Every finding on record at Glencliff Home for the Elderly

Based on interview and record review, it was determined that the facility failed to have an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to improve resident outcomes and reduce antibiotic resistance for a facility census of 63 residents.Findings include:Review on 10/29/25 of the facility's policy titled Antibiotic Stewardship Program, dated April 2025, revealed no antibiotic use protocols and a system to monitor appropriate antibiotic use.Review on 10/29/25 of the facility antibiotic line list for September 2025 revealed that there were 8 residents who were prescribed antibiotics, and there was no evaluation of appropriateness of antibiotic use.Interview on 10/29/2025 at approximately 1:10 p.m. with Staff J (Infection Preventionist) confirmed the above findings. Staff J revealed that he/she does not track or trend appropriate antibiotic use. Staff J was unable to explain a process to determine appropriateness of antibiotic treatments such as utilizing antibiotic use protocols. Further interview revealed Staff J reports total infections to Quality Assurance and Performance Improvement (QAPI) committee.Review on 10/30/2025 of facility's QAPI meeting minutes, dated 10/22/25, revealed only the only infections data reported were total infections treated.Interview on 10/30/2025 at approximately 10:15 a.m. with Staff O (Medical Director) revealed there was no antibiotic use data presented in QAPI or discussion about antibiotic use, such as tracking and trending of appropriateness of antibiotic treatments.

Based on observation, interview and record review, it was determined that the facility failed to ensure that the Infection Preventionist (IP) had the time necessary to properly assess, develop, implement, monitor, and manage the Infection Prevention and Control Program (IPCP) for a facility census of 63 residents.Findings include:Interview on 10/29/2025 at approximately 11:15 a.m. with Staff I (Director of Nursing (DON)) revealed that Staff J (IP) works approximately 7 hours weekly and additionally coordinates resident Minimum Data Set (MDS) Assessments and the QAPI program.Interview on 10/29/2025 at approximately 1:15 p.m. with Staff I (DON) revealed that Staff J (IP) did not work yesterday and was not available by phone. Staff I did not know when Staff J was working this week. Interview on 10/29/25 at approximately 12:30 p.m. with Staff J confirmed the Staff J did not work yesterday and revealed they were available until 1:15 p.m. today. Staff J confirmed that they worked approximately 8 hours a week at the facility. Review on 10/29/25 of Staff J's job description, dated 7/10/19, provided by Staff I, for classification and job position of Registered Nurse III revealed no Infection Prevention Responsibilities.Review on 10/29/25 of the policy titled Overview of the Infection Prevention and Control Program (IPCP), undated, revealed The Infection Preventionist (Infection Preventionist (IP)) is responsible for directing the IPCP. Further review of the policy revealed the major elements of the IPCP included .a system of infection precautions and/or isolation .an employee health program .Antibiotic review .Observation, interview and record review from 10/28/25 to 10/30/25 revealed that the IP failed to direct the IPCP by failing to implement infection control policies for EBP (Cross reference: F880 Infection Prevention & Control); failing to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic appropriateness (Cross reference: F881 Antibiotic Stewardship Program); and failing to educate and offer staff the COVID-19 vaccination (Cross reference: F887 Covid-19 Immunization).

Based on interview and record review, it was determined that the facility failed to ensure that the pharmacist reported any irregularities monthly to the attending physician, the facility's medical director, and the director of nursing for 2 out of 3 months reviewed. (Resident identifiers are #13, #17, #19, #25, and #58). Findings Include:Review on 10/29/25 of the facility's drug regimen reviews (DRR) for the months of August, September, and October 2025 revealed they were not received by the facility until 10/29/25. The DRRs from August and September had the following recommendations: Resident #13's pharmacy recommendations, dated 9/30/25, was to change the Aspirin 81 mg (milligram) EC (Enteric Coated), 4 tabs (324 mg), to one tablet of Aspirin 325 mg tablet to reduce pill burden; Resident #17's pharmacy recommendation, dated 8/31/25, was that Resident #17 had no clinical Atherosclerotic Cardiovascular Disease (ASCVD) medical diagnosis listed for taking Atorvastatin 30 mg daily; Resident #19's pharmacy recommendation dated, 8/31/25, was that Resident #19 had no clinical Atherosclerotic Cardiovascular Disease (ASCVD) medical diagnosis listed for taking Atorvastatin 40 mg daily;Resident #25's pharmacy recommendation, dated 8/31/25, was to specify the minimum time interval between doses for the Hydroxyz [NAME] 25 mg by mouth three times daily as needed for anxiety.Resident #58's pharmacy recommendation, dated 9/12/25, was to add an end date to the Seroquel 100 mg every 8 hours as needed (PRN). Antipsychotic PRN orders cannot exceed a duration of 14 days. Interview on 10/29/25 at approximately 11:00 a.m. with Staff A (Consulting Pharmacist) confirmed the above findings and that he/she did not provide the DRR reports to the facility until 10/29/25. Interview on 10/29/25 at approximately 1:30 p.m. with Staff B (Nurse Practitioner) revealed that he/she had not received or reviewed the August and September 2025 pharmacy recommendations. Review on 10/29/25 of facility's pharmacy contract, dated January 28, 2025 revealed .1.17 The Contractor must complete a Prospective/Concurrent Drug Utilization Review every 30 days of each resident's drug regimen.1.17.3 Submit copies of the completed review, including any irregularities to the Glencliff Home's attending physician, Medical Director, and Director of Nursing within fifteen (15) days from the date of review.

Based on interview and record review it was determined that the facility failed to implement its Enhanced Barrier Protection (EBP) policy for 2 of 3 residents reviewed for EBP. (Resident identifiers are #1 and #56).Findings Include:Resident #1 Review on 10/29/25 of Resident #1's medical record revealed that Resident #1 required EBP for a history of Methicillin-Resistant Staphylococcus Aureus (MRSA), a Multidrug-Resistant Organism (MDRO). Observation on 10/28/25 at approximately 8:30 a.m. on the Gold floor revealed that there was no indication of EBP for Resident #1, such as EBP signage or Personal Protective Equipment (PPE) supplies in their room or outside of the resident's room. Interview on 10/29/25 between 9:05 a.m. to 1:15 p.m. with Staff D (Licensed Nursing Assistant (LNA)), and Staff F (LNA), revealed that there were no resident requiring EBP on the Gold floor. Interview on 10/30/25 at 8:50 a.m. with Staff H (LNA) revealed that when providing care for Resident #1, such as changing linens and resident transfer, Staff H would use gloves and no gown. Resident #56 Review on 10/28/25 of Resident #56's medical record revealed that he/she has a suprapubic catheter in place for a neurogenic bladder diagnosis. Observation on 10/29/25 at approximately 1:00 p.m. at the Gold floor revealed that Resident #56 had a urinary leg bag. Interview on 10/29/25 with Staff I (Director of Nursing) at approximately 11:30 a.m. revealed that a resident with a suprapubic catheter would be on EBP, indicated by EBP signage on the resident's chart, and staff would wear a gown and gloves when performing high contact care such as catheter care. Interview on 10/29/25 at approximately 12:10 p.m. with Staff E (Registered Nurse) revealed that Residents #1 and #56 were on EBP. Review on 10/30/25 of the facility's EBP list revealed that Resident #1 was on the list for an MDRO and Resident #56 was on the list for a superpubic catherter. Review on 10/29/25 of the facilities Infection Prevention Control Manual, reviewed on 7/2025, revealed .EBP's employ targeted gown and glove use in addition to standard precautions and will be used during high contact resident care activities including: dressing, bathing/showering, transferring (except for brief assist in common areas), providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use or wound care . Further review revealed no procedures for who required EBP. Review on 10/30/25 of the CDC website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, revealed, .the MDROs for which the use of EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC but can also include other epidemiologically important MDROs .Additional epidemiologically important MDROs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA) .Precautions .Enhanced Barrier Precautions .Applies to: .All residents with any of the following: .Infection or colonization with an MDRO when Contact Precautions do not apply Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status .PPE used for these situations: .During high-contact resident care activities .Required PPE: .Gloves and gown prior to the high-contact care activity .

Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment determined the amount of time required to fulfill the role of the designated Infection Preventionist (IP).Findings include:Review on 10/29/25 of the facility's Facility Assessment, last reviewed 7/2025, revealed that there was no determination of the time required to fulfill the role of the IP in order to meet the residents' needs.Interview on 10/29/2025 at 12:02 p.m. with Staff M (Deputy Administrator) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to provide staff with education regarding the benefits and potential risks associated with COVID-19 vaccine and failed to offer staff information on obtaining COVID-19 vaccine for 1 of 1 staff reviewed for COVID-19 immunization.Findings include:Review on 10/29/2025 of Staff N's (Medication Nursing Assistant (MNA)) COVID-19 vaccination history revealed 2 prior vaccinations in 2022. The facility was unable to provide evidence that Staff N was provided information on where to obtain COVID-19 vaccines or education regarding COVID-19 vaccines since 2022. Review on 10/29/25 of facility Infection Prevention and Control Manual last review date 7/2025 revealed on page 27 .VACCINATIONS .please see the Center for Disease Control's Adult Vaccination Schedule 2025: https://www.cdc.gov/vaccines/imz-schedules/adult-easyread.htmlInterview on10/29/2025 at approximately 1:10 p.m. with Staff J (Infection Preventionist) confirmed the above policy. Staff J revealed that they do not offer COVID-19 vaccination and no education on the risk and benefits of Covid-19 vaccines to staff.Review on 10/30/25 at Center for Disease Control website https://www.cdc.gov/covid/vaccines/stay-up-to-date.html revealed CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older.

Based on interviews, it was determined that the facility failed to develop a water management program to minimize the risk of Legionella that had the potential to effect the facility census of 67 residents who resided at the facility. Findings include: Interview on 11/7/24 at approximately 9:00 a.m. with Staff B (Maintenance Assistant) revealed that the Staff B was unable to provide the facility water management program. Interview on 11/7/24 at approximately 11:30 a.m. with Staff C (Infectionist Preventionist) revealed that they were not aware of the facility's water management program.

Based on observation, interview, and record review, it was determined that the facility failed to follow the manufacturer's specifications regarding the administration of eye drops for 2 of 2 eye drops observed in 42 medication administration observations (Resident Identifier #20). Findings include: Observation on 11/6/24 at approximately 8:00 a.m. during medication administration for Resident #20 with Staff A (Medication Nursing Assistant (MNA)) revealed that Staff A administered one drop of Brimonidine eye drops to each eye and then proceeded to administer one drop of Lubricant eye drops (brand name omitted) to each eye without spacing out the administration of the two above mentioned eye drops. Review on 11/6/24 of Resident #20's active physician order revealed an order for Brimonidine 0.2 percent (%), one drop in both eyes twice a day for a diagnoses of unspecified glaucoma and an order for a Lubricant eye drop 0.5-0.95 (brand name omitted), one drop ophthalmic [eye] three times a day. Interview on 11/6/24 at approximately 8:05 a.m. with Staff A confirmed that they did not wait and space out the administration of the two eye drops. Review on 11/7/24 of the manufacturer's instructions titled, ALPHAGAN (Brimonidine Tartrate Ophthalmic Solution) 0.2%, revised date of 3/2016, revealed: .If more than one topical ophthalmic product is to be used, the different products should be instilled at least 5 minutes apart .

Based on interview and record review, it was determined that the facility failed to ensure Cardiopulmonary Resuscitation (CPR) policies followed professional standards and failed to document irreversible signs of death for 1 of 2 closed record reviewed (Resident Identifier #67). Findings include: American Heart Association Journals: Circulation, [DATE], Volume 122. Number 18 supply 3, found at https://doi.org/10.1161/CIRCULATIONAHA.110.970905 Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Withholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital Cardiac Arrest (OHCA) Criteria for Not Starting CPR in All OHCA .Basic life support (BLS) training urges all potential rescuers to immediately begin CPR without seeking consent, because any delay in care dramatically decreases the chances of survival. While the general rule is to provide emergency treatment to a victim of cardiac arrest, there are a few exceptions where withholding CPR might be appropriate, as follows: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril, Obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition), A valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNR order . Review on [DATE] of Resident #67's medical record revealed that Resident #67 expired on [DATE]. Further review of Resident #67's medical record revealed Resident #67's advanced directives were to be a Full Code. Review on [DATE] of Resident #67's nurses notes revealed a note dated [DATE], written by Staff F (Licensed Practical Nurse), that stated: .Nurse went to room and noted resident face down on floor with mottling on face, ears, stomach and legs. This nurse checked for a radial pulse and posterior lung sounds and none noted. RN [Registered Nurse] in building notified . Interview on [DATE] at approximately 12:00 p.m. with Staff F revealed that when staff found Resident #67, he/she was laying on his/her right side, but his/her face was facing downward on the floor. Staff F stated that the irreversible signs of death observed were no pulse, no respirations and mottling on his/her left side of the neck going down to the left shoulder and from the left hip down to the left knee and cold to touch. Staff F confirmed that no CPR was initiated. Review on [DATE] of the facility policy titled, Cardiopulmonary Resuscitation (CPR), reviewed/revised ,d+[DATE], revealed: .Purpose: To establish criteria based on the American Heart Association guidelines for not starting CPR on a resident who has a full code status . Any resident in cardiac arrest is to receive cardiopulmonary resuscitation (CPR) unless one of the following criteria have been met and subsequently documented: 1. the resident has a valid DNR order. 2. Physical Assessment of Resident based on American Heart Association Guidelines for irreversible signs of death to include: a. Unresponsiveness b. Apnea c. Absence of pulse d. Absence of heart sounds 3. Presence of Lividity/Rigor mortis or presence of Injuries that are incompatible with life. The nurse will document assessment findings stating any and all signs of irreversible death that are present .

Based on observation, interview, and policy review, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 3 kitchenettes observed. Findings include: Kitchen: Observation on 10/16/2023 at approximately 10:00 a.m. with Staff A (Dietary Manager) revealed the following: Staff F (Dietary Aid) was not wearing a hair restraint while preparing dessert in the bakery room of the kitchen; Dust build up over the hood vent above cooking area. Review on 10/16/23 of the hood vent inspection tag revealed that it was last inspected in February 2023 and was due every 180 days. Interview on 10/16/23 at approximately 10:10 a.m. with Staff A confirmed that inspection was overdue. Review on 10/16/2023 at approximately 10:20 a.m. of dishwasher temperature logs for September 2023 and October 2023 with Staff A revealed no temperatures documented on the following dates: 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/6/23, 9/7/23, 9/8/23, 9/10/23, 9/12/23, 9/13/23, 9/14/23, 9/16/23, 9/17/23, 9/18/23, 9/19/23, 9/20/23, 9/22/23, 9/23/23, 9/25/23, 9/27/23, 9/28/23, 9/29/23, 9/30/23, 10/1/23, 10/2/23, 10/3/23, 10/5/23, 10/5/23, 10/7/23, 10/8/23, 10/9/23, 10/10/23, 10/11/23, 10/12/23, 10/13/23, 10/15/23, 10/16/23 Interview on 10/16/2023 at approximately 10:20 a.m. with Staff A confirmed the above findings. Observation on 10/18/2023 at approximately 11:00 a.m. in the kitchen revealed: Staff G (Dietary Aid) had a long beard with no beard restraint in place while scooping dessert into individual plastic cups; Interview on 10/18/23 at approximately 11:05 a.m. with Staff G confirmed above findings. Policy Review: Review on 10/18/2023 at approximately 1:00 p.m. of policy titled Dress Code revealed: Dietary:While in the kitchen or handling any food employees are to wear hair restraints, such as a hairnet, hat, and/or beard restraint. Rose Unit Kitchenette Observation on 10/16/2023 at approximately 11:00 a.m. with Staff A revealed 3 shakes in the refrigerator with thaw dates of 9/21/23, 9/22/23, and 9/28/23. Interview on 10/16/23 at approximately 11:00 a.m. with Staff A revealed that the date placed on the shakes is the date they are pulled from the freezer. Review on 10/18/2023 of the manufacturer's instructions for Ready Care shakes revealed: After thawing keep refrigerated. Use within 14 days after thawing . 40522

Based on interview and record review, it was determined that the facility failed to establish a monitoring protocol for adverse consequences for residents who use antipsychotic medications for 1 of 4 residents reviewed for unnecessary medications (Resident Identifier is #30). Findings include: Review on 10/18/23 of Resident #30's of the current physician orders in the electronic medical record revealed an order for Abilify 10 milligrams (mg) once a day for Schizophrenia, start date 12/14/22 (antipsychotic medication). Review on 10/18/23 of Resident #30's medical record revealed a Dyskinesia Identification System (DISCUS): Condensed User Scale) assessment, used to identify adverse reactions to antipsychotic medications, was last completed on 1/11/23. Interview on 10/18/23 at 12:40 with Staff C (Assistant Director of Nursing) confirmed the above findings and revealed that a DISCUS should be completed every 6 months for residents on antipsychotic medications. Review on 10/19/23 of the facility's policy on DISCUS Testing Titled: DISCUS Testing .Procedure: 1. Residents with prescribed antipsychotics shall receive a DISCUS rating at least every 6 months .

Based on interview and record review, it was determined that the facility failed to ensure that alleged violation involving abuse were reported to the State Survey Agency (SSA) immediately, but not later than 2 hours after the allegation was made for 3 out of 4 allegations of abuse reviewed (Resident identifiers are #1 and #2). Findings include: Resident #2 Review on 12/27/22 of Resident #2's progress note dated 11/20/22 at 10:13 a.m. revealed the following: [Name omitted] was sleeping in her room when LNA (Licensed Nursing Assistant) staff went in to get her up for the day. They found a male peer lying in her bed spooning her with his pants and her briefs pulled down. The peer's hands were noted to up her shirt. The male peer was asked to leave the room which he complied. She did not give consent for his actions. She cannot recall the incident when interviewed. Call placed to Dr. Wedling, [NAME] and on call guardian [pronoun omitted] informed. Unusual event report completed. Interview on 12/27/22 at approximately 11:00 a.m. with Staff A (Deputy Administrator) revealed that Staff A was notified of the above incident on the morning of 11/20/22. Staff A revealed that the SSA was notified on 11/21/22 which was reported more than 24 hours after the incident occurred involving Resident #2. Resident #1 Review on 12/27/22 of Resident #1's medical record revealed a nurse's note dated 11/25/22, with a time stamp of 1:30 p.m., revealed the following: [Name omitted] came down to dining room and walked up to a female peer sitting at the table. He walked right up to her started rubbing her back and was in her face speaking to her. He was telling her that it was nice she has such a good relationship with another male peer. The female peers face showed she was uncomfortable with it. She did later say to me she was nervous. The male peer who was in a relationship with the female peer became upset and went right up to [Name omitted] and pushed him in the chest and gave him the what for. Staff intervened and everybody went their separate ways. MD [medical doctor], APRN [Advanced Practice Registered Nurse], DON [Director of Nursing], and Administrator notified. Interview on 12/27/22 at approximately 2:25 p.m. with Staff A revealed that they were aware of the incident on 11/25/22 with Resident #2 and did not report this incident to the state agency. 45991

Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations of abuse, neglect, exploitation or mistreatment were thoroughly investigation for 3 of 4 abuse allegations reviewed (Resident Identifiers are #1, #2, #3, and #4). Findings include: Review on 12/27/22 of Resident # 2's medical record revealed a nurse's note dated 11/20/22, with a time stamp of 10:13 a.m. that stated the following: [Name omitted] was sleeping in her room when LNA [Licensed Nursing Assistant] staff went to get her up for the day. They found a male peer lying in her bed spooning' her with his pants and her briefs pulled down. The peer's hands were noted to up [name omitted] shirt. The male peer was asked to leave the room which he complied. [Name omitted] did not give consent for his actions . Further review of Resident #2's medical record revealed a note from the APRN (Advance Practice Registered Nurse) dated 11/21/22, with a time stamp of 2:19 p.m. (greater than 24 hours from above incident) that stated: I am asked to evaluate [name omitted] today after an episode where a male resident was found in her bed yesterday with his pants pulled down and her brief pulled down, in the back, spooning her. In addition his hands were noted to be on her right breast. Examination of the breast show no bruising. Evaluation of the perianal area and posterior vulvar reveals no trauma, including bruising or bleeding, or evidence of penetration of any kind. Assessment: No evidence of trauma s/p [status post] sexual assault . Review on 12/27/22 of Resident #1's medical record revealed the following nurse note dated 11/20/22, with a time stamp of 10:36 a.m.: [Name omitted] was found in a female peer's room spooning her. He pulled down the peer's brief, had her lying on her left side. His pants were pulled down as well. His hands were up her johnny groping her. He was asked to leave the room which he did . Interview on 12/27/22 at approximately 9:50 a.m. with Staff D (Licensed Practical Nurse) revealed that Resident #1 was the peer that entered Resident #2's bed on 11/20/22. Staff D stated that Resident #2 is dependent on staff for all mobility, transfers and care. Review on 12/27/22 of facility investigation for incident dated 11/20/22 involving Resident #1 and Resident #2 revealed that the facility conducted interviews with the nurse who wrote the initial note and notified Deputy Administrator on 11/20/22 and 11/21/22, the APRN on 11/21/22, Resident #1 on 11/21/22 and Resident #2 on 11/21/22. Interview on 12/27/22 at approximately 1:57 p.m. with Staff C (Licensed Nursing Assistant) revealed that on 11/20/22 he/she went into Resident #2's room to provide care and found Resident #1 laying on her left side and appeared to be soundly sleeping. Further observation revealed that Resident #1 was laying behind Resident #2 with his pants down and his hands up Resident #2's shirt fondling Resident #2's breast. The back of Resident #2's briefs were pulled down. Resident #1 was directed to get out of Resident #2's bed. Resident #2 roused from sleep when staff were trying to get Resident #1 out of the bed. Staff C stated that at that time Resident #2 was unaware of the incident that had taken place. Staff C stated that Resident #2 has childlike behaviors and at times will communicate in baby talk. Interview on 12/27/22 at approximately 2:30 p.m. with Staff A (Deputy Administrator) confirmed they were notified on 11/20/22 of the incident and that they initiated their investigation on 11/21/22. Staff A stated they did not speak to the 2 LNA's that found the residents as part of their investigation. Interview on 12/28/22 at approximately 1:30 p.m. with Staff E (Licensed Practical Nurse) revealed that they were the nurse on duty the day of the incident. They stated they immediately called the psychiatric provider, Staff A, and the on call guardian for Resident #2. They stated that Resident #2 was not able to respond to questions when asked at that time. Staff E stated that Resident #2 will have days were she does not communicate at all. Staff E stated that Resident #2 is a childlike resident and is vulnerable. Review on 12/27/22 of Resident #1's medical record revealed a nurse's note dated 11/25/22, with a time stamp of 1:30 p.m., revealed the following: [Name omitted] came down to dining room and walked up to a female peer sitting at the table. He walked right up to her started rubbing her back and was in her face speaking to her. He was telling her that it was nice she has such a good relationship with another male peer. The female peers face showed she was uncomfortable with it. She did later say to me she was nervous. The male peer who was in a relationship with the female peer became upset and went right up to [Name omitted] and pushed him in the chest and gave him the what for. Staff intervened and everybody went their separate ways. MD [medical doctor], APRN [Advanced Practice Registered Nurse], DON [Director of Nursing], and Administrator notified Interview on 12/27/22 at approximately 2:25 p.m. with Staff A revealed that they were aware of the incident on 11/25/22 with Resident #2. Staff A stated that Resident #3 had pushed Resident #1 as they were touching Resident #4 as Resident #4 was uncomfortable with Resident #1's touch. Staff A stated the facility did not have an investigation for this incident and did not report this incident to the state agency. Interview on 12/27/22 at approximately 2:45 p.m. with Resident #3 revealed they did not recall the events of 11/25/22 and that they felt safe and had no issues with other residents. Interview on 12/27/22 at approximately 2:45 p.m. with Resident #4 revealed he/she did not recall the events of 11/25/22 and that they had no issues with any male peer and felt safe in the facility. Review on 12/27/22 at approximately 3:00 p.m. of Resident #3's medical record revealed no indications that an incident had occurred with Resident #1 on 11/25/22. Review on 12/27/22 at approximately 3:00 p.m. of Resident #4's medical record revealed no indications of interactions with Resident #1 on 11/25/22 or witness to interaction with Resident #1 and Resident #3. Interview on 12/27/22 at approximately 3:15 p.m. with Staff confirmed that no notes regarding the incident between Resident #1 and Resident #3 were in Resident #3's medical record. Review on 12/27/22 of the facility policy titled Freedom from Abuse, Neglect, and Exploitation, updated September 2017, revealed .4. Once notified of the incident, the administrator on call or the designated department head shall initiate the investigation in conjunction with the shift supervisor .5. The investigation shall include, but is not limited to: a. obtaining and reviewing an unusual event form. B. obtaining and reviewing reports from supervisors and/or witnesses, when applicable. C. obtaining and reviewing medial reports from the physician, when applicable. D. begin interviewing witnesses to the incident. 6. Upon completion of the above steps, the Administrator on call shall determine whether: a. the evidence does not warrant further investigation and /or disciplinary action. B. There is sufficient evidence to suspect the allegations are founded thus necessitating further investigation and /or disciplinary action .

Based on interview and record review, it was determined that the facility failed to develop and implement policies consistent with regulations for 3 of 4 allegation of abuse reviewed (Resident identifiers are #1 and #2). Findings include: Review on 12/28/22 of Resident #1's medical record revealed a nurse's note dated 11/25/22, with a time stamp of 1:30 p.m., which revealed the following: [Name omitted] came down to dining room and walked up to a female peer sitting at the table. He walked right up to her started rubbing her back and was in her face speaking to her. He was telling her that it was nice she has such a good relationship with another male peer. The female peers face showed she was uncomfortable with it. She did later say to me she was nervous. The male peer who was in a relationship with the female peer became upset and went right up to [Name omitted] and pushed him in the chest and gave him the what for. Staff intervened and everybody went their separate ways. MD [medical doctor], APRN [Advanced Practice Registered Nurse], DON [Director of Nursing], and Administrator notified Interview on 12/28/22 at approximately 2:25 p.m. with Staff A (Deputy Administrator) revealed that they were aware of the above incident. Staff A stated the facility did an investigation for this incident and did not report this incident to the state survey agency. Review on 12/28/22 of Resident # 2's medical record revealed a nurse's note dated 11/20/22, with a time stamp of 10:13 a.m. that stated the following: [Name omitted] was sleeping in her room when LNA [Licensed Nursing Assistant] staff went to get her up for the day. They found a male peer lying in her bed spooning' her with his pants and her briefs pulled down. The peer's hands were noted to up [name omitted] shirt. The male peer was asked to leave the room which he complied. [Name omitted] did not give consent for his actions . Further review of Resident #2's medical record revealed a note from the APRN dated 11/21/22, with a time stamp of 2:19 p.m., which was more than 24 hours after the incident noted above. Interview on 12/27/22 at approximately 2:30 p.m. with Staff A confirmed they were notified on 11/20/22 of the incident and that they reported to the state survey agency on 11/21/22. Staff A confirmed that the APRN did not see the resident until 11/21/22. Staff A confirmed they did not interview the two LNA's who had discovered the 2 residents. Interview on 11/28/22 at approximately 2:30 p.m. with Staff A confirmed that the facility only reports to the state survey agency in the 2 hour time frame if there is abuse with bodily injury. Review on 12/28/22 of the facility policy titled Freedom from Abuse, Neglect, and Exploitation, updated September 2017, revealed .All incidents of suspected abuse or neglect must be immediately reported. (Within 2 hrs [hours] if an event resulted in physical harm, Within 24 hours if no physical harm has been caused) .2. As requested by the Federal Elder Justice Act: Section 1150B establishes two limits for reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion of a crime. A. Serious Bodily Injury- 2 Hour Limit-: if the event causes the reasonable suspicion results in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion. B. All Others- Within 24 Hours: If the event that cause the reasonable suspicion so not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion 4. Once notified of the incident, the administrator on call or the designated department head shall initiate the investigation in conjunction with the shift supervisor .5. The investigation shall include, but is not limited to: a. obtaining and reviewing an unusual event form. B. obtaining and reviewing reports from supervisors and/or witnesses, when applicable. C. obtaining and reviewing medial reports from the physician, when applicable. D. begin interviewing witnesses to the incident. 6. Upon completion of the above steps, the Administrator on call shall determine whether: a. the evidence does not warrant further investigation and /or disciplinary action. B. There is sufficient evidence to suspect the allegations are founded thus necessitating further investigation and /or disciplinary action .

Based on interview and record review, it was determined that the facility failed to ensure that the resident's drug regimen were reviewed by a licensed pharmacist at least once a month and any irregularities noted by the pharmacist during this review is documented in the residents medical record, reviewed by the attending physician, and documented in the resident record what, if any, action has been taken to address the irregularity for 7 of 8 residents reviewed for unnecessary medications out of a final sample of 20. (Resident Identifiers are #8, #18, #21, #37, #43, #55 and #217) Findings include: Resident #43 Review on 10/13/22 of the Consultant Pharmacist's Medication Record Review revealed that Resident #43 no documentation of a licensed pharmacist review of their drug regimen review for the following months in 2022: January, February, May, June, and July. Interview on 10/13/22 at 2:32 p.m. with Staff A (Registered Nurse), confirmed that the Medication Record Reviews for Resident #43 were missing for January, February, May, June and July. Review also revealed that Resident #43 had been at the facility during the months above. Resident #8 Review on 10/13/22 of Resident #8's medical record revealed no documentation of a licensed pharmacist drug regimen review for the month of June 2022. Review also revealed that Resident #8 had been at the facility for the month of June 2022. Resident #18 Review on 10/13/22 of Resident #18's medical record revealed no documentation of a licensed pharmacist drug regimen review for the month of June 2022. Review also revealed that Resident #18 had been at the facility for the month of June 2022. Resident #21 Review on 10/13/22 of Resident #21's medical record revealed no documentation of pharmacist's drug regimen review for June 2022. Review also revealed that Resident #22 had been at the facility for the month of June 2022. Resident #37 Review on 10/13/22 of Resident #37's medical record revealed no documentation of pharmacist's drug regimen review for June 2022. Review also revealed that Resident #37 had been at the facility for the month of June 2022. Interview on 10/13/22 at approximately 2:30 p.m. with Staff A confirmed the above findings for Resident #8, #18, #21, and #37. Resident #55 Review on 10/13/22 of Resident #55's medical record revealed no documentation of a drug regimen review completed by a licensed pharmacist for June 2022 and July 2022. Resident # 217 Review on 10/13/22 of Resident #217's medical record revealed no documentation of drug regimen review completed by a licensed pharmacist for May 2022, June 2022, and July 2022. Interview on 10/13/22 at approximately 1:00 p.m. with Staff A (Registered Nurse) confirmed the above missing information for Resident #55 and Resident #217.

Based on observation, interview, and policy review, it was determined that the facility failed to disposed of expired medications after the expiration date for 1 of 2 medication rooms observed and the facility also failed to secure insulin medications in a locked medication cart for 2 of 3 medication carts observed. Findings include: Observation on 10/11/22 at 8:35 a.m. of the Gold Unit medication room revealed a 2.5 milliliter (ml) vial of [MEDICATION(S)] injectable solution with an expiration date of 09/22 stored with unexpired medications. Interview on 10/11/22 at 8:45 a.m. with Staff F (Registered Nurse) confirmed the above findings. Staff F stated that it should have been removed. Review on 10/13/22 of the facility policy titled, titled Nurse Guidelines Medication with a revised date of 6/22 page 12 Titled Discontinued Medication Disposal or Return And Expired Medications revealed .whenever a medication or treatment (except narcotics and other controlled medications) is discontinued or expired, it is to be returned to the pharmacy where it will be destroyed using their protocol. The 11-7 shift will check for expired medications on a weekly basis and all nurses will follow procedure if they find an expired medication . Observation on 10/12/22 at 3:15 p.m. on the Gold Unit with Staff L (Infection Preventionist) revealed that the Gold Unit insulin medication cart in the common area of the unit had a set of keys attached to the lock of the medication cart. Further observation revealed that the Gold Unit insulin medication cart was left unattended by staff with residents close by and the insulin medication cart was easily opened with the attached set of keys. Interview on 10/12/22 at 3:15 p.m. with Staff L confirmed the above findings. Staff L stated that it is not the practice of the facility. Interview on 10/12/22 at 3:20 p.m. with Staff M (Charge Registered Nurse) confirmed that the keys were present in the lock of the insulin cart and acknowledged that he/she was aware that they were left in the lock. Interview on 10/12/22 at 3:30 p.m. with Staff N (Registered Nurse) confirmed that the keys should never be left in the lock of the medication carts unattended. Review on 10/14/22 of the facility policy and procedure for medication storage Titled: Medication Storage In The Facility revealed .ID1 (Revised date January 2018) Storage of Medications .B .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access .

Based on interview and record review, it was determined that the facility failed to ensure that a resident had adequate supervision and interventions to prevent falls for 1 of 4 residents reviewed for accident hazards. (Resident identifier is #37.) Findings include: Review on 10/12/22 of Resident #37's electronic event log revealed that Resident #37 had falls outside the facility within the facility grounds on 6/25/22 and 9/15/22. Review on 10/12/22 of Resident #37's fall report dated 6/27/22 revealed that Resident #37 was observed to have bruising to left thumb, wrist and forearm which Resident #37 stated that he/she fell outside the facility within facility grounds at night on 6/25/22. Further review of Resident #37's fall report dated 6/27/22 revealed no interventions were used besides monitoring for the bruises. Review also revealed that there was no comprehensive evaluation to identify fall hazards or root cause analysis to implement interventions and ensure that Resident #37 was provided a safe environment and adequate supervision to prevent further falls. Review on 10/12/22 of Resident #37's fall report dated 9/15/22 revealed that Resident #37 self-reported a fall outside the facility. Resident #37 sustained three abrasions to right knee and a bruise to the right upper leg. Further review of the fall, reported dated 9/15/22, revealed that immediate interventions placed were neurological assessments, vital signs, and pain assessment. Review also revealed that there was no comprehensive evaluation to identify fall hazards or root cause analysis to implement interventions and ensure that Resident #37 was provided a safe environment and adequate supervision to prevent further falls. Review on 10/13/22 of Resident #37's fall care plan dated 8/23/22 revealed that Resident #37 was at risk for falls due to [CONDITION(S)] drugs, decreased cognition, and/or deformity of foot. Further review of Resident #37's care plan revealed no interventions to ensure Resident #37 was safe outside the facility building and within facility grounds to prevent further falls. Interview on 10/13/22 at approximately 1:00 p.m. with Staff A (Registered Nurse) confirmed the above findings. Staff A was unable to provide any other documentation of comprehensive evaluations to ensure Resident #37 was safe outside the facility to prevent further falls.

Based on interview and record review, it was determined that the facility failed to ensure that a resident with pressure ulcers had documentation of weekly assessments that contained measurements and description of the pressure ulcer for 2 of 3 residents reviewed for pressure ulcers out of a final sample of 20 residents. (Resident identifiers are #11, and #217.) Findings include: Resident #11 Interview on 10/11/22 at approximately 8:30 a.m. with Staff F (Registered Nurse) revealed that Resident #11 has a pressure ulcer on their left heel. Review on 10/12/22 at approximately 1:23 p.m. of Resident #11's weekly skin assessment form revealed the following for left heel pressure ulcer discovered on 8/25/22 at readmission: 8/25/22 no measurements noted, no pressure stage identified, no odor, pain present and no drainage; 9/15/22 1.5 cm (centimeter) x 1 cm Stage 1, no depth, no drainage, no tunneling, no undermining, no odor, no pain; 9/27/22 4.5 cm x 3.0 cm unstageable, no depth, moderate sanguineous purulent drainage, no tunneling, no undermining, yes odor, questionable pain; 10/5/22 5 cm x 4 cm unstageable, small sanguineous drainage, unable to determine tunneling, odor present, no indication of pain. Interview on 10/12/22 at approximately 1:30 p.m. with Staff K (Wound Nurse) confirmed that Resident #11's pressure ulcer was not assessed and measured the week of 8/29/22, 9/5/22, and 9/19/22. Resident #217 Interview on 10/11/22 at approximately 8:30 a.m. with Staff F revealed that Resident #217 has a pressure ulcer on their left gluteal fold. Review on 10/12/22 at approximately 1:23 p.m. of Resident #217's weekly skin assessment form for left gluteal fold pressure ulcer identified on 7/11/22, revealed the following: 7/11/22 0.5 cm x 0.1 cm pressure ulcer, no depth, no odor, yes pain, no exudates, no tunneling, no undermining; 7/26/22 0.5 cm x 1 cm stage 2, less than 0.1 cm depth, no drainage, no tunneling, no undermining, no odor, pain with touch; 8/2/22 0.5 cm x 1 cm stage 2, less than 0.1 cm depth, scant serousanguineous drainage, no tunneling, no undermining, no odor, pain present; 8/9/22 0.5 cm x 1 cm stage 2, less than 0.1 cm depth, moderate amount of green drainage, no tunneling, no undermining, no odor, pain present; 8/11/22 0.5 cm x 1 cm stage 2, less than 0.1 cm depth, no drainage, no tunneling, no undermining, no odor, no pain; 8/16/22 1.0 cm x 1.5 cm stage 2, less than 0.1 cm depth, scant serous drainage, no tunneling, no undermining, no odor, pain present; 9/6/22 1.0 cm x 1.5 cm stage 2, less than 0.1 cm depth, no drainage, no tunneling, no undermining, no odor, pain present, wound bed dry and light yellow. Interview on 10/12/22 at approximately 1:30 p.m. with Staff K (Wound Nurse) confirmed that Resident #217's pressure ulcer was not assessed and measured the weeks of 7/18/22 and 8/22/22.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that facility-sponsored group and individualized activities were provided to support the resident's physical, mental and psychosocial well-being for 1 of 2 residents reviewed for activities out of a sample of 21 residents and 1 of 3 units observed for activities. (Resident identifier is #11.) Findings include: Gold Unit Observation on 10/11/22 at approximately 10:30 a.m. on the Gold Unit revealed that there were 5 residents in the common area near the nurse's station sitting with the television (TV) on, 1 resident watching the TV, 2 residents were sleeping in broda chairs, 1 resident was not engaging with the TV and talking to themselves, and 1 resident was not facing the TV and staring at the table. Observation on 10/11/22 at approximately 11:00 a.m. on the Gold Unit dining area revealed that there were 4 residents at a table with the TV on, 2 residents were watching TV, 1 resident was staring at the ceiling, and 1 resident trying to get up from a broda chair with repetitive movements and not watching the TV. Observation on 10/11/22 at approximately 2:00 p.m. on the Gold Unit dining area revealed that the TV was on with a news network on. There were residents sitting around the table, 2 residents were not engaging with the TV, and Resident #11 was sleeping in a chair. Review on 10/11/22 of the October 2022 activity calendar revealed that the activity scheduled for Gold Unit 10/11/22 at 1:30 p.m. was a movie. There were no other activities scheduled after 3:00 p.m. Review on 10/12/22 of the October 2022 activity calendar revealed that the activity scheduled for Gold Unit 10/12/22 in the morning was an outside walk. At 1:30 p.m. was canteen. There were no other activities scheduled after 3:00 p.m. Observation on 10/12/22 at approximately 1:30 p.m. in the Gold Unit dining area revealed that the news was on the TV. There were residents sitting around the table. 2 residents were watching the TV and Resident #11 was sleeping in the chair. Interview on 10/13/22 at approximately 10:00 a.m. with Staff A (Registered Nurse) revealed residents in the Gold Unit were residents who had progressed in their mental or cognitive disease and that they were not interviewable. Interview on 10/13/22 at approximately 9:30 a.m. with Staff E (Activity Aide) revealed that due to the facility COVID-19 outbreak they were providing 1:1 visits. Staff E also stated that the activity department was short staffed and limited on what they could do for 3 units. Interview on 10/13/22 at approximately 10:30 a.m. with Staff D (Interim Activity Director) revealed that activity assessments for residents were done initially when they were admitted but Staff D was unaware of any other ongoing activity assessments after admission. Resident #11 Review on 10/12/22 at approximately 2:00 p.m. of Resident #11's activity care plan revealed the following: interventions dated 4/16/20 to allow Resident #11 to express feelings and desires; Inform Resident #11 of upcoming activities by providing a monthly activity calendar; Verbal reminders; Escort and encouragement; and involve Resident #11 with those who have shared interests. Review on 10/13/22 of Resident #11's activity assessments revealed the last activity assessment was on 1/12/22 which stated that Resident #11's daily and activity preferences were snacks between meals, listening to music, spending time outdoors, and doing things with groups of people. Observation on 10/13/22 at approximately 9:00 a.m. revealed Resident #11 to be sleeping in their chair in the dining room with other residents with the news on the television. Review on 10/13/22 at approximately 10:00 a.m. of Resident #11's monthly activities log for the following months revealed: July 2022 Actively participated in beauty parlor 1 day; Sleeping during sensory and visual activity 1 day; Actively participated in outside/walks 1 day. August 2022 Actively participated in sensory and visual activity 1 day; Sleeping during sensory and visual 1 day. September 2022 Actively participated in 4 days of one on one visits; Sleeping during 2 days of one on one visits; Actively participated in 25 days of movie or TV (television). October 2022 Actively participated in 3 days of one on one visits; Actively participated in 1 day of beauty parlor; Actively participated in 12 days of movies or TV. Review on 10/13/22 at approximately 10:15 a.m. of the daily activities calendar for the Gold Unit identified that at 10:00 a.m. there would be Halloween crafts. Observation on 10/13/22 at approximately 10:30 a.m. of Resident #11 revealed Resident #11 to be sitting in their room with the TV on. Review on 10/13/22 of facility policy tilted Activities, revised 4/17, revealed .to provide a complete recreational program for all residents. This program will be ongoing and will be inclusive of evenings and weekends, It will address each individual's preferences to encompass all areas of ones abilities including, but not limited to: Spiritual, Sensory, Social, Physical, and Mental stimulation .daily activities will be scheduled and posed in the facility calendar, as well as posted in each of the resident buildings .

Based on interview and record review, it was determined that the facility failed to ensure that the physician was consulted immediately for the need to alter treatment for 1 of 3 residents reviewed for pressure ulcers in a final sample of 20 residents. (Resident identifier is #63.) Findings include: Review on 10/12/22 of Resident #63's nurse's notes dated 10/1/22 revealed that there were 2 newly identified superficial open areas on Resident #63's right superior aspect of the intergluteal cleft measuring 1 cm (centimeter) in length. Further review of the note dated 10/1/22 revealed .Noted in APRN [Advance Practice Registered Nurse] for provider review and skin sheet completed. Review of Resident #63's medical record revealed no new treatments for the open areas identified on 10/1/22. Interview on 10/13/22 at approximately 12:25 p.m. with Staff F (Registered Nurse) confirmed above findings. Staff F stated that the nurse's note dated 10/1/22 that reference the APRN above meant that the 2 newly identified wounds on 10/1/22 were written in the APRN communication book for the APRN to evaluate on his/her next visit. Review on 10/13/22 at approximately 12:25 p.m. of the APRN communication book noted that the entry for Resident #63's open wounds on 10/1/22 had not been checked off as being evaluated by the APRN. Interview on 10/13/22 at approximately 12:25 p.m. with Staff F revealed Resident #63 had not been evaluated by the provider after identification of open areas on 10/1/22 and no other notification to provider was done besides the written communication by nurse on 10/1/22 in the APRN communication book.

Based on record review, investigation statements, and interview it was determined the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs, administered without indications for use, when 1 resident received medications in error, that resulted in transfer to the emergency room . (Resident identifier is #1.) Findings include: Review on 9/7/11 of Resident # 1's medical record indicates Resident #1 was originally admitted to the nursing facility on 12/2/03 with [DIAGNOSES REDACTED]. Review of Resident #1's MAR (Medication Administration Record) for the month of September 2011 indicates the following medications scheduled for administration at "2000" (800 p.m.), [MEDICATION NAME] 5 mg (milligrams) by mouth, [MEDICATION NAME] 10 mg by mouth, Eskalith 150 mg by mouth, [MEDICATION NAME] 1000 mg by mouth, [MEDICATION NAME] 12.5 mg by mouth, and at "HS" (hour of sleep) [MEDICATION NAME] 100 unit/1 ml (milliliter) give 18 units subcutaneously. Further Review of MAR indicated [REDACTED]. Review on 9/7/11 of medical records "Annual Review Assessment" dated 8/25/11 written by Staff G, MD (Medical Doctor) indicates Resident #'1's hemoglobin A1C (average blood sugar control) is "...running in the 6 to 7 range..." (Per American Diabetes Association, generally indicates estimated average glucose between 126-154) Review on 9/7/11 of "Accused Staff Member's Statement" written by Staff D, LPN on 9/7/11. Staff D admits to administering Resident #1 another resident's medications in the evening of 9/3/11, and failed to report the medication errors. Review on 9/7/11 of Resident #1's nurses notes dated 9/4/11 written by Staff D, indicates Resident #1 experienced symptoms including the onset of persistently elevated blood sugars (e.g. 9/4/11 nursing note documents blood sugar of 438) requiring the use of insulin coverage, persistent and increasing lethargy, and an elevated temperature. Further review of 9/4/11 nurse's notes written by Staff D, indicated Staff D called twice to inform Staff G, MD of Resident #1's persistent symptoms at approximately 4:00 p.m. and 8:00 p.m., resulting in Staff G ordering Resident #1 be transferred to the ER (emergency room ) for evaluation and treatment. During interview on 9/7/11 with Staff B, DON, Staff B revealed that on 9/3/11 at approximately 8:30 p.m., Staff D erroneously administered Resident #1 [MEDICATION NAME] (atypical antipsychotic) 300 mg and [MEDICATION NAME] XR (atypical antipsychotic) 300 mg by mouth. Staff B confirmed Staff D was aware of the medication errors on 9/3/11 and remained silent until the evening of 9/6/11, when Staff D reported the medication errors to Staff E, RN. Staff B also revealed Resident #1 was transferred to the ER (emergency room ) during the evening of 9/4/11. Resident #1 was evaluated at the ER, including a head CT and treated with an antibiotic medication. Staff B revealed the transferring MD and the emergency room staff had no knowledge of the medication errors while attempting to diagnose and treat the cause of Resident #1 symptoms. Review of facility complaint investigator's "Final Report" summary written on 9/8/11 by Staff C, Deputy Administrator, confirmed that Staff D "admitted " to erroneously administering the medications of [MEDICATION NAME] 300 mg and [MEDICATION NAME] XR 300 mg to Resident #1, ordered for Resident #2 at 8:30 p.m. on 9/3/11. Review also confirmed Staff D was aware of the medication errors 15 minutes after the occurrence. Staff D failed to report the errors until the evening of 9/6/11. Staff D continued to work on the evening of 9/4/11 "even though (Staff D) knew the resident was having an adverse reaction to the medications that (Staff D) had erroneously dispensed and that the resident was being sent to the emergency room at ...hospital for evaluation, (Staff D) remained silent placing resident in a life threatening situation." Review of MPR (Medical Prescribing Reference) dated June 2011 indicates [MEDICATION NAME] medication adverse reactions signs and symptoms include, but are not limited to the following: sedation, [MEDICAL CONDITION], and fever. The medication [MEDICATION NAME] XR adverse reaction signs and symptoms include, but are not limited to the following: somnolence, dizziness, and [MEDICAL CONDITION]. Per 9/4/11 nurse's notes Resident #1 exhibited lethargy, increased blood sugars, and fever, which led to an emergency room evaluation with testing including a head CT, and treatment using an antibiotic.

Based on facility document review, medical record review, review of facilities policies and procedures and staff interview, the facility failed to ensure the professional standards of practice were followed during administration of medications to 1 resident resulting in medication errors, with a delay in reporting, and requiring a transfer to the emergency room for evaluation and treatment. (Resident identifier is #1.) Findings include: Reference for the professional standard of practice to ensure safe medication administration is the " Fundamentals of Nursing, Potter-Perry ", 6 th Edition, page 841 - 843. This standard refers to the six rights of medication administration and states the following, "All medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time and 6. The right documentation." Review of facility policy 6.0 "General Dose Preparation and Medication Administration" dated December 2006, indicates the following: Under " PROCEDURE " 2.2 "Facility staff should only prepare medications for one resident at a time." 2.6 "Facility staff should verify that the medication name and dose are correct .." 3.1 "Facility staff should verify each time a medication is administered that it is the correct drug, the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident" Review of facility Medication Administration Manual with revision date of 4/11, under "Medication Errors" "Procedure" a. "If the resident was given the wrong medication or the wrong dosage of the prescribed medication, the MD/APRN is to be notified and appropriate action taken per MD/APRN" Review on 9/7/11 of Resident #1's MAR (Medication Administration Record) for the month of September 2011 indicates the following medications scheduled for administration at "2000" (800 p.m.), [MEDICATION NAME] 5 mg (milligrams) by mouth, [MEDICATION NAME] 10 mg by mouth, Eskalith 150 mg by mouth, [MEDICATION NAME] 1000 mg by mouth, [MEDICATION NAME] 12.5 mg by mouth, and at "HS" (hour of sleep) [MEDICATION NAME] 100 unit/1ml (milliliter) give 18 units subcutaneously. Further review of MAR indicated [REDACTED]. Review on 9/7/11 of medical records "Annual Review Assessment" dated 8/25/11 written by Staff G, MD (Medical Doctor) indicates Resident #1 hemoglobin A1C (average blood sugar control) is "...running in the 6 to 7 range..." (Per American Diabetes Association, generally indicates estimated average glucose between 126-154) Review on 9/7/11 of "Accused Staff Member's Statement" written by Staff D, LPN on 9/7/11. Staff D reveals administering Resident #1 another resident's medications on 9/3/11 in the evening, recognized the errors, and failed to report the medication errors. During interview on 9/7/11 with Staff B, DON, Staff B revealed that at approximately 8:30 p.m. on 9/3/11, Staff D erroneously administered Resident #1 [MEDICATION NAME] (atypical antipsychotic) 300 mg and [MEDICATION NAME] XR (atypical antipsychotic) 300 mg ordered for Resident #2. Staff B revealed Staff D was aware of the medication errors on 9/3/11 and remained silent until the evening of 9/6/11, when Staff D reported the medication errors to Staff E, RN. Staff B also revealed Resident #1 was transferred to the ER (emergency room ) in the evening of 9/4/11 and was evaluated, to include a head CT and treated with an antibiotic medication. Staff B revealed the transferring MD and the emergency room staff had no knowledge of the medication errors while attempting to determine and treat the cause of Resident #1 symptoms. Review of facility complaint investigator's "Final Report" summary written on 9/8/11 by Staff C, Deputy Administrator, confirmed that Staff D "admitted " to erroneously administering the medications of [MEDICATION NAME] 300 mg and [MEDICATION NAME] XR 300 mg to Resident #1, ordered for Resident #2 at 8:30 p.m. on 9/3/11. Review also confirmed Staff D was aware of the medication errors 15 minutes after the occurrence. Staff D failed to report the errors until the evening of 9/6/11. Staff D continued to work on the evening of 9/4/11 "even though (Staff D) knew the resident was having an adverse reaction to the medications that (Staff D) had erroneously dispensed and that the resident was being sent to the emergency room at...hospital for evaluation, (Staff D) remained silent placing resident in a life threatening situation." Further review of the investigator's report reveals Staff D also admitted to pre-pouring the medications in advance. Cross Refer F329 and F333

Based on record review and interview the facility failed to immediately consult with the physician and inform a resident's legal representative after 1 resident was given another resident's medications resulting in transfer to the emergency room . (Resident identifier is: #1.) Findings include: Review on 9/7/11 of "Accused Staff Member ' s Statement" written by Staff D, LPN on 9/7/11. Staff D admits to administering Resident #1 another resident ' s medications in the evening of 9/3/11, "realized this after giving the medication" and failed to report the medication errors. During interview on 9/7/11 with Staff B, DON, Staff B revealed that on 9/3/11 at approximately 8:30 p.m., Staff D erroneously administered Resident #1 [MEDICATION NAME](atypical antipsychotic) 300 mg and [MEDICATION NAME] XR (atypical antipsychotic) 300 mg by mouth. Staff B revealed Staff D was aware of the medication errors on 9/3/11 and remained silent until the evening of 9/6/11, when Staff D reported the medication errors to Staff E, RN. Staff B also confirmed Resident #1 was transferred to the ER (emergency room ) during the evening of 9/4/11. Resident #1 was evaluated at the ER, to include a head CT and treated with an antibiotic medication. Staff B also revealed the transferring MD and the emergency room staff had no knowledge of the medication errors while attempting to diagnose and treat the cause of Resident #1 symptoms. Review of Resident #1's medical record on 9/7/11 revealed that on 9/4/11 at 8 p.m. a nurses' note was written by Staff D, LPN, that Resident #1 was not able to stand by self, "very lethargic, open eyes but then goes back to sleep". Call to Staff G, MD, and new order to send to local emergency department. Guardian on call notified that Resident #1 was sent to local emergency room . Resident #1 in bed at this time and slurred speech is noted. Staff D called the local emergency room and gave a report of Resident #1's symptoms. Staff D failed to report to Staff G, Resident #1's Guardian and the emergency room staff of the medication errors on 9/3/11. Review of facility complaint investigator's "Final Report" summary written on 9/8/11 by Staff C, Deputy Administrator, confirmed that Staff D "admitted " to erroneously administering the medications of [MEDICATION NAME] 300 mg and [MEDICATION NAME] XR 300 mg to Resident #1, ordered for Resident #2 at 8:30 p.m. on 9/3/11. Review also confirmed Staff D was aware of the medication errors 15 minutes after the occurrence. Staff D failed to report the errors until the evening of 9/6/11. Staff D continued to work on the evening of 9/4/11 "even though (Staff D) knew the resident was having an adverse reaction to the medications that (Staff D) had erroneously dispensed and that the resident was being sent to the emergency room at...hospital for evaluation, (Staff D) remained silent placing resident in a life threatening situation." During interview on 9/7/11 with Staff A, Administrator and Staff B, Deputy Administrator confirmed that Staff D had made a medication errors on 9/3/11 and did not follow the facility policy to consult with Resident #1's physician or inform the Guardian.

Based on, record review, review of facility documentation and interviews the facility failed to ensure that a resident is free of any significant medication errors for 1 resident resulting in an adverse reaction requiring transport to the emergency room for evaluation and treatment. (Resident Identifier is #1.) Findings include: Review on 9/7/11 of Resident # 1's medical record indicates Resident #1 was originally admitted to the nursing facility on 12/2/03 with [DIAGNOSES REDACTED]. Review of Resident #1's MAR (Medication Administration Record) for the month of September 2011 indicates the following medications scheduled for administration at "2000" (800 p.m.), [MEDICATION NAME] 5 mg (milligrams) by mouth, [MEDICATION NAME] 10 mg by mouth, Eskalith 150 mg by mouth, [MEDICATION NAME] 1000 mg by mouth, [MEDICATION NAME] 12.5 mg by mouth, and at "HS" (hour of sleep) [MEDICATION NAME] 100 unit/1ml(milliliter) give 18 units subcutaneously. Further Review of MAR indicated [REDACTED]. Review on 9/7/11 of medical records "Annual Review Assessment" dated 8/25/11 written by Staff G, MD (Medical Doctor) indicates Resident #'1's hemoglobin A1C (average blood sugar control) is "...running in the 6 to 7 range..." (Per American Diabetes Association, generally indicates estimated average glucose between 126-154) Review on 9/7/11 of "Accused Staff Member's Statement" written by Staff D, LPN on 9/7/11. Staff D admits to administering Resident #1 another resident's medications in the evening of 9/3/11, and failed to report the medication errors. Review on 9/7/11 of Resident #1's nurses notes dated 9/4/11 written by Staff D, indicates Resident #1 experienced symptoms including the onset of persistently elevated blood sugars (e.g. 9/4/11 nursing note documents blood sugar of 438) requiring the use of insulin coverage, persistent and increasing lethargy, and an elevated temperature. Further review of 9/4/11 nurse's notes written by Staff D, indicated Staff D called twice to inform Staff G, MD of Resident #1's persistent symptoms at approximately 4:00 p.m. and 8:00 p.m., resulting in Staff G ordering Resident #1 be transferred to the ER (emergency room ) for evaluation and treatment. During interview on 9/7/11 with Staff B, DON, Staff B revealed that on 9/3/11 at approximately 8:30 p.m., Staff D erroneously administered Resident #1 [MEDICATION NAME] (atypical antipsychotic) 300 mg and [MEDICATION NAME] XR (atypical antipsychotic) 300 mg by mouth. Staff B confirmed Staff D was aware of the medication errors on 9/3/11 and remained silent until the evening of 9/6/11, when Staff D reported the medication errors to Staff E, RN. Staff B also confirmed Resident #1 was transferred to the ER during the evening of 9/4/11. Resident #1 was evaluated at the ER, including a head CT and treated with an antibiotic medication. Staff B revealed the transferring MD and the emergency room staff had no knowledge of the medication errors, or it's possible impact, while attempting to diagnose and treat the cause of Resident #1 symptoms. Review of facility complaint investigator's "Final Report" summary written on 9/8/11 by Staff C, Deputy Administrator, confirmed that Staff D "admitted " to erroneously administering the medications of [MEDICATION NAME] 300 mg and [MEDICATION NAME] XR 300 mg to Resident #1, ordered for Resident #2 at 8:30 p.m. on 9/3/11. Review also confirmed Staff D was aware of the medication errors 15 minutes after the occurrence. Staff D failed to report the errors until the evening of 9/6/11. Staff D continued to work on the evening of 9/4/11 "even though (Staff D) knew the resident was having an adverse reaction to the medications that (Staff D) had erroneously dispensed and that the resident was being sent to the emergency room at ...hospital for evaluation, (Staff D) remained silent placing resident in a life threatening situation."

Based on record review and interview the facility failed to ensure that it develops and implements policies and procedures to prohibit the neglect of residents that are at risk of elopement receive the necessary supervision to prevent exiting the building that resulted in numerous fractures for 1 resident who expired as a result of the injuries (Resident #1), 1 resident observed exiting the building without supervision (Resident#4) and the potential for 21 other residents with secure care anklets to exit the building without supervision. Resident identifiers are: #1, #2, #4, #5, Findings include: Review of Resident #1's medical record on [DATE] reveals that Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 has a guardian. Review of the nurse's note dated [DATE], written by Staff I, RN reveals that Resident #1 exited the Gold floor to Gazebo area twice this evening; a secure care alarm was added to wheel chair. The guardian emailed. Secure Care added to the plan of care. Review of Resident #1's Care Plan indicates problem area of cognitive loss related to Resident #1 [DIAGNOSES REDACTED]. Under the approach section on [DATE] a secure care alarm was applied to wheelchair for resident's safety per facility's policy. Review on [DATE] of the Anklet Alarm Policy with a reviewed/revised date of [DATE] indicates the guideline is that all residents will be assessed for the need of a secure care anklet. A physician's orders [REDACTED]. Resident #1's medical record revealed no documented evidence that an assessment form was done for Resident #1. Interview on [DATE], with Staff B, DON and Staff D, LPN, License Practical Nurse indicated that the facility does not have a policy to indicate how to determine residents that are at risk for elopement or elopement assessment tool. The facility has a policy for missing or lost residents. Staff B indicated there is no documentation tool on how a resident is determined to be an elopement risk it depends on their cognitive status and if there has been a history of exit seeking and then a care plan is completed for secure care anklet placement. Staff B and D confirmed that on [DATE] a secured alarm was placed on Resident #1's wheelchair neither Staff B or D was aware of why the alarm was place on the wheelchair. Review of a facility fall report for Resident #1 dated [DATE] indicates that at 7:20 p.m. an unwitnessed fall occurred with Resident #1 found lying on right side in fetal position at the base of the gazebo steps. Contacted the medical doctor and guardian. Resident #1 moved with slide board and 6 staff members to facility stretcher. Review of Nurses' note written on [DATE] by Staff I indicates that at 7:20 p.m. Resident #1 " was found lying on right side with knees drawn towards chest and arms cradled to chest. Participated as able with assessment ...was able to move actively move bilateral lower extremities. Movement of left upper extremities halted due to expressed pain of "my pain". Viewing indicated area no recent abnormalities of structure noted resident indicated increased discomfort when hand was placed on left shoulder blade." Review of a nurse's note dated [DATE] by Staff I, indicates 7:20 p.m. late entry at 7:50 p.m. Resident #1 fall, was found at base of Gazebo porch steps. When the resident was asked where Resident #1 was going the response was "who the hell knows." Resident #1 transported to hospital via ambulance. Review of a nurse's note dated [DATE] at 10:00 p.m., indicates the local hospital called to report that Resident #1 was admitted . Review of the hospital diagnostic imaging report dated [DATE] indicates Resident #1 with acute fractures of the left 1 thru 10th ribs, left scapula, left clavicle and the right 1st through 5th ribs. On [DATE] a report was received at the State Agency from the Assistant Deputy Medical Examiner indicating that Resident #1 expired at 6:10 a.m. on [DATE]. Review of the death certificate for Resident #1 reveals the immediate cause of death is [MEDICATION NAME] chest trauma with multiple bilateral rib fractures. The death certificate also indicates that decedent fell down stairs in a wheelchair while exiting a building. The Certificate was certified and signed [DATE]. Further review of facility documentation on [DATE] reveals that Staff I, RN Evening Nurse Coordinator on [DATE] indicated that Resident #1 had his wheelchair beside him on the ground tipped over. Resident #2 alerted nursing staff of Resident #1's fall and that it may have been Resident #2 who pressed the red button to reenter the unit and inadvertently let Resident #1 out. Staff H, LNA indicated to Staff I that here was no alarm that sounded and that Staff H and Staff E, maintenance checked the door alarm with Staff E adjusting the pug in for it as it apparently loosens when the door is slammed. Observation on [DATE] with Staff B, RN DON of the area outside where Resident #1 was found reveals a door that is monitored by secure care for residents with an anklet who are determined to be at risk for elopement otherwise the door opens freely and exits outside to an area that has a wooden porch leading to 4 cement steps exiting to the main driveway. If a resident turns to the right as exiting the door the resident will head towards the gazebo where smoking is allowed. Outside the door is a red button that when pushed allows residents with secure bracelets on to exit/enter the building without sounding the alarm. There is also a keypad on the inside that requires a code to be entered to allow a resident to exit/enter the building without sounding the alarm. During an interview on [DATE] with Staff E, Staff E indicated that Resident #1 was always trying to get outside and was always asking staff to take outside. Staff E indicated that all the transformers plugs were checked to ensure all were tightly plugged in and working. During an interview on [DATE] with Staff H, LNA Staff H indicated that Resident #1 was always trying to get outside. On the evening of [DATE] Staff H indicated that Resident #2 came in from the outside and asked for a cigarette and then stated that someone was on the ground outside. At first glance outside the door Staff H could not see anyone and asked "Are you sure?" and Resident #2 said "yes." That is when Staff H noticed Resident #1 at the bottom of the steps. Staff H indicated that no alarm had sounded from the door. Staff H stated that Resident #2 is known to push the red button outside the door to let other residents access the smoking area of the gazebo. The red button allows overriding the system that magnetizes the door shut and sounds the alarm if the door is opened. Staff H indicated that Resident #2 stated letting someone out but did not know whom. Staff H also indicated that there are other residents who know about pushing the red button because they "copy what they see." Observation on [DATE] at 1:10 p.m. on the gold unit Resident #4 is observed with a secure care anklet on right ankle. Resident #4 is ambulating independently heading towards the exit door to the gazebo area with Resident #5 is ambulating independently and has no secure care anklet is also heading toward the exit door to the gazebo area. Resident #4 stops about four feet from the door and asks Resident #5 "would you push the button for me?" Resident #5 is observed to open the door and press the red button located outside the door and holds it while Resident #4 exits outside the door without the alarm sounding. Resident #4 and #5 are observed to go sit in the gazebo with one other resident present and no staff present. Twenty minutes later staff arrives bringing other residents out to the gazebo area for their scheduled supervised smoking. Review of Resident #4's medical record reveals an Annual Review dated [DATE] by the physician which indicates that in June of 2010 Resident #4 eloped outside to the doctors cottage which is located nearby on the grounds and also was frequently seen walking down the road so an ankle alarm was placed. Resident #4's care plan reveals no documented evidence of a care plan for elopement risk or the application of the secure care to right ankle.

Based on facility document, medical record review, review of facilities policies and procedures and staff interviews, the facility failed to ensure that it implements the policy and procedures to prohibit neglect of a resident being administered medications that resulted in 1 resident with significant medication errors, which the staff member failed to report for 3 days, requiring transfer to a hospital emergency room . (Resident identifier is #1.) Findings include: Review of facility policy 6.0 " General Dose Preparation and Medication Administration" dated December 2006, indicates the following: Under "PROCEDURE" 2.2. "Facility staff should only prepare medications for one resident at a time." 2.6 "Facility staff should verify that the medication name and dose are correct ..." 3.1 "Facility staff should verify each time a medication is administered that it is the correct drug, the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident" Review of facility Medication Administration Manual with revision date of 4/11, under "Medication Errors" "Procedure" a. "If the resident was given the wrong medication or the wrong dosage of the prescribed medication, the MD/APRN is to be notified and appropriate action taken per MD/APRN" Review of Resident #1 ' s MAR (Medication Administration Record) for the month of September 2011 indicates the following medications scheduled for administration at " 2000 " (800 p.m.), [MEDICATION NAME] 5 mg (milligrams) by mouth, [MEDICATION NAME] 10 mg by mouth, Eskalith 150 mg by mouth, [MEDICATION NAME] 1000 mg by mouth, [MEDICATION NAME] 12.5 mg by mouth, and at "HS" (hour of sleep) [MEDICATION NAME] 100 unit/1ml(milliliter) give 18 units subcutaneously. Further review of MAR indicated [REDACTED]. Review on 9/7/11 of medical records "Annual Review Assessment" dated 8/25/11 written by Staff G, MD (Medical Doctor) indicates Resident #'1's hemoglobin A1C (average blood sugar control) is "...running in the 6 to 7 range..." (Per American Diabetes Association, generally indicates estimated average glucose between 126-154) Review on 9/7/11 of "Accused Staff Member's Statement" written by Staff D, LPN on 9/7/11. Staff D admits to administering Resident #1 another resident's medications in the evening of 9/3/11, and failed to report the medication errors. Review on 9/7/11 of Resident #1's nurses notes dated 9/4/11 written by Staff D, indicates Resident #1 experienced symptoms including the onset of persistently elevated blood sugars (e.g. 9/4/11 nursing note documents blood sugar of 438) requiring the use of insulin coverage, persistent and increasing lethargy, and an elevated temperature. Further review of 9/4/11 nurse's notes written by Staff D, indicated Staff D called twice to inform Staff G, MD of Resident #1's persistent symptoms at approximately 4:00 p.m. and 8:00 p.m. Resulting in Staff G ordering Resident #1 be transferred to the ER (emergency room ) for evaluation and treatment. During interview on 9/7/11 with Staff B, DON, Staff B revealed that on 9/3/11 at approximately 8:30 p.m., Staff D erroneously administered Resident #1 [MEDICATION NAME] (atypical antipsychotic) 300 mg and [MEDICATION NAME] XR (atypical antipsychotic) 300 mg by mouth, which were ordered for Resident #2. Staff B revealed that Resident #2 received his/her regularly scheduled medications on 9/3/11. Staff B revealed Staff D was aware of the medication errors on 9/3/11 and remained silent until the evening of 9/6/11, when Staff D reported the medication errors to Staff E, RN. Staff B also confirmed Resident #1 was transferred to the ER (emergency room ) during the evening of 9/4/11. Resident #1 was evaluated at the ER, including a head CT, and treated with an antibiotic medication then was. Staff B revealed the transferring MD and the emergency room staff had no knowledge of the medication errors while attempting to diagnose and treat the cause of Resident #1's symptoms. Review of facility complaint investigator's "Final Report" summary written on 9/8/11 by Staff C, Deputy Administrator, confirmed that Staff D "admitted " to erroneously administering the medications of [MEDICATION NAME] 300 mg and [MEDICATION NAME] XR 300 mg to Resident #1, ordered for Resident #2 at 8:30 p.m. on 9/3/11. Review also confirmed Staff D was aware of the medication errors 15 minutes after the occurrence. Staff D failed to report the errors until the evening of 9/6/11. Staff D continued to work on the evening of 9/4/11 "even though (Staff D) knew the resident was having an adverse reaction to the medications that (Staff D) had erroneously dispensed and that the resident was being sent to the emergency room at ...hospital for evaluation, (Staff D) remained silent placing resident in a life threatening situation." Further review of the investigator's report reveals Staff D also admitted to pre-pouring the medications in advance.

Based on observation, record review, review of the facility policy and procedures, review of facility incident reports and staff interview the facility: (1)- Failed to ensure the safety of residents identified at risk for exit seeking by preventing the residents with a secure care anklet from exiting the building that resulted in numerous fractures for 1 resident who expired as a result of the injuries, 1 resident observed exiting the building without supervision and the potential for 21 other residents with secure care anklets to exit the building without supervision. Resident identifiers are: #1, #2, #4, #5, (2)- Failed to maintain the physical environment in a manner that protects residents from hazards. Findings include: (1) Review of Resident #1's medical record on [DATE] reveals that Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 has a Guardian. Review of the nurse's note dated [DATE] written by Staff I, RN reveals that Resident #1 exited the Gold floor to Gazebo times two this evening; secure care alarm added to wheel chair. Guardian emailed. Added to plan of care. Review of Resident #1's Care Plan indicates problem area of cognitive loss related to Resident #1 [DIAGNOSES REDACTED]. Under the approach section on [DATE] a secure care alarm was applied to wheelchair for resident's safety per facility's policy. Review on [DATE] of the Anklet Alarm Policy with a reviewed/revised date of [DATE] indicates the guideline is that all residents will be assessed for the need of a secure care anklet. A physician's order will be obtained. Under the section labeled Procedure: if a resident is considered an elopement risk, or exhibits unsafe wandering behaviors the resident will be reviewed for the need of a secure care anklet, by the charge nurse. Resident #1's medical record revealed no documented evidence that an assessment form was done for Resident #1. Interview on [DATE]with Staff B and Staff D, LPN, License Practical Nurse indicated that the facility does not have a policy to indicate how to determine residents that are at risk for elopement or elopement assessment tool. The only policy the facility has for elopement is if a resident is missing or lost. Staff B indicated there is no documentation tool on how a resident is determined to be an elopement risk it depends on their cognitive status and if there has been a history of exit seeking and then a care plan is completed for secure care anklet placement. Staff B and D confirmed that on [DATE] a secured alarm was placed on Resident #1's wheelchair neither Staff B or D was aware of why the alarm was place on the wheelchair. Review of a facility fall report for Resident #1 dated [DATE] indicates that at 7:20 p.m. an unwitnessed fall occurred with Resident #1 found lying on right side in fetal position at the base of the gazebo steps. Contacted the medical doctor and guardian. Resident #1 moved with slide board and 6 staff members to facility stretcher. Review of Nurses' note written on [DATE] by Staff I indicates that at 7:20 p.m. Resident #1 " was found lying on right side with knees drawn towards chest and arms cradled to chest. Participated as able with assessment ...was able to move actively move bilateral lower extremities. Movement of left upper extremities halted due to expressed pain of "my pain". Viewing indicated area no recent abnormalities of structure noted resident indicated increased discomfort when hand was placed on left shoulder blade." Review of a nurse's note dated [DATE] by Staff I, indicates 7:20 p.m. late entry at 7:50 p.m. Resident #1 fall, was found at base of Gazebo porch steps. When asked where Resident #1 was going the response was "who the hell knows." Resident #1 transported to hospital via ambulance. Review of a nurse's note dated [DATE] at 10:00 p.m. indicates the local hospital called to report that Resident #1 was admitted . Review of the hospital diagnostic imaging report dated [DATE] indicates Resident #1 with acute fractures of the left 1 thru 10th ribs, left scapula, left clavicle and the right 1st through 5th ribs. On [DATE] a report was received at the State Agency from the Assistant Deputy Medical Examiner indicating that Resident #1 expired at 6:10 a.m. on [DATE]. Review of the death certificate for Resident #1 reveals the immediate cause of death is blunt chest trauma with multiple bilateral rib fractures. The death certificate also indicates that decedent fell down stairs in a wheelchair while exiting a building. Further review of facility documentation on [DATE] reveals that Staff I, RN Evening Nurse Coordinator on [DATE] indicated that Resident #1 had his wheelchair beside him on the ground tipped over. Resident #2 alerted nursing staff of Resident #1's fall and that it may have been Resident #2 who pressed the red button to reenter the unit and inadvertently let Resident #1 out. Staff H, LNA indicated to Staff I that here was no alarm that sounded and that Staff H and Staff E, maintenance checked the door alarm with Staff E adjusting the pug in for it as it apparently loosens when the door is slammed. Observation on [DATE] with Staff B, RN DON of the area outside where Resident #1 was found reveals a door that is monitored by secure care for residents with an anklet who are determined to be at risk for elopement otherwise the door opens freely and exits outside to an area that has a wooden porch leading to 4 cement steps exiting to the main driveway. If a resident turns to the right as exiting the door the resident will head towards the gazebo where smoking is allowed. Outside the door is a red button that when pushed allows residents with secure bracelets on to exit/enter the building without sounding the alarm. There is also a keypad on the inside that requires a code to be entered to allow a resident to exit/enter the building without sounding the alarm. During an interview on [DATE] with Staff E, Staff E indicated that Resident #1 was always trying to get outside and was always asking staff to take outside. Staff E indicated that all the transformers plugs were checked to ensure all were tightly plugged in and working. During an interview on [DATE] with Staff H, Staff H indicated that Resident #1 was always trying to get outside. On the evening of [DATE] Staff H indicated that Resident #2 came in from the outside and asked for a cigarette and then stated that someone was on the ground outside. At first glance outside the door Staff H could not see anyone and asked "Are you sure?" and Resident #2 said "yes." That is when Staff H noticed Resident #1 at the bottom of the steps. Staff H indicated that no alarm had sounded from the door. Staff H stated that Resident #2 is known to push the red button outside the door to let other residents access the smoking area of the gazebo. The red button allows overriding the system to magnetize the door shut and sound the alarm if the door is opened. Staff H indicated that Resident #2 stated letting someone out but did not know whom. Staff H also indicated that there are other residents who know about pushing the red button because they "copy what they see." Observation on [DATE] at 1:10 p.m. on the gold unit Resident #4 is observed with a secure care anklet on right ankle. Resident #4 is ambulating independently heading towards the exit door to the gazebo area with Resident #5 is ambulating independently and has no secure care anklet is also heading toward the exit door to the gazebo area. Resident #4 stops about four feet from the door and asks Resident #5 "would you push the button for me?" Resident #5 is observed to open the door and press the red button located outside the door and holds it while Resident #4 exits outside the door without the alarm sounding. Resident #4 and #5 are observed to go sit in the gazebo with one other resident present and no staff present. Twenty minutes later staff arrives bringing other residents out to the gazebo area for their scheduled supervised smoking. Review of Resident #4's medical record reveals an Annual Review dated [DATE] by the physician which indicates that in June of 2010 Resident #4 eloped outside to the doctors cottage which is located nearby on the grounds and also was frequently seen walking down the road so an ankle alarm was placed. Resident #4's care plan reveals no documented evidence of a care plan for elopement risk or the application of the secure care to right ankle. Observation with use of a secure care transmitter on [DATE] reveals the following: Blue floor main entry doors are able to be activated to open from the inside automatically with the handicap push button that is located on the left side of the doors. The secure care control panel is located on the right side of the door the panel does not magnetize the doors shut when the secure care transmiiter is present in front of the handicap button which when pushed allows the doors to open automatically to exit outside the building and then will signal alarm. Gold floor south exit that is also a fire exit was observed to have a secure care panel present and with the secure care transmitter in use the door did not magnetize shut on 3 out 5 attempts allowing the door to open to a stairwell that also has a door that exits to the outside. Rose floor fire exit located in the TV lounge is observed with a secure care panel present the transformer plug for the secure care panel is plugged into an outlet located at the top of the right hand side of the door. The transformer plug is observed to be not fully plugged into the outlet. (2) Review of a late entry nurse's note on [DATE] by Staff I, Resident #1 was found at base of Gazebo porch steps. Observation of Gazebo porch steps on [DATE] at 9:45 am reveals that the porch is 35.5 inches above grade. Interview with Staff B, DON on [DATE] reveals that Guards were installed on [DATE], after Resident #1's fall, and no protection existed at these stairs before the fall. Staff B indicates that residents as well as staff use the Gazebo porch and steps. Observation on [DATE] at 9:45 am reveals an open guard assembly with no intermediate guards or ornamental pattern to prevent residents & staff from going under the guards. Cross refer to F454.