Every finding on record at Franciscan Health Care Center

Based on observation, interview, record review, and review of facility documentation, the facility failed to ensure necessary care and services (i.e. nail care) were provided for residents unable to carry out their own activities of daily living (ADLs) for 3 of 35 sampled residents, (Resident (R)81, 91, and 100). The findings include:During interview on 09/20/2025 at 1:44 PM, the Division [NAME] President (DVP) stated the facility did not have a policy related to trimming or cleaning residents' nails. The DVP stated the Certified Resident Care Associate's (CRCA) checklist noted the CRCAs were responsible for grooming, which included trimming/cleaning residents' nails who did not have a diagnosis of diabetes.Review of the facility document titled, Job Descriptions, for a Certified Resident Care Associate, revealed staff were to, Assist residents with nail care (i.e., clipping, trimming, and cleaning the finger/toenails. (NOTE: Does not include diabetic residents).1. Record review revealed the Resident Face Sheet noted the facility admitted R!00 on 09/11/2025, with diagnoses that included: cerebral infarction, right lower leg fracture, congestive heart failure (CHF), anxiety, and depression. Continued record review revealed no documented evidence the facility had completed the admission Minimum Data Set (MDS) Assessment for R100. Review of the baseline Care Plan for R100 revealed the facility developed a problem statement initiated on 09/12/2025, noting the resident had a diagnosis of cerebrovascular accident (stroke) and required assistance with his ADL care. Continued review revealed the interventions included for staff to assist the resident with ADL care as needed (initiated 09/12/2025).Observation on 09/15/2025 at 11:07 AM revealed R100 had long fingernails with a black substance under the nail. In interview at the time of the observation R100 stated he had asked staff to trim his fingernails for him, but no one had trimmed them for him. Observation on 09/16/2025 at 9:07 AM; on 09/17/2025 at 1:41 PM; and 09/18/2025 at 10:36 AM, revealed R100 continued to have long, jagged fingernails with a black substance under the nail. In interview on 09/18/2025 at 10:36 AM, R100 stated he wished he could get someone to trim his nails.In interview on 09/19/2025 at 11:55 AM, CRCA 9 stated residents' nail care was provided with showers and as needed. In interview on 09/19/2025 at 12:09 PM, CRCA 10 stated residents were provided nail care when needed. She reported R100's fingernails were long and dirty. the CRCA further stated she had not provided nail care for R100 that week.2. Review of the medical record Resident Face Sheet for R81 revealed the facility admitted the resident on 06/23/2025, with diagnoses that included rheumatoid arthritis and type 2 diabetes mellitus. Review of the Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 08/20/2025, revealed the facility assessed R81 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Continued MDS review revealed the facility also assessed R81 to require supervision or touch assistance for personal hygiene.Review of R81's Care Plan revealed the facility developed a problem statement dated 04/23/2025, noting the resident had potential for decline in functional status related to weakness, dementia, and cerebrovascular accident (CVA). Further review revealed an intervention dated 04/23/2025, directing staff to provide nail care on shower days and prn (as needed).Observation on 09/15/2025 at 1:38 PM, revealed R81 had long fingernails with a dark brown/black substance under them. In interview at the time of observation revealed R81 stated he would like to have staff clean and trim his fingernails.Observation on 09/16/2025 at 11:13 AM, revealed R81 continued to have long fingernails with the dark substance under them. In interview at the time of observation R81 stated no staff had offered to trim his fingernails. He further stated he would like for his fingernails to be trimmed and cleaned.In interview on 09/17/2025 at 12:10 PM, CRCA12 stated he had not offered to trim R81's fingernails because the nurses were responsible for trimming the fingernails of the diabetic residents. The CRCA reported however, he should have offered to clean R81's fingernails. CRCA 12 further stated R81's fingernails should have been trimmed on his previous shower days by the nurses. In interview on 09/18/2025 at 12:35 PM, CRCA 13 stated R81 was a diabetic, so the nurses were responsible to trim his fingernails.In interview on 09/19/2025 at 1:28 PM, R81 stated he received his showers/baths; however, staff did not trim or clean his fingernails. R81 further stated he did not like to have long, dirty fingernails, but he was not steady enough to trim or clean his own fingernails.In interview on 09/20/2025 at 2:40 PM, Registered Nurse (RN) 3 stated nurses were responsible to trim the diabetic residents' fingernails. RN 3 reported R81 had his shower on Wednesday evenings, and the nurse on that shift should have trimmed the resident's fingernails. The RN stated it was the CRCA's responsibility to trim/clean the non-diabetic residents' fingernails and to clean the diabetic residents' fingernails. RN 3 further stated R81's fingernails were long and dirty and needed to be trimmed.3. Record review revealed the Resident Face Sheet noted the facility admitted R91 on 07/13/2025, with diagnoses that included adult failure to thrive and weakness. Review of the admission MDS Assessment, with an ARD of 07/15/2025, revealed the facility assessed R91 to have a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Continued MDS review revealed the facility additionally assessed R91 to require supervision or touch assistance for personal hygiene.Review of R91's Care Plan revealed the facility developed problems that included a problem statement dated 07/21/2025, noting the resident had impairment in function status related to weakness. Further review revealed the interventions included one dated 07/21/2025, directing staff to provide assistance for R91 as needed with self-care and mobility functional tasks.Observation on 09/15/2025 at 1:46 PM, revealed R91's fingernails were long with a dark substance under them. In interview at the time of observation, R91 stated he had not asked to have his fingernails trimmed or cleaned, but would like to have his nails cleaned and trimmed. He said maybe when the activities assistant had a fingernail day they would ask him and would trim and clean his nails. R91 stated staff had not ever offered to clean or trim fingernails. Observation on 09/16/2025 at 9:00 AM, revealed R91's fingernails remained long with a dark substance under them. In interview at the time of observation, R91 stated there still had been no staff offer to trim/clean his fingernails. Observation on 09/20/2025 at 1:30 PM, R91 was observed to continue to have long, dirty fingernails.In interview on 09/20/2025 at 2:10 PM, CRCA 10 stated she had not offered to trim or clean R91's fingernails. CRCA 10 further stated nurses were responsible for trimming the diabetic residents' fingernails.In interview on 09/20/2025 at 2:20 PM, CRCA 16 stated she could trim and clean the non-diabetic residents' fingernails, but the diabetic residents' fingernails were trimmed by the nurses. CRCA 16 observed R91's fingernails and confirmed the resident's fingernails were long, dirty and needed to be trimmed.In interview on 09/19/2025 at 5:50 PM, Licensed Practical Nurse (LPN)14 stated CRCAs were responsible for trimming/cleaning the residents' fingernails except for the diabetics. LPN 14 further stated the nurses were responsible for trimming the diabetics' fingernails.In interview on 09/19/2025 at 6:44 PM, CRCA 15 stated that she cleaned the residents' fingernails on their shower days or as needed. She further stated she could trim the non-diabetic residents' fingernails, but the nurses were responsible for trimming the diabetic residents' fingernails.In interview on 09/20/2025 at 3:21 PM, the Director of Health Services (DHS) stated she did not have a need to do any audits related to resident care, as she only did audits if a concern was brought to her attention. The DHS said she expected her staff to keep the residents' nails cleaned and trimmed. She further stated the CRCAs could trim and clean the non-diabetic residents' fingernails; however, the nurses were responsible for the diabetic residents nails. In interview on 09/20/2025 at 5:08 PM, the Division [NAME] President (DVP) stated he expected the staff to give the resident a shower, and if they needed their nails cleaned/trimmed, staff were to perform those tasks. The DVP reported the CRCA's checklist noted they were responsible for assisting residents with grooming, which would include trimming/cleaning of the non-diabetic residents' fingernails. He said it was a standard for nurses to care for the diabetic residents' fingernails.

Based on observation, interview, record review, facility document and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%) or less, with 6 errors out of 30 opportunities, which yielded a medication error rate of 20% involving 4 of 4 residents observed for medication administration out of the total sample of 35 (Residents (R)21, 2, 13, and 15). The findings include:Review of the facility policy titled, Medication Administration-General Guidelines, revised 11/2018, revealed the FIVE RIGHTS for medication administration included the right resident, right drug, right dose, right route, and right time, and those rights were to be applied for each medication being administered. Per review, a triple check of the Five Rights was recommended at three steps in the process of preparation of a medication for administration. Continued review revealed the three steps included checking when the medication was selected; when the dose was removed from the container; and finally just after the dose was prepared and the medication was put away. Review of the policy further revealed medications were to be administered in accordance with written orders of the prescriber; administered within 60 minutes of the scheduled time, except before, with or after meal orders, which were to be administered based on mealtimes.Review of the Instructions for Use Humalog KwikPen, revised 07/2023, revealed to prime the pen before each injection. Per review, priming the KwikPen meant removing any air from the needle and cartridge which might have collected during normal use. Review further revealed priming was also to ensure the Pen was working correctly. In addition, if priming was not performed before each injection, you may get too much or too little insulin.1. Review of R21's physician Orders revealed an order dated 08/29/2025, for insulin lispro insulin pen 100 units (u) per milliliter (ml) eight units subcutaneously (SQ) three times a day for diabetes.Observation, during medication administration, on 09/17/2025 at 11:48 AM, revealed Registered Nurse (RN) 3 failed to prime R21's insulin pen after placing the new needle on the pen and before turning the dose dial to ordered eight units. In interview, at the time of observation, RN 3 stated he did not know that he needed to prime the pen.In interview on 09/17/2025 at 12:07 PM, Licensed Practical Nurse (LPN) 5 stated the insulin pen needed to be primed with two units prior to use.In interview on 09/17/2025 at 12:08 PM, RN 6 stated she primed the insulin pen with five units. However, observation at the time revealed while demonstrating insulin administration, RN 6 failed to prime the needle prior to turning the dose dial to the prescribed dose.In interview on 09/20/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated the insulin pen needle needed to be primed with two units.In interview on 09/20/2025 at 5:08 PM, the Director of Health Services (DHS) stated the insulin pen needle needed to be primed with two units prior to administering the insulin.2. Review of R2's physician's Orders revealed an order dated 04/08/2025, for artificial tears 0.1-0.3% two drops to both eyes four times a day for dry eyes. Continued review also revealed an order dated 10/25/2024, for dorzolamide 2% one drop in the left eye three times a day for glaucoma.Observation during medication administration on 09/17/2025 at 9:19 AM, revealed RN 4 did not administer R2's artificial tears. Further observation revealed RN 4 administered the dorzolamide eye drops in both eyes instead of just the left eye as ordered.In interview on 09/17/2025 at 2:10 PM, RN 4 confirmed she had not given R2 the artificial tears as ordered. She also confirmed she had administered the dorzolamide in both eyes. RN 4 reviewed R2's physician's order, and said she realized she was only supposed to have placed the dorzolamide in the left eye. She reported she should have read the order completely to ensure she was giving the medication as ordered. RN 4 further stated she should have also checked and double checked the medications with the medication administration record (MAR) to ensure she gave all the medications as ordered.3. Review of R13's physician's Orders revealed an order dated 03/21/2025, for dorzolamide-timolol drops 22.3-6.8 milligrams per milliliter, one drop in each eye once a day for glaucoma.Observation during medication administration on 09/17/2025 at 8:58 AM, revealed RN 4 failed to administer R13's the dorzolamide-timolol eye drops as ordered.In interview on 09/17/2025 at 2:10 PM, RN 4 stated she should have checked and double checked the medications with the MAR to ensure she gave all medications as ordered.In interview on 09/20/2025 at 5:08 PM, the Director of Health Services (DHS) stated when administering medications, the nurse needed to utilize the electronic medication administration record (EMAR). She said the nurse also needed to check the six rights and give medication according to the orders. She further stated the nurses should check and check again.In interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated nurses were to ensure all medications were given as ordered.4. Review of R15's physician's Orders revealed an order dated 07/25/2025, for polyethylene glycol (osmotic laxative) 17 grams by mouth once a day for constipation. Continued review also revealed an order dated 08/25/2025, for Synthroid 25 micrograms (mcg) one tablet once a day at 6:30 AM for hypothyroidism.Observation during medication administration on 09/17/2025 at 8:35 AM, revealed RN 3 administered R15's Synthroid an hour after it was due to be given. Further observation revealed RN 3 failed to administer the polyethylene glycol.In interview on 09/17/2025 at 2:03 PM, RN 3 stated that when giving medications, the nurse should check the label of the medication to the list of medications on the computer and check for the right resident, right medication, right dose, right time, and right route and should check it at least two times. RN #3 confirmed that he did not give the polyethylene glycol and if he went off the time the Synthroid was scheduled to be given, then it would be considered late when he gave it.In interview on 09/17/2025 at 2:10 PM, RN 4 stated if a medication was ordered to be given at a specific time, they had an hour before to an hour after to administer the medication. RN 4 stated therefore, medication due at 6:30 AM could be given from 5:30 AM to 7:30 AM.In interview on 09/20/2025 at 4:21 PM, Nurse Practitioner (NP) 1 stated Synthroid should be given on an empty stomach as that was important for absorption. She further stated it should be given one hour before or three hours after a meal.In interview on 09/20/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated when passing medications, she would check the pill pack with the MAR. She said she would pull out all the medications due to be given and cross reference them with the MAR and read the order on the MAR and the order on the bottle. The ADHS further stated if a medication was due to be administered at 6:30 AM, then it could be given from 5:30 AM to 7:30 AM.In interview on 09/20/2025 at 5:08 PM, the DHS stated when administering medications, the nurse needed to utilize the EMAR, check the rights, and administer medications as ordered. She said the nurses should check and check again. She reported if a medication was due to be administered at 6:30 AM, then they had a half an hour to an hour before or after to give the medication. The DHS said if the resident asked to get a medication later, then they should follow the resident's wishes. She further stated if that continued to happen with a resident, then the nurse should notify the physician.In interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated if residents had a medication ordered, the medication was to be given at the time it was ordered. The DVP further stated they should ensure all medications ordered were given.

Based on observation, interview, record review, and facility policy review, the facility failed to assess residents for self-administering medications for 1 of 2 residents sampled for accidents, (Resident (R)101), out of the total sample of 35. The findings include:Review of the facility policy titled, Guidelines for Self-Administration of Medications, dated 05/22/2018, revealed in the section designated Procedure, residents requesting to self-medicate or who had self-medication as a part of their plan of care were to be assessed using the observation Self Administration of Medication within the electronic health record (EHR). Per policy review, the results of the assessment were to be presented to the physician for evaluation and an order obtained for self-medication. Continued review revealed the order was to include the type of medication(s) the resident was able to self-medicate. Policy review revealed the resident and/or family/responsible party were to be informed of the results of the assessment and whether the resident had been determined to safely self-administer medications. Further review revealed the policy additionally noted the medication the resident could self-administer was to be kept in a locked drawer in the resident's room. Review also revealed the resident was to maintain the key to the locked drawer, and a key was to be maintained by the licensed nurse and/or QMA (Qualified Medication Aide).Review of the Resident Face Sheet revealed the facility admitted R101 on 09/08/2025.Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/12/2025, revealed the facility assessed R101 as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition.Review of R101's Care Plan revealed the facility noted a problem area dated 09/09/2025, indicating the resident had a potential for shortness of breath while lying flat related to chronic obstructive pulmonary disease (COPD). Continued review of R101's Care Plan revealed the interventions included directions for staff to administer medications per the physician's order. Further review revealed no documented evidence the Care Plan included interventions for R101 to self-administer medications or to have medications left at the bedside.Review of R101's physician's order dated 09/14/2025, revealed an order for Trelegy Ellipta (an oral inhaler used to reduce symptoms and exacerbations of COPD) 100-62.5-25 micrograms (mcg) with instructions to inhale one puff daily related to COPD. Further review of the order revealed it included special instructions noting R101's inhaler might be kept at the bedside.Observation on 09/15/2025 at 10:04 AM, revealed R101 lying on the bed with an Ellipta inhaler (medication used to treat COPD) visible on the resident's nightstand. In interview at the time of observation, R101 stated she used the inhaler once a day on her own. R101 further stated the staff usually left the inhaler in her room for ease of use. However, continued review of R101's electronic medical record (EMR) revealed no documented evidence the facility performed an assessment of the resident to see if she was able to self-administer their medication.During interview on 09/16/2025 at 4:15 PM, the Director of Health Services (DHS) stated the facility did not have an assessment for self-administering medications for R101; however, the resident should have had an assessment. She further stated the nurse who took the order for R101's inhaled to be left at bedside, should have followed the proper process (which included assessing the resident).During interview on 09/20/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated if a resident wanted to self-administer their own medications, there was a requirement for the nurse to complete an assessment for self-administration of medications and notify the physician. She said the facility then provided a lock box for the resident to store the medication in, with two keys, one key for the resident, and the other key secured by the nurse. The ADHS reported she was unsure if a physician's order was required for a resident to self-administer medications or keep the medications at the bedside. She further stated the nurse was required to document the resident's use of the medication on the medication administration record (MAR).During interview on 09/20/2025 at 5:08 PM, the DHS stated the facility's policy for a resident to self-administer medications included the need for the resident to be assessed. She said the assessment was to ensure the resident was appropriate to self-administer, and understood how to take the medication correctly. The DHS reported then, the nursing staff was required to notify the physician and obtain an order for the resident to self-administer medications. She stated the medications were to be kept in a locked box or locked drawer. The DHS further stated the nurse must document in the resident's EMR after verification the resident had taken the medication as ordered.During interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated before a resident could self-administer medications, the interdisciplinary team (IDT) must assess whether the resident was knowledgeable and had the physical ability to self-administer their own medications. He reported staff must then obtain a physician's order for the resident to self-administer, and the medication was required to be kept in a safe area.

Based on interview, record review, and facility policy review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form 2 of 3 residents reviewed for beneficiary notification out of the total sample of 35, (Resident (R)6 and 108). Specifically, the facility failed to issue a SNF ABN to Resident #6 and Resident #108 when the facility notified the residents that they were discharged from Medicare Part A services, even though their benefit days had not been exhausted.The findings include:Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), revealed the SNF ABN Form provided information to residents so they could decide whether or not to get the care that might not be paid for by Medicare and assume financial responsibility for that care. Per review, SNFs must use the SNF ABN Form when applicable for SNF Prospective Payment System (PPS) services (Medicare Part A). Further review revealed it was important to note that the SNF ABN Form CMS-10055, was only issued if the beneficiary intended to continue services and the SNF believed the services might not be covered under Medicare.1. Review of the Resident Face Sheet for R6 revealed the facility admitted the resident on 06/30/2023, and readmitted on [DATE], that included diagnoses of type 2 diabetes, bipolar disorder, generalized anxiety disorder, and depression.Review of the SNF Part A PPS Discharge Assessment Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/14/2025, revealed the facility assessed R6 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Further review revealed the start date of R6's most recent Medicare stay was 06/06/2025, and the end date of the stay was 08/14/2025.Review of R6's Care Plan revealed the facility developed a problem initiated 06/12/2025, that noted the resident/family had expressed and acknowledged the need for long term care and had asked that information regarding community services, resources, and referrals not be addressed further. Review further revealed the care plan goal was for the resident's long-term care needs to be met.Review of R6's Inpatient Financial Coverage Review Form, dated 06/03/2025, revealed as of that date, the resident had 100 of 100 days remaining of traditional Medicare benefits.Review of the SNF Beneficiary Notification Review Form, completed by the facility, revealed R6 had a Medicare Part A skilled service episode start date of 06/06/2025, and the last covered day of Part A Service was 08/14/2025. Per review of the form, the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted (the resident had 30 days remaining); however, a SNF ABN Form was not provided. Further review of the Form revealed the facility had not provided a SNF ABN Form because they were not aware that ABN Part A needed to be issued.2. Review of the Resident Face Sheet for R108 revealed the facility admitted the resident on 04/18/2025, diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and type 2 diabetes. Further review of the Resident Face Sheet revealed the facility discharged R108 on 05/25/2025.Review of R108's Care Plan revealed it included a problem statement initiated by the facility on 03/28/2025, that noted the resident planned to return to her previous living environment after successful completion of her rehabilitation program. Continued review revealed the interventions directed staff to encourage the resident and representatives to actively participate in discharge planning (initiated 03/28/2025).Review of R108's Resident Financial Insurance Coverage Review Form, dated 03/25/2025, revealed as of that date, the resident had 82 of 100 days remaining of her traditional Medicare benefits.Review of the SNF Beneficiary Notification Review Form, completed by the facility, revealed R108 had a Medicare Part A skilled service episode with a start date of 03/27/2025, and the last covered day of Part A Service was 05/20/2025. Further review of the Form revealed however, the facility initiated a discharge from Medicare Part A services when R108's benefit days were not exhausted (the resident had 51 days remaining). Review of the Form further revealed the facility had not provided a SNF ABN Form because they were not aware Part A ABN needed to be issued at that time.During interview on 09/17/2025 at 11:23 AM, the Director of Social Services (DSS) stated she had not completed a SNF ABN Form for R6 or R108. During a follow-up interview 09/17/2025 at 12:11 PM, the DSS stated she was the person responsible for issuing SNF ABN Forms for residents since February 2024. She further stated however, she had not been aware of the Form's existence until 08/20/2025. During further interview on 09/17/2025 at 3:24 PM, the DSS stated R6 had been admitted with Medicare Part A for skilled services related to wounds and had 30 days of coverage remaining when her services were terminated. She reported R108 had been admitted with Medicare Part A for skilled services related to therapy and had 51 days of coverage remaining when the resident's Medicare Part A was terminated. The DSS further stated R6 and R108 should have received SNF ABN Forms as required.During interview on 09/20/2025 at 5:03 PM, the Director of Health Services (DHS) stated she expected SNF ABN Forms to be issued timely and according to the facility's policy. During interview on 09/20/2025 at 5:16 PM, the Division [NAME] President (DVP) stated he expected the SNF ABN Forms to be issued anytime there was a change in Medicare benefits for a resident, and the resident was continuing services.

Based on interview, record review, and facility policy review, the facility failed to timely report an allegation of abuse for 1 of 1 resident reviewed for abuse, out of the total sample of 35, (R103).The findings include:Review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised 12/16/2024, revealed under the section titled Procedure the reporting/response noted any staff member, resident, visitor, or resident representative might report known or suspected abuse, exploitation, neglect, or misappropriation to local or state agencies. Per policy review, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were to be reported immediately; however, not later than two hours after the allegation was made if the events that caused the allegation involved abuse or result in serious bodily injury. Continued review revealed if the allegation did not involve abuse or serious bodily injury, the allegation was to be reported no later than 24 hours. Review revealed the allegations were to be reported to the Administrator of the facility and to other officials (including the State Survey Agency [SSA] and Adult Protective Services [APS] where state laws provided for jurisdiction in long term-care facilities) in accordance with State law through established procedures.Review of the Resident Face Sheet for R103 revealed the facility admitted the resident on 09/11/2025, diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen) chronic obstructive pulmonary disease (COPD) with acute exacerbation and enterocolitis (inflammation of the intestine) due to clostridium difficile (c-diff).Record review revealed the facility had R103's admission Minimum Data Set (MDS) Assessment in progress at the time of the SSA Survey.Review of R103's baseline Care Plan revealed the facility developed a problem area initiated on 09/12/2025, noting the resident demonstrated moderate symptoms of depression as evidenced by a score on the Patient Health Questionnaire (PHQ-9, a questionnaire used to assess the severity of depression symptoms). Continued review revealed the Interventions instructed staff to offer and encourage R103 to voice his feelings as needed; observe the resident's mood, affect, and behaviors with all direct care and contacts; and provide supportive counseling contacts as needed.In interview on 09/15/2025 at 10:44 AM, R103 stated the night of his admission [DATE]), a Certified Resident Care Associate (CRCA) yelled at him because he was not familiar with the facility's routine. R103 reported the staff member told him she had many residents assigned to her to care for. The resident said the CRCA also told him activating his call light was not going to get her there any quicker to provide assistance. R103 further stated he had not reported the incident at the time of the occurrence.On 09/15/2025 at 10:50 AM, the SSA Surveyor reported to the Administrator R103's statement regarding an unidentified CRCA yelling at him on the night he was admitted to the facility. The SSA Surveyor also informed the Administrator R103 reported the incident occurred when the CRCA entered his room to answer his call light which had been activated by the resident.In interview on 09/18/2025 at 3:29 PM, the Director of Health Services (DHS) stated after being made aware of the concern voiced by R103 related to a CRCA (identified as CRCA 11) yelling at him, the facility instructed the social worker (SW) to talk to the resident. She said during the conversation between the SW and R103, the resident had not voiced feeling the way CRCA 11 spoke to him to be abusive, but rather that the staff member had a loud voice, so the SW competed a concern form. The DHS reported she spoke with Registered Nurse (RN) 18 and R103, and they felt it was more of a customer service issue. She said R103 reported being satisfied with the care he was receiving, and there had been no further incidents. The DHS further stated the facility had not report incident as an allegation of abuse because the way R103 relayed the concern, it was not considered abuse.In interview on 09/19/2025 at 12:15 PM, R103 stated the facility staff had discussed with him the concern regarding the girl yelling at him on the night of his admission. R103 reported they came in and told him they talked to the staff member, and she said she had not been yelling at the resident, only talking loudly. The resident further stated he told the facility staff that no, CRCA 11 had been yelling and had not been friendly.In interview on 09/19/2025 at 5:14 PM, CRCA 11 acknowledged she had been assigned to R103 on the night of 09/11/2025. She said she had responded to R103, who had been frequently activating his call light on 09/11/2025. CRCA 11 reported however, she never yelled at R103, she had only spoken louder to ensure the resident could hear her. She stated she had continued providing care for R103 following his admission, and the resident had not voiced any concerns to her about her speaking loudly or regarding the care she was providing.In interview on 09/20/2025 at 8:30 AM, R103 was lying on his bed and appeared agitated. R103 he had been surprised the night before (09/19/2025) when nurse who had been assigned to his care on the night of his admission, was again assigned to care for him. The resident said he felt the things the nurse was doing to him the night before had been in retaliation for his previous allegation towards CRCA 11. On 09/20/2025 at 8:36 AM, following the additional allegations voiced by R103, the SSA Surveyor immediately reported to the DHS, the resident's concerns of feeling like the nurse assigned to him on 09/19/2025 had been retaliating against him. The DHS said R103 was telling the SSA Surveyor a different story than what he was telling her. She reported she asked R103 if he had any concerns with the nurse assigned to his care, and the resident said he had no concerns at that time. The DHS further stated she would ensure that RN 18 did not care for R103 again. In interview on 09/20/2025 at 8:43 AM, the Division [NAME] President (DVP) stated the facility was reporting and conducting a full investigation related to the allegations involving R103, provided by the SSA Surveyor on the morning of 09/20/2025. He said after discussing with the facility staff, the Director of Social Services (DSS) went to talk to R103 to gather more information. The DVP reported because of what R103 described to the DSS, the facility handled the concern as a customer service issue, and completed a concern form on R103's behalf. He further stated the facility would have reported the concern at the time of the initial allegation had they felt it to be a matter of abuse. Review of the Resident Concern Log provided by the facility on 09/20/2025 at 11:50 AM ,revealed an entry made by the DSS that noted R103 had voiced a concern about customer service on 09/15/2025. Per review of the log, the concern had been addressed by the DHS on 09/17/2025, and noted she had spoken with R103. Continued review revealed the DHS reviewed the response with R103 provided by the nurse who cared for the resident on 09/11/2025, and the resident was satisfied with the resolution and voiced he had no concerns with any other staff caring for him. Further review revealed the log also noted a concern made by R103 on 09/20/2025 that had been reported to the facility's governing body. In interview on 09/20/2025 at 2:10 PM, the DSS stated she entered R103's room on 09/15/2025, after she was notified of a concern the resident had made. The DSS said at the time, R103 complained of RN 18's behavior on the second shift. She reported R103 told her the emergency medical technicians (EMTs) placed him on his bed and laid his indwelling urinary catheter bag on top of him. The DSS stated R103 reported approximately 30 minutes later, his bed felt wet, so the resident activated his call light to alert staff for assistance. She reported R103 said RN 18 came in his room and spoke to him loudly, saying she was busy with other residents and she would get to hi, as soon as she could. The DSS further stated following the concern voiced by R103 on 09/15/2025, she interviewed all residents on the rehabilitation halls, and no one voiced any concerns.In interview on 09/20/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated all allegations of abuse needed to be reported immediately to the facility's Executive Director and to the SSA. She further stated if a resident reported a staff member yelling at them, that was considered verbal abuse. In interview on 09/20/2025 at 5:08 PM, the DHS stated if an allegation of abuse was made, the facility collected additional information to determine if the allegation needed to be reported and investigated further. In interview on 09/20/2025 at 5:46 PM, the DVP stated anytime there was an allegation of abuse, the allegation was to be reported.

Based on observation, record review, interview, and facility policy review, the facility failed to obtain an order for the use of oxygen for 1 of 4 residents reviewed for respiratory care out of the total sample of 35 (Resident (R)17).The findings include:Review of the facility policy titled, Administration of Oxygen, reviewed 12/13/2024, revealed a section titled , SOP Details that noted staff were to verify the physician's order for the procedure. Further review revealed in cases of emergency oxygen might be administered as a nursing intervention until a physician order may be obtained.Review of the Resident Face Sheet for R17 revealed the facility admitted the resident on 08/21/2025, diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissue), and hypercapnia (elevated levels of carbon dioxide in the blood).Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/28/2025, revealed the facility assessed R17 as having a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident had moderate cognitive impairment. Further review of the MDS revealed the facility assessed R17 to have shortness of breath or trouble breathing when lying flat; however, the use of oxygen was not identified in the assessment.Review of R17's Care Plan revealed the facility developed a problem area initiated 08/22/2025, noting the resident had a potential for shortness of breath while lying flat related to COPD, chronic respiratory failure, and pulmonary fibrosis. Further review revealed the interventions included directions for staff to administer oxygen per physician orders and as needed.Review of R17's hospital Discharge Summary dated 08/21/2025 (date of admission to the facility) revealed documentation of R1's baseline use of supplemental oxygen having been delivered at 4 liters per minute (LPM) at the hospital. However, review of the facility's physician's Orders, for R17, including all active orders, revealed no documented evidence of an order for the use of supplemental oxygen.Observation on 09/15/2025 at 10:52 AM, revealed R17 lying flat on the bed bed with supplemental oxygen being administered at 3.5 liters. Observation on 09/17/2025 at 2:39 PM, revealed R17 sitting in the recliner with supplemental oxygen being administered at 3.5 liters.Review of the facility's vital signs documentation for R17 from 08/16/2025 through 09/16/2025, revealed the use of intermittent oxygen use as follows:-08/21/2025 at 9:42 PM oxygen (O2) saturation 96% with oxygen flow at 3 liters.-08/23/2025 at 9:01 AM O2 saturation 96% with oxygen flow at 2 liters.-08/23/2025 at 6:43 PM O2 saturation 95% with oxygen flow at 2 liters.-08/24/2025 at 1:44 PM O2 saturation 96% with oxygen flow at 2 liters.-08/24/2025 at 6:59 PM O2 saturation 98% with oxygen flow at 2 liters.-08/27/2025 at 6:21 PM O2 saturation 97% with oxygen flow at 2 liters.-08/29/2025 at 10:47 AM O2 saturation 97% with oxygen flow at 3 liters.-08/30/2025 at 11:48 AM O2 saturation 98% with oxygen flow at 2 liters.-09/01/2025 at 9:21 AM O2 saturation 97% with oxygen flow at 2 liters.-09/02/2025 at 7:30 AM O2 saturation 98% with oxygen flow at 2 liters-09/03/2025 at 8:55 AM O2 saturation 97% with oxygen flow at 2 liters.-09/05/2025 at 9:16 AM O2 saturation 98% with oxygen flow at 2 liters.-09/07/2025 at 8:46 AM O2 saturation 94% with oxygen flow at 2 liters.-09/08/2025 at 7:45 AM O2 saturation 99% with oxygen flow at 2 liters.-09/15/2025 at 7:29 AM O2 saturation 97% with oxygen flow at 3 liters.Review of the facility's Resident Progress Notes for R17 revealed a physician's note dated 09/08/2025, that noted the resident's lungs were diminished, with limited ventilation on home oxygen at 4 liters. Per review of the Resident Progress Notes, for R17 revealed a note by the Nurse Practitioner (NP) dated 09/11/2025 documenting the resident remained on continuous oxygen at her home use requirements, with O2 saturation at 100% on 4 liters of oxygen via nasal cannula. Continued review of the Resident Progress Notes revealed a note dated 09/14/2025, documenting the resident used oxygen and to refer to the physician's orders for the liter flow and delivery method. Further review of the Resident Progress Notes for R17 revealed a physician's note dated 09/15/2025, noting the resident had been seen for a diagnosis of pneumonia with a productive cough, and remained on continuous oxygen use per her home requirements.During interview on 09/17/2025 at 2:44 PM, Licensed Practical Nurse (LPN) 2 reviewed R17's electronic medical record (EMR) and stated the resident's physician's orders did not include the use for supplemental oxygen. She said she needed to review R17's hospital records to verify what the resident's oxygen use to be and then contact the physician to get an order for the oxygen. LPN 2 reported the order for oxygen was to include the liters to administer and the mode of how the resident would receive the oxygen such as via nasal cannula (NC) or face mask. She further stated she needed to obtain ancillary orders also to change the oxygen tubing and the frequency to check R17's O2 saturations.During interview on 09/20/2025 at 3:08 PM, the Infection Control Nurse (ICN) stated physician's orders were required for the use of supplemental oxygen which would include the liters, frequency to change the tubing, and to obtain oxygen saturations. She reviewed R17's EMR and verified verbally she had been responsible for entering R17's physician's orders on admission from her hospital discharge summary. The ICN reported she had not transcribed any orders for oxygen use for R17 upon admission. After reviewing R17's hospital discharge summary which included the resident's use of supplemental oxygen at 4 liters, the ICN further stated she should have obtained orders for the resident's O2 from the physician and transcribed the order into the resident's EMR.During interview on 09/20/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated residents who required the use of supplemental oxygen were to have orders transcribed in their EMR that included the number of liters of oxygen to be administered. The ADHS further stated the orders were also to include the frequency to check the resident's oxygen saturation, assessments for the oxygen use and effectiveness, and frequency to change the tubing.During interview on 09/20/2025 at 5:08 PM, the Director of Health Services (DHS) stated residents who required the use of supplemental oxygen were to have orders for the use to include a range for the liters to be administered. During interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated the facility needed to have a physician's order for the use of supplemental oxygen residents. The DVP further stated the orders were to include the flow rate for liters to be administered and typically included the need to change the oxygen tubing.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was assessed for bed rail use and consent obtained for the use of the bed rails for 1 of 2 residents reviewed for accidents, out of the total sample of 35 residents (Resident (R)101). The findings include:Review of the facility policy titled, Guidelines for the Use of Bed Rails, dated 10/09/2017, revealed prior to the installation of bed rails, the facility was to attempt to use alternatives. Per review, if the alternatives attempted were not adequate to meet the resident's needs, the resident was assessed for the use of bed rails. Continued policy review revealed the bed rail assessment was to include review of risks including entrapment; and informed consent for the rails to be obtained from the resident or if applicable, the resident's representative. Further review revealed the facility must ensure the bed was appropriate for the resident and the bed rails were properly installed and maintained. In addition, review of the policy also revealed the use of bed rails as an assistive device was to be addressed in the resident's care plan.Review of the Resident Face Sheet for R101 revealed the facility admitted R101 on 09/08/2025, with diagnoses that included arthritis and cerebrovascular accident (CVA).Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/12/2025, revealed the facility assessed R101 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. Continued review of the MDS revealed the facility assessed the resident to require partial to moderate assistance with rolling left and right in bed, sitting to lying and lying to sitting in bed, and chair/bed to chair transfers. Further review of the MDS revealed the facility had not assessed the use of bed rails for R101 as a restraint during the assessment look-back period. Review of R101's Care Plan revealed the facility developed a problem area dated 09/09/2025, noting the resident had an impairment in functional status related to weakness. Continued review revealed the interventions included instructions for staff to assist R101 as needed with self-care and mobility functional tasks (initiated 09/09/2025). Further review revealed no documented evidence the facility addressed the use of bed rails for R101.Review of the facility's Active Orders for R101 revealed no documented evidence of an order for the use of bed rails.Observation on 09/15/2025 at 10:04 AM, revealed R101 lying on her bed with the head of the bed in an elevated position and quarter bed rails up on both sides of the upper bed. In interview at the time of observation, R101 stated she used the bed rails to sit up in bed.During interview on 09/16/2025 at 4:15 PM, the Director of Health Services (DHS) stated the facility had no assessment or consent for the use of bed rails for R101. During a follow-up interview on 09/20/2025 at 5:08 PM, the DHS stated if a resident wanted to use bed rails, the facility had to complete an assessment and obtain a physician's order. She further stated bed rails for R101 being utilized should have been included in the resident's care plan.During interview on 09/20/2025 at 7:29 PM, the Therapy Director stated routinely when they assessed a resident and determined the resident would benefit from the use of bed rails, they notified nursing staff. She stated the nursing staff completed a bed rail assessment and any associated paperwork. The Therapy Director further stated therapy did not complete bed rail assessments.During interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated the facility needed to assess a resident prior to the use of bed rails. He said if bed rails were used for bed mobility, the facility staff were to assess the resident's strength and encourage range of motion. The DVP reported if the resident continued to request bed rails, facility staff were to assess the resident and provide bed rails if it was deemed safe. He further stated the facility was to have an order for the use of bed rails, and the use of the rails was to be included in the resident's care plan.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication carts were clean, organized, and medications that were opened had an opened date for 5 of 5 medication carts observed (the medication carts involved were: Downtown, Berry, Bell 1, Bell 2, and TCU 1) Further observation revealed 10 total medication carts located within the facility. The findings include:Review of the facility policy titled, Medication Storage in the Facility-Storage of Medications, revised 11/2018, revealed medication storage areas were to be kept clean, well-lit, and free of clutter and extreme temperatures and humidity. Per policy review, certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerine tablets, blood sugar testing solutions and strips, once opened, required an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. Continued review revealed drugs dispensed in the manufacturer's original container were to carry the manufacturer's expiration date. Policy review revealed once opened, the medications were good to use until the manufacture's expiration date was reached unless the medication was: an item for which the manufacturer had specified a usable life after opening; when the original seal of a manufacturer's container or vial was initially broken, the container or vial might be dated. Further review revealed a date opened sticker was to be placed on the medication, and all expired medications removed from the active supply and destroyed in the facility, regardless of amount remaining.Observation during medication administration on 09/17/2025 at 8:27 AM, revealed a bottle of latanoprost (an eye drop for glaucoma) for R15 which did not have an opened date on it. Further observation of the eye drops revealed the pharmacy date on the box was 07/28/2025.Observation during the medication administration on 09/17/2025 at 9:07 AM, revealed a bottle of dorzolamide (an eye drop for glaucoma) eye drops for R2 did not have an opened date on it.Observation of the Downtown medication cart on 09/17/2025 at 3:19 PM, revealed two loose pills with pill powder and debris in the second drawer, two loose pills with pill powder and debris in the third drawer and a spilled liquid medication in the bottom drawer. In interview at the time of observation, RN 3 stated it was the night shift's responsibility to clean and organize the medication carts.Observation of the Berry medication cart on 09/17/2025 at 3:35 PM, revealed a bottle of Humalog insulin on top of the medication cart in the basket with the glucometer and blood sugar supplies. In interview at the time of observation revealed RN 4 stated the insulin should have been put back in the cart after she used it.Observation of the Bell 1 medication cart with Certified Resident Medication Assistant (CRMA) 7 on 09/17/2025 3:42 PM, revealed six loose pills in the second drawer. Observation of the Bell 2 medication cart 7 on 09/17/2025 at 3:46 PM, with CRMA 7 revealed a loose pill in the second drawer, with pill powder and other debris in the back of the drawers.Observation on the TCU 1 medication cart on 09/17/2025 at 4:00 PM revealed broken pieces of pills, debris in the back of the second drawer, and a sticky substance in the bottom drawer. In interview LPN 8 stated it was all the nurses' responsibility to keep the medication carts clean and organized and make sure that all eye drops, inhalers, and insulins were dated when opened. LPN 8 said she could not say how long dorzolamide or latanoprost was good for once opened, but thought it was 45 days.In interview on 09/20/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated night staff was to clean and organize the facility's medication carts, and pharmacy also performed a review of the carts. The ADHS further stated she was unsure about the amount of time the medication was good once it was opened. She further stated she knew the medications needed to be dated when they were opened.In interview on 09/20/2025 at 5:08 PM, the Director of Health Services (DHS) stated any of the nurses could clean the medication carts, and the nurses should make sure the medications on the cart were not expired. The DHS said the facility also had corporate people and pharmacy to observe and review the medication carts. The DHS further stated if the medication were not dated when they were opened, the nurse should go by the pharmacy delivery date to determine how long the medication was good for. In interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated the pharmacy, the DHS, and the charge nurses were to review the facility's medication carts. The DVP further stated nursing was to date medications when they were opened for tracking to know when to discard it.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff cleaned and disinfected glucometers (device used to monitor blood sugar levels) after use for 1 of 2 residents observed for glucometer checks, out of the total sample of 35.The findings include:Review of the facility policy titled, Glucometer Cleaning and Control Test Guidelines, dated 05/11/2016, revealed if glucometers were used from one resident to another, they should be cleaned and disinfected after each use. Further review revealed to see the manufacture [sic] guidelines for cleaning and disinfecting.Review of the manufacturer's guidelines for the facility's, Assure Prism multi Blood Glucose Monitoring System revealed the blood glucose monitor/meter was only to be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. Per review of the guidelines, the meter was to be cleaned and disinfected after use on each resident. Continued review revealed Super Sani-Cloth Germicidal Disposable Wipes had been shown to be safe for this meter. Further review revealed the guidelines for cleaning and disinfecting the monitor/meter included to wipe the entire surface of the meter using the germicidal towelette at least three times vertically and three times horizontally to clean blood and other body fluids from the meter. In addition, review revealed to allow the exterior to remain wet for 1 minute, then wipe meter dry using a dry cloth. Resident Face Sheet indicated the facility admitted Resident #21 on 08/29/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease.Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/02/2025, revealed the facility assessed R21 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.Review of R21's Care Plan revealed the facility developed a problem statement initiated on 08/29/2025, indicating the resident was at risk for hypo/hyperglycemia related to diabetes mellitus. Further review revealed the interventions included an intervention instructing staff to monitor R21's blood sugar per physician orders (implemented 08/29/2025).Observation of Registered Nurse (RN) 3's medication administration on 09/17/2025 at 11:48 AM, after using a glucometer to check the resident's blood sugar, the RN placed the glucometer in a basket of blood sugar finger stick supplies. Per observation, RN 3 failed to clean the glucometer prior to putting it in the finger stick supply basket, which she was observed to take back to the medication cart. Continued observation at 11:55 AM, revealed RN 3 took the finger stick supply basket with the dirty glucometer still in it, into another resident's room in case he needed to check that resident's blood sugar. Further observation revealed the RN carried the basket with the dirty glucometer in it back to the medication cart and put it on top of the cart.During interview on 09/17/2025 at 12:01 PM, RN 3 stated (in regards to cleaning the glucometer) he cleaned the glucometer with Sani-Cloth wipes three times a day. He reported after completing the resident glucose checks he cleaned the glucometer in the morning, after lunch, and after dinner; however, not after each resident use as required per the manufacturer's guidelines.During interview on 09/17/2025 at 12:34 PM, the Director of Health Services (DHS) stated RN 3 had misunderstood the State Survey Agency (SSA) Surveyor's question and meant to say he (RN 3) had cleaned the glucometer three times that day. She further stated however, the glucometer should have been cleaned after the RN used it on R21 and before placing the glucometer into the basket with other finger stick supplies.During interview on 09/17/2025 at 4:38 PM, the Assistant Director of Health Services (ADHS) stated the glucometer was to be cleaned after each use with the disinfecting wipes. In a follow-up interview on 09/20/2025 at 5:08 PM, the DHS stated the glucometer should have been cleaned and sanitized between each resident with the bleach wipes.During interview on 09/20/2025 at 5:46 PM, the Division [NAME] President (DVP) stated glucometers were to be cleaned after each resident interaction with bleach wipes for the appropriate dwell time indicated on the label.

Based on interview and record review, and review of the facility's policy, the facility failed to ensure residents received care to prevent pressure ulcers from developing for one of three residents reviewed for pressure ulcers (Resident (R) 8). The findings include: Review of facility policy, Guidelines for Weekly Skin Observation, reviewed 12/17/2024 revealed a purpose statement, to monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated. Further review revealed item #6 stated, In addition to the Weekly Observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified. Review of facility policy, Turning and Repositioning, reviewed 12/16/2024 revealed an overview statement indicating, those requiring assistance to reposition while in bed and assist with turning and repositioning as needed to maintain skin integrity. Review of R8's Resident Face sheet, revealed the facility admitted the resident on 12/09/2022 with a diagnoses including covid-19 using contact isolation precautions, malignant neoplasm of prostate, rectum and bone. Further, R8 also had a colostomy, foley catheter and weakness. Review of R8's Comprehensive Care Plan, dated 12/19/2022 revealed the facility identified the resident as at risk for skin breakdown and pressure ulcers. Further review revealed the facility listed interventions including conducting weekly skin assessments. Encourage and assist to turn and reposition for comfort and as needed. Float heels as needed with the overall goal of resident's skin will remain intact. Further review of the resident's record revealed a Wound Care assessment dated [DATE] from an area acute care facility, one day prior to R8's admission to facility, revealed the sacrum intact with no redness. Additionally, R8's groin was noted intact and there was no mention of R8's heels. Review of facility Progress Notes, dated 12/12/2022, revealed the facility assessed R8 with a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of Progress Notes dated 12/13/2022, by facility Nurse Practitioner (NP) 1, indicated the NP was unable to visualize buttocks due to resident up in chair and requires a mechanical lift. Further review revealed R8 with generalized weakness, unable to sit on side of bed because he/she was unable to hold self up, and unable to stand and put weight on legs. Review of Progress Notes dated 12/16/2022 by NP 2 revealed R8 would come out of covid-19 isolation tomorrow [12/17/2022]. Review of Progress Notes dated 12/19/2022 by the Assistant Director of Health Services (ADHS) revealed a sacral deep tissue injury with possible abscess, a right heel deep tissue injury, and a penis deep tissue injury due to medical device with wound care orders initiated. Review of Physical Therapy notes, dated 12/19/2022, revealed the Physical Therapist assessed R8's heels bilaterally for softening due to concerns for skin integrity from prolonged periods of time in bed. Review of Progress Notes dated 12/20/2022, revealed a first meeting related to wounds, and orders for a low air loss mattress, antibiotic, doxycycline (an antibiotic that treats bacterial infections) 100 milligrams (mg) for seven days, and nutritional supplements ordered. Review of Progress Notes dated 01/03/2023 revealed the facility transferred R8 to an acute care facility for evaluation related to non-healing coccyx wound despite oral antibiotics for two weeks, and laboratory values still indicated infection with likely source being wounds. Review of daily skin assessments from documented between 12/10/2022-01/03/2023 revealed all were marked as clear/none of the above, indicating to current skin concerns. Review of a facility wound management report, dated 12/28/2022, revealed an unstageable-deep tissue with necrotic tissue on R8's coccyx; penile anterior shaft of penis revealed an unstageable-deep tissue with epithelial tissue; and the right heel revealed unstageable-deep tissue with epithelial tissue. In interview with NP 1, at 10:13 AM on 06/10/2025, she stated she relied on nursing staff to perform skin assessments at times when she was unable. In an interview with Licensed Practical Nurse (LPN) 1, at 1:26 PM on 06/10/2025 revealed she performed resident wound care regular. She stated she would take an hour at a time to care for multiple wounds and skin tears on R8, whose skin tore easily. She stated wound care was being done from the beginning on the resident's coccyx. LPN 1 stated the nurse's role for new admissions included a skin assessment, from head to toe, rolling the resident over in bed, if necessary, and if seated in a chair, get a Hoyer lift to do the skin assessment. LPN 1 stated skin assessments were important because if the resident had a wound documentation and treatment were necessary. In an interview at 1:40 PM on 06/10/2025, with Certified Nursing Assistant (CNA) 1, she stated her role assisted with resident hygiene and she looked at residents' backs for skin issues. She also cleaned the urinary catheter with each brief change and reported any changes to the nurse. CNA1 stated if she observed a wound on a resident she documented it as an open wound. In an interview at 2:13 PM with Registered Nurse (RN) 1, on 06/10/2025, she stated as nurse her role with resident admissions included a skin assessment, and obtaining/entering orders into the computer system. She checked residents' skin on shower days and twice weekly and documented those skin assessments in the progress notes. If performing a head-to-toe assessment, would use a mechanical lift to check the backside of a resident if the resident was unable to turn. RN1 stated the process was the same for residents in isolation precautions. In an interview at 2:34 PM with CNA2 on 06/10/2025 she stated the nurse performed head to toe assessments upon admission. She stated if she noticed a change in a resident's skin she notified the nurse. In an interview with the Director of Nursing at 3:49 PM she stated the expectation was for nurses to complete a head to toe skin assessments of residents upon admission. Additionally, a weekly skin assessment was completed by a nurse. She stated the importance of skin assessments was to identify skin issues upon admission and obtain orders to treat. Executive Director not available for interview.

Based on record review, interview, and document review, the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) for one (1) of one (1) resident, Resident #60, who was reviewed with a Mental Disorder (MD) or Intellectual Disability. Findings Included: A review of the document provided by the facility titled PASRR Quick Sheet. undated revealed New Admissions: If any of the following triggers a positive response, the level 1 (MAP 409) will be checked YES on section I and/or II and contact the PASARR office. Individual has a severe mental illness/behavioral health (BH) diagnosis. Ex: [CONDITION(S)], [CONDITION(S)] Disorder, [CONDITION(S)] Disorder, Anxiety Disorder, [CONDITION(S)], etc. A review of Resident #60's Face Sheet revealed the facility admitted Resident #60 on 06/09/2022 with diagnoses that included [CONDITION(S)] Disorder and Depression. A review of Resident #60's PASARR completed on 06/09/2022 revealed no diagnoses listed in Section two (2): Mental Illness diagnosis. Section two (2) instructions indicated to Identify whether the resident has a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #60's Admission Minimum Data Set (MDS) Assessment, dated 06/13/2022, revealed Resident #60 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that Resident #60 received an anti-psychotic medication and an anti-depressant medication during the review period. A review of Resident #60's Comprehensive Care Plan, with a start date of 06/15/2022, revealed Resident #60 presented with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revealed Resident #60 presented with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 07/12/2022 at 1:58 PM, Customer Service Specialist #1 (CSS #1) stated the Customer Service Specialists completed the new admission PASARR level one (1) reviews. CSS #1 stated she had previously worked at this facility for eight (8) years but was now training a new CSS in the position. CSS #1 stated that Resident #60's PASARR was completed by a CSS from another facility who had been helping at the facility in question. CSS #1 stated if Resident #60 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 07/13/2022 at 11:46 AM, the Director of Nursing (DON) stated that she did not oversee PASARRs. The DON stated that the Social Services Director oversaw that process. In an interview on 07/13/2022 at 12:02 PM, the Administrator stated the expectation for PASARR completion was for the admissions team to complete the level one (1) PASARR and scans the information into the system and, for those residents who triggered for level two (2) PASARR, Social Services took over. The Administrator stated that perhaps because the person completing the PASARR did not see [CONDITION(S)] specifically listed, she did not know it needed to go there. In an interview on 07/14/2022 at 8:45 AM, the Social Services Director stated that if the resident triggered for mental illness on the level one (1) PASARR, they submitted the level one (1) to the system and an appointment time for someone to come and conduct an evaluation was assigned to see if the resident required a level two (2) assessment, that they were appropriate for this level of care, and that the resident's mental health care needs could be met at this level of care.

Based on observation, record review and interview it was determined the facility failed to maintain one freezer at safe temperatures out of the two freezers in the kitchen and the satellite kitchen. In addition, staff did not wear hairnets, wash hands, and apply gloves consistently when in the kitchen. The findings include: Observation with the Dietary Manager (DM), on 08/23/19 at 11:25 AM, revealed the freezer in the satellite kitchen had an internal temperature of 40 degrees, however the temperature reading on the gauge outside the unit showed that it was 10 degrees on the inside. Observation further revealed there was a package of okra and a package of French fries were thawed out and lying on the shelf in the freezer. Interview with the DM, on 08/23/19 at 11:25 AM, revealed the freezer had been out of commission for a while. It was cooling but not freezing. The DM stated he had put an out of service note on the freezer but it was not there now. The DM stated he did not know how long the okra and fries had been in the freezer. The DM revealed if the food had been served to the resident it put the residents at risk for a food borne illness. Interview with the DM, on 08/24/19 at 3:40 PM, revealed he was not aware that the freezer was not working until on tour with the surveyors the day before. The DM stated he had put a work order in before and thought the freezer was fixed. He stated they had used this freezer in the main kitchen while they were waiting for the new freezers to be delivered. They took the freezer back to the satellite kitchen and it did not work after it was brought back, so he placed a work order in for it to be fixed and he thought it was repaired. Interview with the Regional Dietary Supervisor, on 08/24/19 at 3:35 PM, revealed the facility utilized the Tels system to request service for repairs of kitchen items. He stated staff could access the Tels system to see if a work order had been completed. He stated he was not aware the freezer was out of service until yesterday and at that time they took it out of service. Observation, on 08/22/19 at 11:20 AM revealed dietary aid (DA) #1 entered the cooking area of the kitchen and walked over to the serving cart where she bit the side of her thumb. Observation further revealed DA # 1 opened the cold side of the serving cart and then closed it. DA #1 proceeded to walk over to the kitchen area refrigerator and removed covered salad plates and placed them on a metal serving table. Observation revealed DA #1 did not wash her hands or put on gloves during this process. Observation, on 08/22/19 at 11:25 AM, revealed another kitchen staff answered the telephone and returned to the serving table where she picked up an ink pen to write with. This staff member walked to the refrigerator and carried another covered salad plate to the serving table and did not wash her hands. Observation, on 08/22/19 at 11:30 AM, revealed DA #2 was slicing fresh pineapple without washing the fruit first. Interview with DA #2, on 08/22/19 at 11:30 AM, revealed she rinsed the pineapple after she finished slicing them. Observation, on 08/22/19 at 12:40 PM revealed DA #3 rubbed her right gloved hand on her pants and then proceeded to touch fresh strawberries that were lying on the slicing board. Interview with the DM, on 08/23/19 at 11:15 AM, revealed fruit should be washed before slicing it, not after slicing the fruit. The DM stated washing before would prevent food borne illness, contamination, and infections to the residents. The DM further revealed hairnets and handwashing should be done before crossing the yellow line that was at the front of the kitchen door where staff enter. The DM stated if a kitchen staff member had a bandage on their hands then they should have worn gloves at all times because they could contaminate food. He stated if they had a blood borne illness they could spread it to the food and make the residents sick. The DM revealed if a kitchen staff member answered the phone they should have removed their gloves, washed their hands, and put clean gloves back on.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to keep a clean and orderly environment. Observation on 08/23/19 at 9:00 AM, revealed birdseed was stored in one clean linen closet on the Downtown unit out of the seven units in the facility. Further observation, on 08/23/19 at 9:05 AM with Licensed Practical Nurse (LPN) #1, revealed the birdseed bag was opened and there were flying bugs in the bag. The findings include: Review of the facility policy Guidelines for Handling Linen, revised on 05/11/16, revealed the facility established procedures for the cleaning of linen to ensure all resident received fresh linens. The purpose of the policy was to prevent contamination of clean linens. Observation, on 08/23/19 at 9:00 AM, revealed the unlocked linen closet on the Downtown unit had resident gowns, sheets, and pillowcases on the shelves. In addition, two closed containers and one opened bag of birdseed was sitting on the floor in the clean linen room. There was birdseed lying loose on the floor under the shelves. Further observation, on 08/23/19 at 9:05 AM with Licensed Practical Nurse (LPN) #1, revealed the birdseed bag was opened and there were flying bugs in the bag. Interview, on 08/23/19 at 9:05 AM with LPN #1, revealed a resident could trip over the birdseed and get it in their clothes and the birdseed could contaminate the clean linens. LPN #1 stated she did not know how long the birdseed had been in the clean linen room and she did not know who had placed the birdseed in there. She verified there were bugs flying in the birdseed bag and there was birdseed on the floor. Interview with the Director of Nursing (DON), on 08/23/19 at 9:16 AM, revealed the birdseed should be in a closed container and not in the residents clean linen room. The DON further revealed she could not tell what type of risk it posed for the resident because she did not know what type of flying bug was in the birdseed bag. Interview with the Housekeeper, on 08/23/19 at 9:15 AM, revealed birdseed should not be stored in the clean linen closet. The housekeeper stated he needed to get the birdseed out of the clean linen closet and this included the closed container of birdseed. He verified there were bugs in the open bag of birdseed and stated it was hazardous to the residents' health and was cross contamination. Interview with the current Administrator, on 08/24/19 at 3:39 PM, revealed he was not sure if it there was an issue in regards to the bird seed being stored in the clean linen closet or not because the linens were not touching the containers of birdseed. Interview with the Regional Administrator, on 08/24/19 at 3:39 PM, revealed there was a possibility that birdseed could invite other types of infestations, however he had not seen any infestations. The Regional Administrator stated it was not acceptable for birdseed to be opened and in the clean linen room.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the environment remained free from accident hazards. Observation of medication carts revealed two (2) of nine (9) were left unlocked and unattended. The findings include: The facility did not provide a policy for resident safety. Review of the facility's policy, Medication Storage in the Facility, revised (MONTH) (YEAR), revealed medications were stored safely, securely, and properly, following manufacturer's recommendations, and accessible only to licensed facility personnel or those authorized to administer medications. Observation of Belle and Derby Halls, on 08/04/18 at 8:47 AM, revealed a medication cart at the nurses' station at the intersection of Belle and Derby Halls was unlocked and unattended. Two (2) staff passed by the unlocked medication cart. A Licensed Practical Nurse (LPN) approached the cart, retrieved items from the top of the medication cart, and exited the area without locking the medication cart. Continued observation revealed a fourth staff approached and locked the medication cart. Observation, on 08/04/18 at 10:57 AM, revealed a medication cart outside room [ROOM NUMBER] was unlocked and unattended. No staff was in the area of the medication cart until a Registered Nurse (RN) locked the medication cart as she passed by the cart. Interview, on 08/04/18 at 12:37 PM, with Certified Resident Care Associate (CRCA) #1 revealed CRCAs were not responsible for the medication carts. Interview with the Certified Medication Technician (CMT), on 08/04/18 at 1:33 PM, revealed staff should never leave medication carts unlocked and unattended as it affected resident safety. The CMT stated anyone could access and remove medications if staff left the medication cart unlocked. The CMT stated he believed he pushed the lock in when he stepped away from the cart, but evidently, he did not fully engage the lock on the medication cart. He stated the facility provided training, at least annually, on keeping medication carts locked when unattended. Interview with RN #1, on 08/04/18 at 1:58 PM, revealed medication carts were never left unlocked when staff was away from the cart as it was a resident safety issue. RN #1 stated anyone, a resident, staff, or visitor could remove and consume medications from an unlocked and unattended medication cart with an unfortunate outcome. She stated the facility provided training on medication storage and security periodically and she was unaware of any audits by the facility regarding medication cart security. Interview with the Director of Health Services (DHS), on 08/04/18 at 2:20 PM, revealed for safety reasons, staff never left medication carts unlocked and unsupervised. She stated she provided education and/or disciplinary action when unlocked medication carts were encountered, but there was no formal or written audit of medication carts. The DHS stated the facility provided training on medication carts when concerns were identified.

Based on observation, interview, and facility policy review, it was determined the facility failed to store medications in locked compartments. Observations revealed two (2) of nine (9) medication carts were unlocked and unattended. The findings include: Review of the facility's policy, Medication Storage in the Facility, revised (MONTH) (YEAR), revealed medications were stored safely, securely, and properly, following manufacturer's recommendations, and accessible only to licensed facility personnel or those authorized to administer medications. Observation, on 08/04/18 at 8:47 AM, revealed a medication cart at the nurses' station at the intersection of Belle and Derby Halls, was unlocked and unattended. Two (2) staff passed by the unlocked medication cart and then a Licensed Practical Nurse (LPN) approached the cart, retrieved items from the top of the medication cart, and exited the area without locking the medication cart. Continued observations revealed a fourth staff approached and locked the medication cart. Observation, on 08/04/18 at 10:57 AM, revealed a medication cart outside room [ROOM NUMBER] was unlocked and unattended. A Registered Nurse (RN) locked the medication cart as she passed by; no other staff was in the area of the medication cart. Interview with the Certified Medication Technician (CMT), on 08/04/18 at 1:33 PM, revealed medication carts should never be left unlocked and unattended. The CMT stated anyone could access and remove medications if the medication cart was left unlocked. The CMT stated he believed he pushed the lock in when he stepped away from the cart, but must not have fully engaged the lock on the cart. He stated the facility provided training, at least annually on keeping medication carts locked when unattended. Interview with RN #1, on 08/04/18 at 1:58 PM, revealed medication carts were never left unlocked when staff was away from the cart. RN #1 stated a resident, staff, or visitor could remove medications from an unlocked and unattended medication cart. She stated the facility provided training on medication storage and security periodically and she was unaware of any audits by the facility regarding medication cart security. Interview with the Director of Health Services (DHS), on 08/04/18 at 2:20 PM, revealed medication carts were never left unlocked and unsupervised. She stated there was no formal or written audit of medication carts, but she rounded daily to monitor for unlocked carts. The DHS stated the facility provided training on medication carts when concerns were identified, and added that medication cart security was basic nursing knowledge.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner. Observations of the kitchen revealed a soiled toaster, food carts, and dryer filter. The findings include: Review of the facility's Kitchen Cleaning Procedures, not dated, revealed toasters were to be washed on the outside, rinsed, and allowed to air dry. Review of the facility's Kitchen Cleaning Schedule, not dated, revealed the toaster and the dryer were not listed to be cleaned on a schedule. Observation, on 06/05/18 at 8:27 AM and 06/07/18 at 10:35 AM, revealed the toaster had copious amounts of brown-black matter on all four (4) sides and on top. During the 06/05/18 observation, staff placed bread into the toaster and then onto a resident's plate. Observation, on 06/05/18 at 8:40 AM, revealed the mechanical dish dryer was in use and blowing air downward toward clean resident plates. The dryer was on the clean side of the sanitation equipment. The metal filter had thick brown black sticky matter encrusted into the filter. The underside of the dryer had lint/cobweb like debris, and a brown black encrusted matter with a glazed appearance stuck around the air vents and the underside of the unit. The cobweb like matter had blown onto the clean dishes. Observation, on 06/05/18 at 11:45 AM, revealed three (3) food carts had brown-black and white matter splattered on the glass tops of the carts. In addition, numerous baking pans were on a wired shelf facing upward and there was white and brown matter inside the pans. Observation, on 06/07/18 at 10:30 AM, revealed the three (3) food carts were being prepared with resident meal plates and other food was being prepared on top of the carts. The carts remained soiled. Interview with the Director of Food Services (DFS), on 06/05/18 at 8:50 AM, revealed the dryer filter was not cleaned or changed and needed to be cleaned every three (3) months, he thought. He stated the vents under the dryer were dirty and the sanitary condition was bad, as the dishes were contaminated with the matter being blown onto the plates. He stated he did not deal with the dryer because it was a maintenance issue. Continued interview with the DFS, on 06/07/18 at 8:44 AM, revealed all staff was responsible for cleaning equipment in the kitchen. He stated kitchen aides were responsible for the food carts and the cook was responsible for the cooking equipment. He stated staff was trained during orientation of their respective responsibilities for cleaning; however, staff was not required to sign documentation of the completed cleaning task. He stated the dish dryer was not cleaned during the time he had been director, was not part of the cleaning schedule, and was not on the kitchen schedule or maintenance schedule for monitoring. The DFS stated the toaster was to be cleaned daily and it was very dirty when he observed the toaster during the interview. He stated he monitored at least one (1) tray cart per day for sanitation and monitored the cleaning of the equipment daily because he was in the kitchen daily. The DFS stated the cleaning schedule was a basic guide and was not specific as to what equipment needed to be cleaned and when. He stated equipment should be cleaned so pathogens would not cross over to food and cause residents to become ill. Interview with Kitchen Aide #1, on 06/07/18 at 9:33 AM, revealed he cleaned the inside of the cart and the top surface after every meal. He stated the protective glass was to be cleaned when the cart was returned to the kitchen to keep the surface clean and keep residents from becoming ill due to cross contamination. He stated he was trained in infection control during orientation and it was reviewed during monthly in-services and weekly huddles. He stated the supervisor came and inspected the food carts randomly. The Aide stated he was not required to complete a cleaning log. Interview with Kitchen Aide #2, on 06/07/18 at 9:35 AM, revealed she wiped the inside and outside of the food cart before and after meals were served. She stated the carts were to remain clean in order to prevent the residents from becoming ill. She stated she received education on infection control and it was part of the annual training. She stated the supervisor sometimes came and checked the carts for sanitation. She stated there was not a log to record completion of cleaning equipment. Interview with the Cook, on 06/07/18 at 9:46 AM, revealed she was responsible for keeping equipment clean, including pots and pans. She stated pans were to be face down on the metal racks to prevent food and matter from falling into the pans. She stated the toaster was very dirty; however, she ate from the toaster all the time. She stated the toaster was also a potential fire hazard because its current condition. She stated the Assistant DFS (ADFS) was responsible for making sure the kitchen was clean and made rounds when he was working to make sure the equipment was cleaned. She stated she completed annual training for cross contamination and infection control. She further stated staff was in-serviced on the importance of keeping equipment clean with monthly in-services held by the DFS. She further stated the residents were at risk of being ill with dirty equipment. She stated there was not a log for staff to record their cleaning. Interview with the ADFS, on 06/07/18 at 11:36 AM, revealed he was responsible to ensure the kitchen staff kept equipment clean and he reviewed the equipment for cleanliness. He stated the air dryer was not on a cleaning list or listed as a responsibility of kitchen staff and had never been cleaned to his knowledge. He stated the cooks were responsible for any equipment used in food prep and the aides were responsible for the food carts. He stated the aides were taught to clean the inside and outside of the carts as well as the protective clear shields on top of the carts after each meal. The ADFS stated staff and kitchen management completed weekly huddles, which included discussions of cross contamination and cleaning procedures. He stated he did not monitor the toaster but it should be cleaned daily because it was used daily. He stated pots were to be placed upside down to prevent food from falling into the pans. He stated kitchen staff should maintain the cleanliness of the kitchen as they were trained because residents could potentially become ill if equipment was dirty. Interview with the Maintenance Director, on 06/07/18 at 5:07 PM, revealed he did not monitor the dish air dryer located in the kitchen. He stated the dryer was not on his list for care, cleaning, or maintenance. He stated the kitchen Director was responsible to clean the unit and to notify him of mechanical issues. Interview with the Administrator, on 06/07/18 at 5:00 PM, revealed the DFS was to ensure food and equipment sanitation and he ensured the DFS maintained good sanitation because he checked the kitchen every week and if he saw an issue, it was addressed immediately with the DFS. He stated it was important to have appropriate sanitation in the kitchen due to the risk of illness for the residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the plan of care for one (1) of twenty-two (22) sampled residents, Resident #25, related to incontinence. The findings include: Review of the facility's policy, Comprehensive Care Plan Guideline, revised 05/22/18, revealed the facility was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Review of the clinical record revealed the facility admitted Resident #25 on 01/08/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], for Resident #25 revealed the facility assessed the resident required extensive assistance with transfers, toileting, and personal hygiene. In addition, the facility determined the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15). Observation of Resident #25, on 06/05/18 at 8:07 AM, revealed a strong odor of urine in the resident's room and in the corridor at the entrance to the room. Observation, on 06/06/18 at 10:46 AM, revealed Resident #25's pants were wet across his/her abdomen and upper legs. Interview with the resident revealed he/she was soaking wet and needed a change. Review of the Care Plan, initiated 08/25/17, revealed Resident #25 experienced episodes of incontinence with interventions to offer and assist the resident with toileting and provide incontinence care as needed. Review of the Certified Nursing Assistant (CNA) Care Sheet for toileting revealed the Resident #25 was a check and change. Interview with CNA #2, on 06/06/18 at 11:02 AM, revealed she toileted residents every one (1) to two (2) hours and last checked Resident #25 for incontinence at around 8:00 AM. The CNA stated it was important to provide incontinent care to ensure residents remained dry and to prevent skin breakdown. Interview, on 06/07/18 at 2:37 PM, with CNA #4 revealed staff should check and change residents every two (2) hours and as needed. The CNA stated it was important to ensure residents were clean to maintain their dignity. Interview with Licensed Practical Nurse (LPN) #5, on 06/06/18 at 10:39 AM, revealed incontinent care for Resident #25 should be provided at the beginning of the shift, after breakfast, and again after lunch. She stated staff should change a resident more frequently if he/she was a heavy wetter. According to the LPN, Resident #25's incontinence care plan was not followed on 06/06/18. Interview with the Assistant Director of Health Services (ADHS), on 06/07/18 at 5:08 PM, revealed she identified Resident #25 as a breakthrough wetter, but did not revise the CNA care sheet to reflect the need for increased incontinent care. The ADHS stated the care plan guided resident care and its purpose was to ensure the best possible outcomes. The ADHS revealed Resident #25's care plan was not followed related to incontinent care. Interview with the Director of Health Services (DHS), on 06/07/18 at 5:10 PM, revealed the purpose of the care plan was to guide quality of care and address resident needs. The DHS stated staff did not follow Resident #25's care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide the necessary services for two (2) of twenty-two (22) residents unable to carry out activities of daily living for grooming and personal hygiene, Residents #25 and #180. Resident #25 was not provided with timely incontinent care. In addition, Resident #180 was observed with overgrown toenails on both feet. The findings include: Review of the facility's policy, Bladder Continence, revised 11/09/17, revealed the facility was to provide measures for a resident who was incontinent to receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The policy revealed residents that were not eligible for a continence program should be assessed regularly to maintain dignity, skin integrity, and a clean/dry condition. 1. Review of Resident #25's clinical record revealed the facility admitted the resident on 01/08/16, with [DIAGNOSES REDACTED]. Review of Resident #25's Quarterly Minimum Data Set (MDS), dated [DATE], revealed he/she required extensive assistance with transfers, toileting, and personal hygiene. Per the MDS, the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) and determined he/she was interviewable. Observation of Resident #25, on 06/05/18 at 8:07 AM, revealed a strong odor of urine in the resident's room and in the corridor at the entrance to the room. Observation, on 06/06/18 at 10:46 AM, revealed Resident #25's pants were wet across his/her abdomen and upper legs. Interview with the resident revealed he/she was soaking wet and needed a change. Review of the Certified Nursing Assistant (CNA) Care Sheet revealed the resident was a check and change for toileting. Interview with CNA #2, on 06/06/18 at 11:02 AM, revealed she toileted residents every one (1) to two (2) hours and last checked Resident #25 for incontinence at around 8:00 AM. The CNA stated it was important to provide incontinent care to ensure residents remained dry and to prevent skin breakdown. Interview, on 06/07/18 at 2:37 PM, with CNA #4 revealed staff should check and change Resident #25 every two (2) hours and as needed. According to the CNA, the resident did not use the call light to notify staff when he/she was incontinent or needed to be changed. CNA #4 stated he checked residents at the beginning of the shift, before and after meals, at bedtime, and again at the end of the shift to keep residents clean and fresh and maintain their dignity. Interview with Licensed Practical Nurse (LPN) #5, on 06/06/18 at 10:39 AM, revealed Resident #25 was not on a toileting schedule and staff should check him/her for incontinence at the beginning of the shift, after breakfast, and again after lunch. According to the LPN, Resident #25 rarely used his/her call light and stated she never noticed a urine odor in the resident's room. Interview with the Assistant Director of Health Services (ADHS), on 06/07/18 at 2:52 PM, revealed staff should check and change residents every two (2) hours. The ADHS stated Resident #25 was a breakthrough wetter and stated she noticed a urine odor in the resident's room. The ADHS stated she instructed the assigned CNA to check and change the resident more frequently, but revealed the CNA care sheet was not revised to reflect the increased frequency of care. She stated it was important to provide incontinent care to ensure residents were comfortable and to prevent potential skin breakdown and urinary tract infections. Interview with the Director of Health Services (DHS), on 06/07/18 at 4:25 PM, revealed she walked the facility several times a day and monitored resident care. The DHS stated she was not aware of any complaints or concerns regarding incontinent care. The Director stated she noticed a musty smell in Resident #25's room today and asked housekeeping to clean the room. 2. The facility did not provide a policy for nail care. Review of the clinical record revealed the facility admitted Resident #180 on 05/28/18. The Nurses Note, dated 05/29/18, revealed the resident's toenails were extremely long and curled under. Observation of Resident #180, on 06/06/18 at 8:15 AM and 06/07/18 at 3:13 PM, revealed the resident's toenails were thick, long, and curled, touching the pads of multiple toes on both feet. The right second toenail was pressed into the big toe. Interview with Resident #180's Family Member, on 06/06/18 at 9:25 AM, revealed Resident #180's toenails were very thick and long. She stated last week, she declined coordination of care for Podiatry when staff offered to make an appointment, but rethought the offer and requested to several staff to have an appointment and transport services set up. She stated she realized the length of the nails would decrease the resident's therapy outcome. Interview with LPN #2, on 06/06/18 at 11:00 AM, revealed Resident #180's Family Member refused nail care services when staff assessed the resident's toenails. She stated she had not readdressed the need for nail care because of the refusal; however, she was aware the length of the nails impeded his/her ambulation and therefore his/her Physical Therapy (PT) services. She further stated there were no pending Podiatry referral requests for the resident. Interview with Resident #180, on 06/06/18 2:29 PM, revealed a request to several staff had been made to set up a Podiatry appointment since the initial refusal of services. The resident stated he/she wore oversized socks and slippers to therapy to compensate for the length of the toenails. Resident #180 stated the length of the toenails were painful and his/her Family Member had told staff they now wanted the toenails trimmed and staff told them the facility would take care of it as soon as possible. The resident stated the request was late last week and over the weekend, and staff had not addressed the request or spoke to them about an appointment. Interview with CNA #4, on 06/07/18 at 2:10 PM, revealed Resident #180 had requested services for his/her toenails last week and he told LPN #2 of the request. He stated Resident #180 often walked on his/her heels because of the long toenails and stated long toenails could delay or impede a resident's therapy. Interview with the Nurse Practitioner, on 06/07/18 at 2:29 PM, revealed Resident #180's rehabilitation potential would be fair if the nail conditions were as described. She stated the nurses were responsible to do assessments and care of the residents' feet. Interview with the Physical Therapist, on 06/07/18 at 2:38 PM, revealed he noted the poor nail conditions and reported to the nurse taking care of Resident #180 of the need for nail care. He stated the resident had been wearing slipper socks for therapy sessions. He stated it was Physical Therapy's responsibility to ensure all residents met their maximum level of independence when they left the facility and Resident #180's nail condition could be an issue with the resident's rehab potential. Interview with LPN #2, on 06/07/18 at 2:53 PM, revealed she had not followed up with Resident #180's toenail care needs. She stated the Podiatry team had been to the facility a few days before Resident #180's admission so she offered to set up an outside appointment with transportation services but the resident's Family Member refused. She stated Resident #180's toenails were a chronic issue and the resident was okay with them prior to admission. She further stated the facility contact person for nail care was the Social Worker. Interview with the Social Services Director, on 06/07/18 at 3:13 PM, revealed Podiatry came to the facility every sixty-two (62) days. She stated she heard about Resident #180's nail condition days after the initial refusal and staff had not approached social services to speak to the family about possible concerns with sending the resident out for podiatry care. She stated staff had not approached her about setting up services after the family and resident rescinded the initial refusal and then changed their mind. She stated it was her job to assist families with any needs while in the facility and to ensure for a safe and complete discharge. Interview with the ADHS, on 06/07/18 at 3:34 PM, revealed she had no knowledge of Resident #180's toenail condition. She stated staff had not informed her of the need for podiatry care, the general condition of the resident's toenails, or the resident's refusal for care. She stated staff was to communicate with her, the DHS, and Social Services any concerns or needs of the residents. She stated the concerns for Resident #180 with toenails in the current condition was infection, falls, and pain. Interview with the DHS, on 06/07/18 at 3:52 PM, revealed she had not met with the resident or family to discuss care or concerns. She stated the length of the resident's toenails was not impacting rehabilitation of the resident; however, she stated the toenails could affect ambulation, become snagged in the carpet and cause a fall, cause skin tears, and make wearing shoes difficult. She stated she supervised the nurses to ensure residents maintained or achieved their goals. Interview with the Administrator, on 06/07/18 at 5:00 PM, revealed the nursing management team was to acquire services for any resident's needs. He stated the DHS monitored for issues, resolved and reported in the team meeting the findings, and implemented care.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure alleged violations involving abuse were investigated and reported to appropriate State Agencies for one (1) of four (4) sampled residents, Resident #4. Resident #4 alleged Certified Resident Care Associate (CRCA) #3 pulled the covers off of him/her during the night, told him/her to spread his/her legs wide open, and touched him/her along the front of his/her brief. The findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation Guidelines, revised 06/27/17, the facility developed and implemented processes, which strived to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. The facility implemented processes in an effort to provide a comfortable and safe environment. The Executive Director and Director of Health Services were responsible for the implementation and ongoing monitoring of abuse standards and procedures. The Executive Director was accountable for investigating and reporting. A written report of the investigative outcome, including resident response and/or condition, conclusions, and actions taken to prevent reoccurrence, would be submitted to the applicable State Agencies within five (5) days. Review of Resident #4's medical record revealed the facility readmitted the resident on 06/26/15, with [DIAGNOSES REDACTED]. Review of Resident #4's annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) and determined the resident interviewable. Review of a Resident Concern Form, dated 06/06/17, revealed Resident #4 and daughter voiced concern over a male CRCA, CRCA #3, that came into the resident's room during the night, went to the resident's bed and told the resident to open his/her legs so he could check to see if he/she was wet. The resident stated he/she was continent and the other staff knew and did not check him/her. Review of Resident #4's quarterly BIMS, dated 07/21/17, revealed the facility assessed the resident with a score of thirteen (13) out of fifteen (15) and determined the resident interviewable. Interview with Resident #4, on 09/12/17 at 1:58 PM, revealed several weeks ago a man came into his/her room in the middle of the night and pulled the covers off him/her. The resident stated he/she pulled the covers back up over his/her body and the male pulled the covers off again really hard and had a mean look on his face. The resident stated the male said he had to see if he/she was wet and put his hand on the resident's brief. The resident stated the man had dark hair and he/she had never seen him before and he was very strange acting. The resident stated the incident was reported to appropriate staff. Interview with CRCA #3, on 09/12/17 at 2:02 PM, revealed he had to check to see if the resident was wet and no one had told him in report that Resident #4 was mostly continent. He stated he could not remember if he introduced himself to the resident. CRCA #3 stated he did not tell the resident to open his/her legs, he asked. Interview with Licensed Practical Nurse (LPN) #1, on 09/12/17 at 1:15 PM, revealed anytime abuse was suspected, the Executive Director and the Director of Health Care Services should be immediately notified and the involved resident should be kept safe. She stated an investigation would be started that included staff and resident interviews and the involved resident would be physically assessed. She stated the staff person accused of the abuse would automatically be sent home, pending outcome of the investigation. Interview with Resident #4's Family Member, via telephone, on 09/13/17 at 8:10 AM, revealed the resident told her a new employee who was gruff looking, came into his/her room, pulled his/her covers off twice, and yelled at the resident to spread his/her legs as far as he/she could, squeezed the brief in the genital area, and then left. The Family Member stated the resident told her that he/she had never seen the person before and he never introduced himself to the resident. The Family Member stated the resident reported the incident to the night nurse. The Family Member stated the resident seemed to be scared because there was a strange man asking the resident to spread his/her legs open. The Family Member continued to state Resident #4 feared retaliation by the facility if there was a complaint voiced. The Family Member stated she thought it would have been nice to hear back from the facility regarding some sort of resolution of the issue. The Family Member stated neither the resident nor she had been informed of the outcome regarding the incident, which occurred on 06/06/17. Continued interview with Resident #4, on 09/13/17 at 9:05 AM, revealed the situation was upsetting to him/her. The resident stated he/she did not recognize the man who came into his/her room and jerked the covers off him/her twice. The resident stated the man told him/her to spread his/her legs wide open because he had to see if he/she was wet. The resident stated staff did not check him/her for incontinence because he/she was no longer incontinent. The resident stated the man never smiled and just looked mean. He/she stated the man told him/her to spread her legs open in such a demanding way that he/she just did it and he felt the front outside of the brief with his hands and left the room without saying another word. The resident went on to state that what scared him/her the most was how rough the man treated him/her. The resident stated he/she shared the incident with a Family Member and both of them together reported the incident to the Director and Assistant Director of Health Services. Interview with CRCA #4, on 09/13/17 at 10:00 AM, revealed she always introduced herself and asked residents for permission to check and change them and honored what the resident requested and reported any deviations to the nurse. Interview with CRCA #5, on 09/13/17 at 10:15 AM, revealed she always asked a resident if it was okay to touch them before touching them. The CRCA stated touching a resident without their consent was invading their privacy and could be abuse and could mentally affect someone. She stated the facility had in-services on abuse frequently. Interview with LPN #3, on 09/13/17 at 10:50 AM, revealed staff had to wake residents for two (2) hour checks, but should wake them up before providing care or else it could startle them. She stated it was very important to investigate resident complaints such as crude remarks or rough handling because if it happened to one resident, it could happen to others. Interview with CRCA #6, on 09/13/17 at 11:10 AM, revealed she always introduced herself to the residents and asked if it was okay to check and change their brief. She stated barging in on a resident could scare them. Interview with the Executive Director, on 09/13/17 at 3:30 PM, revealed all the information given to the Director of Health Services and the Assistant Director of Health Services indicated Resident #4's concern had more to do with customer service rather than abuse. She stated she was unaware of the occurrence until she signed the Resident Concern Form on 07/08/17, thirty-two (32) days after the event occurred. She stated reading the Resident Concern Form during the survey made her feel she should have looked at the case further and perhaps should have investigated more thoroughly. She stated the Director of Health Services did not call her or notify her of the event and she had not contacted the family. She stated the incident involving Resident #4 and CRCA #3 was not reported to the State; therefore, it was not discussed in the Quality Assessment/Performance Improvement Committee meetings. Interview with Social Worker #1, on 09/13/17 at 4:10 PM, revealed she inputted all Resident Concern Forms and had input the form regarding Resident #4's information. She stated if abuse were suspected, she would get involved in the case as soon as possible. She stated nursing had dealt with Resident #4's concern and if they had not, she probably would have asked what was going on. She would have reported it to the State agency within a two (2) hour period. Interview with the Director of Health Services, on 09/13/17 at 4:30 PM, revealed the facility felt like the issue was resolved on the date the Resident Concern Form was filled out (06/06/17). She stated she called the Executive Director that night and told her exactly what the form stated and made sure they had made the right decision. She stated the incident was a customer service issue and if the Executive Director had asked staff to look further into the issue, they would have done so. Interview with the Assistant Director of Health Services, on 09/13/17 at 5:00 PM, revealed Resident #4 and the resident's Family Member walked down to her office on 06/06/17, and she and the Director of Health Services were present in the office. The resident stated he/she wanted them to know that a man came into his/her room during the night. She stated she could not really remember much of what the resident said, but she felt like if that sort of thing had occurred in the facility, a lot more residents would have filed complaints; however, she did not know what residents who were unable to speak for themselves would do.

Based on interview and record review, it was determined the facility failed to maintain a hazard free environment for one (1) of four (4) sampled residents, Resident #2. Interview with Resident #2 and Certified Resident Care Associate (CRCA) #7 revealed staff kept bleach wipes in resident isolation rooms. Resident #2 stated staff instructed him/her to wipe down the bathroom, with the wipes, after use. The findings include: The facility did not provide a policy related to proper storage of biologicals. Review of the Material Safety Data Sheet (MSDS) for PDI Sani-Cloth Bleach Germicidal Disposable Wipes, dated 03/03/11, revealed the product caused moderate eye irritation and to avoid contact with eyes or clothing. Wear protective eyewear when dispensing and using the product. Prolonged or repeated exposure to the skin could cause drying, defatting, and dermatitis. Review of Resident #2's closed clinical record revealed the facility admitted the resident on 07/12/17, with [DIAGNOSES REDACTED]. Review of Resident #2's admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Resident #2's Comprehensive Care Plan, dated 07/19/17, revealed the resident was on contact isolation related to Clostridium Difficile (a contagious bacterium). Pre-Survey Interview with Resident #2, via telephone, on 09/11/17 at 1:40 PM, revealed staff left bleach wipes in his/her bathroom and instructed him/her to use them to wipe down the bathroom, as he/she needed. The resident stated staff never educated him/her on the use of the bleach wipes and he/she believed handling the wipes required the use of gloves. Interview with Registered Nurse #1, on 09/13/17 at 9:45 AM, revealed staff used bleach wipes in resident rooms to clean up spills such as stool. She stated the wipes should not to be kept in the resident's rooms and residents should not be instructed to use the wipes to clean up after themselves. Interview with CRCA #5, on 09/13/17 at 10:15 AM, revealed staff always wore gloves when using bleach wipes. She stated the bleach wipes should not to be stored in the resident rooms at any time, and the facility really stressed that because bleach was a chemical. Interview with CRCA #7, on 09/13/17 at 11:45 AM, revealed bleach wipes were kept in the resident isolation rooms at all times. The CRCA produced a container of bleach wipes to confirm that was the product left in resident isolation rooms. Interview with the Director of Health Services, on 09/13/17 at 12:00 PM, revealed staff was not supposed to store bleach wipes in resident rooms because bleach was a chemical and residents were not to use them or use them to clean up after themselves. Interview with the Executive Director, on 09/13/17 at 3:30 PM, revealed staff should never keep bleach wipes in resident's room because they could be poisonous. She stated she was ultimately responsible for all actions that took place in the facility.

Based on observation, interview, record review, and review of the facility's change in condition forms, it was determined the facility failed to have an effective system to ensure the review and revision of the care plan for one (1) of seven (7) sampled residents (Resident #1) when a change in condition occurred. The facility identified Resident #1 had experienced a change in condition on 02/07/13 and 03/06/13 when the resident was observed to have increased confusion and wandering behaviors. The facility failed to revise the care plan to reflect those changes. On 04/26/13, Resident #1 was witnessed to leave the facility through the main entrance doors. The resident was redirected back into the facility. On 04/27/13, Resident #1 exited the facility without staff knowledge, was discovered by another resident's family member, and was returned to the facility by staff. In addition, the care plan was not revised on 04/26/13 to reflect the elopement that occurred and/or include preventive interventions and Resident #1 eloped again from the facility without staff knowledge on 04/27/13. (Refer to F-323) The facility's failure to ensure the Care Plan was revised to address residents' change in condition, and to include adequate supervision for residents assessed at risk for elopement placed residents at risk for serious harm, injury, impairment or death to a resident. Immediate Jeopardy was identified on 04/30/13 and determined to exist on 04/27/13. An acceptable Allegation of Compliance (AOC) was received on 05/03/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 05/02/13 as alleged, prior to exit on 05/03/13. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Change in Condition Form guidelines, revised January 8, 2008, revealed upon assessment of a resident's change in status, the Nurse shall initiate the Condition Change Form in order to fully reflect and document the nursing process. The care plan update section will be completed in its entirety. If the problem area is a new area, include measurable and time-specific goal(s), and realistic, individualized approaches, and the disciplines who will be involved in the care of the resident. If a problem has already been identified for this resident, check the appropriate box and document the intervention to be added to the current care plan. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/15/12 with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment, dated 11/26/12, revealed the facility had assessed the resident as having a severe cognition impairment with no behaviors observed. The Quarterly MDS Assessment, dated 02/22/13, revealed the resident had no wandering behaviors. Continued review of the clinical record revealed a change in condition form was completed by Licensed Practical Nurse (LPN) #6, on 02/07/13 at 1:30 PM, that revealed Resident #1 had increased confusion, had been wandering for hours at night, and the resident was standing at the window in his/her room, asking to go home. Review of the Nurses' Note, dated for 02/07/13, revealed the facility obtained a urinalysis secondary to the resident's confusion and wandering. The urinalysis was positive and treatment was obtained. Review of the comprehensive care plan, revised on 02/07/13, revealed the care plan addressed the Urinary Tract Infection [MEDICAL CONDITION]; however, the facility failed to revise the care plan to reflect the resident's wandering behaviors. Further review of Resident #1's clinical record revealed on 03/06/13, LPN #6 completed a change in condition form due to the resident's increased confusion, with the resident stating he/she had to pack their clothes and go home. The Nurses' Note, dated 03/06/13 at 9:00 AM, revealed the resident removed an incontinent brief and started walking in the hallway stating he/she was going home. Review of the care plan section on the form revealed nothing had been checked to indicate a care plan had been revised according to the facility's policy. Interview with LPN #6, on 04/30/13 at 3:45 PM, revealed she had completed the change in condition forms dated 02/07/13 and 03/06/13. She stated whenever Resident #1 became more confused and started to wander, it was usually indicative the resident had a UTI. She stated the night shift Nurse had reported to her that on 02/07/13, the resident had wandered for hours in the hallway outside the resident's room and this was a new behavior for Resident #1 because the resident usually stayed in his/her room. On 03/06/13, she was working on the floor when a Certified Nursing Assistant (CNA) came to her and told her the resident had removed his/her clothing from the closet and was saying he/she was going home. Per interview, she went into the room and asked the resident where he/she was going and the resident responded, "packing to go home." LPN #6 stated she did not complete the care plan revision section (on the change in condition form) and usually did not fill out that section. She indicated the forms were reviewed during the morning meetings (Monday-Friday) and during this meeting, the care plan was usually revised. However, review of the comprehensive care plan, dated 02/07/13, revealed only the UTI had been addressed with clinical interventions to treat and prevent UTI's. The resident's new behaviors of wandering, removal of clothing from the closet, and the resident stating he/she wanted to go home had not been addressed on the care plan. Fuether record review revealed on 04/26/13 at 6:00 PM, Resident #1 was observed by staff to exit the facility through the main entrance doors. The Executive Director witnessed the resident leaving and redirected the resident back into the facility. The resident was placed on visual checks every fifteen (15) minutes and a wander guard device was placed on the resident. Further review of the record revealed the resident's care plan was not revised to include the resident's attempt to exit the facility nor any preventive interventions the facility had implemented. On 04/27/13 at 10:10 AM, Resident #1 exited the facility without staff knowledge and was found by a visitor ambulating on a sidewalk, past the facility's parking lot, toward a busy highway. Review of the comprehensive care plan revealed the facility did not revise the care plan to address the resident's wandering behaviors that occurred on 02/07/13 and 03/06/13 or the elopement that occurred on 04/26/13 until after the resident had exited from the facility on 04/27/13. Interview with the Social Service Director, on 04/30/13 at 2:00 PM, revealed she knew Resident #1 well and sometime during the week of 04/22/13 - 04/26/13 the resident was wandering more. She stated the resident normally stayed in his/her room and watched TV (loves Price is Right game show). However, last week (Tuesday, 04/23/13 or Wednesday, 04/24/13) she observed the resident wandering throughout the hallways, on the unit. She stated she was unaware of the change in condition regarding the behaviors exhibited on 02/07/13 and 03/06/13. She stated the only changes that were discussed in the morning stand up meetings was that the resident had a UTI. No behaviors were discussed. Therefore, she did not document in her notes about the wandering behaviors and did not revise the care plan. She stated when the resident exited the building on 04/26/13, the care plan should have been revised to reflect this new behavior of exit seeking and the interventions the facility implemented. Interview with the Director of Nursing Services, on 04/30/13 at 11:00 AM, revealed staff should have completed the care plan section on the Change in Condition form. She stated the care plan should have been revised during the morning meetings and interventions implemented. She stated the staff was focused on the UTI and the clinical aspects and did not consider the behaviors. Although the resident had exhibited wandering behaviors prior to the attempt to exit the building on 04/26/13, she considered the wandering behviors different from exit seeking. Observation of Resident #1, on 04/29/13 at 3:00 PM, revealed the resident sitting in a recliner in his/her room, dressed with a wander guard device pinned to the back of the resident's shirt. Interview with the resident revealed he/she could not answer any questions or converse in conversation. Review of the acceptable Allegation of Compliance (AOC), dated 05/03/13, revealed the facility took the following immediate actions: 1. All residents in the facility were assessed for indicators of elopement risk, wandering, and unsafe wandering, completed on 04/30/13. 2. All residents were reassessed for elopement potential and Care Plans were updated to include staff interventions to manage unsafe wandering and exit seeking behaviors. Four additional residents were identified as elopement risk. These residents were placed on every fifteen (15) minute checks. These checks were also documented on the 24 hour report and CNA assignment sheets. These actions were completed on 04/30/13. 3. Elopement binders on each Nurses' stations were updated, by the Unit Managers on 04/30/13, with residents' photographs and profile information specific to that resident. Specific demographic information was included for each resident who demonstrated unsafe wandering and exit seeking behaviors. 4. A mandatory in-service was provided for all staff on 04/29/13-05/01/13 that included the elopement policy and procedures, missing resident procedure, door alarms, to ensure staff was competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors as well as revision of care plans. The State Survey Agency validated the AOC on 05/03/13 prior to exit as follows: *The State Survey Agency validated through review of the facility's incident/accident reports titled Exit Seeking Circumstance, assessment, and intervention forms, used by the facility to document and identify residents at risk for elopement, that the facility had identified four (4) residents to be at risk for elopement on 04/30/13. Interview, on 05/03/13, with the Director of Nursing Services revealed the facility had reassessed all residents for elopement risk and placed four residents (Residents #4,#5, #6, and #7) on every fifteen (15) minute checks. Validated through observation and review of the documented scheduled checks. *The State Survey Agency validated through record review of the residents identified to be at risk for elopement that the care plans were updated and CNA assignment sheets were updated with patient information. *The State Survey Agency validated through record review of Elopement binders, on the nursing stations, that all residents identified by the facility to be at risk of elopement were documented by photograph, and included documentation of specific behaviors and demographic information. *The State Survey Agency validated through record review and staff sign in sheets for mandatory staff in-services that the appropriate content was provided to ensure staff were competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors as well as revision of care plans. *Interview, on 05/03/13 at 1:35 PM, with the Staff Development Nurse, revealed all staff including himself had attended a mandatory inservice that focused on elopement procedures, missing resident procedures, identification of elopement risks, door alarms, and revision of care plans. *Interviews with the facility staff, on 05/03/13 on TCU-1 at 2:00 PM with RN #1 and CNA #4; on TCU-2 at 2:15 PM with LPN #5; on TCU-3 at 2:05 PM with LPN #4; on 200 unit at 2:10 PM with LPN #1; on Bell unit at 2:25 PM with RN #2, CNA #5, and CNA 6; and, on 300 unit (Derby City) at 2:40 PM with LPN #2 and CNA # 7 revealed they had been in-serviced on the elopement policy and procedure, proper function of the door alarm system, and missing person procedures. The Nurses were in-serviced on the change in condition forms and care plan updates. All the staff had been informed of which residents were on every fifteen (15) minute checks and completion of those forms. All staff had good knowledge of the material presented in the training.

Based on observation, interview, record review, and review of the facility's policy for elopement, facility investigation, and the log for fifteen (15) minute visual checks, it was determined the facility failed to have an effective system to ensure the provision of adequate supervision to prevent accidents for one (1) resident (Resident #1) of seven (7) sampled residents. The facility failed to follow their Elopement Risk Reduction policy in regard to assessing residents' risk factors for elopement and implementing appropriate measures. On 02/07/13 and 03/06/13, Resident #1 exhibited a change in condition related to increased wandering behaviors, increased confusion, and removal of clothing from the closet with verbalization of wanting to go home. The facility failed to identify the potential elopement risk related to the resident's increased wandering and verbalizations of wanting to go home and failed to implement interventions for increased supervision. (Refer to F280) On 04/26/13 at 6:00 PM, Resident #1 was observed to exit the facility through the front entrance. The facility implemented fifteen (15) minute visual checks to monitor the resident's whereabouts; however, record review and staff interview revealed the fifteen (15) minute checks were not completed on 04/27/13 from 6:00 AM-11:00 AM due to a miscommunication between the night shift and day shift staff. On 04/27/13, Resident #1, who had exhibited wandering and exit seeking behaviors, exited the facility without staff knowledge. The resident was last seen by staff at 9:30 AM. The resident was found by a visitor at 10:10 AM, ambulating on a sidewalk, past the facility's parking lot, toward a busy highway with six (6) lanes of traffic. The facility's failure to have an effective system in place to provide supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 04/30/13 and determined to exist on 04/27/13. An acceptable Allegation of Compliance (AOC) was received on 05/03/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 05/02/13, as alleged, prior to exit on 05/03/13. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled Elopement Risk Reduction, revision date of 09/16/11, revealed each resident would be assessed upon admission, monthly, and with a change in condition to determine the supervision required to leave facility grounds. A plan of care would be developed and implemented for each resident identified as having the potential to leave the facility unauthorized, requiring supervision for off ground privileges, or wandering to an unsafe area. An album would be kept at a secure location, known to staff, that contains a photograph and identification information about each resident who may be at risk for elopement. Review of facility's Change in Condition form guidelines, revised January 2008, revealed this form was to be utilized to document the change in the resident's status, physician's response, notification of change, and the care plan updated. The policy instructed the staff to complete the care plan section in its entirety. If a problem area is new, the care plan was to include measurable and time-specific goals. The date on the care plan section must be completed and reflective of the date the care plan update was made. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/15/12 with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment, dated 11/26/12 and the Quarterly MDS Assessment, dated 02/22/13, revealed the facility had assessed the resident as having a severe cognition impairment. Neither MDS assessments identified the resident as having wandering behaviors. Continued review of the clinical record revealed a change in condition form was completed by Licensed Practical Nurse (LPN) #6, on 02/07/13 at 1:30 PM, that revealed the resident was confused, had been wandering for hours at night, and was standing at the window in his/her room, asking to go home. Review of the Nurses' Note, dated for 02/07/13, revealed the facility obtained a urinalysis secondary to the resident's confusion and wandering. On 03/06/13, the same nurse completed a change in condition form due to the resident's increased confusion, with the resident stating he/she had to pack their clothes and go home. The Nurses' Note, dated 03/06/13 at 9:00 AM, revealed the resident removed an incontinent brief and started walking in the hallway stating he/she was going home. Review of the care plan section on the change in condition forms revealed the care plan section had not been checked to indicate a care plan had been revised for either incident. Interview with LPN #6, on 04/30/13 at 3:45 PM, revealed she was the Unit Manager where Resident #1 resided. She revealed she had completed the change in condition forms dated 02/07/13 and 03/06/13. After the nurse reviewed the forms, she stated whenever Resident #1 became more confused and started to wander, it was usually indicative the resident had a Urinary Tract Infection (UTI). She stated the night shift nurse had reported to her that on 02/07/13, the resident had wandered for hours in the hallway outside the resident's room. She indicated this was a new behavior for this resident because the resident usually stayed in his/her room. On 03/06/13, LPN #6 was working as a floor nurse when a Certified Nursing Assistant (CNA) came to her and told her the resident had removed his/her clothing from the closet and was saying he/she was going home. The nurse went into the room and asked the resident where he/she was going and the resident responded, "packing to go home." LPN #6 revealed she had failed to complete the care plan revision section on the change in condition form; however, indicated she did not usually fill out that section. She stated the change in condition forms are reviewed during the morning meetings (Monday-Friday) and the care plans are usually revised if needed. Review of the comprehensive care plan, dated 02/07/13, revealed only the UTI had been addressed with clinical interventions to treat and prevent UTI's. The resident's new behaviors of wandering, removal of clothing from the closet, and the resident stating he/she wanted to go home had not been addressed on the care plan. Review of the record revealed, on 04/26/13 at 6:00 PM, Resident #1 was observed to exit the facility through the main entrance doors. The Executive Director witnessed the resident leaving and redirected the resident back into the facility. The resident was placed on visual checks for every fifteen (15) minutes and a wander guard device was applied. However, review of the log for the fifteen (15) minute checks, dated 04/27/13, revealed no documented evidence the checks were conducted between 6:00 AM through 11:00 AM. Interview with LPN #1, on 04/29/13 at 5:00 PM, revealed she had received the wrong information regarding which resident was to be on the fifteen (15) minute visual checks. She said the night shift nurse had given her another resident's name and that was the resident she was watching, not Resident #1. Review of the facility's incident report revealed the resident was found outside the facility at 10:10 AM, on 04/27/13. Resident #1 exited the facility without staff knowledge and was found by a visitor ambulating on a sidewalk, past the facility's parking lot, toward a busy highway with six (6) lanes of traffic. The resident was assessed to have no injuries. On 04/29/13 at 4:10 PM, an interview with the family members who observed Resident #1 in the parking lot, revealed they (couple) were driving down the driveway to the nursing facility when they had almost reached the parking lot, they saw Resident #1 with his/her walker ambulating alone toward the busy highway. They knew the resident well and knew the resident should not be out alone. They ran into the facility and reported what they saw to the staff. Two staff members went out and retrieved the resident. They stated they had not seen the resident outside alone before, but had over heard staff redirecting the resident often. Interview with CNA #1, on 04/29/13 at 4:30 PM, revealed a family member came into the facility on [DATE] and reported Resident #1 was outside and pointed where. The CNA and a housekeeper ran outside and found the resident at the end of the parking lot. When she asked the resident where he/she was going, the resident replied, "home." The CNA brought the resident back into the building through the Assisted Living facility. CNA #1 stated she asked the resident if those where the doors where he/she had exited the facility and the resident nodded their head to indicate yes. Interview with LPN #1, on 04/29/13 at 5:00 PM, revealed she remembered Resident #1 wandering about the hallways the morning of 04/27/13. She stated after breakfast, the resident would usually stay in his/her room and watch the Price is Right (game show). However, he/she did not the morning of 04/27/13, the day the resident eloped. She stated the resident had been more agitated lately and the resident had tried the Assisted Living door earlier. She redirected the resident away from the door. She revealed the resident would wander when the resident had a UTI; however, the wandering appeared to be worse that day. She stated she was conducting the medication pass and did not see the resident exit the building on 04/27/13. She did not hear any door alarm sound and did not know the resident was missing until the family member reported seeing the resident outside the facility. Interview with CNA #3, on 04/30/13 at 9:00 AM, revealed she was assigned to Resident #1 on 04/27/13. She stated she last saw the resident approximately 9:30 AM when she assisted the resident from the dining room to her/his room. She indicated she had toileted the resident and assisted the resident to sit in a recliner in the resident's room. She then left to assist other residents from the dining room. She stated she did not hear any door alarm sound. She revealed the resident was up and down a lot that day and the resident liked to walk all the time, even in the hallways. This was a new behavior for him/her that started about a month ago. She stated after family visits, the resident would walk the halls searching for them. The resident routinely walked family members to the main entrance and gave them good-bye kisses. CNA #3 stated she was busy with other residents when Resident #1 was found outside. The nurses were suppose to document the visual checks, not the aides. Interview with CNA #2, on 04/30/13 at 10:30 AM, per telephone, revealed she was working the day the resident eloped from the facility. She stated she was not responsible for Resident #1 that day, but had provided care for the resident many times and knew the resident well. She revealed Resident #1 was observed to be wandering in the hallways and stated the resident walked fast and went everywhere. The resident had talked about going home before. Recently, the resident was observed with clothes in his/her hands walking down the hallway saying he/she was going home. CNA #2 observed the resident sitting in the area beside the door that leads to the Assisted Living Facility before. The resident waited until someone opened the door and then the resident grabbed the door and tried to go through to the Assisted Living Facility. When she tried to redirect the resident, he/she got mad at her. She indicated the resident had wandered the hallways before, but it appeared to increase last week. The CNA stated it appeared the resident was waiting for someone to open the door. She just knew the resident left the building through the Assisted Living exit door and when the resident was brought back into the building, the resident had pointed toward the Assisted Living exit door when asked which door he/she had exited. When asked if she had reported the resident had attempted to leave through the Assisted Living exit door, this CNA stated LPN #3 had been present. However, interview with LPN #3, on 04/30/13 at 1:30 PM, revealed the nurse denied she ever saw the resident attempt to go through the door that leads to the Assisted Living Facility. Observation of Resident #1, on 04/29/13 at 3:00 PM, revealed the resident sitting in a recliner in his/her room with a wander guard device pinned to the back of the resident's shirt. Interview with the resident revealed the resident could not answer questions regarding the elopement. The resident's daughter was visiting and interview at this time with the daughter revealed the resident had been at the nursing facility for about five months. She stated whenever the resident had a UTI, the resident became more confused, restless, and would wander. The daughter stated last Wednesday (04/24/13), LPN #1 called her and told the daughter the resident was restless and wandering. The nurse requested the daughter to come to the facility and sit with the resident. She said a facility nurse called again on Thursday, 04/25/13 and reported to the daughter the resident was agitated and wanted to leave the facility. On Friday, 04/26/13, the nursing facility called her and told her she needed to come to the nursing facility and sit with the resident because the resident had attempted to leave the building. On Saturday morning, 04/27/13, the nursing facility called the daughter to informed her the resident had gotten out of the facility. The daughter stated recently the resident appeared to be more determined to get out than before. Interview with the Director of Nursing Services, on 04/29/13 at 3:45 PM, in the presence of the Director of Clinical Operations, revealed she had received a telephone call on Saturday morning from the House Supervisor reporting Resident #1 had gotten out of the building. She stated the resident was observed by another resident's family member to be at the end of the parking lot. She indicated she had just begun the investigation of the incident and had not interviewed all staff working that day. She had spoken with the staff (CNA #1 and a housekeeper) who went outside and brought the resident back into the facility. The resident was assessed and found the resident had not sustained any injuries. The alarm system was checked and it was found to be working properly. She stated the resident was observed to leave the facility on Friday, 04/26/13, through the main entrance doors. The resident was redirected back into the facility and a wander guard alarming device was placed on the resident. In addition, the resident was placed on fifteen (15) minute visual checks. She stated the facility was investigating to determine if the resident exited through the door that leads to the Assisted Living facility because that door was not equipped with a wander guard alarm. She revealed a Mass service was being held in the Assisted Living chapel at the time the resident was found outside. Observation of the door between the Nursing Facility and the Assisted Living Facility, on 04/29/13 at 8:30 AM, revealed the door was located on the unit where Resident #1 resided. The door required a code to the key pad before the door would unlock. This door was not equipped with a wander guard alarm. Observation revealed staff, volunteer, and visitors had the code to the door. Observation through the door revealed the Assisted Living chapel was located about fifty feet from the door. Once inside the Assisted Living Facility, the front entrance doors (unlocked) are located around the corner from the chapel. There are no staff positioned at those exit doors. Through the exit doors, there is a straight pathway to where Resident #1 was found on 04/27/13 by a visitor. Further interview with the Director of Nursing Services and Director of Clinical Operations on 04/30/13 at 11:00 AM, revealed the nursing staff had knowledge the resident became more confused and increased wandering behaviors when the resident was experiencing a UTI. However, they could not say any additional safety measures or increased supervision had been implemented during those times. The Director of Nursing Services said the nursing staff had been focused on treating the UTI and missed the new behavior for Resident #1. When the change in condition forms for 02/07/13 and 03/06/13 were reviewed with the surveyor, they stated the focus had been on the UTI and not the behaviors. In addition, the care plan section had not been completed per policy. The Director of Nursing Services said the staff supervised the resident when the resident was experiencing a UTI, with all eyes on the resident and the staff redirect the resident, but did not answer how often or when. Review of the AOC revealed the facility implemented the following measures: 04/26/13-05/01/13. The immediate actions taken were: 1. The facility performed a physical assessment on Resident #1 and found no injuries. 2. Resident #1 was placed on every fifteen (15) minute visual checks on 04/26/13. 3. A wander guard device was placed on the resident on 04/26/13. 4. An elopement risk assessment was completed for Resident #1 and the resident's picture and profile was placed in the elopement binder on 04/27/13. 5. Resident #1's care plan was revised to address the wandering behaviors on 04/27/13. 6. The Plant Operation Director checked all exit door alarms and found they were operational on 04/27/13. 7. Stop signs were placed on each exit door to notify families and visitors to seek staff assistance before allowing residents out the exit door on 04/26/13. Additional measures taken by the facility were: 8. The code to the affected door (entrance to the Assisted Living Facility from the nursing facility) was changed on 05/01/13. Only staff are allowed to have the code and must input for visitors. All nursing facility residents are to be escorted and remain under supervision during activities conducted in the Assisted Living Facility. 9. All residents were reassessed for elopement potential on 04/30/13 and found there were four (4) additional residents identified as elopement risk. These residents were placed on every fifteen (15) minute visual checks to increase observation. These checks will be communicated between ongoing and outgoing nurses during shift change and then communicated to the nursing aides by the nurse. These checks will be documented on the 24 hour report and CNA assignment sheets. Audits will be performed by the the Unit Manager, Director and Assistant Director of Nursing Services. 10. The care plan for the four residents were revised to include elopement risk on 04/30/13. 11. Pictures of the four (4) residents identified at risk for elopement were placed in the elopement binder located at each nurses station. (Resident #4, #5, #6, and #7) on 04/30/13. 12. Training of staff (all departments) on the elopement policy, alarm policy and procedures, missing resident procedure, and elopement binder was conducted on 04/29/13 through 05/01/13. The nurses were reeducated on the change in condition form and revision of care plan on 05/01/13. 13. A Quality Assurance (QA) meeting was conducted on 05/01/13 with the Medical Director in attendance. All audits will be reviewed during the monthly QA meetings. 14. An Elopement drill was conducted on 04/30/13. Monthly drills will be conducted for the next six (6) months. The State Survey Agency validated the AOC on 05/03/13 prior to exit as follows: *Observation of Resident #1, on 04/29/13 at 3:00 PM, revealed the resident sitting in a recliner with a wander guard device pinned to the resident's top. Review of the treatment record (April and May) revealed the wander guard device had been checked every shift to ensure placement and operational. *Review of the exit seeking risk form completed by the facility on 04/30/13 revealed all residents had been reassessed for elopement risk. The additional four (4) residents identified by the facility to be at elopement risk had individualized care plans developed to address the risk. *Observation of all exit doors (8) with the Plant Operation Director, on 04/30/13 at 8:50 AM, revealed all alarms were operational. Only the main entrance door and the Rehab entrance were equipped with a wander guard alarm system. There was documented evidence the exit alarm doors were checked daily. An elopement drill was performed on 04/30/13 with staff signatures to validate. Observation revealed all exit doors had Stop signs applied to instruct visitors to seek staff assistance before allowing residents out the door. These stop signs were applied prior to initiation of the survey. *Observation and interview validated the code to the Assisted Living door had been changed. Observation, on 05/02/13 at 10:30 AM, revealed the staff put the code into the key pad for visitors and the volunteer was observed to escort residents to and from the Mass church services held in the Assisted Living chapel. Interview with the volunteer revealed she had been instructed to stay with the nursing facility residents during the entire activity and assist them back and forth. *Validated each Nurses' station (6 total) and the front desk had the elopement risk binder with Resident #1, #2, #4, #5, #6 and #7 pictures and profile included. *Review of the every fifteen (15) minute visual checks for the dates of 04/30/13 through 05/03/13 validated the staff had completed the visual checks as scheduled for Residents #1, #3, #5, #6, and #7. Resident #4 was in the hospital. Review of audits conducted on 04/30/13-05/03/13 validated completion. *Validation of staff training 04/29/13-05/01/13 via sign-in roster checked against staffing roster. Validated all staff had been trained by 05/01/13 except for those on vacation, medical leave, or had not worked yet. Validated a PRN (as needed) nurse received training prior to working on 05/02/13. *Interviews with the facility staff, on 05/03/13 on TCU-1 at 2:00 PM with RN #1 and CNA #4; on TCU-2 at 2:15 PM with LPN #5; on TCU-3 at 2:05 PM with LPN #4; on 200 unit at 2:10 PM with LPN #1; on Bell unit at 2:25 PM with RN #2, CNA #5 and CNA #6; and, on 300 unit (Derby City) at 2:40 PM with LPN #2 and CNA #7 revealed they had been in-serviced on the elopement policy and procedure, proper function of the door alarm system, and missing person procedures. The Nurses were in-serviced on the change in condition forms and all had been informed of which residents were on every fifteen (15) minute checks and completion of those forms. All staff had good knowledge of the material presented in the training. *Interview with the Medical Director, on 05/02/13 at 11:00 AM, revealed she had been notified of the elopement and spoke with the Executive Director on 04/30/13, the day the facility was notified of the Immediate Jeopardy. She came to the nursing facility on 05/01/13 for a QA meeting. This was validated by the QA signature sheet. The Medical Director revealed the facility requested her input and she assisted with the development of the AOC. She stated she would be attending monthly QA meetings and would be reviewing audit tools to determine if additional education or actions were required. *Interview with the Executive Director, on 05/03/13 at 3:00 PM, revealed the AOC implementation will continue with morning meetings, audits, and monthly QA meetings to ensure ongoing compliance.

Based on interview, record and policy review, it was determined the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, psychosocial well being for one (Resident #1) of seven (7) sampled residents. The Administration failed to have an effective system to ensure policies and procedures were implemented to provide adequate supervision to prevent accidents related to residents who were identified at risk for elopement/wandering, and care plans were revised to include effective interventions. (Refer to F-280 and F-323). On 04/27/13, Resident #1 exited the facility without staff knowledge. The resident was last seen by staff at 9:30 AM and was found by a visitor at 10:10 AM, ambulating on a sidewalk, past the facility's parking lot, toward a busy highway with six (6) lanes of traffic. The family member recognized the resident and informed facility staff of the resident's location. The resident was returned to the facility and assessed as having sustained no injuries. Interview and record review revealed the facility assessed Resident #1 to have a change in condition due to wandering behaviors, increased confusion, and removal of clothing from the closet with verbalization of a desire to go home on 02/07/13 and 03/06/13. However, the facility failed to reassess Resident #1 for elopement risk and did not revise the care plan to reflect those changes and implement increased supervision for Resident #1. On 04/26/13, Resident #1 was observed to exit the facility through the front entrance and was placed on fifteen (15) minute visual checks and a wander guard bracelet was applied to the resident's right wrist. However, review of the log for the fifteen (15) minute checks revealed no documented evidence the visual checks were completed from 6:00 AM-11:00 AM on 04/27/13, the day the resident eloped from the facility. Staff interviews revealed the 15 minute checks were not conducted during that time because of a miscommunication between the night shift and day shift staff where another resident (not Resident #1) was being monitored. These facility failures resulted in Resident #1 exiting the building on 04/27/13 without staff knowledge. The facility's failure to administer the facility effectively and efficiently, to provide adequate supervision of cognitively impaired individuals with known elopement risk, and failure to implement policy and procedures placed residents with potential elopement risk in a situation that was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 04/30/13 and determined to exist on 04/27/13. An acceptable Allegation of Compliance (AOC) was received on 05/03/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 05/02/13 as alleged, prior to survey exit on 05/03/13. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled "Elopement Risk Reduction", revision date of 09/16/11, revealed each resident would be assessed upon admission, monthly, and with a change in condition to determine the supervision required to leave facility grounds. A plan of care would be developed and implemented for each resident identified as having the potential to leave the facility unauthorized, requiring supervision for off ground privileges, or wandering to an unsafe area. An album would be kept at a secure location, known to staff, that contains a photograph and identification information about each resident who may be at risk for elopement. Review of the facility's policy titled "Change in Condition Form Guidelines", revised January 2008, revealed this form was to be utilized to document the change in the resident's status, physician's response, notification of change, and the care plan updated. The policy instructed the staff to complete the care plan section in its entirety. If a problem area was new, the care plan was to include measurable and time-specific goals. The date on the Care Plan section must be completed and reflective of the date the care plan was updated. Record review and interview revealed the facility completed a change in condition form on 02/07/13 and 03/06/13 when Resident #1 was observed to have increased confusion, wandering behaviors, and with the resident stating she/he had to pack their clothes and go home. However, staff interviews revealed this change in condition/behavior was contributed to the resident's [DIAGNOSES REDACTED]. The facility failed to reassess Resident #1 for elopement risk after the change in condition to determine if supervision was required according to facility policy and failed to revise the resident's comprehensive care plan to address the resident's increased wandering behaviors. On 04/26/13, Resident #1 was observed leaving the facility through the main entrance and was placed on fifteen (15) minute visual checks. However, documentation on the log revealed the facility failed to conduct the 15 minute checks on 04/27/13 from 6:00 AM to 11:00 AM. Staff interview revealed the wrong information was received regarding which resident was to be on the fifteen minute visual checks and the visual checks were conducted on the wrong resident. On 04/27/13 at 10:10 AM, a family member reported Resident #1 was outside ambulating toward a busy highway. The resident had eloped from the facility without staff knowledge and was last seen at 9:30 AM. Interview with the Director of Nursing Services and Director of Clinical Operations, on 04/30/13 at 11:00 AM, revealed oversight had not been provided to ensure the visual checks had been completed on Resident #1. Per interview, nursing staff had knowledge the resident became more confused and increased wandering behaviors when the resident was experiencing a UTI; however, additional safety measures or increased supervision had not been implemented. Review of the AOC revealed the facility implemented the following measures: 04/26/13-05/01/13. The immediate actions taken were: 1. The facility performed a physical assessment on Resident #1 and found no injuries. The resident had been placed on every fifteen (15) minute visual checks and a wander guard device was placed on the resident on 04/26/13. 2. An elopement risk assessment was completed for Resident #1 and the resident's picture and profile was placed in the elopement binder. 04/27/13 3. Resident #1's care plan was revised to address the wandering behaviors. 04/27/13 4. The Plant Operation Director checked all exit door alarms and found they were operational. 04/27/13 5. Stop signs placed on each exit doors to notify families and visitors to seek staff assistance before allowing residents out the exit door. 04/26/13 Additional actions taken were: 6. The code to the affected door (entrance to the Assisted Living Facility from the nursing facility) was changed on 05/01/13. Only staff are allowed to have the code and must input for visitors. All nursing facility residents are to be escorted and remained under supervision during activities conducted in the Assisted Living Facility. 7. All residents were reassessed for elopement potential on 04/30/13 and found there were four (4) additional residents identified as elopement risk. These residents were placed on every fifteen (15) minute visual checks to increase observation. These checks will be communicated between ongoing and outgoing Nurses during shift change and then communicated to the nursing aides by the Nurse. These checks will be documented on the 24 hour report and CNA assignment sheets. Audits will be performed by the the Unit Manager, Director and Assistant Director of Nursing Services. 8. The care plan for the four (4) residents were revised to include elopement risk on 04/30/13. 9. Pictures of the four (4) residents identified at risk for elopement were placed in the elopement binder located at each Nurses' station. (Resident # 4, #5, #6, and #7). 04/30/13 10. Training of staff (all departments) on the elopement policy, alarm policy and procedures, missing resident procedure, and elopement binder was conducted on 04/29/13 through 05/01/13. The Nurses were reeducated on the change in condition form on 05/01/13. 11. A Quality Assurance (QA) meeting was conducted on 05/01/13 with the Medical Director in attendance. All audits will be reviewed during the monthly QA meetings. 12. Elopement drill was conducted on 04/30/13. Monthly drills will be conducted for the next six (6) months. The State Survey Agency validated the AOC on 05/03/13 prior to exit as follows: *Observation of Resident #1, on 04/29/13 at 3:00 PM, revealed the resident sitting in a recliner with a wander guard device pinned to the resident's top. Review of the treatment record (April and May) revealed the wander guard device had been checked every shift to ensure placement and operational. *Review of the exit seeking risk form completed by the facility on 04/30/13 revealed all residents had been reassessed for elopement risk. The additional four (4) residents identified by the facility to be at elopement risk had individualized care plans developed to address the risk. *Observation of all exit doors (8) with the Plant Operation Director, on 04/30/13 at 8:50 AM, revealed all alarms were operational. Only the main entrance door and the Rehab entrance were equipped with a wander guard alarm system. There were documented evidence the exit alarm doors were checked daily. An elopement drill was performed on 04/30/13 with staff signatures to validate. Observation revealed all exit doors have Stop signs applied to instruct visitors to seek staff assistance before allowing residents out the door. These stop signs were applied prior to initiation of the survey. *Through observation and interview validated the code to the Assisted Living door had been changed. Observation, on 05/02/13 at 10:30 AM, revealed the staff put the code into the key pad for visitors and the volunteer was observed to escort residents to and from the Mass church services held in the Assisted Living chapel. Interview with the volunteer revealed she had been instructed to stay with the nursing facility residents during the entire activity and assist them back and forward. *Validated each Nurses' station (6) and the front desk had the elopement risk binder with Resident #1, #2, #4, #5, #6 and #7 pictures and profile included. 05/02/13 *Review of the every fifteen (15) minute visual checks for the dates of 04/30/13 through 05/03/13 validated the staff had completed the visual checks as scheduled for Residents #1, #3, #5, #6, and #7. Resident #4 was in the hospital. Review of audits conducted on 04/30/13-05/03/13 validated completion. *Validation of staff training 04/29/13-05/01/13 via sign-in roster checked against staffing roster. Validated all staff had been trained by 05/01/13 except for those on vacation, medical leave, or had not worked yet. Validated a PRN (as needed) Nurse received training prior to working on 05/02/13. *Interviews with the facility staff, on 05/03/13 on TCU-1 at 2:00 PM with RN #1 and CNA #4; on TCU-2 at 2:15 PM with LPN #5; on TCU-3 at 2:05 PM with LPN #4; on 200 unit at 2:10 PM with LPN #1; on Bell unit at 2:25 PM with RN #2, CNA #5 and CNA #6; and, on 300 unit (Derby City) at 2:40 PM with LPN #2 and CNA #7 revealed they had been in-serviced on the elopement policy and procedure, proper function of the door alarm system, and missing person procedures. The Nurses were in-serviced on the change in condition forms and all had been informed of which residents were on every fifteen (15) minute checks and completion of those forms. All staff had good knowledge of the material presented in the training. *Interview with the Medical Director, on 05/02/13 at 11:00 AM revealed she had been notified of the elopement and spoke with the Executive Director on 04/30/13, the day the facility was notified of the Immediate Jeopardy. She came to the nursing facility on 05/01/13 for a QA meeting. This was validated by the QA signature sheet. The Medical Director revealed the facility requested her input and she assisted with the development of the AOC. She stated she would be attending monthly QA meetings and would be reviewing audit tools to determine if additional education or actions were required. *Validated the Divisional Vice President was in attendance of the QA meeting on 05/01/13 to provide guidance to the related Elopement events, investigation, reviewed the Elopement Policies and Procedures, Condition change forms, and documentation with emphasis on behavioral changes. There were no policy changes. *Interview with the Executive Director, on 05/03/13 at 3:00 PM, revealed the AOC implementation would continue with morning meetings, audits, and monthly QA meetings to ensure ongoing compliance.