 p.m. CNA K said Resident #1 "often" went outside to smoke without supervision and she never heard an alarm go off when Resident #1 exited the building on [DATE]. During an interview on [DATE] at 3:00 p.m. housekeeper E said she did not know which residents were at risk for elopement. She said she was unaware of how to find out who was a risk for elopement. During an interview on [DATE] at 3:05 p.m., CNA P said he was not aware of residents who were at risk for elopement. CNA F said he had not been inserviced in the last ,[DATE] weeks on anything. CNA F said he would ask the charge nurse or look in the elopement book at the nursing station to find out who was at risk for elopement. During an interview on [DATE] at 3:15 p.m. CNA G said she identified residents at risk for elopement by looking for a Wanderguard bracelet on their ankles. She said she did not know where to look to find out who was at risk for elopement. She said unless someone told her who was at risk she would not know. During an interview on [DATE] at 3:30 p.m. CNA J said she was unaware of where to find who was at risk for elopement. She said if no one told her she would not know. During an interview on [DATE] at 4:15 p.m., CNA F said the exit door on hall 400 "often" did not close properly and would not lock when the Wanderguard bracelet activated the alarm. CNA F said Resident #1 was upset and attempted to leave after being out on pass with her husband. He said the resident had been out on pass with her husband a "few days" prior to the incident on [DATE]. He said he had never been trained regarding interventions to address Resident #1's behavior or elopement attempts. During an interview on [DATE] at 4:20 p.m., LVN B said Resident #1 often wandered and had to be chased when she got outside. LVN B said Resident #1 was often upset after being out on pass with her husband and would attempt to leave. She said Resident #1 had been out on pass with her husband a "few days" prior to the incident on [DATE]. She said she had never been trained regarding interventions to address Resident #1's behavior or elopement attempts. The undated elopement book located at the nursing station did not coincide with the list of residents who were elopement risk provided by the administrator on [DATE]. The elopement book included Resident #s 1, 2, 3, 4 and 6 and the list provided by the administrator included Resident #s 2, 3, 4 and 10. During an interview on [DATE] at 5:35 p.m. the DON said she felt LVN N, RN L and CNA K and CNA M did not give factual information in their reports of the incident with Resident #1. She said RN L told her during a phone interview Resident #1 was found across the highway in a ditch but later recanted her story during an interview in person with the DON and the regional clinical specialist. She said Resident #1 always had exit seeking behaviors after going out on pass with her husband. She said Resident #1 had been out on pass with her husband "a few days" prior to the incident on [DATE]. She said she never inserviced staff or put a plan into action regarding Resident #1's behaviors. The DON said Resident #1 wore a Wanderguard bracelet due to elopement attempts and she did not know how Resident #1 could have exited the facility without staff disarming the Wanderguard system. The DON said an elopement book was located at the nursing station and contained a list of residents who were at risk for elopement. She said the book was updated each time a resident was added or discharged and nursing staff were notified of any changed during report at shift change and the charge nurse notified the CNAs on duty. She said the elopement book must have not been updated, because it did not match the list provided by the administrator. She said Resident #1 was deceased , Resident #10 was no longer at risk for elopement, and those at risk for elopement included Resident #s 2, 3, 4, and 6. She said it was the responsibility of nurses on night shift to check batteries in Wanderguard bracelets weekly and to assure they were functioning properly. During an interview on [DATE] at 12:30 p.m., the administrator said they began investigating the conditions surrounding the [DATE] incident involving Resident #1 because staff gave conflicting statements. He said he felt LVN N provided false documentation and RN L, CNA K and CNA M gave false information in their statements and all had been terminated. He said based on the investigation, "all evidence shows the resident (Resident #1) was outside" when the incident occurred, but he did not know how she got out unless someone deactivated the door alarm. He said he changed the code on the alarm system following the incident and staff were in-serviced on requirements for residents who wore Wanderguard bracelets and instructed that any resident who wore a Wanderguard bracelet was not allowed to go out of the facility unsupervised. During an observation and interview on [DATE] at 12:40 p.m., the exit door on hall 300 was ajar and when approached with a Wanderguard bracelet device the door did not lock. The surveyor walked through the door and outside with the Wanderguard bracelet device in hand. The administrator was notified. The smoking policy dated [DATE] indicated "if a resident is deemed "unsafe", they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted and residents will be required to smoke with supervision only, according to schedule." Immediate Jeopardy The administrator and DON were notified on [DATE] at 6:20 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:33 p.m. and included: "Wander management tools (elopement assessments) are being completed for all residents by the ADON and MDS coordinator, to be completed by [DATE] Audit of all current residents at risk to wander to ensure bracelets are in place completed by ADON [DATE]. Verification that all bracelets currently on residents are functioning will be completed by DON [DATE] Elopement book will be updated by the DON with current list of all residents at risk to wander on [DATE] after wander management tools are completed Inservice for nursing staff by DON prior to their next shift to work and on [DATE] related to Wanderguard elopement book, location of book, list of residents at risk to wander, and the resident care guides (reference guide for CNAs) are to include information for elopement risk residents In-service for licensed nurses by DON prior to their next shift to work and on [DATE] on completing wander management tools in their entirety to include of the resident is or is not at risk to wander. Inservice for nursing staff by DON prior to their next shift and on [DATE] to communicate during shift change report of any new residents at risk to wander, or any changes in smoking habits and this will be updated on the resident care guides which are located in the resident rooms inside the closet door for reference In-service for staff by the Director of Nurses prior to their next shift to work and on [DATE] that absolutely no unsafe smokers are to be allowed to smoke unattended per facility policy. Audit of all residents who smoke to ensure their assessments are current and correct by social worker to be completed by [DATE]. Social Worker will complete a list of unsafe smokers and this list will be maintained by the social worker and will be posted by the social worker in nursing station, and in the nurses' treatment books and CNA ADL books. Maintenance manager completed a check of all exit doors on [DATE] to ensure that the departure alert system is functioning correctly. All doors are functioning correctly. In-service for staff by administrator prior to next shift worked and on [DATE] related to disarming alarm system and entering code to disarm alarm system. In-service by regional clinical specialist for Administrator and Director of Nurses on [DATE] on Wander Management and monitoring system protocol to include the policy, procedures for assessment of residents to determine risk for elopement, application of bracelet and monitoring of bracelet and door modules. Documentation of monitoring for placement and testing of bracelets, and of door modules. Forms to be completed to indicate process is completed. Signaling devices (bracelets) must be tested daily and door modules must be tested at least weekly on each shift. The charge nurses are to test the signaling devices and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: The Wander management tools (elopement assessments) were reviewed and had been completed for all residents in the facility. All residents identified to be at risk for elopement were observed to assure Wanderguard bracelets were in place and functioning properly. The elopement book was reviewed and had been updated with a list of all residents who were at risk to wander. Twelve CNAs were interviewed and said they had been inserviced prior to their next shift related to Wanderguard elopement book, location of book, list of residents at risk to wander, the resident care guides, procedures for unsafe smokers and procedures for door alarm system and using the code Seven nurses were interviewed and said they had been inserviced prior to their next shift related to Wanderguard elopement book, location of book, list of residents at risk to wander, the resident care guides, completion of management tools and communication procedures in relation to residents at risk to wander and smoking habits, procedures for unsafe smokers and procedures for door alarm system and using the code Smoking assessments were reviewed for all residents who smoked and none were evaluated as unsafe A check of all exit doors was completed to ensure the departure alert system was functioning correctly The administrator and the DON were interviewed and said they were in-serviced on the wander management and monitoring system protocol policy, procedures for assessment of residents, documentation of monitoring for placement and testing of bracelets, and of door modules. On [DATE] at 5:54 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the administrator dated [DATE] indicated 4 residents were at risk for elopement.

Based on observation, interview and record review the facility failed to ensure services provided met professional standards of quality for 1 of 9 residents reviewed for assessments. Resident #1 was at risk for elopement. She eloped from the facility [DATE] and was found in a ditch across the highway from the facility with a fractured arm and ankle. LNV N and RN L provided inaccurate information regarding the circumstances surrounding Resident #1's fall. The inaccurate information was used by emergency personnell to assess and treat Resident #1's injuries following the fall. Resident #1 was admitted to the hospital on life support [DATE]. Resident #1's life support was removed and she died in the hospital on [DATE]. This failure contributed to Resident #1 not receiving timely medical evaluation and treatment. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 5:54 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 4 residents who were at risk for elopement at risk for injury or death. Findings included: The website, <http://www.bon.state.tx.us/practice/gen_practice.html#Scope_of_Practice>, Rule 217.11 - Standards of Nursing Practice, accessed [DATE] indicated: "(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (B) Implement measures to promote a safe environment for clients and others; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered..." Physician orders [REDACTED]. The orders indicated Resident #1 was to have a Wanderguard for safety. The MDS dated [DATE] indicated Resident #1 always understood others, was always able to make herself understood, had adequate vision and was independent with all her ADLs. The MDS indicated Resident #1 had trouble sleeping, felt bad about herself or that she was a failure or had let herself or her family down for half or more of the days in the past two week period. The MDS indicated Resident #1 did not exhibit wandering behavior in the prior seven days. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #1 had a life long history of depression, was tearful, had decreased vision and required assistance with ADLs and ambulation, supervision when smoking and was at risk for elopement. The care plan indicated she wore a Wanderguard bracelet to prevent unsupervised exits. Care plan goals included: *"resident will be safe and secure within the facility; *resident will not receive preventable injury as a result from wandering; and *will not be injured as a result of smoking." Care plan interventions required staff to: *monitor behavior at least every shift; *notify the physician of any negative behavior; *observe for changes in mood status; *check Resident #1 frequently for wandering; and *remove her from unsafe situations." Resident #1's nursing notes dated [DATE] indicated the following: *at 2:15 a.m. - staff heard resident yelling and found her lying in the floor on her left side next to the bed. Resident #1 was screaming, "I think my left shoulder and ankle are broke. I think my whole left side is busted up." "Screams in severe pain when left upper extremity touched"; *at 2:20 a.m. - notified physician of incident and orders received to transfer to hospital. A EMS record dated [DATE] indicated Resident #1 was taken to the emergency room after a fall. The report indicated Resident #1 had a deformed shoulder and complained of pain with movement of her arm. The emergency room record dated [DATE] at 4:00 a.m. indicated Resident #1 was received after she had fallen and was found on the floor. The records indicated Resident #1 had a deformity of her shoulder and complained of pain in her left arm and both ankles. Radiology reports dated [DATE] indicated Resident #1 had a fractured left foot and left humerus (upper arm). An incident/accident report dated [DATE] at 2:15 a.m., indicated LVN N heard Resident #1 yelling and entered her room and found her lying in the floor next to the bed on her left side. LVN N assessed Resident #1 and resident was unable to move her upper extremities, and complained of her whole left side hurting. Witness statements attached to the incident report dated as follows indicated: *[DATE] - CNA S indicated Resident #1 told her she was outside the night before trying to get away and fell in the ditch. *[DATE] - LVN A indicated Resident #1 told her she was outside alone but "they" found me. She said Resident #1 said she was trying to run away and tripped in the ditch and fell . *[DATE] - RN L indicated she was called to Resident #1's room by LVN N to assess Resident #1 for injuries from a fall. She said Resident #1 complained of left shoulder pain. She said they transferred Resident #1 to a wheelchair to transport her to a local hospital by facility van but did not because she was complaining of excruciating pain. RN L said Resident #1 was transferred back to her room and put bed. She said LVN N called the ambulance service for transfer to the hospital. *[DATE] - CNA M indicated she was called to help pick Resident #1 up off of the floor and placed in a wheelchair to go to the hospital via facility van, but the resident was screaming out in pain so she put Resident #1 back in bed. *[DATE] - CNA K indicated the charge nurse told her to help with Resident #1. She said Resident #1 was in her room in the floor lying on her left side. She said she and the charge nurse put the resident back in bed. She said Resident #1 was transferred to a wheelchair to be taken to the hospital via facility van and she started crying and was placed back in bed and the charge nurse called an ambulance. *[DATE] - LVN C indicated she was assessing Resident #1 on [DATE] because she had a fall on [DATE]. She said Resident #1 told her she had fell on the rocks outside and not in her room. She said Resident #1 had an abrasion on her left cheek. *[DATE] - DON indicated she called RN L on the phone with the ADON in her office. The DON said RN L said Resident #1 had gone outside and across the highway. She said RN L was in the culvert across the highway and was lying on her left side. She said RN L said Resident #1 was unable to stand so they (RN L, LVN N and CNA M) got a wheelchair and transported her back to her room and assessed her. *[DATE] - LVN N indicated she entered Resident #1's room and found her lying in the floor on her left side and assessed her and called CNAs to help assist her from the floor. She said she called RN L to re-assess Resident #1. She said they assisted Resident #1 to the wheelchair and she began to scream out in pain so she was placed back in bed. She said she called for an ambulance. Resident #1's nursing notes dated [DATE] indicated the following: *at 5:30 p.m., Resident #1 was non-responsive. Her respirations were labored. Staff were unable to obtain a blood pressure or oxygen saturation reading. *at 5:35 p.m., Resident #1 was not breathing and CPR was initiated by the EMS. *at 6:15 p.m., Resident #1 was transferred to the local hospital. An EMS transfer record dated [DATE] indicated Resident #1 was transferred from the facility in [MEDICAL CONDITION]. The EMT attempted to insert an endotracheal tube (a tube inserted in the airway to provide artificial respiration) but were unsuccessful because of resident had vomit in her throat. An emergency department workup dated [DATE] indicated Resident #1 was received from the nursing home unresponsive with agonal respirations (an abnormal pattern of breathing characterized by gasping and labored breathing). Her glucose level was 1102. The work-up indicated Resident #1 was transferred to a hospital that could provide a higher level of care. A hospital history and physical dated [DATE] indicated Resident #1 was admitted to the ICU on mechanical ventilator support and an IV insulin drip. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. During an interview on [DATE] at 11:45 a.m., LVN C said after arriving to work [DATE] Resident #1 said she had fallen on some rocks. LVN C said Resident #1 seemed more drowsy than normal and her cognition was "not good". During an interview on [DATE] at 12:30 p.m., the administrator said they began investigating the conditions surrounding the [DATE] incident involving Resident #1 because staff gave conflicting statements. He said he felt LVN N provided false documentation and RN L, CNA K and CNA M gave false information in their statements and all had been terminated. He said based on the investigation "all evidence shows the resident (Resident #1) was outside" when the incident occurred. During an interview on [DATE] at 1:30 p.m., CNA O said on [DATE] at approximately 2:00 a.m. she noticed Resident #1 was not in her room. CNO O said a few minutes later LVN N, RN L and CNAs K and M came into the room with Resident #1 in a wheelchair. During an interview on [DATE] at 5:35 p.m. the DON said RN L told her during a phone interview Resident #1 was found across the road in a ditch; then later recanted her statement. During a phone interview on [DATE] at 6:02 p.m. LVN N denied allowing Resident #1 to go outside during her shift. She said she heard Resident #1 yelling and found her on the floor next to her bed complaining of pain to her shoulder, hip and knee. LVN N said Resident #1 could raise her leg in the air and moved her fingers and hand but complained of pain in the shoulder when asked to move that area. LVN N said she asked CNAs M and K to help put her back in the bed and asked RN L to assess Resident #1 and they decided to transport her to the hospital via the facility van. LVN N said CNAs M and K helped put Resident #1 in a wheelchair but Resident #1 complained of pain, so they put her back to bed and called an ambulance. She said she did not go to Resident #1's room to give a report to EMS because she was completing necessary paperwork. She said she told the truth in her written statement provided on [DATE]. During an interview on [DATE] at 7:40 p.m. CNA K said on [DATE] at approximately 2:00 a.m. she went outside to the front of the facility with LVN N to take a break and heard someone in a loud voice say, "HEY." She said they saw Resident #1 across the highway sitting in the ditch on the grass flicking a cigarette lighter. CNA K said Resident #1 complained of pain in her left side. CNA K said LVN N called the facility on her cell phone and asked RN L and CNA M to come across the highway to help. CNA K said RN L used a pen light to assess Resident #1 for injuries. CNA K said she went back to the facility to get a wheelchair and sheets. CNA K said she held the wheelchair secure while LVN N, RN L and CNA M placed Resident #1 on the sheets and transferred her from the ground to the wheelchair. CNA K said they took Resident #1 back to the facility put her in the bed and called an ambulance. During an interview on [DATE] at 10:30 p.m. RN L said on [DATE] she was called on the phone by LVN N to get a pair of gloves and come outside. She said she went outside and observed Resident #1 sitting in the ditch on the opposite side of the highway from the facility. She said LVN N told her to say the incident happened in Resident #1's room. During an interview on [DATE] at 9:25 a.m. CNA M said on [DATE] at approximately 2:00 a.m. RN L told her to get some gloves and go across the highway. CNA M went across the highway where Resident #1 was sitting in the grass in a ditch screaming, crying and complaining of pain. CNA M said CNA K went back to facility and got sheets and a wheelchair and returned across the highway. CNA M said she helped RN L and LVN N put Resident #1 in the wheelchair by placing sheets under her and lifting her while CNA K secured the wheelchair. CNA M said Resident #1 was taken back into the facility and put to bed. During an interview on [DATE] at 2:00 p.m., Resident #1's physician said he first became aware Resident #1's fall had occurred outside the facility [DATE] when Resident #1's husband told him. He said another physician saw Resident #1 in the emergency room [DATE]. Resident #1's physician said when he saw her in the emergency roiagnom on [DATE] she had bruising on her chest not consistent with a fall from a bed or CPR. He said her abdomen was distended so the emergency department placed an NG tube and got an immediate return of coffee ground emesis (vomiting of dark brown, granular material that resembles coffee grounds and results from upper GI bleeding). He said not knowing the circumstances surrounding Resident #1's fall was pivotal to the care she received in the ER [DATE]. Immediate Jeopardy The administrator was notified on [DATE] at 4:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:38 p.m. and included: *"Licensed Nurses will receive In-service training on [DATE] by the ADON and prior to the next shift to work and on [DATE] by Nurse Practitioner and Regional Clinical Specialist with a completion date for all licensed staff by [DATE], related to that the nurse must provide the physician with accurate and complete information for incidents that occur. Incident reports must be completed and assessments must be completed for any incident. This information should include date and time, location, how, where, why and what possibly contributed to the occurrence of the incident. Assessment should include Vital signs, type of injury, description and location of pain, physical assessment of all areas of the body, and any treatment provided. They should not move a resident from the location of the incident until a complete and thorough assessment is done, and then only if it is safe to do so as to not cause further injury and only if the resident is not in pain. Physician and Responsible party notification of all incidents that occur must be done. Residents must also be assessed for changes of condition with physical assessment, vital signs, possible causative factors, and perform any testing such as blood sugars, urine dipsticks, Oxygen saturations that may pertain to their change of condition with a completion date for all licensed staff by [DATE]. *Licensed Nurses will receive In-service training on Nov. 8, 2012 by the ADON and prior to their next shift to work and on [DATE] by Nurse Practitioner and the Regional Clinical Specialist related to falsification of documentation. They will be informed that falsification of documentation and or falsification of any information pertaining to a resident in their care will be grounds for suspension, and possible termination and referral to the Board of Nurse Examiners, with a completion date for all licensed staff by [DATE]. *An In-service on [DATE] by the Administrator for the DON was conducted related to all incident reports must be investigated by the DON, and this should be completed within 3 days of the incident occurring. All incident reports will be brought to the morning meeting for review. If the DON needs assistance in the investigation they should contact the Regional Clinical Specialist." Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: *Seven licensed nurses were interviewed to verify knowledge of inservice training received in relation to notification to physician and or responsible party following injury or change of condition, completion of assessments, incident reports and investigations, how to properly assess a resident following an injury or change of condition and falsification of documents. *The DON was interviewed and said she received training regarding investigating incident reports. She said investigations were to be completed within 3 days of the incident occurring. She said all incident reports would be brought to the morning meeting for review. The DON said she would contact the Regional Clinical Specialist if she needed assistance in the investigation. On [DATE] at 11:40 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A resident census list dated [DATE] indicated 4 residents were at risk for elopement.

Based on interview and record review the facility failed to ensure care and services were provided according to the comprehensive assessment and plan of care for 1 of 4 residents reviewed for diabetes. (Resident #1) Resident #1 was a brittle diabetic (hard-to-control swings in blood glucose levels). The facility did not: *obtain accepatable parameters for the resident's blood sugars from the physician; *obtain insulin orders for the amount and timing of administration when the resident ' s blood sugars exceeded acceptable limits; *obtain correct instructions for administration of Resident #1's diabetic medication; and *from at [DATE] through [DATE] did not consult with the physician regarding nursing procedures for the resident's high blood sugars. Resident #1 was admitted to the hospital [DATE] in critical condition with [DIAGNOSES REDACTED]. Resident #1 died [DATE]. This failure contributed to Resident #1's development of diabetic ketoacidosis. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 5:54 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 11 residents with diabetes at risk of not receiving timely medical evaluation and treatment. Findings included: Physician orders [REDACTED]. The orders required her to receive [MEDICATION NAME] 0.5 units per hour from midnight to 10 a.m., 0.6 units per hour from 10 a.m. to 10 p.m. and 0.4 units per hour from 10 p.m. to midnight. The orders indicated the insulin cartridge of [MEDICATION NAME] should be changed every 6 days. The orders required Resident #1 to receive finger stick blood sugar monitoring twice a day. Physician orders [REDACTED]. The orders indicated Resident #1's physician was to follow her care and provide adjustments for insulin pump management as needed. The section of the orders titled "General Parameters" indicated the high blood sugar allowable range was 120 to 350. The MDS dated [DATE] indicated Resident #1 always understood others, was always able to make herself understood, had adequate vision and was independent with all her ADLs. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #1 had diabetes and had "labile blood sugars". The care plan goal indicated Resdient #1's blood sugars would be below 120. Care plan interventions required staff to: *obtain finger stick blood sugars as ordered; *observe for signs and symptoms of low and high blood sugars; and *administer [MEDICATION NAME] per physician order. The careplan did not address when to consult with the physician regarding Resident #1's blood sugar. MARs dated [DATE] indicated Resident #1's blood sugar level was as follows: *[DATE] at 11:30 a.m. and 4:30 p.m. - "Hi" *[DATE] at 2:00 a.m. and 4:00 a.m. - blank *[DATE] at 11:30 a.m. - 437 *[DATE] at 7:30 p.m. - 474 *[DATE] at 2:00 a.m. - 369 *[DATE] at 7:30 p.m. - blank *[DATE] at 4:30 p.m. - 438 *[DATE] at 7:30 p.m. - 355 *[DATE] at 6:30 a.m. - 9:00 a.m., 11:30 a.m. and 2:00 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 6:30 a.m. and 4:30 p.m. - blank *[DATE] at 2:00 a.m. - 394 *[DATE] at 4:00 a.m. - 516 *[DATE] at 4:30 p.m. and 7:30 p.m. - blank The undated "Blood Glucose Monitoring System Guide" provided with the blood glucose machine used by the facility indicated a reading of "HI" meant the resident's blood sugar was greater than 600. The guide indicated the physician or healthcare professional should be notified immediately. MARs dated [DATE] indicated Resident #1's blood sugar level was as follows: *[DATE] at 4:00 a.m. - blank *[DATE] at 2:00 a.m. - 366, 4:30 p.m. - 386, and 2:00 a.m. - 488 *[DATE] at 4:00 a.m. - 396 *[DATE] at 4:30 p.m. and 7:30 p.m. - blank *[DATE] at 2:00 p.m. - blank and 4:30 p.m. - 437 *[DATE] at 4:30 p.m. - 448 and 7:30 p.m. - 364 *[DATE] at 2:00 a.m. - 388 and 4:30 p.m. - 440 *[DATE] at 4:30 p.m. - Hi and 7:30 p.m. - 374 *[DATE] at 2:00 a.m. - 509, 2:00 a.m. - 457, 4:30 p.m. and 7:30 p.m. - blank *[DATE] at 9:00 a.m. - blank and11:30 a.m. - 383 *[DATE] at 9:00 a.m. - blank,11:30 a.m. - 400, and 4:30 p.m. - 407 *[DATE] at 4:30 p.m. - 452 and 7:30 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 2:00 a.m. - 411, 4:30 p.m. - 376 and 2:00 p.m. blank *[DATE] at 2:00 a.m. - 414, 4:00 a.m. - 364, 9:00 a.m., 2:00 p.m. and 7:30 p.m. - blank, and 4:30 p.m. - 522 *[DATE] at 2:00 a.m. - 377; at 9:00 a.m., 2:00 p.m. and 7:30 p.m. - blank *[DATE] at 2:00 a.m. - 613, 4:00 a.m. - 521, 6:30 a.m. - 435 *[DATE] at 7:30 p.m. - blank *[DATE] at 2:00 a.m. - Hi at 4:00 a.m. - 600, 6:30 a.m. - 511, 9:00 a.m. - 364, and 2:00 p.m. - blank *[DATE] at 2:00 p.m. - blank *[DATE] at 11:30 a.m. - 396, and 2:00 p.m. - blank *[DATE] at 4:30 p.m. - 391, and 7:30 p.m. - blank *[DATE] at 2:00 a.m. - 501, 4:00 a.m. - 433, 6:30 a.m. - 360, 11:30 a.m. - Hi *[DATE] at 4:30 p.m. - Hi and 7:30 p.m. - 376 MARs dated [DATE] indicated Resident #1's blood sugar level was as follows: *[DATE] at 4:30 p.m. - 434 *[DATE] at 4:30 p.m. - 475 *[DATE] at 4:30 p.m. - blank *[DATE] at 4:30 p.m. - Hi *[DATE] at 6:30 p.m. - Hi, untimed - Hi and 4:30 p.m. - 507 *[DATE] at 6:30 a.m. - 397 *[DATE] at 4:30 p.m. - 499 *[DATE] at 4:30 p.m. - 389 *[DATE] at 6:30 a.m. - Hi *[DATE] at 6:30 a.m. - Hi and 4:30 p.m. - 468 Resident #1's nursing notes indicated the following: *,[DATE] to [DATE] - nothing documented; *[DATE] at 8:00 a.m. - orders were received to increase Resident #1's [MEDICATION NAME]; *,[DATE] to [DATE] - nothing documented regarding blood sugars; *[DATE] at 1:30 p.m. - "blood sugar 376 no complaints noted". *,[DATE] to ,[DATE] - nothing documented regarding blood sugars; *[DATE] - new orders were received to monitor Resident #1's blood sugars twice a day; *[DATE] - blood sugar stable; *,[DATE] to [DATE] - nothing documented; *[DATE] at 4:45 a.m. - blood sugar 489 *,[DATE] to [DATE] - nothing documented regarding blood sugars. During an interview on [DATE] at 10:20 a.m. LVN A said Resident #1's blood sugar level read "hi" she did not alter what she did for the resident. She said she did not always consult the physician for blood glucose reading higher than 400 because Resident #1 always ran high. She said she did not have parameters for Resident #1's blood sugar levels. During an interview on [DATE] at 10:32 a.m. LVN D said Resident #1's blood glucose level read "hi" she would administer Resident #1's regular scheduled [MEDICATION NAME]. She said she would not re-check the blood glucose reading. She said she did not always consult the physician and did not always document when she did consult the physician. During an interview on [DATE] at 11:09 a.m., LVN C said Resident #1 had an insulin pump that continuously administered insulin and she received a [MEDICATION NAME] dose of insulin three times a day. She said she was not sure what "hi" meant on the machine they used to check blood sugars but she thought it meant the resident's blood sugar was greater than 400. She said she did not consult with Resident #1's physician regarding her blood sugar after Resident #1 received the insulin pump. She said, "If I called the doctor every time her blood sugar was high, I would be calling him quite often." She said Resident #1 was very asymptomatic with regard to high blood sugar and she would not consult with the physician unless Resident #1 was symptomatic. During an interview on [DATE] at 12:25 p.m., LVN D said she thought a "hi" reading on the blood sugar machine meant the resident's blood sugar was greater than 500 but she wasn't sure. She said she had not received training regarding the machine used to check blood sugars. She said Resident #1 did not have parameter for consulting with the physician regarding her blood sugars after she received the insulin pump. She said after receiving the insulin Resident #1's "normal" blood sugars in the "mid 250's". She said a "hi" reading was unusual but she would not consult the physician until Resident #1's blood sugar had been high for ",[DATE] days". During an interview on [DATE] at 12:41 p.m., LVN A said a reading of "hi" on the blood sugar machine meant the resident's blood sugar could not be read by the machine. She said she thought it meant the resident's blood sugar was greater than 500. She said the only training she received regarding the blood sugar machine was a brief inservice by the supplier when they started using the machine. She said Resident #1's blood sugar had registered "hi" before when she checked but she could not remember if she had consulted with the physician regarding the reading. During an interview on [DATE] at 3:40 p.m. LVN B said Resident #1 did not have blood sugar parameters after she received the insulin pump. She said she would only consult the physician if resident #1's blood sugars ran high ,[DATE] days in a row. She said she thought a "hi" meant the resident's blood sugar was greater than 500. During an interview on [DATE] at 2:00 p.m., Resident #1's physician said Resident #1 had been a "brittle diabetic" for years. He said he admitted Resident #1 to the facility so she could get an insulin pump and stabilize her blood sugar levels. He said Resident #1 suffered from "autonomic nerve [MEDICAL CONDITION]" and was unaware of when her blood sugars were high or low. He said he "would definitely expect a call if Resident #1's blood sugar were greater than 400". He said his goal for Resident #1's blood sugar was 250. The "Obtaining a Fingerstick Glucose Level" policy dated [DATE] read, "Documentation 6. The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on a sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc." During an interview on [DATE] at 12:57 p.m. the DON said they did not have a policy for reporting blood sugars. She said they would go by the physician orders [REDACTED]. She said Resident #1 received a pump because she was a "brittle diabetic". She said Resident #1 had blood sugar parameters to report prior to receiving her pump but not after. She said, in the absence of a physician order [REDACTED]. The facility routine order protocol dated [DATE] did not address consulting with the physician regarding blood sugar levels. During an interview on [DATE] at 12:57 p.m. the DON said, "I really don't know what I would report. I guess 350 - 400." Resident #1's nursing notes dated [DATE] indicated the following: *at 5:30 p.m., Resident #1 was non-responsive. Her respirations were labored. Staff were unable to obtain a blood pressure or oxygen saturation reading. *at 5:35 p.m., Resident #1 was not breathing and CPR was initiated by the EMS. *at 6:15 p.m., Resident #1 was transferred to the local hospital. An EMS transfer record dated [DATE] indicated Resident #1 was transferred from the facility in [MEDICAL CONDITION]. An emergency department workup dated [DATE] indicated Resident #1 was received from the nursing home unresponsive with agonal respirations (an abnormal pattern of breathing characterized by gasping and labored breathing). Her glucose level was 1102. The work-up indicated Resident #1 was transferred to a hospital that could provide a higher level of care. A hospital history and physical dated [DATE] indicated Resident #1 was admitted to the ICU on mechanical ventilator support and an IV insulin drip. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. The website, http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm, accessed [DATE], indicated diabetic ketoacidosis was a medical emergency and could lead to severe illness or death. Immediate Jeopardy The administrator was notified on [DATE] at 4:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:38 p.m. and included: *"On Nov. 7, 2012 Parameters for notification to MD by the Director of Nurses by written standing orders related to high and low results of fingerstick blood sugar tests were signed by the physicians and added to the fingerstick orders. All residents with diabetes will receive blood sugar monitoring. Parameters are to notify MD when blood sugar is less than 60 or greater than 400. These parameters are indicated in writing on the fingerstick order on the Treatment Administration record. In-service for Licensed Nurses is scheduled to be conducted on [DATE] by the ADON and prior to the next scheduled shift to work by the ADON and [DATE] by Nurse Practitioner and the Regional Clinical Specialist with a completion date for all licensed staff by [DATE]. *Diabetic residents that receive blood sugar monitoring will have their care plans updated with parameter notification to MD by [DATE]. *Licensed Nurses will receive In-service training on [DATE] by the ADON and prior to the next shift to work and on [DATE] by Nurse Practitioner and Regional Clinical Specialist with a completion date for all licensed staff by [DATE], related to that the nurse must provide the physician with accurate and complete information for incidents that occur. Incident reports must be completed and assessments must be completed for any incident. This information should include date and time, location, how, where, why and what possibly contributed to the occurrence of the incident. Assessment should include Vital signs, type of injury, description and location of pain, physical assessment of all areas of the body, and any treatment provided. They should not move a resident from the location of the incident until a complete and thorough assessment is done, and then only if it is safe to do so as to not cause further injury and only if the resident is not in pain. Physician and Responsible party notification of all incidents that occur must be done. Residents must also be assessed for changes of condition with physical assessment, vital signs, possible causative factors, and perform any testing such as blood sugars, urine dipsticks, Oxygen saturations that may pertain to their change of condition with a completion date for all licensed staff by [DATE]. *Licensed Nurses will receive In-service training on Nov. 8, 2012 by the ADON and prior to their next shift to work and on [DATE] by Nurse Practitioner and the Regional Clinical Specialist related to falsification of documentation. They will be informed that falsification of documentation and or falsification of any information pertaining to a resident in their care will be grounds for suspension, and possible termination and referral to the Board of Nurse Examiners, with a completion date for all licensed staff by [DATE]. *An In-service on [DATE] by the Administrator for the DON was conducted related to all incident reports must be investigated by the DON, and this should be completed within 3 days of the incident occurring. All incident reports will be brought to the morning meeting for review. If the DON needs assistance in the investigation they should contact the Regional Clinical Specialist. *If in the future this facility admits a resident with an insulin pump, or has a resident that requires an insulin pump, the following process will be followed: *The manufacturer of the pump will be contacted and requested to provide operational information and educational In-servicing to the licensed staff prior to the resident coming into the facility with the pump in place. The licensed staff will also receive In-servicing on signs and symptoms of hypo/[MEDICAL CONDITION] and reporting these to the MD. The Medical Director will oversee the resident for any complications that may occur. In the event he is not available, the protocol for managing the residents' blood sugars will be to disconnect the insulin pump, take blood sugar reading by fingerstick every 2 hours until further instructions received from the MD. In case of abnormal blood sugar readings the staff will follow the standing orders for sliding scale using Humalog insulin in the case of hyperglycemic results and D50 glucose tablets in the case of hypoglycemic results." Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: *A copy of signed physician standing orders for reporting blood sugars was verified; *All diabetic resident's treatment administration records were checked for updated parameter notification and instruction; *All diabetic resident's clinical records were checked for updated care plans with parameter notification *Seven licensed nurses were interviewed to verify knowledge of inservice training received in relation to notification to physician and or responsible party following injury or change of condition, completion of assessments, incident reports and investigations, how to properly assess a resident following an injury or change of condition and falsification of documents *A copy of signed standing orders for protocol of insulin pumps was verified On [DATE] at 11:40 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A resident census list dated [DATE] indicated 4 residents were at risk for elopement. A resident census list dated [DATE] indicated 11 residents had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 1 of 5 residents reviewed for wandering. (Resident #1) Resident #1 was at risk for elopement & required supervision when outside. The facility did not: *provide supervision to prevent Resident #1 from leaving the facility. She was found across the highway in a ditch with fractures; *ensure the Wandergard system (a device that automatically locks doors and alarms when designated residents attempt to exit) was functional on 2 doors; *ensure staff were aware of which residents were exit seekers; *ensure 4 staff used correct protocol when the resident was found injured off of the facility property; *did not provide the hospital with correct information regarding the resident ' s incident; after being found in the ditch, 4 staff took the resident back to facility before they called EMS. On [DATE] Resident #1 was sent to the hospital and treated for [REDACTED]. The resident was taken back to the hospital and was admitted on [DATE]. Resident #1 died at the hospital on [DATE]. This failure contributed to Resident #1's elopement, injury, hospitalization and death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE] at 5:54 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 4 residents who were at risk for elopement at risk for injury or death. Findings included: Physician orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 always understood others and was always able to make herself understood had adequate vision and was independent with all her ADLs. The MDS indicated Resident #1 had trouble sleeping, felt bad about herself or that she was a failure or had let herself or her family down for half or more of the days in the past two week period. The MDS indicated Resident #1 did not exhibit wandering behavior in the prior seven days. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE] indicated Resident #1 had a life long history of depression and was tearful at time. The care plan indicated the resident would be observed for changes in mood status and would be monitored for behavior at least every shift and the physician would be notified of any negative behavior. The care plan indicated Resident #1 had decreased vision and required assistance with ADLs and ambulation, supervision when smoking, and that she was at risk for elopement, wearing a Wanderguard bracelet to prevent unsupervised exits. Care plan interventions required staff to check Resident #1 frequently for wandering and remove her from unsafe situations. The wander data collection tool dated [DATE] was incomplete and did not indicate if Resident #1 was at risk for elopement. Nursing notes dated [DATE] indicated Resident #1 returned from being out on pass with her husband and began to exhibit exit seeking behaviors and/or behavior changes at the following times: *2:00 p.m. crying, exit seeking *3:18 p.m. verbally aggressive, cursing *3:40 p.m. exit seeking, difficult to redirect *4:10 p.m. exited facility *9:30 p.m. exit seeking *11:00 p.m. verbally aggressive, cursing, threats of physical violence, unable to calm *11:30 p.m. crying, verbally aggressive, cursing During an interview on [DATE] at 7:40 p.m. CNA K said on [DATE] she was outside hall 400 at approximately 1:00 a.m. when she saw Resident #1 exit hall 400 door alone to smoke. CNA K said at approximately 2:00 a.m. she went outside to the front of the facility with LVN N to take a break and heard someone in a loud voice say, "HEY." She said they saw Resident #1 across the highway sitting in the ditch flicking a cigarette lighter. CNA K said she went back to the facility to get a wheelchair and sheets. CNA K said they lifted Resident #1 with the sheets to the wheelchair and pushed her back across the highway and put her in the bed. She said she was unaware Resident #1 was an elopement risk. During an interview on [DATE] at 9:25 a.m. CNA M said on [DATE] at approximately 2:00 a.m. she went across the highway where Resident #1 was sitting in the grass in a ditch screaming and crying complaining of pain. CNA M said she helped RN L and LVN N put Resident #1 in the wheelchair by placing sheets under her to lift her into the wheelchair. CNA M said Resident #1 was taken back across the highway to the facility and put to bed. CNA M said residents and employees always used the exit on hall 400 to go outside to smoke. CNA M said she was not aware of residents who were at risk for elopement. CNA M said she only knew residents on halls 400, 500 and 600 where she worked and was not familiar with Resident #1 who resided on hall 200. She said the exit door on hall 400 would not close sometimes because it "got stuck". CNA M said she knew the alarm would sound if a resident wearing a Wanderguard bracelet tried to go outside, but she had not heard the alarm the night of Resident #1's incident. CNA M said the highway Resident #1 crossed was the major highway through the town. She said, "it is a very busy highway, with diesels and everything." During an observation on [DATE] at 9:00 a.m. the speed limit on the highway in front of the facility was 65 miles per hour. During an interview on [DATE] at 10:30 p.m. RN L said on [DATE] she was called on the phone by LVN N to get a pair of gloves and come outside. She said she went outside and observed Resident #1 sitting in the ditch on the opposite side of the highway from the facility. She said Resident #1 was unable to stand and she told CNA K to go get a wheelchair and two sheets. She said they placed the sheets under Resident #1 and lifted her into the wheelchair and pushed her across the highway to her room. She said earlier that night Resident #1 came to the nurse desk and asked for cigarettes and she told her to ask LVN N. She said the hall 400 exit door alarm by the laundry did not work. During an interview on [DATE] at 11:45 a.m., LVN C said after arriving to work [DATE] Resident #1 said she had fallen on some rocks. LVN C said Resident #1 seemed more drowsy than normal and her cognition was "not good". LVN C said Resident #1 wore an alarm on her ankle due to being an elopement risk and had to be supervised when she went out to smoke. LVN C said Resident #1 was often upset and she attempted to leave after being out on pass with her husband. She said Resident #1 had "recently" returned from an outing with her husband prior to the [DATE] incident. She said she had never been instructed regarding interventions to address Resident #1's behavior or elopement attempts. LVN C said she "recently" passed the facility while off duty and saw Resident #1 outside smoking without supervision but did not report it. LVN C said night shift charge nurses were responsible for checking batteries in Wanderguard bracelets weekly to assure they were functioning correctly. She said charge nurses were responsible for checking placement of the Wanderguard bracelets on residents every shift. During an interview on [DATE] at 1:30 p.m., CNA O said on [DATE] she was working alone on halls 100, 200 and 300. She said LVN N was the charge nurse for those halls. She said CNA K and CNA M were working on halls 400, 500 and 600 with RN L as the charge nurse. CNA O said at approximately 1:00 a.m. Resident #1 was walking from her room on Hall 200 and asked if she could go out to smoke. CNA O said she told Resident #1 to ask LVN N, who was at the nursing station. She said a few minutes later Resident #1 was headed toward hall 400 and told her LVN N said she could go out hall 400 to smoke. CNA O said she was not aware Resident #1 wore a Wanderguard bracelet and did not remember hearing the Wanderguard alarm that night. CNA O said at approximately 2:00 a.m. she was filling ice pitchers and noticed Resident #1 was not in her room. CNA O said a few minutes later LVN N, RN L and CNAs K and M came into the room with Resident #1 in a wheelchair. CNA O said Resident #1 screamed in pain and when touched shouted "that hurts". CNA O said when LVN N, RN L and CNA K and CNA M transferred Resident #1 from the wheelchair to the bed there was grass in the seat of the wheelchair. CNA O said when the EMTs transferred Resident #1 from her bed to the gurney; there was grass on the bed where Resident #1 was lying. CNA O said Resident #1 told the EMTs she was trying to run away and fell down outside. She said the DON and ADON had been working on the Wanderguard alarms a few days prior to the incident with Resident #1. CNA O said she was not aware of residents who were at risk for elopement or who wore Wanderguard bracelets. CNA O said it was common for Resident #1 and Resident #5 to be outside smoking together without staff present. CNA O said she was not aware of anyone who required supervision to smoke and she did not know how the Wanderguard system worked. During a phone interview on [DATE] at 6:02 p.m. LVN N denied allowing Resident #1 to go outside during her shift. She said she heard Resident #1 yelling and found her on the floor next to her bed complaining of pain to the shoulder, hip and knee. An incident/accident report dated [DATE] at 2:15 a.m., indicated LVN N heard Resident #1 yelling and entered her room and found her lying in the floor next to the bed on her left side. LVN N assessed Resident #1 and the resident was unable to move her upper extremities, and complained of her whole left side hurting. A witness statement dated [DATE] by the EMT indicated they were called to the facility on [DATE] for a fall in the early morning hours. He said when he went to Resident #1's room she was in pain and crying. He said he asked Resident #1 what happened. Resident #1 said she was trying to escape and tripped in the ditch outside, fell , and hurt her arm. He said Resident #1 indicated she wanted to go home. He said while transferring Resident #1 onto a cot he noticed grass in the bed and on Resident #1. While transferring Resident #1 she was crying and hollering in pain. He said no one at the facility gave him a report as to what happened. The emergency room record dated [DATE] at 4:00 a.m. indicated Resident #1 was received at the hospital after she had fallen and was found on the floor. The records indicated Resident #1 had a deformity of her shoulder and complained of pain in her left arm and both ankles. Radiology reports dated [DATE] indicated Resident #1 had a fractured left foot and left humerus (upper arm). A hospital history and physical dated [DATE] indicated Resident #1 returned to the hospital and was admitted to the ICU on mechanical ventilator support. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. During an observation and interview on [DATE] at 1:33 p.m. the exit door by the hall 400 employee time clock did not lock, when surveyor exited the door twice with a Wanderguard in hand. On the third attempt, the door locked and would not let surveyor exit. The maintenance supervisor said the door was supposed to lock when a person with a Wanderguard bracelet approached. He said if the exit doors were not shut properly, the doors would not lock. He said an employee could disable the lock, but not the alarm. He said he checked the Wanderguard bracelet batteries every week along with the doors and locks. He said if the Wanderguard bracelet battery was dead the doors would not lock and the alarm would not sound. During an interview on [DATE] at 7:40 p.m. CNA K said Resident #1 "often" went outside to smoke without supervision and she never heard an alarm go off when Resident #1 exited the building on [DATE]. During an interview on [DATE] at 3:00 p.m. housekeeper E said she did not know which residents were at risk for elopement. She said she was unaware of how to find out who was a risk for elopement. During an interview on [DATE] at 3:05 p.m., CNA P said he was not aware of residents who were at risk for elopement. CNA F said he had not been inserviced in the last ,[DATE] weeks on anything. CNA F said he would ask the charge nurse or look in the elopement book at the nursing station to find out who was at risk for elopement. During an interview on [DATE] at 3:15 p.m. CNA G said she identified residents at risk for elopement by looking for a Wanderguard bracelet on their ankles. She said she did not know where to look to find out who was at risk for elopement. She said unless someone told her who was at risk she would not know. During an interview on [DATE] at 3:30 p.m. CNA J said she was unaware of where to find who was at risk for elopement. She said if no one told her she would not know. During an interview on [DATE] at 4:15 p.m., CNA F said the exit door on hall 400 "often" did not close properly and would not lock when the Wanderguard bracelet activated the alarm. CNA F said Resident #1 was upset and attempted to leave after being out on pass with her husband. He said the resident had been out on pass with her husband a "few days" prior to the incident on [DATE]. He said he had never been trained regarding interventions to address Resident #1's behavior or elopement attempts. During an interview on [DATE] at 4:20 p.m., LVN B said Resident #1 often wandered and had to be chased when she got outside. LVN B said Resident #1 was often upset after being out on pass with her husband and would attempt to leave. She said Resident #1 had been out on pass with her husband a "few days" prior to the incident on [DATE]. She said she had never been trained regarding interventions to address Resident #1's behavior or elopement attempts. The undated elopement book located at the nursing station did not coincide with the list of residents who were elopement risk provided by the administrator on [DATE]. The elopement book included Resident #s 1, 2, 3, 4 and 6 and the list provided by the administrator included Resident #s 2, 3, 4 and 10. During an interview on [DATE] at 5:35 p.m. the DON said she felt LVN N, RN L and CNA K and CNA M did not give factual information in their reports of the incident with Resident #1. She said RN L told her during a phone interview Resident #1 was found across the highway in a ditch but later recanted her story during an interview in person with the DON and the regional clinical specialist. She said Resident #1 always had exit seeking behaviors after going out on pass with her husband. She said Resident #1 had been out on pass with her husband "a few days" prior to the incident on [DATE]. She said she never inserviced staff or put a plan into action regarding Resident #1's behaviors. The DON said Resident #1 wore a Wanderguard bracelet due to elopement attempts and she did not know how Resident #1 could have exited the facility without staff disarming the Wanderguard system. The DON said an elopement book was located at the nursing station and contained a list of residents who were at risk for elopement. She said the book was updated each time a resident was added or discharged and nursing staff were notified of any changed during report at shift change and the charge nurse notified the CNAs on duty. She said the elopement book must have not been updated, because it did not match the list provided by the administrator. She said Resident #1 was deceased , Resident #10 was no longer at risk for elopement, and those at risk for elopement included Resident #s 2, 3, 4, and 6. She said it was the responsibility of nurses on night shift to check batteries in Wanderguard bracelets weekly and to assure they were functioning properly. During an interview on [DATE] at 12:30 p.m., the administrator said they began investigating the conditions surrounding the [DATE] incident involving Resident #1 because staff gave conflicting statements. He said he felt LVN N provided false documentation and RN L, CNA K and CNA M gave false information in their statements and all had been terminated. He said based on the investigation, "all evidence shows the resident (Resident #1) was outside" when the incident occurred, but he did not know how she got out unless someone deactivated the door alarm. He said he changed the code on the alarm system following the incident and staff were in-serviced on requirements for residents who wore Wanderguard bracelets and instructed that any resident who wore a Wanderguard bracelet was not allowed to go out of the facility unsupervised. During an observation and interview on [DATE] at 12:40 p.m., the exit door on hall 300 was ajar and when approached with a Wanderguard bracelet device the door did not lock. The surveyor walked through the door and outside with the Wanderguard bracelet device in hand. The administrator was notified. The policy for resident elopement dated [DATE] indicated: *"it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. *all residents will be assessed for behaviors or conditions that may place them at risk for elopement. *all residents so identified will have these issues addressed in their individual care plans. *all staff is responsible to ensure resident safety *at no time shall the door alarm be turned off without continuous supervision of the exit door. The person responsible for turning off the alarm shall be responsible for resetting it and ensure that it is working properly. *Residents identified at risk for elopement will be reviewed by the interdisciplinary team to identify if the causative factors can be eliminated. If the causative factors cannot be eliminated, the team will develop and implement strategies to prevent elopement such as: location monitoring, structured activity programs, psychosocial interventions and evaluation of medication... *All staff shall be inserviced on: how to identify residents at risk for elopement; how to supervise, monitor and redirect the resident and what to do after the resident is recovered. *When a resident is found: if there is sign of injury, call for an ambulance. *if the resident appears unharmed, get the resident to safety and perform a complete assessment including but not limited to, vital signs, bead to toe assessment, mental status, etc. and document appropriately." The policy did not address what staff should do if the doors did not function properly when a resident with a Wanderguard bracelet approached. The undated "Wanderer Management and Monitoring System" policy included: *"Once a resident is admitted to the facility, Elopement Policy will be followed. *Use the "Elopement Risk Factor" form on all new admissions and quarterly if resident has been determined to be a wander risk. *Maintain a tracking system within your facility that indicates which resident has a signaling device, when it was placed on the resident and when it is due to expire. Binder to be kept at a central location to include resident pictures, Residents with Signaling Devices form, Weekly Checklist for Door modules form and may also include updated resident face sheets." The policy did not address what staff should do if the doors did not function properly when a resident with a Wanderguard bracelet approached. The Wanderguard Departure Alert System User Manual dated 2003 read: *pg. 15 "1. The system is designed such that the maximum opportunity for the monitor to " hear " the signal being transmitted by the signaling device, especially under interference conditions, is when the signaling device is worn on the resident's wrist. *Devices placed on the wrist are more readily visible so staff can check routinely to verify placement ...When a transmitter is placed on the ankle - which should not be done without specific instructions from (manufacture name removed), the transmitter cannot be visually checked because it is almost always hidden beneath trousers or stockings. As a result, a lost signaling device could go undetected." *pg. 20 "3. Staff must test signaling devices daily: otherwise device expiration or device failure may go undetected." The smoking policy dated [DATE] indicated "if a resident is deemed "unsafe", they will be required to surrender all smoking paraphernalia to facility. Staff will maintain/keep all smoking materials and distribute the materials to residents at smoking times. Furthermore, a smoking schedule will be posted and residents will be required to smoke with supervision only, according to schedule." Immediate Jeopardy The administrator and DON were notified on [DATE] at 6:20 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:33 p.m. and included: "Wander management tools (elopement assessments) are being completed for all residents by the ADON and MDS coordinator, to be completed by [DATE] Audit of all current residents at risk to wander to ensure bracelets are in place completed by ADON [DATE]. Verification that all bracelets currently on residents are functioning will be completed by DON [DATE] Elopement book will be updated by the DON with current list of all residents at risk to wander on [DATE] after wander management tools are completed Inservice for nursing staff by DON prior to their next shift to work and on [DATE] related to Wanderguard elopement book, location of book, list of residents at risk to wander, and the resident care guides (reference guide for CNAs) are to include information for elopement risk residents In-service for licensed nurses by DON prior to their next shift to work and on [DATE] on completing wander management tools in their entirety to include of the resident is or is not at risk to wander. Inservice for nursing staff by DON prior to their next shift and on [DATE] to communicate during shift change report of any new residents at risk to wander, or any changes in smoking habits and this will be updated on the resident care guides which are located in the resident rooms inside the closet door for reference In-service for staff by the Director of Nurses prior to their next shift to work and on [DATE] that absolutely no unsafe smokers are to be allowed to smoke unattended per facility policy. Audit of all residents who smoke to ensure their assessments are current and correct by social worker to be completed by [DATE]. Social Worker will complete a list of unsafe smokers and this list will be maintained by the social worker and will be posted by the social worker in nursing station, and in the nurses' treatment books and CNA ADL books. Maintenance manager completed a check of all exit doors on [DATE] to ensure that the departure alert system is functioning correctly. All doors are functioning correctly. In-service for staff by administrator prior to next shift worked and on [DATE] related to disarming alarm system and entering code to disarm alarm system. In-service by regional clinical specialist for Administrator and Director of Nurses on [DATE] on Wander Management and monitoring system protocol to include the policy, procedures for assessment of residents to determine risk for elopement, application of bracelet and monitoring of bracelet and door modules. Documentation of monitoring for placement and testing of bracelets, and of door modules. Forms to be completed to indicate process is completed. Signaling devices (bracelets) must be tested daily and door modules must be tested at least weekly on each shift. The charge nurses are to test the signaling devices and document on the medication administration record and test the door modules on Sundays on night shift and the maintenance manager is to check the door modules weekly on the day and evening shift." Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: The Wander management tools (elopement assessments) were reviewed and had been completed for all residents in the facility. All residents identified to be at risk for elopement were observed to assure Wanderguard bracelets were in place and functioning properly. The elopement book was reviewed and had been updated with a list of all residents who were at risk to wander. Twelve CNAs were interviewed and said they had been inserviced prior to their next shift related to Wanderguard elopement book, location of book, list of residents at risk to wander, the resident care guides, procedures for unsafe smokers and procedures for door alarm system and using the code Seven nurses were interviewed and said they had been inserviced prior to their next shift related to Wanderguard elopement book, location of book, list of residents at risk to wander, the resident care guides, completion of management tools and communication procedures in relation to residents at risk to wander and smoking habits, procedures for unsafe smokers and procedures for door alarm system and using the code Smoking assessments were reviewed for all residents who smoked and none were evaluated as unsafe A check of all exit doors was completed to ensure the departure alert system was functioning correctly The administrator and the DON were interviewed and said they were in-serviced on the wander management and monitoring system protocol policy, procedures for assessment of residents, documentation of monitoring for placement and testing of bracelets, and of door modules. On [DATE] at 5:54 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by the administrator dated [DATE] indicated 4 residents were at risk for elopement.

Based on interview and record review the facility failed to ensure insulin was administered correctly for 1 of 4 residents reviewed for insulin use. (Resident #1) Resident #1 received Apidra (rapid acting insulin) for diabetes through an insulin pump from 8/24/12 to 10/25/12. The facility changed the medication every 6 days instead of every 48 hours according to the manufacturer's specification. Resident #1 was admitted to the hospital 10/25/12 with [DIAGNOSES REDACTED]. This failure contributed to Resident #1 developing diabetic ketoacidosis. An Immediate Jeopardy situation was identified on 11/8/12.The immediate Jeopardy was removed on 11/9/12. The facility remained out of compliance at pattern of actual harm due to the facility's need to develop a policy, train the nursing staff and evaluate the effectiveness of the corrective systems. This failure could place 11 residents with diabetes at risk for not receiving the intended therapeutic benefit of their medication. Findings included: Physician dated October 2012 indicated Resident #1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders required her to receive Apidra 0.5 units per hour from midnight to 10 a.m., 0.6 units per hour from 10 a.m. to 10 p.m., and 0.4 units per hour from 10 p.m. to midnight. The orders indicated the insulin cartridge of Apidra should be changed every 6 days. The website, http://www.apidra.com, accessed 11/2/12 read: *"Change the Apidra in the pump reservoir every 48 hours. *Infusion sets: Infusion sets (reservoirs, tubing, and catheters) and the Apidra in the reservoir should be discarded after 48 hours of use or after exposure to temperatures that exceed 98.6." *17 Patient Counseling Information, 17.2 For patients using continuous subcutaneous insulin pumps: To minimize insulin degradation (decreased effectiveness), infusion set occlusion and loss of the preservative (metacresol), the infusion sets (reservoir, tubing, and catheter) and the Apidra in the reservoir should be replaced every 48 hours..." During an interview on 11/2/12 at 2:00 p.m., Resident #1's physician said he signed a telephone order written by the DON to change Resident #1's diabetic medication every six days because he trusted the DON had researched the information. He said he wanted to follow manufacture specifications and thought that was what he was doing when he signed the order. He said, "I trust the nurses to write the right thing. I don't know how to work with a nurse I can not trust." Resident #1's MDS dated [DATE] indicated she was alert and oriented, ambulatory and able to complete ADLs by herself. The MDS indicated her [DIAGNOSES REDACTED]. Resident #1's undated care plan indicated she had an insulin pump. Care plan interventions included "Apidra per doctor's orders" and "change infusion site and cartridge per doctor's orders". Resident #1's MARs indicated: *August 2012 - Change insulin cartridges every 6 days. *September 2012 - Change insulin cartridges of Apidra every 6 days. *October 2012 - Change insulin cartridges of Apidra every 6 days. MARs dated August 2012 indicated Resident #1's blood sugar level was as follows: *8/21/12 at 11:30 a.m. and 4:30 p.m. - "Hi" *8/21/12 at 2:00 a.m. and 4:00 a.m. - blank *8/22/12 at 11:30 a.m. - 437 *8/22/12 at 7:30 p.m. - 474 *8/23/12 at 2:00 a.m. - 369 *8/23/12 at 7:30 p.m. - blank *8/24/12 at 4:30 p.m. - 438 *8/24/12 at 7:30 p.m. - 355 *8/25/12 at 6:30 a.m. - 9:00 a.m., 11:30 a.m. and 2:00 p.m. - blank *8/27/12 at 2:00 p.m. - blank *8/28/12 at 2:00 p.m. - blank *8/29/12 at 6:30 a.m. and 4:30 p.m. - blank *8/31/12 at 2:00 a.m. - 394 *8/31/12 at 4:00 a.m. - 516 *8/31/12 at 4:30 p.m. and 7:30 p.m. - blank The undated "Blood Glucose Monitoring System Guide" provided with the blood glucose machine used by the facility indicated a reading of "HI" meant the resident's blood sugar was greater than 600. The guide indicated the physician or healthcare professional should be notified immediately. MARs dated September 2012 indicated Resident #1's blood sugar level was as follows: *9/1/12 at 4:00 a.m. - blank *9/2/12 at 2:00 a.m. - 366, 4:30 p.m. - 386, and 2:00 a.m. - 488 *9/5/12 at 4:00 a.m. - 396 *9/6/12 at 4:30 p.m. and 7:30 p.m. - blank *9/8/12 at 2:00 p.m. - blank and 4:30 p.m. - 437 *9/9/12 at 4:30 p.m. - 448 and 7:30 p.m. - 364 *9/10/12 at 2:00 a.m. - 388 and 4:30 p.m. - 440 *9/11/12 at 4:30 p.m. - Hi and 7:30 p.m. - 374 *9/12/12 at 2:00 a.m. - 509, 2:00 a.m. - 457, 4:30 p.m. and 7:30 p.m. - blank *9/13/12 at 9:00 a.m. - blank and11:30 a.m. - 383 *9/14/12 at 9:00 a.m. - blank,11:30 a.m. - 400, and 4:30 p.m. - 407 *9/16/12 at 4:30 p.m. - 452 and 7:30 p.m. - blank *9/19/12 at 2:00 p.m. - blank *9/20/12 at 2:00 a.m. - 411, 4:30 p.m. - 376 and 2:00 p.m. blank *9/21/12 at 2:00 a.m. - 414, 4:00 a.m. - 364, 9:00 a.m., 2:00 p.m. and 7:30 p.m. - blank, and 4:30 p.m. - 522 *9/22/12 at 2:00 a.m. - 377; at 9:00 a.m., 2:00 p.m. and 7:30 p.m. - blank *9/23/12 at 2:00 a.m. - 613, 4:00 a.m. - 521, 6:30 a.m. - 435 *9/24/12 at 7:30 p.m. - blank *9/25/12 at 2:00 a.m. - Hi at 4:00 a.m. - 600, 6:30 a.m. - 511, 9:00 a.m. - 364, and 2:00 p.m. - blank *9/26/12 at 2:00 p.m. - blank *9/27/12 at 11:30 a.m. - 396, and 2:00 p.m. - blank *9/28/12 at 4:30 p.m. - 391, and 7:30 p.m. - blank *9/29/12 at 2:00 a.m. - 501, 4:00 a.m. - 433, 6:30 a.m. - 360, 11:30 a.m. - Hi *9/30/12 at 4:30 p.m. - Hi and 7:30 p.m. - 376 MARs dated October 2012 indicated Resident #1's blood sugar level was as follows: *10/3/12 at 4:30 p.m. - 434 *10/9/12 at 4:30 p.m. - 475 *10/11/12 at 4:30 p.m. - blank *10/12/12 at 4:30 p.m. - Hi *10/13/12 at 6:30 p.m. - Hi, untimed - Hi and 4:30 p.m. - 507 *10/14/12 at 6:30 a.m. - 397 *10/22/12 at 4:30 p.m. - 499 *10/23/12 at 4:30 p.m. - 389 *10/24/12 at 6:30 a.m. - Hi *10/25/12 at 6:30 a.m. - Hi and 4:30 p.m. - 468 During an interview on 11/2/12 at 11:09 a.m., LVN C said Resident #1's insulin cartridge and insulin was replaced every 6 days. During an interview on 11/2/12 at 12:25 p.m., LVN D said Resident #1 received an insulin pump about "6-8 weeks ago". She said Resident #1 received a continuous infusion of insulin. She said the insulin cartridge and insulin was replaced every six days. During an interview on 11/2/12 at 12:41 p.m., LVN A said Resident #1's insulin cartridge was replaced every 6 days. During an interview on 11/2/12 at 3:30 p.m., LVN B said Resident #1 received continuous infusion of insulin via an insulin pump. She said Resident #1's insulin cartridge in the pump was replaced every 6 days. During an interview on 11/2/12 at 6:55 p.m., the DON said Resident #1's insulin was not changed every 48 hours. She said she never spoke with the pharmacy consultant or Resident #1's physician regarding how often to change Resident #1's insulin. She said she got the information about changing Resident #1's insulin cartridge every six days from information Resident #1's husband provided and her medical supply representative. She said she wrote the physician order [REDACTED]. Resident #1's nursing notes dated 10/25/12 indicated the following: *at 5:00 p.m., Resident #1 was non-responsive. Staff were unable to obtain a blood pressure or oxygen saturation reading. *at 5:35 p.m., Resident #1 was not breathing and CPR was initiated by the EMS. *at 6:15 p.m., Resident #1 was transferred to the local hospital. An emergency department workup dated 10/25/12 indicated Resident #1 was received from the nursing home unresponsive with agional respirations (an abnormal pattern of breathing characterized by gasping and labored breathing). Her glucose level was 1102. The work-up indicated Resident #1 was transferred to a hospital that could provide a higher level of care. A hospital history and physical dated 10/25/12 indicated Resident #1 was admitted to the ICU on mechanical ventilator support and an IV insulin drip. The impression was that Resident #1 was critically ill with a poor prognosis. Her admitting [DIAGNOSES REDACTED]. A hospital physician progress notes [REDACTED]. The website, http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm, accessed 11/5/12, indicated diabetic ketoacidosis was a medical emergency and could lead to severe illness or death. Immediate Jeopardy The administrator was notified on 11/08/12 at 4:30 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 11/08/12 at 7:38 p.m. and included: On Nov. 7, 2012 Parameters for notification to MD by the Director of Nurses by written standing orders related to high and low results of finger stick blood sugar tests were signed by the physicians and added to the finger stick orders. All residents with diabetes will receive blood sugar monitoring. Parameters are to notify MD when blood sugar is less than 60 or greater than 400. These parameters are indicated in writing on the finger stick order on the Treatment Administration record. In-service for Licensed Nurses is scheduled to be conducted on [DATE] by the ADON and prior to the next scheduled shift to work by the ADON and [DATE] by Nurse Practitioner and the Regional Clinical Specialist with a completion date for all licensed staff by [DATE]. *Diabetic residents that receive blood sugar monitoring will have their care plans updated with parameter notification to MD by [DATE]. *If in the future this facility admits a resident with an insulin pump, or has a resident that requires an insulin pump, the following process will be followed: *The manufacturer of the pump will be contacted and requested to provide operational information and educational In-servicing to the licensed staff prior to the resident coming into the facility with the pump in place. The licensed staff will also receive In-servicing on signs and symptoms of hypo/hyperglycemia and reporting these to the MD. The Medical Director will oversee the resident for any complications that may occur. In the event he is not available, the protocol for managing the residents ' blood sugars will be to disconnect the insulin pump, take blood sugar reading by finger stick every 2 hours until further instructions received from the MD. In case of abnormal blood sugar readings the staff will follow the standing orders for sliding scale using Humalog insulin in the case of hyperglycemic results and D50 glucose tablets in the case of hypoglycemic results. Plan of Removal Verification The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: *A copy of signed physician standing orders for reporting blood sugars was verified; *All diabetic resident's treatment administration records were checked for updated parameter notification and instruction; *All diabetic resident's clinical records were checked for updated care plans with parameter notification *Seven licensed nurses were interviewed to verify knowledge of in-service training received in relation to notification to physician and or responsible party following injury or change of condition, completion of assessments, incident reports and investigations, how to properly assess a resident following an injury or change of condition and falsification of documents *A copy of signed standing orders for protocol of insulin pumps was verified On 11/9/12 at 11:40 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance with a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A resident census list dated 11/9/12 indicated 11 residents had a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to ensure respiratory/oxygen therapy was provided for 1 of 4 residents reviewed for respiratory care. (Resident #5) Resident #5 required use of a bi-pap machine to aide breathing at night while sleeping. Resident #5 did not receive bi-pap treatments for at least 10 days because the machine was not functioning properly. The facility did not provide replacement supplies for the machine until after the resident was admitted to the hospital on [DATE]. This failure contributed to Resident #5's decline in respiratory status resulting in a 9 day hospital stay. Findings included: Physician orders [REDACTED]. The orders required Resident #5 to have bi-pap treatments while sleeping. The most recent MDS assessment dated [DATE] indicated Resident #5 was not cognitively impaired and was dependent on staff for ADLs, transfers and bed mobility. The care plan dated 9/21/11 indicated staff were to ensure Resident #5's bi-pap machine was used properly, and contact the medical supply company if there were any problems concerning bi-pap treatments. During an interview on 11/2/11 at 11:20 a.m., LVN A said the night nurses had reported to her Resident #5's bi-pap machine was not being used because the mask did not seal properly around the resident's face. She said she reported it to the DON "several times in the past several weeks". During an interview on 11/2/11 at 12:40 p.m., LVN B said the night nurses had reported to her Resident #5's bi-pap machine was not being used because it "alarmed continuously" and the mask did not seal around the resident's face. She said the night nurses had been reporting the problem for two weeks. She said she told the DON "several times". During an interview on 11/2/11 at 1:00 p.m., LVN C said the night nurses had reported to her Resident #5's bi-pap machine was not being used because it was not "functioning properly". She said she had asked the DON for "several weeks" if they could replace the broken part or get another machine, but she had not received any feedback. During an interview on 11/2/11 at 2:15 p.m., RN D said she worked nights and reported to nurses on the day shift "several times over the past several weeks" that Resident #5's bi-pap machine was alarming frequently and leaking around the mask. She said the alarm meant the machine was not getting the correct airflow pressure and needed to be checked. She said the day shift nurses told her they reported the problem with the bi-pap machine to the DON and administrator. During an interview on 11/2/11 at 6:00 p.m., LVN E said she worked nights and reported to nurses on the day shift "several times over the past several weeks" that Resident #5's bi-pap machine alarmed frequently because the mask was not sealing around the resident's face. She said a new mask was obtained after Resident #5 was admitted to the hospital. During an interview on 11/3/11 at 7:30 a.m., Resident #5 said he asked staff for a new mask or to have his bi-pap machine adjusted. He said his mask did not seal properly and the machine alarmed constantly. During an interview on 11/3/11 at 7:45 a.m., the DON said one of the nurses told her Resident #5 needed a new mask for his bi-pap machine Wednesday (10/19/11) before he went to the hospital. She said she forgot to follow up until after the resident was admitted to the hospital 10/25/11. Resident #5's nursing notes included the following: *10/15/11 at 11:00 p.m., "bi-pap not in use due to inappropriate mask fit and leaks"; *10/17/11 at 11:00 p.m., "bi-pap not in use continues to alarm, inappropriate mask fit"; *10/21/11 at 11:00 p.m., "bi-pap not in use, inappropriate fit, awaiting new equipment"; *10/22/11 at 11:00 p.m., "bi-pap continues out of use, awaiting new hose and mask replacement"; *10/23/11 at 11:00 p.m., "awaiting bi-pap repair/replacement"; *10/24/11 at 11:00 p.m., "O2 saturation 74%, removed oxygen cannula and replaced with O2 mask"; and *10/25/11 at 5:00 a.m., "resident skin cold clammy and diaphoretic (sweaty), O2 sat 64%. O2 concentrator set at the maximum. Physician notified with orders to transfer to the hospital". A hospital history and physical dated 10/25/11 indicated Resident #5 was in the emergency room after being found in the nursing home with a low blood oxygen level and difficulty breathing. The history and physical indicated he was placed on bi-pap at the hospital which seemed to help him keep his oxygen saturation around 88%. The history and physical indicated his examination showed unresponsiveness due to severe low blood oxygen level. Physician orders [REDACTED]. The web site, <http://www.mayoclinic.com/health/hypoxemia/MY >, viewed 11/7/11 indicated normal oxygen saturation was 95-100%. [MEDICAL CONDITION] (low blood oxygen) describes a lower than normal level of oxygen in the blood. Values under 90% are considered low and can result in a decreased level of consciousness and difficulty breathing. During an interview on 11/3/11 at 11:45 a.m., the DON said one resident received bi-pap treatment.