Every finding on record at Fonda Specialty Care

Based on record review, facility policy review, and staff interview, the facility failed to ensure residents received medications per the physicians orders for 1 of 3 residents (Resident #1). The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including atrial fibrillation and heart failure. The resident received pain medication and had moderate pain. The Care Plan revised 7/1/23 identified the resident had altered respiratory status/difficulty breathing related to chronic reparatory failure with hypoxia. The interventions included oxygen (O2) via nasal prongs at 2 liters. The Progress Notes dated 12/27/23 at 1:08 p.m. documented an order received to obtain an influenza swab due to cough. The Progress Notes dated 12/27/23 at 3:58 p.m. documented the lab called with results. The resident tested positive for Influenza A. The Progress Notes dated 12/27/23 at 4:59 p.m. documented receipt of a new order received for Tamiflu 75 mg BID (2 times a day) for 5 days. The Progress Notes dated 12/29/23 at 11:42 a.m. documented receipt of an order to schedule albuterol nebulizer TID (3 times a day ) for 5 days. The December 2023 Medication Administration Record (MAR) showed the order for Tamiflu Oral Capsule 75 mg two times a day for Influenza A for 5 Days with a start date of 12/27/23. The Tamiflu documented as given 12/27/23 at HS (hour of sleep/bedtime). The MAR showed the Tamiflu discontinued 12/28/23 and rewritten with a start date of 12/28/23. The resident received 1 dose on 12/28/23 at HS and 2 doses on the 29th, 30th, and 31st. The January 2024 MAR showed the order for Tamiflu Oral Capsule 75 mg two times a day for Influenza A for 5 days with a start date of 12/28/23. The MAR documented the resident received 1 dose of the Tamiflu 1/1/24. The Progress Notes dated 1/1/24 at 7:14 p.m. documented the resident's order for Tamiflu 75 mg 2 times a day for Influenza A for 5 days completed. According to the clinical record, the resident received 9 doses of the Tamiflu, and the order called for 10 doses. The Progress Notes dated 12/28/23 at 1:52 p.m. documented the resident was Influenza A positive. The resident stated she still did not feel well. The Progress Notes dated 12/29/23 at 12 a.m. documented an acute follow-up. The resident had Influenza A, having increased shortness of breath, and having to sleep with the head of the bed elevated. She had sinus congestion, and a cough with thick yellow mucus. She was very tired, wore out, and not sleeping well. She had been on Tamiflu since Wednesday, and on oxygen. Lungs were congested with rhonchi, moist cough, and breathing non labored. Encouraged the resident to force fluids and have good nutrition. The Progress Notes dated 12/29/23 at 11:19 a.m. documented the resident had notable congestion when conversing. The Nurse Practitioner saw the resident and added nebulizer treatments to help her cough up the secretions. The January 2024 MAR showed the order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% 1 inhalation, inhale orally via nebulizer three times a day for URI (upper respiratory infection) for 5 days, with a start date of 12/29/23. The Progress Notes dated 12/30/23 at 10:40 a.m. documented the resident had a moist cough and occasional headache. She had congestion you could hear in her voice. The Progress Notes dated 12/30/23 at 11:11 a.m. documented the resident's Albuterol Sulfate Inhalation Nebulization Solution on order. The Progress Notes dated 12/30/23 at 3:03 p.m. documented the the resident's Albuterol Sulfate Inhalation Nebulization Solution not available. The Progress Notes dated 12/31/23 at 3:01 p.m. documented the resident's Albuterol Sulfate Inhalation Nebulization Solution not available. The Progress Notes dated 1/1/24 at 6:41 a.m. documented the resident's Albuterol Sulfate Inhalation Nebulization Solution not available. The Progress Notes dated 1/1/24 at 3 p.m. documented the resident's Albuterol Sulfate Inhalation Nebulization Solution not available. The December 2023 MAR documented the resident received the Albuterol nebulization 1 dose on 12/29/23 and 2 doses on 12/31/23. The January 2024 MAR documented the resident received the Albuterol nebulization 3 doses on 1/2/24 and 2 doses on 1/3/24. According to the December 2023 and January 2024 MAR's the resident only received 8 out of 15 doses ordered. The resident's orders included LiquaCel Oral Liquid (Amino Acids) Give 30 ml by mouth two times a day for the promotion of healing with a start date of 3/31/23. The January 2024 MAR showed the LiquaCel not given 1/23/24 through 1/30/24. The Progress Notes dated 1/27/24 at 4:18 p.m. documented a call placed to the on call Nurse Practitioner (NP). The resident was out of LiquiCel amino acids, they were on order. Requested order to substitute Arginaid until the Liquicel amino acids arrived. Order received from the NP. The January 2024 MAR showed the resident missed 8 doses of LiquiCel before the facility notified the provider, and a substitute ordered. The Progress Notes dated 3/23/24 at 6:33 a.m. documented LiquaCel Oral Liquid give 30 ml by mouth two times a day to promote healing, on order. The Progress Notes dated 3/27/24 at 3:07 p.m. documented regarding the LiquaCel order, the Registered Nurse requested Arginaid for medication on order. The Progress Notes dated 3/27/24 at 3:08 p.m. documented communication with the physician with notification LiquaCel was on back order and questioned if they could give the resident Arginaid until it arrived. The Progress Notes dated 3/28/24 at 9:06 a.m. documented the NP confirmed to give Arginaid a.m. and p.m. On 4/15/24 at 3:30 p.m. the resident stated she had not had medications available multiple times while a resident at the facility. She said she had Influenza A in January. The doctor ordered nebulizer treatments but she didn't get them for 5 days. They had run out of pain medication at times and she needed it to keep her pain under control. On 4/17/24 at 5:05 p.m. the Director of Nursing (DON) stated she would need to look into it more, but residents should receive the number of medications ordered. She said when they didn't get a medication they were supposed to call the provider and get a hold order until they received the medication. The facility policy, dated 2/2023, for Ordering and Receiving Medication included medications (prescription and non-prescription), related supplies, and equipment were to be routinely ordered and delivered in a timely manner. Anticipated 2 business days for delivery of reordered medication refills. When there was a delay in the dispensing of medication such as unavailability prior to authorization, the Pharmacy would notify the nursing staff. Nursing staff would document reason for the delay and notify the Physician or prescriber. If there were further directions from the physician those directions would be communicated to the pharmacy.

Based on record review, staff and resident interview the facility failed to provide pharmaceutical services to meet the needs of 1 of 3 residents reviewed (Resident #1). The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including atrial fibrillation and heart failure. The resident received pain medication and had moderate pain. The Care Plan revised 10/10/22 identified the resident had chronic pain related to cervical disc degeneration. The interventions included administering analgesic medications as ordered by my provider. Due to her diagnosis the resident had a low tolerance for pain, her acceptable level was 3. The resident had as needed (PRN) Tylenol available. She would continue to have a low pain tolerance and high pain rating. The Clinical Physician's Orders dated 4/18/24 documented the resident had the following orders: a. Percocet Oral Tablet 5-325 mg (milligrams) 1 tablet by mouth one time a day for pain active since 10/7/23. b. Percocet Oral Tablet 7.5-325 mg 1 tablet by mouth three times a day for pain active since 10/6/23. The Progress Notes dated 1/6/24 at 12:58 p.m. documented Percocet Oral Tablet 5-325 mg 1 tablet by mouth one time a day for pain not available from pharmacy. Staff called the pharmacy and left a message with no response. The Progress Notes dated 1/6/24 12:59 p.m. documented the resident received Acetaminophen Tablet 325 mg per request in replace of Oxycodone that was not available from pharmacy. At 2:56 p.m. the Acetaminophen ineffective with the follow-up pain scale a 4. The Progress Notes dated 1/7/24 at 11:01 a.m. documented the on call pharmacist gave the okay to remove one Percocet 5-325 mg from the Emergency (E)-kit for the resident's missing dose. The Progress Notes dated 3/4/24 at 8:20 p.m. documented the resident's Percocet 7.5-325 mg three times a day for pain was on order. The Progress Notes dated 3/5/24 at 4:48 a.m. documented the resident was out of her Percocet. Staff called the pharmacy to see why they didn't send it. The pharmacy stated they sent it on February 29th but it was not on the delivery sheets. The pharmacist said he would look into it in morning due to it being after hours. The medication was not in the Emergency (E)-kit. Staff to get an order to put on hold until it became available. The nurse stated they needed to call the primary care provider (PCP) because he prescribed it. The PCP was out of the office due to after hours, so sent a fax. The Progress Notes dated 3/5/24 at 6:15 a.m. documented the resident's pain medication on order. On 4/15/24 at 3:30 p.m. the resident stated she had not had meds available multiple times while a resident at the facility. They had run out of pain medication at times and she needed it to keep her pain under control. On 4/17/24 at 5:05 p.m. the Director of Nursing (DON) stated she would need to look into it more, but residents should receive the number of medications ordered. She said when they didn't get a medication they were supposed to call the provider and get a hold order until they received the medication. The facility policy dated 2/2023 for Ordering and Receiving Medication included medications (prescription and non-prescription), related supplies, and equipment were to be routinely ordered and delivered in a timely manner. Anticipated 2 business days for delivery of reordered medication refills. When there was a delay in the dispensing of medication such as unavailability prior to authorization, the Pharmacy would notify the nursing staff. Nursing staff would document reason for the delay and notify the Physician or prescriber. If there were further directions from the physician those directions would be communicated to the pharmacy.

Based on record review, staff interview and policy review, the facility failed to notify the physician and the family of a change in condition for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 entered the facility 12/7/23. The Medical Diagnosis page documented the resident's diagnoses included congenital stenosis of the aortic (heart) valve, abdominal aortic aneurysm (weakened area) without rupture, chronic obstructive pulmonary (lung) disease (COPD), obstructive sleep apnea, chronic kidney disease, wound of the front wall of the thorax (area between the neck and the abdomen), and methecillin resistant staphylococcus aureus (MRSA/infection). The Care Plan dated 12/7/23 identified the resident was a new admit to the facility. The interventions included staff would keep the resident and the resident's family updated on his condition and physician orders. The Care Plan identified the resident had pain related to a sternal incision. The interventions included evaluating the effectiveness of pain interventions, and notifying the physician if interventions were unsuccessful, or the complaint was a significant change from the resident's past experience of pain. The Progress Notes dated 12/8/23 at 11:47 a.m. documented the resident had a sternal wound 9 cm long and 1 cm wide. It had a small amount of thick, yellow exudate (drainage) located toward the abdominal end of the wound. The wound itself was pink/red in color. There were some metal filaments coming through the top or closer to the neck part of the wound. The resident tolerated cleansing of the wound and redressing of the area without complaint of pain or discomfort. The Progress Notes dated 12/8/23 at 1:46 p.m. documented the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The Progress Notes dated 12/8/23 at 2:45 p.m. documented the resident was alert and oriented. The Weights and Vitals record documented the resident experienced the following pain levels: a. 12/8/23, 0 at 11:54 a.m. b. 12/8/23, 0 at 7:03 p.m. c. 12/9/23, 5 at 5:48 a.m. d. 12/9/23, 5 at 10:32 a.m. e. 12/9/23, 0 at 1:38 p.m. f. 12/9/23, 10 at 7:36 p.m. g. 12/9/23, 8 at 9:30 p.m. Pain was rated on a scale of 0-10, 0 indicating no pain, and 10 indicating severe (worst) pain. The Medication Administration Record (MAR) documented the resident had the order for Tylenol (Acetaminophen), 1000 mg by mouth every 6 hours as needed (PRN) for pain/discomfort with a start date of 12/7/23 at 3:45 p.m. The Progress Notes dated 12/9/23 documented: a. At 5:48 a.m. the resident received Tylenol 1000 mg by mouth for pain/discomfort, restlessness, and inability to express needs. b. At 10:32 a.m. the resident's follow up pain scale was a 5. The resident received Tylenol 1000 mg for yelling out in increased general pain. c. At 1:38 p.m. the follow-up pain scale was 0. d. At 7:36 p.m. the resident received Tylenol 1000 mg by mouth (pain 10). e. At 9:30 p.m. the PRN administration was ineffective, follow-up pain scale was 8. f. At 9:50 p.m. the resident had continual moaning and yelling out. He did not make sense, and unable to specify needs. Tylenol given and he let it sit in his mouth, and seemed to not understand to swallow. He was restless. Cares were given and they repositioned him. The facility failed to notify the physician or the family of the resident's increased pain with continual moaning and yelling out, his inability to specify needs, and his lack of adequate relief from interventions. On 12/18/23 at 10:25 a.m. Staff G Registered Nurse (RN) stated when the resident came he was very tired but alert and able to answer questions. On 12/18/23 at 1:20 p.m. Staff F Certified Nursing Assistant (CNA) stated the resident was cognitive, he could tell you the right answers. On 12/18/23 at 3:10 p.m. Staff E CNA/Certified Medication Aide (CMA) stated when she worked (12/7 evening shift documented administering medication to resident) and the resident could tell you what he needed and put his light on, but he didn't put it on very often. He did not call out, did not complain of pain, and was pretty quiet. On 12/18/23 at 12:37 p.m. Staff H CNA stated she worked over night (Friday) 12/8 to (Saturday) 12/9. The resident did some calling out during the night. They would reposition and try to make him comfortable. The resident did complain of discomfort, Staff H told the nurse, and the nurse gave him Tylenol. On 12/18/23 at 2:50 p.m. Staff D CNA worked the 7th (Thursday) and the 9th (Saturday). On the first day he was okay and alert. The 1st day he seemed with it, and then Saturday he did not. He would dangle his foot off the bed, they would put it back, and he would put it back down. He kept yelling for his mom. He wouldn't answer when they asked him what was wrong. On 12/18/23 at 1:35 p.m. Staff C RN stated she worked Saturday the 9th (6 a.m. to 6 p.m.) and she didn't really know much about the resident. That day was kind of rough and she interviewed the CNA to see if this is how he was because she didn't know if this was a change in condition. His vitals were good in the morning, but he wouldn't get out of bed. He was hurting and all he had was Tylenol. Staff C said she was in there several times and so were the aides. They changed and repositioned him. She thought he ate breakfast, but not much for lunch, and she didn't know what he ate for supper. She would go in there and ask if he needed something, but there was no coherence. He called out so they tried to make him comfortable. She thought the calling out got better after he took the Tylenol. She didn't call the physician or his family because she didn't know there was a change in condition, but looking back she maybe should have. On 12/11/23 at 3:15 p.m. Staff A CMA stated on Saturday evening shift the resident was super restless and hurting all over. She said she told the nurse about his calling out and not being able to get him comfortable. They decided to give him more Tylenol to try and get it under control. He wasn't due for it, but there wasn't anything else to give him. On 12/12/23 at 1:15 p.m. Staff B RN stated the resident really couldn't explain how bad his pain was. Staff B stated she wasn't aware that the CMA had given him Tylenol earlier in the evening (12/9), it wasn't conveyed to her. She said it was like he couldn't swallow the Tylenol. She said he didn't have it in his mouth when they went down to do his care so she assumed he swallowed it. Staff B said she did not notify the wife or the doctor that night because there was no change in the resident from Friday night to Saturday night. On 12/19/23 at 10:30 a.m. the resident's Physician said the change with the pain was something the facility could notify the physician of for alternative pain medications available. He said the resident had a sternal wound that measured 9 centimeters by 1 centimeter so he would have a reason to have pain. It didn't look like they ever completely or definitively cleared the infection. He was super high risk for something to happen. According to the facility's Change in a Resident's Condition or Status Policy Statement revised February 2021, the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition.

Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention when a resident had a change in mental status and pain level for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 entered the facility 12/7/23. The Medical Diagnosis page documented the resident's diagnoses included congenital stenosis of the aortic (heart) valve, abdominal aortic aneurysm (weakened area) without rupture, chronic obstructive pulmonary (lung) disease (COPD), obstructive sleep apnea, chronic kidney disease, wound of the front wall of the thorax (area between the neck and the abdomen), and methecillin resistant staphylococcus aureus (MRSA/infection)). The Care Plan dated 12/7/23 identified the resident was a new admit to the facility. The interventions included staff would keep the resident and the resident's family updated on his condition and physician orders. The Care Plan identified the resident had pain related to a sternal incision. The interventions included evaluating the effectiveness of pain interventions, and notifying the physician if interventions were unsuccessful, or the complaint was a significant change from the resident's past experience of pain. The Progress Notes dated 12/8/23 at 11:47 a.m. documented the resident had a sternal wound 9 cm long and 1 cm wide. It had a small amount of thick, yellow exudate (drainage) located toward the abdominal end of the wound. The wound itself was pink/red in color. There were some metal filaments coming through the top or closer to the neck part of the wound. The resident tolerated cleansing of the wound and redressing of the area without complaint of pain or discomfort. The Progress Notes dated 12/8/23 at 1:46 p.m. documented the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The Progress Notes dated 12/8/23 at 2:45 p.m. documented the resident was alert and oriented. The Medication Administration Record (MAR) documented the resident had the order for Tylenol (Acetaminophen), 1000 mg by mouth every 6 hours as needed (PRN) for pain/discomfort with a start date of 12/7/23 at 3:45 p.m. The facility used a Pain Assessment in Advanced Dementia Scale (PAINAD) if the resident could not verbalize pain. The areas observed included: a. Breathing b. Negative verbalization c. Facial expression d. Body language e. Consolability. Each area could score 0-2. They final score would range from 0-10. When added up, 0 was no pain and 10 was severe (worst) pain. The Weights and Vitals record documented the resident experienced the following pain levels: a. 12/8/23, 0 at 11:54 a.m. b. 12/8/23, 0 at 7:03 p.m. c. 12/9/23, 5 at 5:48 a.m. (PAINAD) d. 12/9/23, 5 at 10:32 a.m. (PAINAD) e. 12/9/23, 0 at 1:38 p.m. (PAINAD) f. 12/9/23, 10 at 7:36 p.m. g. 12/9/23, 8 at 9:30 p.m. (PAINAD) The Progress Notes dated 12/9/23 documented: a. At 5:48 a.m. the resident received Tylenol Oral Tablet 1000 mg by mouth for pain/discomfort, restlessness, and inability to express needs. b. At 10:32 a.m. the resident's follow up pain scale was a 5. The resident received Tylenol 1000 mg for yelling out in increased general pain. c. At 1:38 p.m. the follow-up pain scale was 0. d. At 7:36 p.m. the resident received Tylenol 1000 mg by mouth (pain 10). e. At 9:30 p.m. the PRN administration was ineffective, follow-up pain scale was 8. f. At 9:50 p.m. the resident had continual moaning and yelling out. He did not make sense, and unable to specify needs. Tylenol given and he let it sit in his mouth, and seemed to not understand to swallow. He was restless. Cares were given and they repositioned him. Per the resident's individual plan of care the facility failed to evaluate the effectiveness of pain interventions, and notify the physician if interventions were unsuccessful, or the complaint was a significant change from the resident's past experience of pain. The facility administered as needed Tylenol nearly 4 hours early with no notification of the physician of the resident's severe pain without adequate relief. On 12/18/23 at 10:25 a.m. Staff G Registered Nurse (RN) stated when the resident came (12/7) he was very tired but alert and able to answer questions. On 12/18/23 at 1:20 p.m. Staff F Certified Nursing Assistant (CNA) stated the resident was cognitive, he could tell you the right answers. The 2nd day the resident was in the facility he and another CNA were getting him up for breakfast and as soon as they sat him down he said he was dizzy, and didn't think he could make it so they laid him back down. The resident didn't want to eat and said leave me my juice and my water. He wasn't calling out. That would have been Thursday (12/7) and Friday (12/8). Staff F did not work that weekend. On 12/18/23 at 3:10 p.m. Staff E CNA/CMA stated she worked with the resident as med aide (12/7 per documentation on the MAR). He could tell you what he needed and put his light on, but he didn't put it on very often. He did not call out, did not complain of pain, and was pretty quiet. On 12/18/23 at 12:37 p.m. Staff H Certified Nursing Assistant (CNA) stated she worked over night (Friday) 12/8 to (Saturday) 12/9. The resident did some calling out during the night. They would reposition and try to make him comfortable. The resident did complain of discomfort. Staff H told the nurse, and the nurse gave him Tylenol. On 12/18/23 at 1:35 p.m. Staff C RN stated she worked Saturday the 9th and she didn't really know much about the resident. That day was kind of rough and she interviewed the CNA to see if this is how he was because she didn't know if this was a change in condition. His vitals were good in the morning, but he wouldn't get out of bed. He was hurting and all he had was Tylenol. Staff C said she was in there several times and so were the aides. They changed and repositioned him. She thought he ate breakfast, but not much for lunch, and she didn't know what he ate for supper. She would go in there and ask if he needed something, but there was no coherence. He called out so they tried to make him comfortable. She thought the calling out got better after he took the Tylenol. She didn't call the physician or his family because she didn't know there was a change in condition, but looking back she maybe should have. On 12/18/23 at 2:50 p.m. Staff D CNA worked the 7th (Thursday) and the 9th (Saturday). On the first day he was okay and alert. The 1st day he seemed with it, and then Saturday he did not. He wouldn't answer when they asked him what was wrong. On 12/11/23 at 3:15 p.m. Staff A CMA stated on Saturday evening shift the resident was super restless and hurting all over. She said she told the nurse about his calling out and not being able to get him comfortable. They decided to give him more Tylenol to try and get it under control. He wasn't due for it, but there wasn't anything else to give him. On 12/12/23 at 1:15 p.m. Staff B RN stated the resident really couldn't explain how bad his pain was, and thought she would have just done the PAINAD to try and decipher how bad it was. Staff B stated she wasn't aware that the CMA had given him Tylenol earlier in the evening, it wasn't conveyed to her. She said it was like he couldn't swallow the Tylenol. She said he didn't have it in his mouth when they went down to do his care so she assumed he swallowed it. Staff B said she did not notify the wife or the doctor that night because there was no change in the resident from Friday night to Saturday night. On 12/19/23 at 10:30 a.m. the resident's Physician said the change with the pain was something the facility could notify the physician of for alternative pain medications available. He said the resident had a sternal wound that measured 9 centimeters by 1 centimeter so he would have a reason to have pain. It didn't look like they ever completely or definitively cleared the infection. He was super high risk for something to happen. According to the facility's Change in a Resident's Condition or Status Policy Statement revised February 2021, the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition. The facility policy Acute Condition Changes-Clinical Protocol revised March 2018 documented the nursing staff would contact the physician based on the urgency of the situation. For emergencies, they would call or page the physician and request a prompt response. The attending physician or a practitioner providing backup coverage would respond in a timely manner to notification of problems or changes in condition or status. The nurse and physician would discuss and evaluate the situation. As needed the physician would discuss with the staff and resident and/or family the pros and cons of diagnosing and managing the situation in the facility or need for hospitalization . The physician would help identify and authorize appropriate treatments. If it was decided after sufficient review, that care or observation could not reasonably be provided in the facility, the physician would authorize transfer to an appropriate setting. The staff would monitor and document the resident's progress and responses to treatment, and the physician would adjust treatment accordingly.

Based on observations and interviews the facility failed to maintain a home-like environment with the facility repeatedly having a strong offensive urine odor throughout the facility. The facility reported a census of 43 residents. Findings include: On 11/14/23 at 9:10 AM, entered facility through the front door, upon entrance in facility and during the walk thru the facility, a strong urine odor throughout the entire facility. On 11/15/23 from 7:30 AM to 4:30 PM, during several walkabouts throughout the halls of the facility, have smelled a strong urine odor throughout the facility, intermittently throughout the day. On 11/16/23 at 7:30AM, entered facility through front door, observation of staff stripping and cleaning beds and rooms, no strong urine odor noted in the hallways. On 11/20/23 at 8:49 AM, entered facility through the front door, lounge area and down long hallway with strong urine odor. Interview on 11/16/23 at 3:36 PM, the Ombudsman (state resident advocate) stated she was in the facility on 9/19/23 and the facility smelled very strongly of urine throughout the facility and felt the odor could be coming from the carpet. The Ombudsman stated on 9/20/23 she spoke with the Administrator (ADM) and expressed her concern of the offensive odor and the ADM talked of shampooing carpets, understood her concern, and was trying to get the corporation to replace the flooring but was not in the budget.

Based on observation and staff interview, the facility failed to meet professional standards of quality by not having a physician's order for a resident admitted with a foley catheter (indwelling catheter to empty the bladder of urine) for one of twelve residents reviewed, (Resident #45). The facility reported a census of 43 residents. Findings include: Resident #45's Progress Notes documented the resident admitted on [DATE] at 1:46 PM and no catheter present. Observation on 11/14/23 at 11:14 AM, Resident #45 in bed with catheter bag attached to bed, dark colored urine in catheter bag. During interview on 11/15/23 at 2:30 PM, Resident #22 stated she had a catheter. Review of Resident #45's record of bladder elimination on 11/16/23, documented an indwelling catheter 11/9/23 to current date of 11/16/23. Review of Resident #45's Physician Orders lacked an order for a foley catheter. Review of Resident #45's Hospice Plan of Care dated 11/8/23, documented supplies of foley catheter. Resident #45's Baseline Care Plan initiated 11/8/23, lacked documentation of foley catheter and care. Facility policy Admission/Readmission Orders revised 9/2017 revealed essential information for new admissions should include medications and treatments (for example, catheter care). Interview on 11/20/23 at 2:16 PM, the Director of Nursing confirmed the resident did have a catheter and expectation for physician's order for catheter and care.

Based on clinical record review, staff interviews and policy review the facility failed to accurately complete an MDS (Minimum Data Set) assessment reflective of the resident status for 2 out of 12 residents (Resident #12 and #23).The facility reported a census of 43 residents. Findings include: 1. Resident #12 ' s MDS assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 05, indicating severely impaired cognition. The MDS identified Resident #12 required maximal assistance with bed mobility, transfers and toileting use. The MDS included diagnoses of thyroid disorder, non-Alzheimer ' s dementia, parkinson ' s disease, anxiety disorder, and bipolar disorder. A Wound Evaluation dated 10/17/23 revealed Resident #12 had an unstageable (inability to see wound bed) pressure ulcer to the right and left heel. A Wound Evaluation dated 10/25/23 revealed Resident #12 had a stage 2 pressure ulcer to the intergluteal cleft (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough (dead nonviable tissue that is usually cream or yellow in color) May also present as an intact or open/ruptured blister). The Clinical Census revealed Resident #12 was admitted to hospice care on 11/6/23. The Significant Change MDS with an ARD (assessment reference date) of 11/13/23 revealed Resident #12 ' s pressure ulcers were not coded in Section M of the MDS and hospice care while a resident was not coded in Section O of the MDS. On 11/16/23 at 4:04 PM, Staff A, MDS Coordinator acknowledged and verified Resident #12's Significant Change MDS was not coded correctly for pressure ulcers and hospice care. Staff A reported she would complete an MDS modification and make the corrections. 2. Resident #23 ' s MDS assessment dated [DATE] identified a BIMS score of 09, indicating moderately impaired cognition. The MDS identified Resident #23 was independent with bed mobility, transfers and toilet use. The MDS included diagnoses of anemia, hypertension, diabetes mellitus, Alzheimer ' s disease, depression and post traumatic stress disorder. The MDS documented Resident #23 had an invasive mechanical ventilator (machine used to assist with breathing). Review of the clinical record revealed Resident #23 did not have a ventilator. On 11/14/23 at 10:00 AM, the Director of Nursing verified Resident #23 did not have a ventilator. On 11/16/23 at 4:04 PM, Staff A acknowledged and verified Resident #23's MDS was not coded correctly as Resident #23 does not have a ventilator. A facility policy titled Certifying Accuracy of the Resident Assessment revised November 2019 documented any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. The policy further documented that the information captured on the assessment reflected the status of the resident during the observation period for that assessment.

Based on observation, record review, resident interview and policy review the facility failed to update the resident's care plan after a resident attempted to leave the facility for 1 of 12 residents reviewed (Resident #22). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #22, dated 10/19/23, included diagnosis of depression and heart failure. The MDS documented the resident was independent with transfers, had ability to walk and propel self in a wheelchair at least 150 feet independently, wandering behavior not exhibited, and had a Brief Interview for Mental Status (BIMS) score of 13, indicating mild cognitive impairment for decision-making. Observation on 11/14/23 at 1:03 PM, Resident #22 propelled self in a wheelchair from the dining room to his room. Resident #22's nursing Progress Notes documented: 1.11/11/2023 at 1:42 AM- Has been attempting to leave building for past 30 min. Staff standing in front of him, explaining he cannot go outside due to cold and he has no coat on. Stating he wants to go home. He is pushing staff and keeps going back to the door to leave. Will sit in recliner for 30 seconds and then head toward the front door again. Will continue to provide 1:1 to avoid elopement. 2. 11/11/2023 at 2:30 AM - Took 5 min nap in recliner and up again at this time trying to leave through front door. 3. 11/11/2023 at 2:35 AM - Denies any pain or headache, has been toileted, declines snack, states he just wants to go home. 4. 11/11/2023 at 4:00 AM- Staff able to persuade resident to go to his room and assisted him into recliner. Has been up and exit seeking since 1:20 AM. 5. 11/11/2023 4:09 AM- Up again to living room. Interview on 11/15/23 at 3:31 PM, Resident #22 stated that night he just wanted to leave the facility and go home. Resident #22's Care Plan with target date 2/1/24, lacked documentation of update with wandering/elopement risks and interventions. Facility policy titled Wandering and Elopements revised 3/2019, revealed if identified as at risk for wandering or elopement, the resident's care plan will include strategies and interventions to maintain the resident's safety. Interview on 11/20/23 at 2:17 PM, the Director of Nursing confirmed Resident #22's care plan was not updated with wandering/elopement risk and interventions.

Based on clinical record review, staff interview and policy review the facility failed to communicate necessary information to the receiving facility when a resident was transferred to the hospital emergently due to change in condition for 1 out of 2 residents (Resident #44) reviewed for hospitalization s. The facility reported a census of 43 residents. Findings include: Resident #44 ' s MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition. The MDS identified Resident #44 required extensive assistance of two persons with bed mobility, and toileting use. The MDS identified Resident #44 was dependent with assistance of two persons with transfers. The MDS included diagnoses of end stage renal disease (kidney), methicillin- resistant staph infection, absence of left leg below the knee and obesity. A Progress Note dated 9/3/23 at 7:25 AM revealed during the night Resident #44 ' s skin became pale in color, and cool to touch. The note documented Resident 44 ' s oxygen saturation (O2 sat) taken on multiple fingers read 59%, blood pressure 72/46, pulse 78 beats per minute and temperature 96 degrees. The note indicated the Physician on call and family were notified of the change in condition. The note documented the facility contacted 911 emergency services and sent Resident #44 to the hospital. The Progress Notes lacked documentation on what information the facility sent with the resident, communicated or sent with the ambulance crew or communicated to the hospital. The clinical record lacked documentation that the facility communicated necessary information to the receiving provider (hospital). The clinical record lacked a completed transfer form. On 11/20/23 at 12:30 PM, the Director of Nursing (DON) acknowledged and verified she could not locate a completed transfer form for Resident #44 on 9/3/23. The DON reported her expectations were for the nurse to complete and send a transfer form along with the medication administration records, resident face sheet, insurance cards, advance directives, progress notes for the last 24 hours and to call the emergency room to inform them the resident was coming. The DON verified and acknowledged the information expected to be communicated was not documented in Resident #44 ' s medical record. A facility form titled Transfer or Discharge, Emergency revised December 2016 documented emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident. The policy further documented should a emergency transfer become necessary, the facility will implement the following procedures: a. Notify the resident ' s attending physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative of other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary.

Based on observations, record review, policy review, and staff interview the facility failed to complete proper hand hygiene during cares for two of two residents reviewed (Resident #27, #34) and to maintain standard precaution for infection control. The facility reported a census of 43 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #27 dated 8/24/2023, included diagnoses of malignant neoplasm of brain (brain tumor that has spread) and mild intellectual disabilities. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, and toilet use and was always incontinent of bladder and bowel. The MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment for decision-making. Observation on 11/15/23 at 8:41 AM, Staff B, Certified Nurse Aide and Staff C, Non-Certified Aide returned Resident #27 to his room in a shower chair. With a bath blanket spread on the bed, Staff B and Staff C transferred Resident #27 to bed with a full body lift and the sling that was under the resident in the shower chair, with the sling wet from the shower. Staff B and Staff C applied gloves, did not perform hand hygiene, and applied a brief and pants on Resident #27 and removed the wet sling and bath blanket and placed on Resident #27's bed linen. Staff C, with same gloves on, exited the resident's room and touched the resident's room door handle (room is shared with another resident), touched the supply closet door handle in the hallway, and got socks, Staff C proceeded to return to resident's room with the same gloves, applied socks to resident, and with the same gloves on went back out of room to the supply closet and got blanket and trash bag. Staff B left Resident #27's room with same gloves on and returned with same gloves on, with a box of gloves. Staff B and Staff C placed the sling and bath blanket in the garbage bag, leaving the bed sheet under the resident with wet areas from the wet sling. Staff B confirmed the sling remained under Resident #27 during his shower. Staff B and Staff C removed gloves and sanitized hands. 2. The MDS assessment for Resident #34 dated 11/2/2023, included diagnoses of Non-Alzheimer's Dementia and Anxiety Disorder. The MDS documented the resident required partial assistance with toileting and was occasionally incontinent of bowel and bladder. The MDS documented a score of 14, indicating no cognitive impairment for decision-making. Observation on 11/16/23 at 9:17 AM, Staff B washed hands, applied gloves, and assisted Resident #34 to ambulate to the bathroom with a gait belt on and walker. Staff B proceeded to pull down the resident's pants and pull-up, completed peri care, removed gloves (did not complete hand hygiene), pulled up pull-up and pants, had resident wash hands, and walked resident back to the recliner. Staff B proceeded to remove the gait belt, placed on her shoulder and washed her hands. Review of facility policy titled Handwashing/Hand Hygiene revised 8/2019, documented use an alcohol-based hand rub or soap and water for the following situations: before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. Interview on 11/20/23 at 2:17 PM, the Director of Nursing stated expectation to change gloves and complete hand hygiene when going from dirty to clean.

Based on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one of two residents reviewed, (Resident #27). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #27 dated 8/24/2023, included diagnoses of malignant neoplasm of brain (brain tumor that has spread) and mild intellectual disabilities. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, and toilet use and was always incontinent of bladder and bowel. The MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment for decision-making. Observation on 11/16/23 at 8:53 AM, Staff B, Certified Nurse Aide (CNA) and Staff D, CNA washed hands, applied gloves, and with Resident #27 lying in bed, Staff B lowered the wet brief and cleansed the front perineal area. Staff B and Staff D, assisted the resident to turn to the left side. With bowel movement visible on the resident's buttocks, Staff B cleansed the right buttock and hip, between buttocks and inner half of left buttock, not cleansing the outer side of the left buttock or left hip area. Staff B confirmed the brief was wet and had bowel movement. Staff B removed her gloves, applied new gloves, and Staff B and Staff D applied a clean brief, gathered trash and supplies, removed gloves and washed hands. Facility policy titled Perineal Care revised 2/2018, documented wash the perineal area, remove gloves and sanitize/wash hands, and wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks, remove gloves, wash and dry hands thoroughly, and reposition the bed covers. Interview on 11/20/23 at 2:17 PM, the Director of Nursing stated expectation to cleanse both hips and to change gloves and hand hygiene when going from dirty to clean.

Based on clinical record review and staff interview, the facility failed to complete a baseline care plan that included the minimum healthcare information necessary to properly care for the immediate needs of a resident with a foley catheter (indwelling catheter to empty urine from the bladder) for one of three residents reviewed, (Resident #45). The facility reported a census of 43 residents. Findings include: Resident #45's Progress Notes documented the resident admitted on [DATE] at 1:46 PM and no catheter present. Observation on 11/14/23 at 11:14 AM, Resident #45 in bed with catheter bag attached to bed, dark colored urine in catheter bag. During interview on 11/15/23 at 2:30 PM, Resident #22 stated she had a catheter. Review of Resident #45's record of bladder elimination on 11/16/23, documented an indwelling catheter 11/9/23 to current date of 11/16/23. Review of Resident #45's Physician Orders lack an order for a foley catheter. Review of Resident #45's Hospice Plan of Care dated 11/8/23, documented supplies of foley catheter. Resident #45's Baseline Care Plan initiated 11/8/23, lacked documentation of foley catheter and care. Facility policy Care Plans-Baseline revised 12/2016, documented the Interdisciplinary Team will implement a baseline care plan to meet the resident's immediate care needs. Interview on 11/20/23 at 2:16 PM, the Director of Nursing confirmed the resident did have a catheter and expectation for catheter and care to be included in the baseline care plan.

Based on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions related to risk for skin impairment and pressure ulcers for 1 out of 12 residents (Resident #12) reviewed for comprehensive care plans.The facility reported a census of 43 residents. Findings include: Resident #12 ' s MDS (Minimum Data Set) assessment dated [DATE] identified a BIMS (Brief Interview for Mental Status) score of 09, indicating moderately impaired cognition. The MDS identified Resident #12 required extensive assistance of two persons with bed mobility, transfers and toileting use. The MDS included diagnoses of thyroid disorder, non-Alzheimer ' s dementia, parkinson ' s disease, anxiety disorder, and bipolar disorder. The MDS identified Resident #12 was at risk for developing pressure ulcers. The MDS documented Resident #12 had a pressure reducing device for the chair and bed. A Wound Evaluation dated 10/17/23 revealed Resident #12 had new unstageable (inability to see wound bed) pressure ulcers to the right and left heel. A Progress Note dated 10/25/23 at 1:35 PM documented Resident #12 had a MASD (moisture associated skin damage) to the intergluteal cleft that deteriorated to a stage 2 pressure ulcer. A Wound Evaluation dated 10/25/23 revealed Resident #23 had a stage 2 pressure ulcer to the intergluteal cleft (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough (dead nonviable tissue that is usually cream or yellow in color) May also present as an intact or open/ruptured blister). The Care Plan with a target date 11/13/23 did not identify Resident #12 was at risk for skin impairments and/or developing pressure ulcers. The Care Plan lacked focus areas, goals and interventions/tasks to manage, treat and prevent skin impairments and pressure ulcers. The Care Plan was updated on 11/3/23 to reflect Resident #12 had pressure ulcers to both heels and coccyx. On 11/16/23 4:04 PM, Staff A, MDS Coordinator acknowledge and verified a comprehensive skin/pressure ulcer care plan was not completed until after Resident #12 developed pressure ulcers. Staff A acknowledged Resident #12 was at risk for developing pressure ulcers before the ulcers developed. A facility policy titled Care Plan, Comprehensive Person-Centered revised December 2016 documented a comprehensive, person centered care plan that included measurable objectives and timetable to meet the resident ' s physical, psychosocial and functional needs would be developed and implemented for each resident. The comprehensive, person-centered care plan will include: a. Measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well-being; c. Describe services that are not provided due to the resident exercising his or her rights, including the right to refuse treatment. d. Include the resident ' s stated goals upon admission and desired outcomes; e. Incorporate identified problem areas; f. Incorporate risk factors associated with the identified problems g. Reflect treatment goals, timetable and objectives in measurable outcomes; h. Identify the professional services that are responsible for each element of care; i. Aid in preventing or reducing decline in the resident ' s functional status and/or functional levels; and j. Reflect currently recognized standards of practice for problem areas and conditions.

Based on facility record review, staff interviews, and policy review, the facility failed to ensure drug records are in order and accurate. The facility also failed to implement a system to consistently and accurately reconcile controlled medications. The facility reported a census of 41 residents. Findings include: A facility form titled Control Drugs- Count Record labeled for Medication Cart A documented by signing the form, staff are acknowledging they counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record. The record required documentation of the date, shift, Nurse on signature and the Nurse off signature. The document directed staff to record any discrepancies or pertinent notes in the comments section. Review of the count record for medication cart A revealed the lack of staff signatures, indicating reconciliation of controlled medications for medication cart A did not occur on the following months, dates and shifts: March 2023: 3/27- 2 PM 3/28- 6 AM 3/31- 10 PM April 2023: 4/1- 10 PM 4/5- 10 PM 4/6- 6 AM, 10 PM 4/7- 6 AM 4/10- 10 PM 4/11- 6 AM 4/12- 10 PM 4/13- 6 AM 4/16- 10 PM 4/17- 6 AM, 10 PM 4/18- 6 AM, 2 PM, 10 PM 4/19- 6 AM, 2 PM, 10 PM 4/20- 6 AM 4/21- 6 AM, 2 PM 4/22- 6 AM, 2 PM, 10 PM 4/23- 6 AM, 2 PM, 10 PM 4/24- 6 AM, 2 PM, 10 PM 4/25- 6 AM 4/27- 10 PM 4/28- 6 AM, 10 PM 4/29- 6 AM, 10 PM 4/30- 10 PM May 20203: 5/1- 6 AM, 2 PM, 10 PM 5/2- 6 AM, 2 PM 5/7- 8:15 PM 5/8- 6 AM 5/9- 10 PM 5/10- 6 AM, 9:30 PM 5/11- 6 AM 5/15- 6 AM, 10 PM 5/16- 6 AM, 9 PM 5/17- 6 AM, 10 PM 5/18- 6 AM June 2023 6/13- 2 PM 6/16-3 PM 6/18- 2 PM, 10 PM July 2023 7/12- 6 AM 7/13- 9 PM August 2023 8/2- 6 AM A facility form called Control Drugs- Count Record labeled for Medication Cart B revealed the lack of staff signatures, indicating reconciliation of controlled medications in medication cart B did not occur on the following months, dates and shifts: April 2023 4/1- 6 AM 4/2- 10 PM 4/3- 6 AM 4/5- 10 PM 4/6- 6 AM, 10 PM 4/7- 6 AM 4/10- 10 PM 4/11- 6 AM, 10 PM 4/12- 6 AM, 10 PM 4/13- 6 AM 4/16- 10 PM 4/17- 6 AM, 2 PM, 10 PM 4/18- 6 AM, 2 PM, 10 PM 4/19- 6 AM, 2 PM, 10 PM 4/20- 6 AM, 2 PM, 4/22- 6 AM, 2 PM, 10 PM 4/23-6 AM, 2 PM, 10 PM 4/24- 6 AM, 2 PM, 10 PM 4/25- 6 AM 4/26- 6 AM, 10 PM 4/27- 10 PM 4/28- 6 AM, 2 PM, 10 PM 4/29- 6 AM, 10 PM May 2023 5/1- 6 AM, 2 PM, 10 PM 5/2- 6 AM, 2 PM, 10 PM 5/3- 6 AM, 2 PM, 10 PM 5/4- 6 AM, 2 PM 5/5- 2 PM, 10 PM 5/6- 6 AM 5/9- 10 PM 5/10-6 AM, 9:30 PM 5/11- 6 AM 5/14- 10 PM 5/15-6 AM, 2 PM, 10 PM 5/16- 6 AM, 9 PM 5/17- 6 AM, 10 PM 5/18-6 AM 5/26- 6 AM, 2 PM June 2023 6/15- 2 PM 6/18-10 PM A facility form titled Control Drugs- Count Record used for the Medication Room, where liquid Ativan (antianxiety) and Morphine (pain medication) are stored, revealed the lack of staff signatures, indicating reconciliation of these controlled medications did not occur on the following months, dates and shifts: April 2023: 4/8- 6 PM 4/9- 6 PM 4/14-6 AM, 6 PM 4/20- 6 PM 4/22- 6 PM 4/23-6 PM 4/25-3 PM, 10 PM 4/27- 6 PM 4/28- 6 AM, 6 PM 4/29- 6 PM 4/30- 6 AM May 2023: 5/2/23- 6 PM 5/9- 6 PM 5/10- 6 AM, 6 PM 5/11- 6 AM 5/17- 6 PM 5/18- 6 AM June 2023: 6/1- 2 PM July 2023: 7/2- 6 AM, 6 PM On 8/2/23 at 12:29 PM, the Director of Nursing (DON) reported she had completed two facility investigations related to the narcotic count being incorrect. On 8/2/23 at 3:00 PM, the DON reported on 5/18/23 she was informed Resident #3 ' s liquid morphine count was incorrect. The DON reported the narcotic count was not completed for Resident #3 on 5/17/23 at 6 PM or 5/18/23 at 6 AM. On 8/3/23 at 2 PM, the DON reported on 6/5/23 she was informed the narcotic count for Resident #11 was incorrect as there were four tablets of tramadol (pain medication) unaccounted for. The DON reported she had verified Resident #11 ' s count was correct on 6/1/23 at 10 PM. The DON reported the facility investigation concluded Staff B, Certified Medication Aide (CMA) gave tramadol 2 tablets on 6/2/23 and 6/3/23 and had not documented it. Review of Resident #3 ' s Individual Narcotic Record revealed Staff A, Registered Nurse (RN) documented she gave Morphine Sulfate 0.25 ml (milliliters) on 5/17/23 at 5 PM. The narcotic record indicated there was 24.25 ml remaining after the Morphine was administered. Review of Resident #3 ' s Individual Narcotic Record on 5/18/23 at 6 PM revealed the Morphine Sulfate count was 16 ml and there were no documented doses given after 5/17/23 at 5 PM. Review of Resident #11 ' s individual Narcotic Record directed staff to administer Tramadol HCL 50 mg (milligrams) 2 tablets every 6 hours as needed. The narcotic record documented Staff B gave one dose (two tablets) on 5/30/23 at 2:45 PM and one dose on 6/2/23 at 4:48 PM. A typed recount statement from Staff A dated 6-2 to 6-4-23 revealed Staff A documented she neglected to count narcotics with Staff B when her shift ended on 6/3/23 at 9:30 PM and the following morning on 6/4/23 at 6 AM with Staff C to validate and maintain checks and balances or to locate any discrepancies. Review of the facility form titled Controlled Drugs- Count Record for medication carts A and B revealed Staff A signed the document that she had completed the narcotic count on 6/3/23 at 9:30 PM and on 6/4/23 at 6 AM. On 8/3/23 at 3:30 PM, the DON stated her expectation for narcotic count is for the nurses and/or CMAs to count at the beginning and end of shift and ensure that the count is right. On 8/3/23 at 3:55 PM, Staff B stated she could not state for sure if she was the one that committed the medication discrepancy with the Tramadol. Staff B stated there was a possibility she could have given it but could not say with 100% certainty if it was her or someone else. Staff B reported at the discretion of her boss, she documented on Resident #11 ' s Individual Narcotic Record that she administered Tramadol on 5/30/23 at 2:24 PM and 6/2/23 at 4:48 PM. Staff B reported she can not say for sure she gave the medications on the dates and times that are recorded on the narcotic record. Staff B stated she wished she had not signed the narcotic record that she gave the medication as she does not know for sure. On 8/7/23 at 3:23 PM, Staff C reported when she first started as a CMA in April or May, she would trust her fell ow CMA or Nurse and not always complete a narcotic count at the beginning of the shift. Staff C stated she would sign the narcotic count form at the end of her shift after she had passed the narcotic medications. On 8/7/23 at 1:15 PM, the DON acknowledged and verified narcotic counts were not being done correctly. She stated she had started auditing the narcotic counts as of 6/6/23. On 8/7/23 at 1:17 PM, Staff D Licensed Practical Nurse (LPN) reported she went to the DON regarding the morphine discrepancy with Resident #3. Staff D stated she won't sign her name to the narcotic count unless it is correct. Staff D stated liquid narcotics had been off several times over the past year. Staff D reported she had witnessed staff not counting narcotics at the end of their shift, handing off the keys and be on their way. On 8/7/23 at 1:45 PM, the Assistant Director of Nursing (ADON) reported she could not recall 100% if she completed a narcotic count on 5/18/23 at noon with the other nurse. The ADON reported she thought the other nurse was in a hurry to leave so there is a possibility they did not count. The ADON stated the liquid morphine bottles are dark and hard to read. On 8/7/23 at 8:25 PM, Staff E, LPN reported she does not recall if she completed narcotic count on the evening of 5/17/23 or the morning of 5/18/23. Staff E stated she does narcotic count with everyone but makes a point to count with agency nurses. Staff E stated she probably forgot to sign the book if there were blanks on those days. Staff E reported she did not do the narcotic count on the evening of 6/4/23 and did not verify with Staff B the count was correct. Review of the facility form titled Controlled Drugs-Count Record for the Medication Room revealed on 5/17 at 6 PM and on 5/18/23 at 6 AM the record was blank and without a staff signature indicating narcotic count was not done. According to the facility nurse schedule, Staff E was scheduled to work on 5/17/23 from 6 PM to 6 AM. Review of the facility form titled Controlled Drugs- Count Record for medication carts A and B revealed Staff E signed the document that she had completed the narcotic count on 6/4/23 at 6 PM. A facility policy titled Controlled Substances revised April 2019 documented controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift. The policy directed staff at the end of the shift to complete the following: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the control substance count are documented and reported to the Director of Nursing immediately. c. The Director of Nursing Services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the Administrator. d. The Director of Nursing Services consults with the provider pharmacy and the Administrator to determine whether further legal action is indicated.

The facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice. The facility failed to give the required suctioning for 1 resident that required suctioning by patting/pointing and mouthing indicating that it was difficult to breathe, (Resident #2). The facility census was 43 residents. Findings include The 5-day Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with diagnoses which included cancer, heart failure, pneumonia, Alzheimer's Disease, malnutrition, and respiratory failure. The MDS identified the resident as no speech, or absence of spoken words, with the ability to usually be understood (difficulty communication some words or finishing thoughts but is able if prompted or given time) and Brief Interview for Mental Status (BIMS) score of 5, for which indicated severe decision making abilities. The resident required extensive assistance of two for personal hygiene, bed mobility, dressing and one assist for eating. The resident received oxygen therapy, suctioning and tracheostomy cares. The Plan of Care with an initiated date of [DATE], had a focus area of I am unable to care for my tracheostomy. Interventions include: *Perform my tracheostomy care every shift. *Suction as necessary. The Physicians Orders dated [DATE], instructed staff to: Irrigation/suctioning with 1 cc sterile saline every 8 hours as needed for phlegm. The Progress Notes dated and documented: *[DATE] at 3:41 a.m., documented: At 2:00 a.m. called to residents room resident is changing color to blue and yellowish, moist-diaphoretic. Difficult to get vitals Blood pressure ,d+[DATE], heart rate 78 and irregular, respirations 20 and unable to get a pulse oxygen reading. Orders checked, no order for nitro. Call to hospital talked with emergency room nurse and order to transport for evaluation. Call placed and ambulance in route. Return call back from emergency room to send resident to local hospital. Residents condition continues to decline oxygen remains on, no responding from resident. Multiple calls have been placed to family members without answer and messages to call back as soon as they got the call. At 2:28 a.m., called back to room as getting paper work ready. Resident without respirations, no heart rate or blood pressure and color is ash yellow. At 2:40 a.m., ambulance arrives and check resident and run strip which is flat line. Continue with calls to family members no answer. *[DATE] at 4:08 a.m., Text: Return call from emergency room and order from doctor received to release remains. Return call from son, and will come to facility to see his father. Confirmed funeral home choice. Did let him know his father went fast and that we respected the DNR request we had on file. *[DATE] at 5:58 a.m., Family has been here with resident since prior 5:00 a.m., funeral home was notified to come and are here now. Spoke briefly with family. Family has left and funeral home staff is taking remains at this time. *[DATE] at 6:22 a.m., Discharge Summary Note Text: funeral home has picked up body. Family did not take belongings at this time. Pharmacy updated per fax medications to be destroyed and or gotten ready to go back to pharmacy. The Emergency Medical System dated [DATE], documented, crew dispatched 911 priority to nursing home for a [AGE] year male, unresponsive and unable to obtain an oxygen saturation reading. Crew responded emergent lights and no sirens as no traffic was encountered at the early time of day. Crew arrived to be greeted at the door by two employees who stated You know he's dead right? Just come in and talk with the charge nurse, don't bring in any equipment Crew entered the facility to find the charge nurse on the phone attempting to call the family. Charge Nurse, stated called time of death at 2:25 a.m., would you please confirm death?' I retrieved the cardiac monitor from the ambulance. We entered the patients room and observed an [AGE] year male sitting upright in his recliner, no pulse, not breathing; pale mottled skin cool to the touch, with lividly beginning to appear in his feet. Obtained the 12 lead while I spoke with the nurse and obtained a copy of the patients DNR order. Nurse stated he was very sweaty when she came in to check on him, patient had dented chest pain, and went unresponsive. Patient has a tracheostomy and was prescribed oxygen which the patient removed often. She tried to get an oxygen saturation reading and called for an ambulance. Patient expired prior to our arrival. 12 lead EKG shows asystole in all 12 leads. No resuscitation efforts were made due to the valid DNR order. No other EMS services were requested. Charge nurse thanked us and we returned to base, no patient transport, All times based on call summery report. In an interview on [DATE] at 11:00 a.m., Staff A, LPN (licensed practical nurse), confirmed and verified that Resident #2 was able to communicate to staff that they needed to be suctioned by pointing/patting the stoma. Resident #2 would consistently have thick phlegm which would cause a difficult time with breathing and was a sign that the resident needed to be suctioned. Staff A confirmed and verified that there was a suction machine in the residents room and that a procedure for suctioning was at the nurses station. It was a common occurrence that he needed to be suctioned. In an interview on [DATE] at 12:26 p.m., Staff B, CMA/CNA (certified medication aide/certified nursing assistant) confirmed and verified that Resident #2 would need suctioning as soon as possible if resident was coughing/pointing/patting the stoma. Resident #2 would have thick phlegm which caused coughing and would scare the resident due to not being able to cough up the phlegm. Staff B stated that when Resident #2 would make sign gestures to be suctioned, you needed to get the nurse right away. The suction machine was available right there on the bedside dresser. In an interview on [DATE] at 1:00 p.m., Staff C, RN (registered nurse) confirmed and verified that Resident #2 would point/pat at the stoma when needed to be suctioned and would cough to try and bring up the thick phlegm. Staff C, stated that the resident would panic when the stoma needed to be suctioned. Staff C also confirmed and verified that the suction machine was available in the residents room and the procedure for the suctioning was at the nurses station. Resident was very good about making gestures to make his needs known especially since he was not able to talk. In an interview on [DATE] at 1:26 p.m., Staff D, CNA, confirmed and verified that Resident #2 was doing well and would let her know multiple times that he needed suctioning by patting or pointing to his stoma. About 2:00 a.m., went in to check and change the resident, he was sitting in his recliner, we stood him up and changed him, sat him back down, Staff D was cleaning up his room when Staff F, CNA, said that the resident is in trouble and we need to get the nurse right away, the resident was patting at the stoma and mouthing that he could not breathe and grasping for air. Staff D left the room to get the nurse, when Staff D came back a couple of minutes later, the resident was pale, turning purple and then blue. The nurse came in and took vitals. Staff D attempted to get O2 and it would not read, Staff D told the nurse that there was no reading. The nurse explained that it was normal since he was having a heart attack, Staff D told the nurse that he was pointing to the stoma and mouthing that it was difficult to breathe. The nurse said just a minute and left the room. Staff D explained that the resident was very good about letting the staff know when needed to be suctioned, by pointing/patting or mouthing the words that he needed to be suctioned. The suction machine was available right on the bedside dresser. In an interview on [DATE] at 2:50 p.m., Staff E, CNA, confirmed and verified that Resident #2 was very good about letting staff know when he needed to be suctioned due to a lot of phlegm, by pointing or patting on the stoma. The suction machine was readily available on the resident bedside dresser. In an interview on [DATE] at 4:10 p.m., Staff F, CNA, confirmed about 1:45 a.m., Staff F and Staff D went into Resident #2 room to do rounds, the resident was visibly soiled, Staff D and Staff F, stood the resident up for which he had soiled himself with urine and bowel. Staff F and Staff D proceeded to sit the resident down in a recliner, the resident started to point to at the stoma and pat at it, indicting that the stoma needed to be suctioned. Staff D went out to get the nurse that the resident needed to be suctioned. Resident#2 started to get really pale, and started to gasp for air. Staff F went out to the nurse and said would you please suction him, he needs to be suctioned. The nurse came into the residents room, explained that she needed to do an assessment, and left the room. The nurse came back in with some supplies, took his blood pressure/pulse and attempted to take his 02 sats, the resident started to turn pale, purple and then blue. Resident #2 was very compliant with pointing or patting at his stoma to have the nurse suction him, there was a suction machine right in the room readily accessible. In an interview on [DATE] at 4:30 p.m., Staff G, LPN, stated that Staff D and Staff F came out of Resident #2 room, about 1:45 a.m., and told Staff G that the resident was having explosive diarrhea. Staff G went into help, he was standing with no problems, no problems with breathing but did appear to be exhausted from standing. Staff G then left the room. Around 2:00 a.m., Staff D came out of the room and said that the resident was looking pale and turning purple, Staff G went back into the room and the resident was sitting in the recliner, he looked dusty and purple, staff wanted me to suction him, I told the staff no I was told that I would not have to do anything with the tracheostomy. I told the 2 staff that I needed to go get my supplies to check his blood pressure, pulse and 02 sats, I left the room and went to the nurses station to retrieve my equipment, I went back to the residents room and by then he was clammy, low blood pressure, and irregular pulse, I told the staff that I needed to go back to the nurses station and find out if the residents was a full code or DNR. Staff F then came out and said that I was needed right away in the residents room, I went back into his room and he had no blood pressure, no pulse, and no respirations, I pronounced him deceased , by this time the ambulance got to the facility and I showed them to the residents room and they pronounced him deceased also. I don't recall seeing any phlegm in his stoma, Staff D and Staff F did tell me that he needed to be suctioned due to pointing/patting at his stoma and mouthing that he was having a difficult time breathing. I again was told that I didn't have to do anything with his trach. Staff G, admitted that they did not attempt to suction. Staff G explained that her mind set went to the resident having a full blown heart attack and not needed to be suctioned. Staff G, stated that it did not occur to her to suction. In an interview on [DATE] at 5:15 p.m., Staff H, CMA/CNA, confirmed and verified that Resident #2 was very good about letting staff know when he needed to be suctioned, he would attempt to cough and bring up his own, but if he could not bring up the phlegm then he would point/pat at the stoma indicating that he needed to be suctioned. In an interview on [DATE] at 10:30 a.m., Staff I, ADON (assistant director of nursing), confirmed and verified that it is the expectation of the nurses to suction Resident #2 when he would point/pat at the stoma indicating that he needed to be suctioned or was having a difficult time with coughing up the thick phlegm. Staff I stated that the suction machine was readily available for the nurses to utilize. In an interview on [DATE] at 10:50 a.m., Staff J, RN, confirmed and verified that Resident #2 would point/pat at the stoma indicating that it needed to be suctioned. Staff J stated that the resident would have thick phlegm which he would attempt to try and cough up but if not able to would need to be suctioned and that the suction machine was readily available for the nurses to use and if staff stated that the resident needed to be suctioned, it was important to suction quickly. In an interview on [DATE] at 3:40 p.m., with the Primary Care Provider, confirmed and verified that if the resident expressed respiratory distress to the staff of pointing/patting his stoma then it would be a simple procedure to suction him. If the resident went into a hypoxia state, yes that would cause the heart to go into failure and cause a heart failure/attack. Just because Resident #2 didn't like the trach tube in does not mean that the staff should not have attempted to suction the resident. Resident #2 was very well aware of the need to be suctioned. If staff told the nurse that he needed to be suctioned due to respiratory distress, then the nurse should have at least attempted suctioning and then call 911 and send to the ER. Suctioning is a simple procedure that nurses should be able to do. If he did have a mucus plug that got lodged and he was not able to cough it up, yes, with out 02 to his heart, it could cause heart attack/failure and put the resident into cardiac arrest. However, even being a DNR does not mean that we don't treat the symptoms and send to the ER. Any resident with this type of condition, we need to educate the nurse to do suctioning and take care of the secretions. The [NAME] Tube Care Procedure Guide from the University of Arkansas for medical sciences with no date documented the following: (Laryngectomy Tube) *Suctioning Your Trachea: For a while. you will probably need a suction machine to help clear the sputum from your airway. Before suctioning. check your [NAME] tube to be sure it isn't blocked with mucus. If it is blocked follow the steps above for cleaning the tube. If you still have trouble coughing up your mucus, you will need to suction. It is best to remove the [NAME] tube if' there are secretions/mucus. You may suction your trachea without the [NAME] tube in place. Steps included: 2. Wash your hands well and fill the bowl with water and set it aside, turn on the suction machine and adjust the regulator dial to the right selling. 4. Remove the suction catheter from its wrapper or airtight container. Attach the suction catheter to the control valve on the suction tubing. 5. Dip the loose lip of the catheter into the water. This will help the catheter glide more easily. Put your thumb on the port and suck up some of the water to make sure the suction is working. Then release your thumb from the port and empty the water. 6. Put a saline solution mist or up to 3 cc of saline in your stoma. This will loosen secretions. 7. Take a few deep breaths and gently insert the moist catheter between 5 and 8 inches into the trachea through your [NAME] tube or stoma until you feel resistance. Caution: Take care not to injure yourself. Be careful not to cover the catheter's suction port during insertion. The suction pressure that results can damage the tissues that line your trachea. 8. With your thumb, cover and uncover the suction portion, start and stop the suction. As you do this, slowly take the catheter out of the trachea, rolling it between your thumb and finger as you go. This should take no more than 10 seconds. (Longer than that steals oxygen from your lungs.) 9. Repeat if needed for a lot of secretions. 10. You may see a small amount of blood, This is normal and not a cause for concern. 11. Put the catheter tip in the water to clean the suction catheter and the connection, then turn off the suction machine and disconnect tubing. Throw the disposable catheter in a plastic-lined wastebasket.

Based on the facility nursing schedule and staff interview the facility failed to ensure a Registered Nurse (RN) on duty 8 hours per day, 7 days a week. The facility failed to ensure an RN on duty for 8 hours/day for 5 days from 9/14/22 - 10/14/22. The facility reported a census of 43 residents. Findings include: 1. The document titled Two Week Work Schedule dated 9/8/22 - 9/21/22 revealed no RN on duty for: a. Wednesday 9/14/22 b. Thursday 9/15/22 2. The document titled Two Week Work Schedule dated 9/22/22 - 10/5/22 revealed no RN on duty for Sunday 9/25/22. 3. The document titled Two Week Work Schedule dated 10/6/22 - 10/19/22 revealed no RN on duty for: a. Wednesday 10/12/22 b. Thursday 10/13/22 On 10/19/22 at 1:49 PM, the Regional Nurse Consultant confirmed the facility did not have RN coverage for 9/14, 9/15, 9/25, 10/12, & 10/13/22. The Nurse Consultant stated expected 8hr/day of RN coverage.

Based on observation, interviews and regulation review the facility failed to provide food at appetizing temperatures for 3 of 3 resident reviewed for food temperatures. The facility reported a census of 43 residents. Findings include: On 10/18/22 at 11:08 AM, Resident #20 stated that his food was often served to him cold. On 10/18/22 at 12:05 PM staff pushed a tray of plates down the hallway to serve the residents in their rooms. An investigation of the temperatures of the food revealed the following: Resident #20 had a grilled cheese sandwich temperature of 123 degrees Fahrenheit (F), the sandwich was served. Resident #23 had a goulash dish that was 122 degrees F and was served. Resident #13 had a chicken breast with a temperature of 118 degrees and it was served. Certified Nursing Assistant (CNA) Staff C looked at the thermometer and said she didn't know what the temperatures should have been. On 10/24/22 at 11:20 AM the Dietary Manager said she would expect the staff to bring food back to the kitchen to be reheated if it was not up to the recommended temperatures. If a resident said that his of her food was cold, she would expect staff to bring it back to be warmed. According to the Food and Drug Administration, hot foods should be kept at an internal temperature of 140 F or warmer. Retrieved from Serving Up Safe Buffets | FDA on 10/24/22

Based on observations, interviews and regulation review the facility failed to ensure the water in the dishwasher, in the multi-use sink, and in the surface cleaning water was at the recommended sanitation level. The refrigerator contained unmarked foods and out of date foods. The staff failed to use recommended hand hygiene while serving a meal. The facility reported a census of 43 residents. Findings include: 1) An observation on 10/17/22 at 9:54 AM revealed there were two carts full of dirty dishes from the breakfast meal. The Dietary Manager (DM) said they were not using disposable dishware for the Covid-19 positive residents and they were not separating the dishes according to the resident's infection status. The DM said the dishwasher was a low temperature machine and she had daily temperatures logged but she did not have a log for the level of sanitizer in the water. The DM was unsure of what sanitation testing strips to use for the dishwasher to test the sanitizer level. She retrieved a bottle of Ecolab high level chlorine sink and surface strips and tested the dishwasher water, the water in the sink, and a bucket of water used to clean surfaces. The strip showed dark blue in color but she was not sure if that was the recommended level and said that the service provider did the testing when he came once a month. The DM did not know when the sanitizer had last been tested in the dishwasher or in the sink dispenser but said that she would call the Ecolab representative. On 10/17/22 at 4:10 PM, the DM said the Ecolab representative tested the sanitizer in the dishwasher and found that the water did not contain sanitizer. The bucket under the sink with the sanitizer was low and not getting to the dishwasher. The sink and the wash buckets were not getting sanitizer because the hose had been kicked behind something under the sink. She said that he fixed those problems. He also gave her the right test strips for the dishwasher because the ones she had were only for testing the sink water and the surface cleaning water. On 10/18/22 at 7:18 AM the Ecolab representative said there was a 5 gallon bucket under the sink with a hole in the lid where the hose went down into the bucket and fed the sanitizer up into the dishwasher. This 5 gallon bucket of sanitizer was near empty. He could not say how long the dishwasher may have been without sanitizer but he serviced this kitchen once a month. He said they either ran out of test strips or they didn't know about the correct ones to use. He checked the multi sink and sanitizer and the line had been pinched under the sink and there was no product going through into the washing sink. 2) In an observation of the refrigerators in the kitchen on 10/17/22 at 9:46 AM, several items were found to be undated and/or outdated: a. A bowl of oranges, uncovered and undated. b. A bowl of pureed chicken covered with tin foil, no date. c. A container of pork and beans dated 10/15/22. d. A large container of gravy with meat dated 10/12/22. f. A bowl with pureed ham and cheese sandwich no date. 3) An observation on 10/19/22 at 12:16 revealed Staff L used gloved hands to prepare meals. She touched the plates, surfaces, papers and without hand hygiene or removing the gloves and she grabbed inside the bread bag and pulled out pieces of bread on 5 separate occasions. On 10/24/22 at 11:20 AM the DM said she had started a log to document the sanitation levels going forward. She said that she understood she should have changed her gloves before touching bread or she could have used tongs to handle the bread. A facility policy revised on July 2014 title: Preventing Foodborne Illness - Food Handling stated that all food service equipment and utensils would be sanitized according to current guidelines and manufacturer's recommendations.

Based on observations, interviews and regulation review the facility failed to implement appropriate standards of infection control for residents on transmission based precautions for 9 of 43 residents reviewed. The facility also failed to implement appropriate infection control practices during wound care for 2 of 3 residents reviewed. The facility had an outbreak of Covid-19 and staff failed to use the recommended Personal Protective Equipment (PPE) to prevent the spread of germs. The facility reported a census of 43 residents. Findings include: On 10/17/22 at 9:45 AM the Administrator said there were 16 residents that were positive for Covid-19. According to a document titled: Covid Line Listing the following residents tested positive for Covid-19: Resident #11 in room [ROOM NUMBER] tested positive on 10/15/22 Resident #21 in room [ROOM NUMBER] tested positive on 10/13/22 Resident #9 in room [ROOM NUMBER] tested positive on 10/17/22 Resident #20 in room [ROOM NUMBER] tested positive on 10/13/22 Resident #32 in room [ROOM NUMBER] tested positive on 10/13/22 Resident #16 in room [ROOM NUMBER] tested positive on 10/13/22 Resident #19 in room [ROOM NUMBER] tested positive on 10/13/22 1) On 10/17/22 at 10:18 AM the Activities Director, Staff A stepped out of room [ROOM NUMBER] with 2 boxes of soda, one in each hand. Staff A was not wearing gloves, surgical mask, or gown. She failed to washer her hands and did not use sanitizer. Staff A walked down the hallway with the soda and put it in a closet and proceeded to enter anther resident's room. 2) On 10/17/22 at 10:23 AM Certified Medication Aide (CMA) Staff B came out of room [ROOM NUMBER]. She was not wearing gloves and she failed to perform hand hygiene. 3) On 10/18/22 at 7:50 AM housekeeping Staff D went in and out of rooms #16, #14 and #12 and was not wearing a gown or gloves. 4) On 10/18/22 at 7:46 AM Registered Nurse (RN) Staff E went into room # 17. She grabbed the resident's oxygen tubing that was lying on the floor and set it up on the nightstand. The RN was not wearing gloves or a gown. 5) On 10/18/22 at 7:55 AM Staff A pushed a laundry tub down the hallway wearing a cloth gown. She came out of room [ROOM NUMBER], went into a storage room then into another resident's room. She pushed the cart down the 100 hallway, went into the nurses station with the same gown. 6) On 10/18/22 at 12:00 PM Staff A was in room [ROOM NUMBER] and was not wearing a gown or gloves. On 10/17/22 at 10:20 AM Certified Nursing Assistant (CNA) Staff F and CNA Staff G said Resident #19 in room [ROOM NUMBER], was positive for Covid-19 but there is no sign on the door because it made upset him and he would tear the sign off the door. They said that all the staff knew that he was positive. On 10/18/22 at 7:30 AM CNA Staff C said all of the Covid positive residents had signs on the door to their rooms. She was not sure if Resident #19 was positive or not. On 10/18/22 at 8:50 AM the Administrator said they did not have a specific policy related to plan for Covid-19 but they were following the guidance of memos from the Center for Disease Control. The Administrator referred to QSO-20-39 dated September 17, 2020. The memo was related to visitation guidance and did not address plans for outbreak or appropriate staff use of Personal Protective Equipment (PPE). 7. The Minimum Data Set (MDS) for Resident #6, dated of 7/27/22, identified a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. The MDS listed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan for Resident #6, with a revised date of 9/19/22, identified the resident with potential/actual impairment to the skin integrity of the buttocks related to abrasion from moisture. The Care Plan interventions included: a. Encourage good nutrition & hydration in order to promote healthier skin. b. Treatment as ordered. On 10/17/22 at 12:17 PM, Resident #6 lying in the bed, eyes closed, head of bed elevated, and covered with blankets. The Treatment Administration Record (TAR) for Resident #6 dated October 2022, revealed an order to apply [MEDICATION(S)] non-sting barrier to the right heel and cover with [MEDICATION(S)] form, change on bath days and as needed, to the blister on the left heel. Start date of 10/6/22. On 10/19/22 at 9:47 AM, Resident #6 lying in bed on back with heel protectors on bilateral feet and padded cushion underneath the calves to float the heels. Staff J Registered Nurse (RN) removed the old dressing from the right heel of Resident #6 and placed the dressing in the receptacle. Staff J proceeded to wipe the wound on the right heel with the [MEDICATION(S)] barrier and then placed the new foam dressing. Staff J failed to change gloves and/or perform hand hygiene after the dirty dressing removed and prior to placing the new dressing. The facility document titled Wound Care revised date of October 2010, identified the purpose was to provide guidelines for the care of wounds to promote healing. a. Put on an exam glove, loosen the tape, and remove the dressing. b. Pull the glove over the dressing and discard into the appropriate receptacle. Wash & dry hands thoroughly. c. Put on glove. d. Wash tissue around the wound that would usually be covered by the dressing, tape, or gauze with antiseptic or soap & water. e. Apply the treatment as indicated. f. Dress the wound. 8. The MDS assessment for Resident #11 dated 8/2/22, identified a BIMS score of 14, which indicated no cognitive impairment. The MDS documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan for Resident #11, identified a diabetic ulcer of the left heel related to diabetes. The Care Plan interventions included: a. Heel protectors on when in bed or in the recliner. b. Treatment as ordered to the ulcer. c. Weekly documentation to include the measurement of each area of skin breakdown's width, length, depth, type of tissue & exudate, and any other notable changes or observations. On 10/17/22 at 11:57 AM, Resident #11 in room in recliner with feet elevated. Resident #11 stated the heel protector boots on the bed, to be worn while in bed. Resident #11 stated had an area on heel that required a dressing change. Resident #11 repositioned self in recliner throughout the visit. The TAR for Resident #11, dated October 2022, included an order: apply [MEDICATION(S)] non-sting barrier & cover with [MEDICATION(S)] foam adhesive dressing every Wednesday, start date 10/5/22. On 10/19/22 at 9:29 AM, Resident #11 in recliner with feet elevated. Staff J RN removed the old dressing from the residents gripper sock on the left foot and placed in the receptacle. Staff J proceeded to apply the non-sting barrier and cover with new foam dressing. Staff J failed to failed to change gloves and/or perform hand hygiene after the dirty dressing removed and prior to placing the new dressing. On 10/20/22 at 12:39 PM, the Administrator stated expected gloves to be changed and hand hygiene performed during dressing changes after the dirty dressing removed and prior to placing the new dressing for Residents #6 & #11.

Based on clinical record review, facility policy review, the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), and staff interview the facility failed to complete an admission assessment within 14 days for 1 of 1 resident reviewed (Resident #145). The facility reported a census of 43 residents. Findings Include: The Minimum Data Set (MDS) assessment completed 10/5/22, coded as an entry tracking form identified Resident #145's date of admission to the facility 9/29/22. The facility document titled Clinical Census dated 10/20/22, revealed resident active at the facility on 9/29/22. The facility document titled Clinical - MDS dated [DATE], revealed an Admission assessment dated [DATE] with status as in progress. Clinical record review for Resident #145 lacked an admission MDS completed by 10/12/22. The facility document titled MDS Completion & Submission Timeframes revised July 2017, stated the facility would conduct and submit resident assessments in accordance with federal & state submission timeframes. Policy interpretation & implementation: time frames for completion & submission of assessments based on the requirements published in the Resident Assessment Instrument Manual. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual) dated October 2019, identified an admission assessment was a comprehensive assessment for a new resident, that must be completed by the end of day 14, counting date of admission to the nursing home as day 1. Federal statue & regulations required that residents assessed promptly upon admission (but not later than day 14) and the results used in planning and providing appropriate care to attain or maintain the highest practical well-being. On 10/20/22 9:26 AM, Staff I Licensed Practical Nurse (LPN) confirmed the admission MDS for Resident #145 had not been completed. On 10/20/22 at 12:39 PM, the Administrator stated the facility followed the RAI manual for MDS completion dates and would expect Resident #145's admission MDS to be completed by day 14.

Based on observation, record review, and staff and family interviews, the facility failed to implement interventions intended to alert staff of elopement attempts for 2 of 4 residents reviewed (Resident # 1 and #2) who had exhibited elopement behaviors. Resident #1 eloped from the facility during the night and sustained hypothermia, facial lacerations and abrasions, prior to being located on an unoccupied house porch. The facility reported a census of 38 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment, with an assessment reference date of 05/05/11, Resident #1 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment, exhibited fluctuating patterns of inattention (easily distracted, out of touch or difficulty following what was said) and exhibited no wandering behaviors. The MDS further indicated the resident independently ambulated on the unit, but required limited assistance with locomotion off the unit. The resident's physician's orders [REDACTED]. A physician's orders [REDACTED]. The resident's care plan dated 1/14/2009, with a goal date of 6/2/11, identified the resident as exhibiting anxiety due to being out of his/her home and directed staff to observe for changes in mental status and behaviors, and report abnormalities to the physician. The care plan did not identify any wandering behaviors or attempts to elope from the facility. An earlier care plan noted the resident wore a Wanderguard bracelet (An alarm will sound when the wearer of a Wanderguard bracelet gets within a certain proximity of the alarm; alarms are generally placed at exit doors) which was discontinued on 6/21/10 at the family's request. On 4/07/11 at 8:00 p.m., nursing documented the resident as more confused and indicated the resident had come into the hallway to use the restroom, and was redirected with much encouragement. On 4/14/11 at 7:20 p.m., staff documented the resident talked non-sensibly and was oriented to name only, but redirected easily. There was no mention of the resident attempting to leave the facility. Nurses' notes dated 04/17/11 at 6:15 p.m. documented Resident #1 as confused, insisting on going home, knocking on another resident's door for a ride, and would not redirect even with much encouragement. The facility called the resident's family member who arrived at 6:45 p.m. and stayed with the resident for awhile. A nursing note date 4/18/11 at 3:15 p.m. indicated the resident's daughter called the facility to discuss the resident's health status, and that the facility had a call in to the resident's primary care physician to request a prn (as needed) medication. The note further indicated the daughter stated the family had talked to a VA doctor who indicated that discontinuing the resident's Namenda shouldn't cause the resident's current behaviors. The Treatment Record dated April 2011 showed Resident #1 had a Wanderguard applied 04/14/11, initiated by Staff H, licensed practical nurse (LPN). The Treatment Record dated May 2011 showed Resident #1 continued wearing the Wanderguard through 04/12/11. On 04/13/11 the record documented the Wanderguard as "Not on." The dates 05/14/11 to 05/20/11 had circles marked in the initial boxes. The nursing notes for this period of time lacked information regarding why the Wanderguard bracelet had been initiated. The Behavioral Sheet for May 2011 showed Resident #1 exhibited questionable paranoid ideas, verbal abuse, and increased confusion on 5/15 and 5/19/2011. The nurses' notes dated 05/19/11 at 9:20 a.m. documented an aide discussed with the nurse Resident #1's behaviors. According to the note, Resident #1 displayed increased confusion and aggressiveness. Resident #1 took his/her fist and hit the aide in the chest when assisting him/her with dressing in the morning. Resident #1 demonstrated resistance to activities of daily living (ADLs). When the aide returned to assist Resident #1 he/she remained resistive to cares... Speech somewhat slurred and difficult to understand. Resident #1 ambulated per usual, but ambulated more in hall than usual. Resident #1 appeared more confused and needed redirection regarding daily activities. A nurses' note dated 5/19/11 at 10:30 a.m. indicated the resident's physician had seen the resident at the facility. Then note documented staff discussed with the physician the resident's current mood and behaviors and previous use of Namenda and how medication could affect behavior with persons with dementia. Staff further documented the resident's primary care physician wanted a psychiatrist to follow up with the resident. At 5:30 p.m.. staff met with the resident's family member and discussed Resident #1's increased cognitive decline since stopping Namenda the end of March. The family member indicated he/she really didn't see a decline (in the resident's condition). Nurses' notes dated 05/20/11 at 3:00 a.m. documented a CNA had notified the nurse that Resident #1 was not in his/her room. Staff searched the facility and grounds; one CNA went to the resident's former home as well as a park and tennis court looking for the resident. At 3:30 a.m. staff called the DON who came to the facility. At 3:45 a.m. staff notified the administrator. Facility staff called additional staff in at 4:00 a.m. as well as local law enforcement who arrived at the facility with a thermo imaging sensor. The fire department joined in the search who actually found the resident on an adjacent property between 4:15 and 4:30 a.m. The fire department transferred the resident to an emergency room . Nurse's notes dated 05/20/11 at 2:30 p.m. documented a late entry for 05/19/11 at 8:40 p.m. A CNA had waved for the nurse to go down to the employee's entrance door because Resident #1 was outside the door talking about going home. The alarm had sounded. Two staff members redirected the resident back into the facility with difficulty, assisted him/her to his/her bedroom and helped the resident to bed.. An Elopement Risk assessment dated [DATE] documented no changes from the previous assessment dated [DATE]. The resident scored "5" on both assessments; a total score of 10 means the resident should wear a Wanderguard bracelet. The last assessment indicated Resident #1 made no statements of wanting to leave the facility, exhibited no anxious behaviors, and had no history of wandering or elopement. According to a Police Report dated 05/20/11 at 3:41 a.m., the Chief of Police received a call from the County Communication Center regarding a missing person. The Director of Nursing advised him the resident had last been seen at approximately midnight. He arrived at the facility at 3:50 a.m. He deployed the thermal imaging device to look into the open areas around the facility. At 3:59 a.m. after doing a 360 degree search around the facility with the thermal imager, he notified the communications center he had not located the individual, and requested the local fire department and ambulance service for additional resources to begin a larger search of the area... He the spoke to the administrator from the care center. She advised him 15 more staff members were coming in to assist with the search... At that time they were checking open structures and places the resident could go to escape the weather near the facility. Since midnight, there had been several strong rain showers in the area. At approximately 4:17 a.m., the Chief of Police received a call the missing resident had been located on an enclosed back porch (of a house) located adjacent to the facility's property, extremely wet and missing a shoe. The local weather at www.weather.com on 05/20/11, between 12:03 a.m. and 4:04 a.m. revealed the temperature ranged from 58 to 61 degrees (Fahrenheit), with rain showers and wind at 13 to 23 miles per hour. An Outpatient and Emergency Record dated 05/20/11 at 5:15 a.m. documented Resident #1 arrived per ambulance cart after being found outside on a porch of a house in his/her t-shirt, pullup, socks, and 1 shoe. The ambulance crew stated Resident #1 had been outside for a couple of hours. Resident #1 had apparently fallen because he/she had a 2 centimeter (cm) laceration on the forehead, 1/2 cm on the bridge of his/her nose, and 2 & 1/2 cm laceration on the front of his/her nose. Resident #1 had dried blood on his/her face, nose, hands, and other injuries noted. Resident #1 was hypothermic, so staff removed the resident's wet clothes, applied a bear hugger and warm blankets. At 6:00 a.m., staff initiated warm intravenous fluids. Resident #1 talked incoherently. Resident #1 did his/her open eyes to loud verbal and painful stimuli. A History and Physical report dated 05/20/11 documented Resident #1 had arrived via ambulance to the hospital because of hypothermia, and lacerations to the resident's forehead nose. The report indicated Resident #1 had apparently left the nursing home, wandered the neighborhood for 2 hours and was subsequently found on an unoccupied house porch. He/she was placed on a board and secured with a c-collar. Because of Resident #1's profound Alzheimer's Dementia he/she could not give any details or history or express him/herself about any pain or discomfort. The report stated Resident #1 had apparently been experiencing some agitation after the discontinuation of Namenda. The Resident's temperature registered 95.3 degrees. A Discharge Summary dated 05/24/11 documented Resident #1 would go to skilled care for physical therapy. The report listed the resident's principle [DIAGNOSES REDACTED]. During an interview on 0524/11 at 3:04 p.m., Staff F, CNA, stated that on 05/19/11 around 9:00 p.m., she went to punch out for the evening and walked toward the employee's exit door. Resident #1 already had the door open on his/her way out. The alarm sounded. She did not have a walkie talkie so she waved at the nurse, and the nurse and a CNA came down to assist in bringing Resident #1 back into the facility. Resident #1 resisted, but when told he/she did not have a jacket, he/she came back in. Staff F then went home. Staff F stated that normally when an alarm went off, they would check the door, and when someone said all clear, they pushed the reset button. Staff F did not know what they did with the alarm that evening. Staff F knew Resident #1 previously had worn a Wanderguard. Staff F stated residents wore Wanderguards to alert staff if they tried to leave the facility unattended. During an interview on 05/24/11 at 4:02 p.m., Staff H, Licensed Practical Nurse (LPN), stated in April she put a Wanderguard alarm on Resident #1. Staff H stated she could not remember why she had done this, and did not document why she placed the Wanderguard bracelet on the resident. Staff H stated if she placed a Wanderguard on Resident #1, he probably had tried to get out of the facility. Staff H stated Resident #1 had declined quickly since the discontinuation of a medication. Resident #1 needed more assistance with activities of daily living (ADLs) and could not find his/her own room. Staff H didn't know why Resident #1 no longer wore a Wanderguard, she had questioned it for 5 to 6 days prior to the elopement. Staff H thought Resident #1 should have a Wanderguard and that once in awhile Resident #1 would go out the door. Staff H thought the family didn't want the resident to wear a Wanderguard bracelet, but she had never talked to them about the Wanderguard or the reason she thought he/she needed it. Staff H stated on 05/19/11 around 9:00 p.m., Staff F waved her down to the employee's exit door. Resident #1 attempted to leave the facility and said he/she was going home. Staff H stated she did not remember what happened with the alarm, and they had no protocol for checking alarms. Staff H stated that she had found alarms off every once in awhile. During an interview on 05/24/11 at 2:22 p.m., Staff D, CNA, stated on 05/19/11 around 9:00 p.m., she stood behind the nurse's station and the nurse stood in front of the station. The door alarm to the southwest (employee) exit sounded. Staff D knew Staff F was going home and thought she forgot the code (that silenced the alarm). Staff D pressed the reset button and when she let it up the alarm still sounded. Staff D turned the alarm off and told the nurse. The nurse told Staff D she thought Staff F needed help and they both went down there. They assisted Staff F in getting Resident #1 back into the facility. Staff D and Staff I assisted Resident #1 to bed and the nurse went went back to the nurse's station. Resident #1 went to bed in a t-shirt, incontinence brief and socks. Resident #1's shoes sat in front of his/her dresser. Staff D further indicated she had removed the resident's hearing aides and that he/she seemed very confused. Staff D thought the nurse had turned the alarm back on. Staff D did not go back behind the nurse's station after that. Staff D stated the nurse went behind the nurse's station after the incident. Staff D stated the nurse was responsible for assuring the alarms were on. During an interview on 05/24/11 at 3:23 p.m., Staff G, Registered Nurse (RN), stated the night Resident #1 eloped, it rained. They conducted resident rounds at 12:00 a.m., 2:00 a.m., and 4:00 a.m. Staff G stated she could not say for sure that she saw the alarm had been turned off. Staff G stated during 2:00 a.m. rounds, they discovered Resident #1 as not in his/her bed and immediately started a search for him/her in the facility. When they were sure he/she was not in the facility, they started a search of the facility grounds. Staff G did not remember the evening nurse telling her Resident #1 tried to elope on the evening shift. Staff G did not know why Resident #1 didn't have the Wanderguard on, other than the family didn't want the resident to wear the bracelet. Staff G had not personally talked to the family. Staff G stated if Resident #1 had the Wanderguard on, it would have alerted them when he/she exited the facility. Staff G stated Resident #1 had followed people out of the facility before this incident. During an interview on 05/24/11 at 4:27 p.m., Staff I, CNA, stated she arrived for work at 6:00 p.m. on 05/19/11, and had a busy night. Staff I stated she knew there had some kind of a problem with Resident #1. Staff I and Staff D assisted Resident #1 get ready for bed. Resident #1 seemed a little rattled and didn't want to take his/her clothes off. She knew the staff had trouble with the resident at the door. Staff I stated Resident #1 definitely seemed more confused. Staff I recalled Resident #1 tried previously to leave the facility. Staff I stated about 6 weeks ago, staff put a Wanderguard on Resident #1 because he/she tried to go out the door. Staff I stated she did not go behind the nurse's station the night (the resident eloped) so she didn't see if the alarm was off. Staff I stated she had found the alarms off before. Staff I went out the employee's exit door at 11:00 p.m. to smoke. She pushed the code to the keypad and the light turned from red to green, indicating she could open the door without setting off the alarm. Staff I did not hear a door alarm go off that night. During an interview on 05/25/11 at 8:39 a.m., Staff J, CNA, stated the night Resident #1 eloped, it rained and stormed. Staff J stated during report she remembered hearing Resident #1 had been more agitated than usual. She stated Staff I told her she had had difficulty getting Resident #1 to undress for bed. She did not recall hearing about Resident #1 attempting to elope from the facility. Staff J thought it common knowledge Resident #1 made attempts to elope, and that's why he/she wore a Wanderguard. Staff J stated she knew Resident #1 tried to elope when he/she had the Wanderguard on. Staff J caught Resident #1 heading out one morning, but she caught him/her before he/she got to the door. Staff J stated Resident #1 should have worn a Wanderguard. Staff J stated she knew the door alarms got shut off at times. Staff J stated she did not go behind the nurse's station that night (elopement) to see the toggles to the door alarms. She did not recall going out the employee exit door that night, and didn't hear a door alarm that night. During an observation on 05/24/11 at 7:54 a.m., the Administrator sat in a chair at the nurse's station. The Administrator stated she, and Staff A from maintenance, were checking the door alarms. When Staff A opened a door the alarm sounded and a light came on above the toggle of the door opened. The toggles/lights were labeled to indicate which door alarm activated. When Staff A opened, and then closed a door, the Administrator pushed a reset button to silence the alarm. The box with the door alarm toggles was in front of the Administrator (as she sat at the nurse's station) within easy view and reach. During an interview on 05/24/11 at 8:13 a.m., the Administrator stated it appeared the alarm to the door (employee's exit door) they presumed the resident had exited from on 5/20/11 had been turned off during the evening shift when Resident #1 attempted to follow a staff member out the door. During an observation on 5/24/11, immediately after the above interview, the Administrator indicated the employee's exit door was located in close proximity to Resident #1's room. It took 20 steps to reach the employee's exit door from the resident's room door; the path included taking a left turn into a short hallway a few feet from the resident's bedroom door. The exit door had a keypad which could bypass the sounding of the alarm by punching in the appropriate code. There was also a Wanderguard monitor mounted by the door. At 10:03 a.m. on 5/24/11, the Administrator stated there was no code to keep the Wanderguard alarm from sounding. Staff had to go to physically go to the monitor mounted at the exit doors and silence a Wanderguard alarm. The Administrator stated prior to the incident, the door alarms were checked daily by maintenance. When asked who checked the alarms on weekends, the Administrator stated they may have been lax about doing that. She stated the nurses were usually very good about checking the toggle switches at the nurse's station to ensure the door alarms were on. She thought it would be obvious if one of the toggles was down on the alarm box. They did not have a door alarm policy prior to the incident. During an interview on 05/24/11 at 1:16 p.m., Staff A, Maintenance, stated he walked through the facility every morning and checked the door alarms. Staff A did not know if someone checked the alarms on his days off. Staff A checked the Wanderguard monitors every Tuesday. Staff A stated he had placed a plate under the toggles of the door alarms, making it impossible to turn the door alarms off. Staff A did this after the resident eloped from the facility. Observation of the metal plate under the door alarm toggles confirmed the door alarms could no longer be turned off. Staff A did not know of any other problems with the door alarms. During observation on 05/25/11 at 7:30 a.m., Staff A checked door alarms. The north courtyard alarm sounded. The north courtyard door did not have a Wanderguard monitor. Observation revealed the courtyard area was completely enclosed with a fence and the gate had a lock on it. Staff A stated staff had a key to the lock. The front entrance door alarm and Wanderguard alarm both sounded. The employee's (southwest) exit door and Wanderguard alarm both sounded. The dining room exit door and the Wanderguard monitor both sounded when activated. Staff A stated the front entrance and southwest exit canopy lights remained on at night. During an interview on 05/25/11 at 8:36 a.m., a representative from the company who installed the facility's door alarm keypads stated the keypads allowed someone who knew the appropriate code to punch it in the keypad. When the light changed from red to green, the person could open the door and walk through without the alarm sounding. The keypad delayed the alarm for 15 to 30 seconds. If the door remained open past the delay time, the alarm would sound. If the alarm was turned off, a person could open the door and the alarm would not sound. The keypad would still display a red light unless the code was punched in (but wouldn't sound whether the code was entered or not). During an interview 05/24/11 at 1:20 p.m., Staff B, CNA, stated Resident #1 had been more restless lately, wandering more, and they were watching him/her closer. Staff B knew Resident #1 had worn a Wanderguard bracelet, but not sure when this had occurred. Staff B stated the door alarms were occasionally shut off temporarily to bring in supplies. She stated when an alarm sounded, it stayed on until they heard the all clear over the walkie talkie. During an interview on 05/24/11 at 2:39 p.m., Staff E, CNA, stated that on 05/19/11, Resident #1 seemed confused. Staff E stated Resident #1 wandered and would sit at the back door. Staff E stated her family member (also a staff member) had to go outside and bring Resident #1 back into the facility about a week prior to the resident's elopement. Staff E stated Resident #1 should have worn a Wanderguard bracelet. They were always worried about him/her walking out. Staff E stated if a door alarm sounded they checked to see who went out or came in and what door had been opened. Staff E stated she didn't think she had ever turned an alarm off, but she had seen other staff shut an alarm off, and then would turn it back on. During an interview on 05/25/11 at 4:37 p.m., Staff M, CNA, stated Resident #1 had recently tried to elope when she worked the night shift recently (the last 1 to 3 weeks). Staff M heard a door alarm sound around 1:30 a.m. and found Resident #1 outside the employee's exit door. She went out the door to bring Resident #1 back inside. Resident #1 stated he/she needed to fix a car or tire. Staff M redirected Resident #1 back inside the facility. Staff M stated when she went to check the door alarm, the nurse went to check a personal alarm that had sounded. Staff M stated they discussed the incident afterward. During an interview on 05/27/11 at 9:35 a.m., Staff N, CNA, stated she knew Resident #1 had worn a Wanderguard bracelet but didn't know the reason why he/she had worn it. Staff N stated Resident was up wandering around at 5:00 a.m. one morning. Staff had assisted the resident with getting dressed. He/she had worn the Wanderguard at that time. During an interview on 05/25/11 at 3:30 p.m., Staff L, RN, stated she knew someone had recently placed a Wanderguard bracelet on Resident #1. Staff L stated she couldn't say for sure why the resident wore the bracelet, but she thought it was because Resident #1 was at risk for elopement. She verbalized Resident #1 wearing a Wanderguard bracelet was a good idea. During an interview on 05/25/11 at 10:21 a.m., Staff K, RN, stated when completing the Elopement Risk Assessment she read the resident's chart. Staff K stated she also worked the floor about 1 day a pay period. Staff K stated there was nothing in Resident #1's chart which indicated he/she had made attempts to elope from the facility. Staff K did not know Resident #1 had worn a Wanderguard bracelet for part of April and May, 2011. Staff K had reviewed the charting during the previous month's time. During a subsequent interview on 05/26/11 at 2:30 p.m., Staff K stated before the resident's elopement, she looked back in the nurse's notes for the past month. When asked about the documentation in the nurses' notes dated 4/17/11 indicating Resident #1 had insisted on going home, and why this was not identified on the risk assessment dated [DATE], Staff K stated, "I guess I missed that." A signed statement by the DON dated 05/23/11 indicated she had been notified on 5/20/11 at approximately 3:30 a.m. that the resident was missing from the facility. The statement went on to state that emergency medical technicians had found Resident #1 on the back porch of a residence adjacent to the facility. He/she was dressed in a pull up, t-shirt, 2 socks and 1 shoe. A second undated note signed by the DON documented they discovered during the resident's elopement investigation that a Wanderguard bracelet had been applied to Resident #1 in April 2011. The Wanderguard continued until May 13th when documentation then showed circles on the Treatment Administration Record (TAR) from May 14th through the 20th. The DON indicated she had not been informed of the resident's Wanderguard placement in April. Facility staff, as a care team, had discontinued Resident #1's Wanderguard in June 2010. The family had been very adamant that they did not want a Wanderguard on Resident #1. The DON documented she took vacation May 13th to the 16th. On her return, she was not notified of any issues or concerns regarding placement of a Wanderguard on Resident #1. The DON recalled standing at the nurses' station with several staff present, someone asking if Resident #1 wore a Wanderguard bracelet. Not knowing one had been put on him/her, she made the comment that the resident's family did not want him/her to wear one. A statement signed by Staff G on 5/23/11 revealed she had received a note on 5/14/11 from Staff H which stated, "Resident's Wanderguard in question." When Staff G made rounds with the Wanderguard signaling device tester on 5/14/11, Resident #1 did not have a Wanderguard on. She had checked both the resident's arms and legs for the bracelet. She left a note for the DON that night regarding the resident's Wanderguard. She was off May 15th and 16th. She left a note on the 17th for Staff K and the DON concerning Resident #1's Wanderguard and other care plan issues. Staff G further related that when initiating or discontinuing a Wanderguard bracelet, they document the reason why the device has been initiated or discontinued in the resident's nurses' notes, the care plan, the treatment record, communicate the information during shift-to-shift report, and ensure families have been notified. If the intervention is initiated during the night, staff wait until morning to notify the family. Staff G stated she had drawn the circles on the resident's TAR because she was waiting for "official" notification the Wanderguard had been discontinued before yellowing out the entry (which means the treatment has been discontinued). Staff G stated she didn't document in the nurses' notes regarding the Wanderguard because of the controversy with the family over it. Staff G did not replace the Wanderguard because she knew the family did not want it and did not feel Resident #1 was capable of exiting the facility. Staff G knew the door alarm would sound at the nurses' station if it wasn't shut off. She did not notice that the employee's exit door alarm had been shut off the night the resident eloped. During an interview on 05/26/11 (during concerns and findings) the DON stated she hadn't received any notes regarding Resident #1 and a Wanderguard. During an interview on 05/25/11 at 8:10 a.m., the DON stated she didn't know Resident #1 had made prior attempts to leave the facility. The DON stated the family insisted the Wanderguard bracelet come off the resident last June. The DON agreed to discontinue the bracelet but indicated she felt the family should have been notified of elopement attempts so they could make an informed decision regarding the use of the Wanderguard. The DON stated they held a care conference on 05/19/11 with a family member present, but elopement risk wasn't discussed because staff present didn't know about it. During an interview on 05/24/11/at 1:32 p.m., Resident #1's family member stated he/she attended a care conference on 05/19/11. They did not discuss any wandering behavior. He/she could not remember any discussion of wandering behavior since Resident #1 entered the facility 2 years ago. He/she knew Resident #1 wore a Wanderguard when he/she first came to the facility. The resident's family member stated another resident's family member had reported to her that Resident #1 had followed them out of the facility one day. On a subsequent interview on 05/25/11 at 10:00 a.m., the family member stated she had received no reports from the facility about Resident #1 trying to leave the facility. The family member did not know Resident #1 had worn a Wanderguard bracelet in April and May 2011. The family member stated if he/she had known Resident #1 had attempted to leave the facility, he/she would not have had a problem with him/her wearing a Wanderguard to keep him/her safe. During an interview on 05/25/11 at 10:55 a.m., a family member of another resident stated Resident #1 had followed them out of the building between 3:30 and 4:00 p.m. on 05/15/11. By the time the concerned family member stopped Resident #1, he/she had almost made it to the street. He/she walked Resident #1 up to the door and staff came out to get him/her. During an interview on 05/25/11 at 10:13 a.m., another one of Resident #1's family members stated the facility did not notify him/her of any attempts of his/her family member to leave the facility. The family member knew Resident #1 had recently worn a Wanderguard because he saw it and he/she didn't have a problem with it. On a subsequent interview on 05/27/11 at 2:03 p.m., the family member stated they moved Resident #1 to another long term care facility. Resident #1 still could not walk, and wasn't feeding him/herself. They did not know if Resident #1 would return to his/her prior level of functioning. The facility's Elopement Prevention Policy identified its purpose was to maintain resident safety and prevention of injury. The procedure included the following statements: a. Evaluate all residents for potential of elopement from the facility. b. Evaluate and identify factors for potential elopement from the facility. 1. Alzheimer's/Dementia diagnoses. 2. Mobility. 3. Medication. 4. Aimless wandering. 5. Verbal expressions of desire to leave. 6. Perimeter wandering. 7. Sudden changes in behavior. The above indicators are not the sole determining factors in identifying a resident at risk. Each resident must be looked at individually and a determination made as an interdisciplinary team. c. Provide a Wanderguard bracelet to all residents determined to have potential for elopement. d. Document all attempts for elopement and evaluate precipitating factors. Document effective measures taken to return resident to the facility. e. Assess resident's ability to remain in the facility safely. f. The resident's care plan would contain interventions and actions to monitor and prevent elopement. g. All staff would respond promptly to all door alarms. If the immediate reason for the door alarm not determined, all residents would be accounted for at the time. h. All door alarms would be checked daily by the quality assurance (QA) team member to assure they were working properly. The QA team member to document condition of alarms. According to the facility policy regarding the Wanderguard Device: A Wanderguard device would be used for residents identified by the care plan team as attempting to elope from the facility. The Checklist for Wanderguard Monitors revealed should check them for functioning each Tuesday beginning 01/04/11 to 05/24/11. A box at the bottom of the checklist read: Follow the testing instructions outlined in the Wanderguard User Manual. Test your Wanderguard monitors at least daily during QA rounds, with all surrounding power devices turned on. The Test Wing Door Alarms showed the door alarms in April and May 2011 were not initialed as checked on: 04/02, 04