Every finding on record at Gonzales Healthcare Center

Based on observations and interviews the facility failed to:1. Ensure the walk-in cooler was maintained in a clean and sanitary condition;2. Ensure portable fans used in the kitchen were maintained in a sanitary condition to prevent the risk of cross contamination; and,3. Ensure individuals in the facility's kitchen maintained appropriate hair restraints. Findings:1. Observation on 08/04/2026 at 9:28AM revealed an orange/rust-colored liquid was actively dripping from an overhead sprinkler in the facility's walk-in cooler. Further observation revealed multiple areas of an unknown black/gray substance was present on the walls and ceiling of the facility's walk-in cooler. Observation of the facility's kitchen with S1Dietary Manager on 08/05/2026 at 9:50AM, revealed an orange/rust-colored liquid was actively dripping from an overhead sprinkler in the facility's walk-in cooler. Further observation revealed multiple areas of an unknown black/gray substance was present on the walls and ceiling of the facility's walk-in cooler. In an interview on 08/05/2026 at 9:50AM, S1Dietary Manager indicated the walk-in cooler was scheduled to be cleaned weekly and deep cleaned monthly. S1Dietary Manager confirmed the orange/rust-colored liquid was actively dripping from the overhead sprinkler and should not have been. S1Dietary Manager further confirmed the unknown black/gray substance observed on the walls and ceiling of the walk-in cooler was unsanitary and should not have been present. 2.Observation of the facility's kitchen on 08/04/2026 at 9:28AM revealed two black portable fans with an unknown gray, dusty substance present, with airflow directed towards the facility's steam table, fryer, and food preparation area. Observation with S1Dietary Manager on 08/05/2026 at 9:47AM revealed two black portable fans with an unknown gray, dusty substance present, with airflow directed towards the facility's steam table, fryer, and food preparation area. Further observation of the two black portable fans revealed an unknown gray, dusty substance covered in a layer of an unknown greasy film was present on the fan blades of the above mentioned black portable fans. In an interview on 08/05/2026 at 9:47AM, S1Dietary Manager indicated the above mention black portable fans were not cleaned since they were placed in the facility's kitchen. S1Dietary Manager further indicated the unknown gray, dusty substance and unknown gray substance covered in a layer of an unknown greasy film noted on the fan blades should not have been present on the two black portable fans located in the facility's kitchen. 3.Observation on 08/04/2026 at 11:14AM revealed the facility's contracted dish machine technician was present in the facility's kitchen. Further observation revealed the facility's contracted dish machine technician's hair/ponytail was blown by one of the above mentioned black fans towards the food preparation area and the facility's fryer In an interview on 08/04/2026 at 11:15AM, S1Dietary Manager indicated the facility's contracted dish machine technician should have been wearing a hairnet or another type of hair restraint while present in the kitchen.

Based on interviews and record reviews, the facility failed to ensure a thorough investigation was completed for an allegation of physical abuse for 2 (Resident #21 and Resident #60) of 3 sampled residents reviewed for abuse and/or neglect. Findings:Review of the facility's Training on Resident-to-Resident Abuse Prevention and Response policy and procedure revised on 10/22/2025 revealed, in part, the facility would conduct a thorough investigation and document all findings and actions taken. Review of the facility's documentation of the investigation sent to the state agency on 04/29/2026 revealed, in part, Resident #60 was the reported victim and Resident #21 was the reported accused for an allegation of physical abuse. S1Administrator further wrote the incident was witnessed by staff and residents. Resident #21 Review of Resident #21's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/2026 revealed, in part, Resident #21 had a Brief Interview Mental Status (BIMS) Score of 15, which indicated Resident #21 was cognitively intact. In an interview on 05/12/2026 at 10:50AM, Resident #21 indicated she had an altercation with Resident #60 in the dining room on 04/29/2026. Resident #60 Review of Resident #60's MDS with an ARD of 04/07/2026 revealed, in part, Resident #60 had a BIMS score of 13, which indicated Resident #60's was cognitively intact. In an interview on 05/12/2026 at 1:04PM, Resident #60 indicated she had an altercation with Resident #21 on 04/29/2026. Review of the facility's investigation documents for Resident #21 and Resident #60's alleged physical altercation on 04/29/2026 revealed, in part, no documented evidence the facility interviewed and/or obtained a witness statement from S9Assistant Dietary Manager. In an interview on 05/13/2026 at 9:05AM, S9Assistant Dietary Manager indicated she was the only staff member present in the dining room on 04/29/2026 and witnessed the resident-to-resident altercation between Resident #21 and Resident #60. S9Assistant Dietary Manager further indicated the facility's administrative staff never questioned her and/or obtained a witnessed statement for 04/29/2026 during Resident #21 and Resident #60's resident-to-resident altercation. In an interview on 05/13/2026 at 2:44PM, S1Administrator indicated he was responsible for overseeing the investigation for Resident #21 and Resident #60's alleged resident-to-resident physical altercation on 04/29/2026. S1Administrator further indicated he was not aware S9Assistant Dietary Manager was present in the dining room when the incident occurred and did not interview and/or obtain a statement from S9Assistant Dietary Manager who observed Resident #21 and Resident #60 during the resident-to-resident altercation on 04/29/2026. S1Administrator further indicated the facility's investigation of the alleged resident-to-resident physical abuse for Resident #21 and Resident #60 was lacking and the facility could have done a better job gathering information and documenting the investigation.

Based on observations, interviews, and record reviews, the facility failed to ensure an ordered nutritional supplement was provided for 1 (Resident #5) of 1 sampled resident reviewed for nutritional supplements.Findings:Review of Resident #5's clinical record revealed Resident #5 had diagnoses which included Unspecified Protein-Calorie Malnutrition.Review of Resident #5's May 2026 physician orders revealed an order for a Mighty Shake nutritional supplements to be given to Resident #5 with lunch and supper.Review of Resident #5's Care plan with implementation date of 10/16/2025 revealed to provide Resident #5 with nutritional supplements as ordered.Observation on 05/11/2026 at 12:01PM revealed Resident #5's lunch meal tray did not contain the ordered Mighty Shake supplement.Observation on 05/12/2026 at 12:10PM revealed Resident #5's lunch meal tray did not contain the ordered Mighty Shake supplement.In an interview on 05/13/2026 at 9:29AM, S3Assistant Director of Nursing indicated Resident #5 was to receive Mighty Shake supplements from dietary with his lunch and supper meal tray. In an interview on 05/13/2026 at 10:16AM, Resident #5 indicated the Mighty Shake nutritional supplements had not been placed on his meal trays. In an interview on 05/13/2026 at 4:18PM, S8Dietary Manager indicated dietary staff had not been putting Mighty Shake nutritional supplements on Resident #5's lunch and supper meal trays.

Based on observations, interviews, and record reviews the facility failed to:1. Ensure a Personal Protective Equipment gown was used during intravenous central line (tube placed in a large vein for medication administration) medication administration (Resident #5); and,2. Ensure proper hand hygiene during nephrostomy tube (catheter inserted into the kidney to drain urine) site care (Resident #55).This deficient practice was identified for 1 (Resident #55) of 29 sampled residents observed and/or investigated during the medication administration and/or the infection control tasks. Findings:1. Review of the facility's Enhanced Barrier Precautions policy and procedure, last reviewed on 03/03/2026 revealed, in part, applying personal protective equipment for residents on Enhanced Barrier Precautions was based on the activity provided and/or assistance needed while in the resident's room. Further review revealed Enhanced Barrier Precautions are used when there is an indwelling medical device such as central lines. Further review revealed during device care or use, including central line, urinary catheter, feeding tube, tracheostomy/ventilator, apply gloves and a gown when care was provided. Review of Resident #55's electronic medical record revealed, in part, a diagnosis of urinary tract infection (an infection in the urinary system) dated 05/04/2026. Review of Resident #55's May 2026 Physician Orders revealed, in part, Meropenem 1 gram (an intravenous antibiotic solution used to treat severe bacterial infections) and to administer two times a day related to a urinary tract infection and unspecified Escherichia Coli (a type of bacteria), for 7 days beginning on 05/04/2026 and with an end date of 05/12/2026. Review of Resident #55's May 2026 electronic medication administration record revealed, in part, Meropenem 1 gram, an intravenous antibiotic solution, was administered through Resident #55's central line device as ordered on 05/11/2026 at 8:00AM. Observation on 05/11/2026 at 9:22AM revealed an Enhanced Barrier Precautions sign on the outside of Resident #55's door. Observation on 05/11/2026 at 9:23AM, during medication administration revealed S5Licensed Practical Nurse administered Resident #55's scheduled Meropenem 1 gram, intravenous antibiotic solution, without a personal protective equipment gown as required for Enhanced Barrier Precautions. In an interview on 05/13/2026 at 1:28PM, S5Licensed Practical Nurse indicated on 05/11/2026 she failed to apply a personal protective equipment gown as required for Enhanced Barrier Precautions during Resident #55's central line intravenous antibiotic solution administration. In an interview on 05/13/2026 at 1:30PM, S3Assistant Director of Nursing/Infection Preventionist indicated S5Licensed Practical Nurse did not apply a gown as required for Enhanced Barrier Precautions during Resident #55's central line intravenous antibiotic solution administration, and should have. 2. Review of facility's Handwashing/Hand Hygiene policy and procedure, last revised/reviewed on 04/16/2026, revealed, in part, when applying gloves, remove one glove from the dispensing box at a time, touching only the top of the cuff. Resident #55 was admitted to the facility on [DATE] with diagnosis, in part, acute kidney failure, urinary tract infection, and obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing properly). Review of Resident #55's Physician's Orders revealed an order that Resident #55's nephrostomy tube site was to be cleansed with wound cleanser, pat dry, and cover with split gauze and cover with mediplex tape daily and as needed on 04/30/2026. Observation on 05/12/2026 at 2:10PM revealed S4Wound Care Nurse performed hand hygiene and then placed on a placed a PPE gown and placed one pair of gloves on top of another pair of gloves and proceeded to revoke the dressing from Resident #55's nephrostomy tube site and cleaned with normal saline. S4Wound Care Nurse then removed her top layer of gloves and took a pair of gloves from her pocket and put on top of the remaining pair of gloves S4Wound Care Nurse was already wearing. S4Wound Care Nurse then put on the new split gauzed dressing and taped it down. In an interview on 05/12/2026 at 2:18PM, S4Wound Care Nurse indicated she should not have used the gloves that were in her pocket. In an interview on 05/12/2026 at 4:25PM, S3Assistant Director of Nursing/Infection Preventionist confirmed S4Wound Care Nurse should not have used gloves that were in her pocket. In an interview on 05/13/2026 at 10:50AM, S2Director of Nursing indicated S4Wound Care Nurse should not have used gloves that were in her pocket. S2Director of Nursing further indicated S4Wound Care Nurse should not have double gloved.

Based on observations and interviews the facility failed to: 1. ensure expired medications were not available for resident use on 2 (Medication Cart c, Medication Cart e) of 2 (Medication Cart c, Medication Cart e) medication carts observed; 2. ensure expired medications were not available for resident use in 2 (Medication Room h, Medication Room g) of 2 (Medication Room h, Medication Room g) medication rooms observed; and, 3. ensure food items were not stored in the medication room for 1 (Medication Room g) of 2 (Medication Room h, Medication Room g). Findings: Observation on 05/07/2025 at 9:19AM, revealed a bottle of Fish Oil 1000 milligrams (mg) capsule which expired on 02/2025 available for resident use on Medication Cart c. In an interview on 05/07/2025 at 9:20AM, S3Licensed Practical Nurse (LPN) indicated the above mentioned medication should not have been on the Medication Cart. Observation on 05/07/2025 at 9:33AM revealed a half-eaten cake on the counter in Medication Room g. In an interview on 05/08/2025 at 9:36AM, S4Registered Nurse indicated the cake should not have been stored in the medication room. Observation on 05/07/2025 at 10:26AM, revealed Dakin's Solution (a solution used for wound care) which expired on 04/2024 and Vashe (a solution used for wound care) which expired on 04/30/2025 available for resident use in Medication Room h. Observation on 05/07/2025 at 10:28AM revealed Dakin's Solution which expired on 02/2024 available for resident use on Medication Cart e. In an interview on 05/07/2025 at 10:30AM, S5LPN indicated the expired Dakin's Solution and Vashe should not have been available for resident use. In an interview on 05/07/2025 at 3:45PM, S1Director Of Nursing confirmed a half-eaten cake should not be stored in the medication room and expired medication should not be available for resident use.

Based on observation, interview, and record reviews, the facility failed to ensure a resident's care plan intervention for a low air loss mattress to bed was in place for 1 (Resident #6) of 2 (Resident #6, Resident #30) sampled residents investigated for pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings: Review of the facility's Quality Assurance (QA) Meeting Minutes dated 04/29/2025 revealed, no documentation that wound management or missing medical equipment was discussed or tracked as part of the facility's QA monitoring. Review of Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/2025 revealed, in part, Resident #6 had a diagnosis of a Stage IV Pressure Ulcer (PU) (a wound that extends into deep tissues including muscle, tendons, and ligaments). Review of Resident #6's Weekly Wound Observation Tool dated 04/29/2025 revealed, in part, Resident #6 had a Stage IV PU to the sacrum. Review of Resident #6's active May 2025 Physician's Orders revealed, in part, an order for a Low Air Loss (LAL) mattress (medical mattress designed to treat and prevent pressure ulcer with air-filled chambers that slowly release air to keep skin dry and reduce pressure on the body) to bed and to ensure that the bed was functioning properly every shift for pressure prevention and wound healing. Review of Resident #6's Stage IV PU care plan revealed, in part, an intervention for LAL mattress to bed. Observation on 05/07/2025 at 12:10PM revealed, in part, Resident #6 lying in bed on a mattress that was not a low air low mattress. Review of Resident #6's general nurse's note dated 04/23/2025 revealed, in part, the medical equipment supplier picked up Resident #6's LAL mattress and pump. In an interview on 05/07/2025 at 1:53PM S1Director of Nursing confirmed the mattress on Resident #6's bed was not a LAL mattress and Resident #6 should have one as ordered by the physician and per Resident #6's plan of care.

Based on observations, interview, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (Resident #6, Resident #12) of 4 (Resident #6, Resident #12, Resident #37, Resident #51) sampled residents investigated for accommodation of needs. Findings: Review of the facility's Resident Call System policy, dated 10/2022 , reviewed on 03/28/2025 , revealed, in part, each resident will be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Resident #6 Review of Resident #6's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/06/2025 revealed, in part, Resident #6 required substantial and/or maximal assistance for activities of daily living (ADL) from staff. Observation on 05/05/25 at 11:11AM revealed Resident #6 was lying in bed and Resident #6's call light was noted out of reach, lying underneath the bed. Resident #12 Review of Resident #12's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/22/2025 revealed, in part, Resident #12 was dependent on staff for Activities of Daily Living (ADLs) Observation on 05/05/2025 at 11:12AM, revealed Resident #12 was lying in bed and Resident #12's call light was hanging at the head of the bed out of reach. Further observation revealed Resident #12 was unable to reach the call light when she reached for it. In an interview on 05/07/2025 at 1:18PM S1Director of Nursing (DON) indicated it is the facility's policy for call lights to be within reach at all times for all residents.

Based on interviews and record reviews, the facility failed to ensure a resident remained free from neglect when nursing staff failed to provide peri-care for 1(Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy, dated 05/17/2024, revealed, in part, neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Review of Resident #3's medical records revealed, in part, Resident #3 was admitted to the facility on [DATE], with diagnoses of dysphagia following cerebral infarction, generalized muscle weakness, other lack of coordination, unsteadiness on feet, and neuromuscular dysfunction of bladder. Review of Resident #3's quarterly Minimum, Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025 revealed, in part, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #3 was cognitively intact. Further review revealed Resident #3 was always incontinent of bowel and bladder and was dependent upon staff for toileting hygiene needs. Review of Resident #3's Care Plan dated 01/01/2025 revealed, in part, Resident #3 had a neurogenic bladder. Further review revealed interventions included for the facility's staff to perform incontinent care on Resident #3 during daily care and as needed (PRN), to change Resident #3's clothing PRN after incontinence episodes, and to provide Resident #3 with briefs/incontinent pads as needed. Review of the facility's Statewide Incident Management System SIMS investigation completed by S1Administrator, dated 02/02/2025, revealed, in part, Resident #3 alleged she was neglected by S4Certified Nursing Assistant (CNA) and S5CNA when she was left wet and dirty for an extended period of time. Review also revealed, Resident #3's oncoming CNAs confirmed Resident #3's allegations and reported they found Resident #3 wet, over saturated and dirty brief. Review further revealed that S4CNA indicated he viewed the schedule for that shift and he was not assigned to Resident #3's room, but S5CNA indicated she had a verbal conversation with S4CNA about him adding Resident #3 to his assignment. Review also revealed S6Licensed Practical Nurse (LPN) indicated she was not aware of any changes in the CNAs assignment on 02/02/2025, and S5CNA recorded ADL documentation on 02/02/2025 for Resident #3 and his roommate. Further review revealed Resident #3's allegation of neglect was substantiated by the facility. In an interview on 03/10/2025 at 3:44PM, S2Director of Nursing (DON) confirmed that the miscommunication about the assignment for 02/02/2025 between S4CNA and S5CNA did result in Resident #3 being neglected by the staff, and it should not have.

Based on interviews and record reviews, the facility failed to implement the facility's abuse policy by failing to ensure staff reported an allegation of abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prohibition policy and procedure, revised on 05/17/2024, revealed in part, each resident had the right to be free from abuse and mistreatment. Further review revealed verbal abuse was defined as use of oral language that willfully included derogatory terms to residents. Further review revealed any employee who became aware of an allegation of abuse should report the incident to the abuse coordinator immediately. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 01/17/2025 revealed, in part, Resident #1 had a Brief Interview of Mental Status score of 15, which indicated Resident #1's cognition was intact. In an interview on 03/03/2025 at 11:21AM, Resident #1 indicated S7Certified Nursing Assistant (CNA) was disrespectful to her last night and told her to shut up. Resident #1 further indicated the allegation of verbal abuse was reported to the social worker this morning on 03/03/2025. In an interview on 03/06/2025 at 12:03PM, S9Social Service Assistant (SSA) indicated on 03/03/2025 Resident #1 alleged that an unknown CNA told her to shut up. S9SSA further indicated she did not report the allegation of verbal abuse to anyone. In an interview on 03/06/2025 at 12:40PM, S1Administrator indicated he was not aware of Resident #1's allegation that an unknown CNA told her to shut up. S1Administrator confirmed the allegation of verbal abuse should have been reported to him immediately by S9SSA, and was not.

Based on interviews and record reviews, the facility failed to report an allegation of abuse and/or neglect to the State Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prohibition policy and procedure, revised on 05/17/2024, revealed in part, mental abuse was defined as humiliation and threats of depravation, examples of verbal/mental abuse included denying food or care. Further review revealed the facility would report all allegations of abuse to the State Agency immediately or within two hours of the allegation. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 01/17/2025 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #1's cognition was intact. Further review revealed Resident #1 had a diagnosis of cerebral palsy (a condition that affects muscle control and causes deficits in functional mobility), impaired range of motion in her bilateral upper extremities, and was dependent on staff for eating. Review of the facility's Life Satisfaction Rounds dated 03/03/2025 documented by S9Social Service Assistant (SSA) revealed, in part, Resident #1 alleged S8CNA told her to learn how to feed herself. In an interview on 03/06/2025 at 12:03PM, S9SSA confirmed she completed the above mentioned Life Satisfaction Rounds on 03/03/2025. S9SSA indicated on 03/03/2025 Resident #1 alleged S8CNA told her she needed to learn how to feed herself. S9SSA further indicated she turned in the above mentioned Life Satisfaction Rounds to S1Administrator on 03/03/2025. Review of the facility's incident reports submitted to the state agency revealed, in part, there was no documented evidence, and the facility did not present any documented evidence Resident #1's allegation of abuse and/or neglect was reported to the State Agency until 03/06/2025. In an interview on 03/06/2025 at 12:40PM, S1Administrator indicated he was aware of the above mentioned Life Satisfaction Round dated 03/03/2025 which indicated S8CNA told Resident #1 to learn how to feed herself. S1Administrator further indicated he did not report the allegation of abuse and/or neglect to the State Agency until 03/06/2025.

Based on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after many allegations of abuse and neglect were identified in 2024. Findings: Review of the facility's Quality Assessment and Assurance (QAA) policy and procedure last reviewed on 01/2024 revealed, in part, the QAA committee would develop and implement appropriate plans of action to correct identified deficiencies. Review of the facility's Immediate Plan of Improvement: Abuse and Neglect record dated 01/05/2025 revealed, in part, the facility identified a concern of having many abuse and neglect allegations in 2024. Further review revealed the corrective actions implemented by the facility were to initiate staff in-services on types of abuse and the importance of reporting suspected abuse or neglect immediately to the abuse coordinator (S1Administrator). Further review revealed the facility would implement a monthly in-service on abuse with staff, monitor the number of facility incident reports submitted to the state agency, and review the reports for any additional interventions that could be put in place. Review of the facility's QAA documentation revealed an in-service on abuse policies and procedures was completed on 01/05/2025 and an in-service on workplace aggression/violence was completed on 01/09/2025. Further review revealed no documented evidence and the facility did not present any evidence an in-service on abuse was completed with staff in the month of February 2025. Further review revealed no documented evidence and the facility did not present any evidence the facility evaluated the effectiveness of the abuse in-service training completed in January 2025. Further review revealed no documented evidence and the facility did not present any documented evidence of the monitoring, evaluation, or findings of the facility reported incidents. In an interview on 03/06/2025 at 3:05 PM, S1Administrator indicated he could not provide documentation showing how the facility monitored the effectiveness of the abuse in-services. S1Administrator further indicated he could not provide evidence the facility monitored and/or evaluated the facility reported incidents because he kept all the information in his head. S1Administrator further indicated the facility did not need to monitor the effectiveness of the abuse in-services because effectiveness could be determined by the number of facility incidents reported to the state agency concerning abuse. When S1Administrator was asked to clarify if the facility's plan was to wait for an incident of abuse or neglect to happen to a resident as opposed to monitoring the effectiveness of the staff's abuse training, S1Administrator responded, What's wrong with that?

Based on record reviews and interview, the facility failed to ensure the activities program was directed by a qualified professional for 1 (S4Former Activities Director) of 1 (S4Former Activities Director) staff personnel files reviewed for activities director qualifications. Findings: Review of the facility's job description for the Activities Director revealed, in part, the following education and experience requirements: Education: must possess, as a minimum, two years of college. Degree preferred but not necessary. Experience: Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for certification as a recreation specialist or as an activities professional; or Must have a minimum two year experience in a social or recreation program within the last five years, one of which was full time in a patient activities program in a health care setting; or Must be a qualified occupational therapist or occupational therapy assistant; or Must have completed a training course approved by this state. Review of S4FAD's personnel record revealed no documented evidence, and the facility did not present any documented evidence, S4FAD had any qualifications required in the facility's job description for Activities Director. The facility did not provide any documentation that S4FAD had any of the listed qualifications for Activities Director. In an interview on 11/06/2024 at 11:47 a.m., S1Administrator indicated the facility did not have any documentation S4FAD was qualified for the position of Activities Director as required.

Based on record reviews and interviews, the facility failed to keep a resident free from staff to resident verbal abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy Revised 01/01/2024 revealed, in part: Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Policy: The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Definitions: Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying things to frighten a resident, denying food or care, isolating resident, etc. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 09/22/2024 revealed, in part, Resident #1's Brief Interview for Mental Status (BIMS) score was a 15, which indicated her cognition was intact. Review of Resident #1's care plan revealed, in part, Resident #1 required staff assistance for meeting emotional, intellectual, physical, and social needs. Review of S2Regional [NAME] President (S2RVP) statement on 10/10/2024 revealed, in part, on 10/10/2024 I (S2RVP) was walking down Hall A, S4 Former Activities Director (S4FAD) was entering a resident's room when I (S2RVP) was coming up the hall. I (S2RVP) heard and saw S4FAD talking to Resident #1 with a raised voice. S4FAD told Resident #1 she needed to stop all that crying. I (S2RVP) witnessed S4FAD pointing her finger at Resident #1. In an interview on 11/04/2024 at 10:38 a.m., Resident #1 indicated the incident between her and S4FAD on 10/10/2024 started in the dining room. Resident #1 indicated she inquired about going to a health fair on 10/15/2024. Resident #1 indicated S4FAD told her they would not be able to accommodate the residents who wanted to go because the smaller van was broken and the other van would be used to bring residents to doctors' appointments. Resident #1 indicated later on the same day S4FAD came to her room and she again asked S4FAD about the health fair and that is when things got heated. Resident #1 stated S4FAD yelled that if she was going to an appointment then she would not want to miss her doctor's appointment. Resident #1 stated she yelled back at S4FAD, and they were going back and forth yelling at each other. In an interview on 11/04/2024 at 11:19 a.m., S2VP indicated he witnessed S4FAD walk into Resident #1's room and heard S4FAD speaking loudly to Resident #1. S2VP stated he heard S4FAD speaking to Resident #1 in a loud and verbally inappropriate way, that, we were not going to keep doing this. S2VP further indicated S4FAD was verbally inappropriate to Resident #1. In an interview on 11/06/2024 at 12:06 p.m., S1Administrator stated he substantiated that S4FAD verbally abused Resident #1, and should not have.

Based on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identification of residents not receiving incontinence care as needed. Findings: Review of the facility's policy title, Quality Assurance Policy and Procedure last revised on March 2023 revealed, in part, the Quality Assessment and Assurance (QAA) committee would regularly review and analyze data collected and make improvements. Further review revealed the QAA committee would develop and implement appropriate plans of action to correct identified quality deficiencies. Review of the facility's QAA Plan of Action and Implementation record revealed, in part, a plan of action was implemented for timely documentation for activities of daily living (ADL) on 04/18/2024 as a result of deficient practice cited on a prior complaint survey conducted on 03/14/2024. Review of Quality Assessment and Assurance Plan of Action and Implementation Record dated 04/18/2024 revealed, in part, all omissions of ADL documentation will be monitored in Point Click Care (software used by the facility for documentation) daily, in-services are to be held with nursing staff to check ADL documentation during every shift and to notify Certified Nursing Assistant/Assistants (CNA) of omission of ADL documentation. Further review revealed nursing staff are responsible to ensure documentation is entered into Point Click Care by the end of every shift and administrative nursing staff are to check omissions of ADL documentation daily and to notify CNA of omissions of ADL documentation. Further review revealed all new hired CNA's and current CNA's are to be in-serviced on importance of ADL documentation and documentation must be completed at end of shift. Review of Documentation Survey report for September 2024 for Resident #1 revealed, in part, no documented evidence Resident #1 was assisted by staff with toilet use and/or toilet transfer on the night shift of: 09/01/2024; 09/02/2024; 09/03/2024; 09/04/2024; 09/05/2024; 09/06/2024; 09/07/2024; 09/08/2024; 09/09/2024; 09/10/2024; 09/11/2024; 09/12/2024; 09/13/2024; 09/15/2024; and 09/16/2024. In an interview on 09/17/2024 at 4:05 p.m. S3Corporate Clinical Specialist indicated there was no documentation of staff assisting Resident #1 with toilet use and transfer on the above mentioned dates. In an interview on 09/18/2024 at 2:43 p.m. S6Director of Nursing (DON) indicated she could not produce any documented evidence of an audit tool for ADL documentation monitoring per the facility's QAA plan. S6DON further indicated the QAA plan was not being followed by CNA's, and could not provide any documented evidence the QAA plan was revised nor documented evidence of staff disciplinary action for not following the QAA plan. S6DON indicated she could not produce any documented evidence all staff was in-serviced on ADL documentation for September 2024.

Based on interviews and record reviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident investigated for neglect. Findings: Review of the facility's policy titled Abuse Prohibition last reviewed on 05/17/2024 revealed, in part, the facility will thoroughly investigate all alleged violations of neglect and take appropriate actions. Further review revealed the facility was to conduct interviews and/or obtain written statements from individuals, (residents, visitors, or staff) who may have firsthand knowledge of the incident. Review of the Health Standards Incident Report (HSIR) revealed, in part, there was an allegation of neglect involving Resident #2 for timely incontinence care. Resident #2 Review of S5Licensed Practical Nurse (LPN) 's witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, the witness statement was a photocopy of an alleged conversation between S5LPN and S1Administrator. Further review revealed, S5LPN's signature was not present on the above mentioned statement to prove the validity of the statement Review of S5LPN's witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, the witness statement was a photocopy of an alleged conversation between S5LPN and S1Administrator. Further review revealed, S5LPN's signature was not present on the above mentioned statement to prove the validity of the statement. Review of S4Certified Nursing Assistant (CNA)'s witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, S4CNA's signature was not present on the above mentioned statement to prove the validity of the statement. In an interview on 09/17/2024 at 3:05 p.m. S1Administrator indicated a photocopy of a text message from allegedly S5LPN should not have been used as a witness statement in an investigation of neglect for Resident #2. S1Administrator further indicated S5LPN and S4CNA should have signed their witness statements. Resident #3 Review of the Health Standards Incident Report (HSIR) revealed, in part, there was an allegation of neglect involving Resident #3 for timely incontinence care. There was no documented evidence and the facility did not present any evidence S2Interim Administrator conducted an interview with Resident #3 regarding the above mentioned allegation of neglect. In an interview on 09/17/2024 at 12:46 p.m. S2Interim Administrator indicated she did not get a witness statement from Resident #3 as part of her investigation regarding he allegation of neglect involving Resident #3.

Based on interviews and record review the facility failed to ensure the investigation of an allegation of neglect was reported to the State Survey agency within the required time frame for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated. Findings: Resident #1 Review of the Health Standards Incident Report (HSIR) dated 09/03/2024 at 9:18 a.m. revealed, in part, a an allegation of neglect involving Resident #1 was reported to the State Survey Agency on 09/03/2024 at 9:18 a.m. Further review revealed a final investigation report was due on 09/10/2024 at close of business. Review of S2Interim Administrator's email dated 09/10/2024 at 4:12 p.m. revealed, in part, S2Interim Administrator emailed a State Survey Agency Program Manager to request an extension for the due date to report the results of the above mentioned investigation. Review of an email dated 09/10/2024 at 4:31 p.m. revealed, in part, an extension was granted for 09/12/2024 by close of business. Review the HSIR dated 09/10/2024 revealed, in part, S1Administrator sent the final investigation report to the State Survey Agency on 09/16/2024 at 1:35 p.m. In an interview on 09/17/2024 at 9:52 a.m., S1Administrator indicated a State Survey Agency Program Manager extended the due date for the final report of the above mentioned investigation until 09/12/2024. S1Administrator further indicated he did not send the final report of the investigation into the allegation of neglect involving Resident #1 to the State Survey Agency until he returned to work on 09/16/2024. In an interview on 09/17/2024 at 12:46 p.m. S2Interim Administrator indicated she performed the final investigation report for Resident #1 and did not have access to enter the final investigation report to the State Survey Office. In an interview on 09/17/2024 at 1:33 p.m. S3Corporate Clinical Specialist indicated the final investigation report for Resident #1 was sent to State Office on 09/16/2024 at 1:35 p.m. Resident #3 Review of the HSIR dated 09/03/2024 at 10:35 a.m. revealed, in part, an allegation of neglect involving Resident #3 was reported to the State Survey Agency on 09/03/2024 at 10:35 a.m. Further review revealed a final investigation report was due on 09/10/2024 at close of business. Review of S2Administrator's email dated 09/10/2024 at 4:12 p.m. revealed, in part, S2Interim Administrator emailed a State Survey Agency Program Manager to request an extension for the due date to report the results of the above mentioned investigation. Review of an email dated 09/10/2024 at 4:31 p.m. revealed, in part, an extension was granted an extension for 09/12/2024 by close of business. Review the HSIR dated 09/10/2024 revealed, in part, S1Administrator sent the final investigation report to the State Survey Agency on 09/16/2024 at 2:05 p.m. In an interview on 09/17/2024 at 9:52 a.m., S1Administrator indicated a State Survey Agency Program Manager extended the due date for the final report of the above mentioned investigation until 09/12/2024. S1Administrator further indicated he did not send the final report of the investigation into the allegation of neglect involving Resident #3 to the State Survey Agency until he returned to work on 09/16/2024. In an interview on 09/17/2024 at 12:46 p.m. S2Interim Administrator indicated she was unable to submit the final investigation report for the allegation of neglect involving Resident #3 because she did not have access to the State Incident Management System (SIMS). In an interview on 09/17/2024 at 1:33 p.m. S3Corporate Clinical Specialist indicated the final investigation report for Resident #1 was sent to State Office on 09/16/2024 at 1:35 p.m.

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure residents were properly restrained in the facility's transportation vehicles, vehicle transportation logs were completed as required for the facility's transportation vehicles, and the facility's transportation drivers were competent on the use of the facility's van and bus restraint systems prior to transporting residents. This lack of administrative oversight resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. for Resident #5 when S6Driver failed to properly secure the resident in a forward facing direction in the facility's transportation bus, Resident #5's wheelchair tipped over backwards during transport, and caused Resident #5 to strike the back of her head. Resident #5 was transported to the hospital where she was assessed as having an abrasion to the back of the head and had to receive pain medication. The IJ continued on 09/03/2024 at 12:30 p.m. for Random Resident #6, when S4ActivitiesDirector (AD) was observed failing to secure Random Resident #6 into the facility's transport van using both the lap belt and the shoulder strap and left the facility with Random Resident #6 improperly restrained. S1Administrator was notified of the Immediate Jeopardy on 09/03/2024 at 5:58 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 2:39 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to the 75 residents who resided in the facility and may use the facility's transportation vehicles. Findings: Cross reference F689. Review of the facility's job description for the Administrator dated 2003 revealed, in part, the Administrator shall ensure all facility personnel follow established safety regulations. Review of the facility's policy titled Facility Vehicle Log dated 04/2015 revealed, in part, the van use log will be completed by the driver for each trip. Further review revealed the driver's weekly vehicle safety inspection will be completed by the driver each week. Review of the facility's Van Use Log for the transport bus revealed, in part, incomplete entries for mileage and times. Further review revealed no entry dated 08/22/2024 for Resident #5's initial transport by S6Driver in which the fall with injury occurred. Review of the facility's Driver Weekly Safety Inspection log for bus #09796 dated 08/02/2024, 08/09/2024, and 08/23/2024 revealed, in part, blank forms with no entries or inspections performed. Review of the facility's Quality Assurance (QA) Plan for transporting residents safely in facility vehicles dated 08/27/2024 revealed, no documented evidence, and the facility could not provide any documented evidence, that weekly driver audits were performed from 08/27/2024 through 09/03/2024 or that an immediate in-service safety training for all drivers was performed from 08/27/2024 to 09/03/2024. In an interview on 09/03/2024 at 1:10 p.m., S1Administrator indicated the facility's transportation drivers should secure the facility's residents in the transportation vehicles according to the manufacturer's instructions and facility policy. S1Administrator further indicated he was aware the transported residents should have both a lap belt and shoulder strap during transport in a facility vehicle. S1Administrator offered no explanation or comment related to the deficient practice. In an interview on 09/03/2024 at 1:50 p.m., S1Administrator confirmed there had been no weekly driver audits performed since the QA plan for transporting residents safely in facility vehicles began on 08/27/2024. In an interview on 09/04/2024 at 10:00 a.m., S1Administrator indicated he was overall responsible for the safety of residents being transported in facility vehicles. S1Administrator further indicated the van's transportation logs should have been reviewed for completeness and accuracy. In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated he was overall responsible for the training and competency of the facility's vehicle drivers. In an interview on 09/04/2024 at 11:15 a.m., S5Maintenance Director confirmed there was no documented evidence and he was unable to provide any documented evidence that safety inspections were performed for the weeks of 08/02/2024, 08/09/2024, and 08/23/2024 and should have been. In an interview on 09/04/2024 at 1:15 p.m., S1Administrator indicated the facility was unable to produce any documented evidence that the required weekly safety inspections were performed on transport bus.

Based on observation, interview, and record review, the facility failed to properly secure residents in the facility's transportation vehicles for 2 (Resident #5 and Random Resident #6) of 2 (Resident #5 and Random Resident #6) sampled residents reviewed for accident hazards. This deficient practice resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. for Resident #5 when S6Driver failed to properly secure the resident in a forward facing direction in the facility's transportation bus, Resident #5's wheelchair tipped over backwards during transport, and caused Resident #5 to strike the back of her head. Resident #5 was transported to the hospital where she was assessed as having an abrasion to the back of the head and had to receive pain medication. The IJ continued on 09/03/2024 at 12:30 p.m. for Random Resident #6, when S4ActivitiesDirector (AD) was observed failing to secure Random Resident #6 into the facility's transport van using both the lap belt and the shoulder strap and left the facility with Random Resident #6 improperly restrained. S1Administrator was notified of the Immediate Jeopardy on 09/03/2024 at 5:59 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 2:39 p.m., after it was verified through observations, interviews, and record reviews, that the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to the 75 residents who resided in the facility and may use the use of the facility's transportation vehicles. Findings: Resident #5 Review of the facility's Policy and Procedure titled Securing Residents in Van dated 04/2015 revealed, in part, the driver shall ensure residents in wheelchairs are forward facing in vehicles. Review of Resident #5's Electronic Medical Record (EMR) revealed, in part, Resident #5 was admitted to the facility on [DATE] with diagnoses of muscle weakness, cognitive communication deficit, and lower back pain. Review of Resident #5's care plan with a planned review date of 09/29/2024 revealed, in part, Resident #5 was at high risk for falls due to confusion and gait/balance problems. Review of S6Driver's written and signed statement revealed, in part, Resident #5 was being transported in the facility bus, when the van hit a bump in the road. S6Driver then saw Resident #5's wheelchair had tipped backwards. Further review revealed S6Driver did not have Resident #5 forward facing in the facility vehicle. Review of Resident #5's medical records revealed, in part, Resident #5 was evaluated at a local emergency department on 08/22/2024 for a head injury sustained during transport in the facility's bus. Review of Resident #5's nurse's notes dated 08/22/2024 revealed, in part, Resident #5 had an abrasion to the back of her head. Further review revealed Resident #5 received pain medication while in the emergency department. In an interview on 09/03/2024 at 11:30 a.m., S1Administrator indicated Resident #5 was not secured in accordance with facility transportation guidelines. In an interview on 09/05/2024 at 11:30 a.m., S5Maintenance Director (MD) indicated resident wheelchairs should be secured to the transport vehicle using 4 straps and forward per the training videos related to vehicle safety. S5MD further indicated if a wheelchair is strapped down properly it should not move or tip over. Random Resident #6 Review of Facility's Policy and Procedure entitled Securing Residents in Van dated 04/2015 revealed, in part, the driver shall ensure the shoulder straps cross diagonally across the upper chest of the passenger. Review of Random Resident #6's record revealed, in part, Random Resident #6 was admitted to the facility on [DATE] with diagnoses of muscle weakness, hemiplegia, and intervertebral disc degeneration. Review of Random Resident #6's care plan with a planned review date of 09/01/2024 revealed, in part, Random Resident #6 was a high risk for falls and at risk for bleeding if a fall would occur. Observation on 09/03/2024 at 12:08 p.m., revealed S4AD loaded Random Resident #6 in the facility's transportation van without using the vehicle's installed shoulder straps. In an interview on 09/03/2024 at 12:15 p.m., S4AD indicated Random Resident #6 did not need to use the shoulder strap to secure residents in the facility transport vehicles. S4AD further indicated she did not routinely use the shoulder strap when she transported residents. Observation on 09/03/2024 at 12:30 p.m. revealed S4AD left the facility, and transported Random Resident #6 in the facility's transportation van without securing Random Resident #6 with the shoulder straps. In an interview on 09/03/2024 at 12:55 p.m., S5MD indicated the shoulder harness should always be used to secure residents in the facility's transport van. S5MD further indicated S4AD should have used the shoulder strap prior to transporting Random Resident #6. In an interview on 09/03/2024 at 1:10 p.m., S1Administrator indicated Resident #6 should have been secured with the shoulder belt.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from verbal abuse by staff. This deficient practice was identified for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy review dated 05/17/2024 revealed, in part, verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to the residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of the facility's documentation related to an incident dated 07/26/2024 revealed an anonymous bystander from Resident #1's physician's office and staff from Resident #1's physician office reported to the facility that they witnessed S4Transportation Driver (S4TD) refuse to assist Resident #1 with filling out his paperwork and yelled nothing was wrong with his hands he was there for his legs. Review of Resident #1's record revealed he was admitted on [DATE] with diagnoses, in part, of right ankle effusion, sepsis, generalized weakness and injury to left eye. Review of Resident #1's Minimum Date Set with an Assessment Reference Date of 07/25/2024 revealed Resident #1 had a Brief Interview for Mental Status of 14 which indicated Resident #1 was cognitively intact. In an interview on 08/12/2024 at 10:34 a.m. Resident #1 indicated S4TD was rude to him while he was at his physician's appointment. Resident #1 further indicated he needed help filling out his paperwork, and when he requested help S4TD told him there is something wrong with your legs, not your hands, you can do it yourself. In an interview on 08/14/2024 at 1:51 p.m. S1Administrator (ADM) indicated a bystander in the waiting room at Resident #1's physician's office, reported they witnessed S4TD refused to assist Resident #1 with his paperwork and yelled at Resident #1. S1ADM further indicated Resident #1's physician's office corroborated the bystander's report. S4TD was suspended on 07/26/2024 and subsequently was terminated on 08/05/2024 after the facility investigation substantiated the above mentioned verbal abuse occurred.

Based on record review and interview the facility failed to report the results of an investigation to the required state agency within 5 working days of a reportable incident for 1 (Resident #6) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect. Findings: Review of Resident #6's Facility Reported Incident entered on 05/30/2024 revealed an allegation of neglect. Review of the Facility Reported Incident log documentation revealed Resident #6 had an incident reported on 05/30/2024 and the investigation report was due to the state survey agency on 06/06/2024. In an interview on 06/13/2024 at 1:45 p.m., S4Corporate Clinical Specialist stated the results of Resident #6's investigation were submitted to the state survey agency on 06/07/2024 and should have been submitted by 06/06/2024. .

Based on record reviews and interviews, the facility failed to ensure a resident remained free from neglect and psychosocial harm when nursing staff failed to provide care and services to a newly admitted resident for 1 (Resident #5) of 19 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) reviewed for neglect. This deficient practice resulted in actual harm on 02/08/2024 at 10:00 p.m. when S6Licensed Practical Nurse (LPN) and S7Certified Nursing Assistant (CNA) both arrived to work at 10:00 p.m. and failed to receive a nursing report (a verbal report on a residents current medical condition and care needs) from the off-going nursing staff that the facility had a new admit, Resident #5. Resident #5 was discovered on 02/09/2024 at approximately 3:00 a.m. sitting alone in her wheelchair in a dark room by S6LPN and S7CNA. Resident #5 indicated she was scared and crying with complaints of pain which required medication. Findings: Resident #5 was admitted to the facility on [DATE] for orthopedic aftercare following a left below the knee surgical amputation. Review of Resident #5's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/15/2024 revealed, in part, a Brief Interview for Mental Status Score (BIMS) of 15. A BIMS score of 15 which indicated Resident #5 was cognitively intact. Further review revealed Resident #5 required substantial to maximal assistance with transfers to and from a bed to a chair or a wheelchair. Review of the facility's documentation for the investigation of Resident #5's allegation of neglect revealed, in part, Resident #5 reported on 02/08/2024 she waited in her room from 10:30 p.m. to approximately 3:00 a.m. for assistance to get in her bed. Resident #5 indicated she had activated the call bell for assistance. Further review revealed Resident #5 indicated on 02/08/2024 at approximately 10:00 p.m. she was provided assistance with toileting and assisted back to her wheelchair. Resident #5 indicated staff entered her room at approximately 3:00 a.m. and told her they were sorry because they were not aware she was in the room and the call bell had not alerted a need for assistance. Further review revealed on 02/09/2024 S1Administrator and S2Director of Nursing (DON) spoke with Resident #5 to discuss the allegation of neglect and determined Resident #5 did not understand how to use the call system. Review of S6LPN's witness form dated 02/09/2024 revealed, in part, S6LPN made rounds by herself and noted Resident #5's room was dark with no movement in the room. S6LPN documented she had not received report from the off-going nurse and had received report from a CNA. Further review revealed when S6LPN placed medications into residents bins she observed medications for Resident #5 so she went to room a and discovered Resident #5 in a dark room sitting in her wheelchair. Resident #5 indicated she had waited for someone to help her all night. Resident #5 requested and received pain medication. Review of Resident #5's February 2024 electronic Medication Administration Record revealed, in part, Resident #5 received Norco Oral Tablet (a pain medication) 10-325 milligram (mg) on 02/09/2024 at 3:55 a.m. for pain rated at a pain level of 5 on a scale of 1-10. Further review revealed the Norco was administered by S6LPN. In an interview on 03/13/2024 at 3:24 p.m., Resident #5 indicated she was admitted to the facility on [DATE]. Resident #5 indicated she arrived in a wheelchair and remained in the wheelchair in her room for supper. Resident #5 indicated she needed to use the bathroom so she pressed the call button but no one came to the room for several hours. Resident #5 indicated at about 3:00 a.m. a staff member came to the room and assisted her to bed. Resident #5 indicated she had cried because she was scared, tired, and alone. Resident #5 indicated she had pain from sitting in her wheelchair and she had put a pillow on the arm of her wheelchair and tried to sleep but she could not sleep. Resident #5 indicated when the staff realized she was in the room they assisted her to bed but she still did not sleep well because she was scared. In an interview on 03/13/2024 at 3:59 p.m., S5Licensed Practical Nurse (LPN) indicated she was the nurse who admitted Resident #5 to the facility on [DATE]. S5LPN indicated she worked the 2:00 p.m. to 10:00 p.m. shift on 02/08/2024. S5LPN indicated S6LPN was her relief on 02/08/2024 at 10:00 p.m. S5LPN indicated when she attempted to give report to S6LPN, but S6LPN replaced, I don't need report as long as everyone is breathing. I'm here to do one job. S5LPN indicated she had wrote Resident #5's name as a new admission on the 24-hour nursing report sheet. In an interview on 03/14/2024 at 9:24 a.m., S3Assisstant Director of Nursing (ADON) indicated it was the expectation when a nurse or a CNA accepts responsibility for the care of a resident they were expected to receive a verbal report from the off-going nurse. S3ADON further indicated the nurses complete the 24-hour nursing report sheet and it was the expectation the oncoming nurse would review the 24-hour nursing report sheet. S3ADON indicated new admissions were documented on the 24-hour nursing report sheet. S3ADON indicated the oncoming CNA was expected to receive report from the off-going CNA. In an interview on 03/14/2024 at 9:54 a.m., S7CNA indicated when she arrived for her shift on 02/08/2024 at 10:00 p.m. a CNA who was also scheduled for the same 10:00 p.m. shift gave her a report and told her room a was not occupied by a resident; therefore, she never went in room a. S7CNA indicated at about 3:00 a.m. S6LPN reported to her she had received medications from the offsite pharmacy for room a and thought there may be a resident in the room. S7CNA indicated she and S6LPN entered room a and Resident #5 was discovered in her wheelchair crying. S7CNA indicated Resident #5 indicated she was scared. In an interview on 03/14/2024 at 11:42 a.m., S1Administrator indicated on 02/09/2024 it was reported to him that Resident #5 wanted to speak to him and S2DON. S1Administrator indicated Resident #5 was admitted on [DATE] and she reported someone took her to the bathroom on the evening of 02/08/2024, put her in her wheelchair in her room, and no one came to check on her or put her in her bed until approximately 3:00 a.m. S1Administrator confirmed he was aware S6LPN had not received a nursing report when she started the 10:00 p.m. shift on 02/08/2024 and S7CNA had not received report from the off-going CNA. S1Administraot indicated he felt Resident #5's allegation of neglect was unsubstantiated because S6LPN and S7CNA did not intend to neglect Resident #5. In an interview on 03/14/24 at 11:42 a.m., S2DON indicated Resident #5 reported she needed assistance to get in bed on the night of 02/08/2024, but no one came to her room to assist her. S2DON indicated Resident #5 reported to her she attempted to lift her walker to attempt to activate the call button on the wall but was unable to reach it with her walker. In an interview on 03/14/2024 at 11:47 a.m., S1DON indicated Resident #5 was neglected because the facility failed to meet her needs on the night of 02/08/2024.

Based on record review and interview the facility failed to be administered in a manner to follow their policy to provide adequate supervision to provide the safest environment possible. The facility failed to: 1) have a system in place to verify exit doors equipped with coded alert bracelet alarm systems were closing completely and working properly after being opened by visitors, staff, and/or contract workers on 7/14/12 after resident # 4 eloped from the facility 2) have a system in place to verify and monitor that the coded alert bracelet, secured to the extremity of residents identified as wanderers, correctly activated the exit door audible alarm when the resident went through the exit door on 7/14/12 after resident # 4 eloped from the facility and the audible alarm did not sound. 3) have a system in place to verify that the coded alert bracelet, secured on residents identified as wanderers, locked the closed exit doors when the resident approached the door armed with the alarm system on 7/14/12 after resident # 4 eloped from the facility through an exit door armed with the alarm system. 4) immediately conduct an investigation to determine how a confused, wandering resident ( #4) got out of the facility on 07/14/012 and crossed the road without facility staff being aware of her exit from the building. 5) have a system of monitoring in place to ensure the iron gate leading off the patio area was secured and locked at all times, to prevent confused, wandering residents from leaving the facility grounds without staff knowledge after resident # 4 eloped on 7/14/12. 6) ensure facility and contractor staff were inserviced on resident safety in regard to the proper closure of facility exit doors equipped with the " coded alert bracelet " alarm system and the iron gate to prevent a wandering resident's elopement on 7/14/12. 7) have a system in place to monitor the correct operation of the " coded alert bracelet: " door alarm system. 8) immediately check the " coded alert bracelet door alarm system " to ensure it was functioning correctly on 7/14/12 after the exit door alarm on " a " hall did not lock and did not produce an audible alarm sound when a resident (#4) wearing a coded alert bracelet exited the facility building through the door on 7/14/12. 9) implement interventions to increase direct supervision of wandering residents on 7/14/12 after a resident eloped from the facility without staff knowledge. 10) implement the facility post elopement policy and procedure to have the facility's quality assurances /improvement team review facility systems to evaluate if all systems are working properly after a confused, wandering resident # 4 wearing a coded alert bracelet device eloped from the facility without staff knowledge on 7/14/12. The immediate jeopardy (IJ) began on 7/14/12 for resident # 4, a confused resident with wandering behaviors, after he was discovered across the street from the facility by a staff member. At the time of the elopement, Resident #4 was wearing a " coded alert bracelet " device designed to lock the facility exit doors when the resident came in close proximity to any closed exit door equipped with the " Coded Alert Bracelet " alarm system. The resident's coded alert bracelet also was designed to sound an audible alarm if the exit door was open and the resident wearing the coded alert bracelet neared the door in order to alert staff of possible resident elopement or wandering out of the facility. Review of the 7/14/12 video surveillance revealed that the resident eloped through the exit door on " a " hall. After exiting the facility building, the resident went through an unsecured iron gate leading off the patio area, left the facility grounds, and crossed the street. Initially, facility staff were unaware how the resident exited the facility. The exit door alarm on " a " hall door did not lock and did not produce an audible alarm sound to alert staff of the possibility of resident elopement. The immediate jeopardy continued on 7/14/12 for resident # 4 and the other 15 residents (#4, & #9 through #22) identified by the facility as having wandering behaviors when resident # 4 was returned to the facility and the facility failed to immediately identify and implement interventions to prevent resident elopement from the facility. The IJ was lifted on 7/18/12 at 2:40pm, when an acceptable plan of removal was presented to the surveyors. The facility's plan revealed they locked the door where Resident #4 went out the facility's exit door, on hall ' a " , which then leads to an iron gate to the street. The system will be checked by the installation company, the safety ankle devices were checked on other residents at all other exits to ensure they were working correctly, signs were placed on all exit doors to ensure that visitors are aware to check with staff prior to letting resident's out the facility. The deficient practice remains at Scope/ Severity of level 2 (E), potential for more than minimum harm, pattern. Findings: Review of the facility's policy on Wandering Management, Monitoring System & Resident Elopement Protocol revealed, in part, the policy of the facility was that all residents are afforded adequate supervision to provide the safest environment possible. A missing resident shall be defined as a resident who has left the facility grounds without signing him/herself out. Further review revealed post elopement, the facility Quality Assurances /Improvement team shall review facility systems to evaluate if all systems are working properly. Review of the grievance Log dated 7/13/12 (Incident occurred on 7/14/12 a Saturday) revealed Resident #4 name and the grievance/concern was elopement, resident crossed the highway. Review of the Grievance/Incident report dated 7/14/12 revealed Elopement -Resident was observed crossing the street. The staff redirected the resident inside where she was evaluated for injury. The alarm was checked and ankle alarm was also tested . The documentation of facility follow/Up section revealed under the section titled what other action taken to resolve the incident was sign placed on doors not to assist with residents going in and out. To check with nursing staff first. Review of the facility's Incident Report Log dated 7/14/12 revealed Resident #4 was documented on for elopement and was found outside on sidewalk on 7/14/12 at 9:20am. Review of the Incident/Accident Report revealed it was dated 7/14/12 and Resident #4 was found outside the building at 9:20am. The resident was found outside on the sidewalk across the street from the facility. The resident was standing with hands behind back, had no complaints of pain and or injuries noted. Level of consciousness was confused and disoriented. Review of the facility's Accident and Incident and Grievance reports revealed no documentation of the facility's monitoring of the exit doors and iron gate to prevent the ongoing risk of elopement and/or was provided. In an interview on 7/17/12 at 10:35am, S1/Administrator stated that she was not finished with the investigation yet; she had five days to complete it and was still working on it to see what had happened. Review of the facility's Investigation follow-Up form revealed, in part, recommendations/new interventions, to make sure ankle safety device is on resident and working. Put signs up outside to inform all visitors to check with staff before allowing residents outside. The section titled Notification Summary revealed it was reported to Quality Assurance committee, family and doctor was notified. Review of Resident #4's Minimum Data Set (Assessment form) revealed it was a quarterly review assessment which was completed on 6/12/12 for Resident #4 ' s cognitive pattern. Resident #4 could not repeat words after first attempt, not able to report correct year, month, day of week, not able to recall sock, blue, and bed. Had short term and long term memory problems, was moderately impaired-decisions were poor: cues/supervision required. Review of a written statement per S6/RN Weekend Supervisor (who was working the day Resident #4 eloped) revealed it was not timed nor dated. The statement revealed a resident came to S6/RN and said that a resident came to her and said that Resident #4 went through the black iron gate off " a " hall because the gate was left open. S6/RN also put signs at every door for folks not to allow residents to exit without checking with staff. Also oriented staff to key (red fire box "b" & " c " hall nurse station) can be used to lock gate. Finally, S6/RN reminded yard man or maintenance men to ensure the gate is locked when job is finished. In an interview on 7/17/12 at 1:53pm, S4/ LPN stated that she was here the day Resident #4 eloped. She stated that she gave her (Resident #4) medication that day and was told she (Resident #4) crossed the street but 2 nursing assistants had already gotten her back into the facility, but she did not know which door she got out of. When she came back in her alarm was on her ankle and thinks maybe a family member let her out. She further stated that she checked her alarm and it was working. She stated the alarms are on all perimeters of the building. She stated that staff would be able to hear the alarm if the resident did go out through an open door. The alarm will keep alarming until someone puts the code in to shut it off. She said that the resident was asked why she went outside and the resident said she was going look for her mother. In an interview on 7/17/12 at 2:00pm, Resident #4 stated that she did not know how she left the building or why she was leaving the building. She was confused and was not cognitive enough to get an interview by the surveyor. Review of Resident #4's Nurses Notes dated 7/14/12 at 9:20am, revealed the resident was found across the street and 2 other Certified Nursing Assistants (C.N.A.) were going to get the resident. The resident was found across the street standing on sidewalk with hands behind her back saying, " I went to go see my mom ". Resident was last seen when medications were given to her. Observation on 7/18/12 at 9:05am by the surveyor revealed the street the resident had crossed had a posted speed limit of 35MPH. In an interview on 7/18/12 at 10:08am, Resident #23 stated that construction workers were working the day the resident eloped and she had witnessed them leaving the iron gate open which leads to the front of the street. In an interview on 7/18/12 at 10:15am, S5/Maintenance stated that there was constructions crews working at the facility on the day Resident #4 eloped from the building. He indicated he did not know if the construction crew had left the gate open or not and, he had explained to them about locking the gate up. He stated that he told them to make sure the gate was locked but there was no monitoring to ensure it was locked because it was on a Saturday. He further indicated that family members go out the gate at times too. In an interview on 7/19/12 at 10:25am, S2/DON stated that she was told that a guy was cutting the grass and perhaps he left the gate open but was not sure if that person did or not. She further stated that since the administrator was not here, she would look for more detailed information of an investigation since the surveyor informed her he was just presented with only a statement about one resident (#23) about the incident. In an interview on 7/18/12 at 11:00am, S1/Administrator indicated that family members do not go out the Iron Gate as maintenance had previously stated. She stated that we are still investigating how she eloped. She said that she thought the resident went out the front door and the surveillance video was not yet viewed by her. She was advised by the surveyor that the care plan revealed Resident #4 went out the back iron gate, but she stated was not aware of that yet. In an interview on 7/18/12 at 12:55pm, S5/Maintenance stated that there was a problem with the door Resident #4 took to exit out the facility. He stated he found out today the same door was not locking and he fixed the safety device system by hooking up wires to another port on the circuit so it would function properly but when he pressed on the door it would not lock. He thinks a storm on Friday (7/13/12) caused the system to quit working which allowed Resident #4 to exit the building. He further stated on Saturday 7/14/12 he called S6/RN Weekend Supervisor who found that the iron gate was not locked and told her how to reset the codes so the iron gate would lock. In an interview on 7/18/12 at 12:45pm, S7/Construction Worker, hired contractor, stated that he worked 7/14/12 and his staff at times takes garbage out the facility through the Iron Gate but made sure it was locked. Review of the security camera on 7/18/12 at 1:50pm by two surveyors revealed Resident #4 opened the facility's closed door near hall " a " at 9:18am and exited the building. Further review revealed at 9:23am the resident was brought back into the facility through another door per staff. Review of S5/Maintenance written statement dated 7/18/12 at 2:30pm revealed, in part, he talked to the weekend supervisor on the telephone how to lock the gate. On Monday, 7/16/12 (the following Monday) he checked the iron gate and it was locked. On 7/18/12 at 9:00am, S5/Maintenance discovered the wall panel for the back door where Resident #4 went out of had two ports blown out from the electrical surge and he rewired a fixed problem. He then locked the door down because ankle safety device would not be working at this time. In an interview on 7/18/12 at 4:00pm, S5/Maintenance stated that he was fishing at the time when the weekend supervisor called him about the back gate not locking. He said that the facility does not have a policy for him to come in and check on the safety device system to prevent wandering but it is understood that he should come in to check on the ankle safety device and fire alarm system. Review of a written statement presented on 7/18/12 at approximately 4:00pm revealed it was a statement per S6/Weekend Supervisor. This statement was not dated and/or timed. The statement revealed, in part, she (Weekend Supervisor) received a report from the 4 floor nurses. She was informed Resident #4 was found near the street by C.N.A who escorted her back into the facility. She immediately found Resident #4, provided and assessment and ensured her safety device was functioning properly. She determined it to be properly working. She then went to each door in the facility to verify that door locks were functioning correctly. Upon assessment of " a " hall patio, she determined that the gate was unlocked. She texted the administrator to inform her that the black iron gate off of " a " hall patio was unlocked and could not be locked. She (Administrator) texted me and said it should autolock but to call maintenance as soon as possible. She (Weekend Supervisor) immediately called maintenance and stayed on the phone as he (maintenance) gave her the instructions on now to reactivate the lock on the gate. I removed the key from " c " hall firebox and used the attached barrel key to reactivate the lock on the gate. She inserviced the four hall nurses (one of which was S4/LPN as interviewed above) of how to reactivate the lock by using the key from the firebox and the importance of ensuring the gate is locked at all times. She then posted a sign at every door in the facility stating not to let a resident exit the building unless checking with staff first. The signs were posted as a safety measure because it was undetermined how the resident exited the building. As she was posting signs, Resident #23 came to her and said that she thought Resident#4 had exited through the black iron gate from the patio on " a " hall. Review of S1/Administrator's written Statement dated July 18, 2012 revealed, in part, she was contacted by S4/LPN on July 14, 2012 and was told Resident #4 was found outside the facility crossing the road by a family. S4/LPN was instructed to put signs at all exit doors and talk with staff about not allowing visitors to let residents out the door. The weekend manager along with S4/LPN checked all doors to ensure they were working properly. Resident #4's alarm was also checked to ensure it was working properly. Review of S4/LPN written statement about the incident dated July 18, 2012, revealed, in part, the administrator was called about the Resident #4 found across the street. A head to toe assessment was done on the resident and tested the ankle safety device functioning as well as doors. The administrator informed S4/LPN to place signs on doors to inform visitors to check with staff before allowing any resident out of the doors. All instructions were followed through instantly and thoroughly per administrator request. In an interview on 7/18/12 at 4:15pm, S1/Administrator stated that maintenance was called to come to the facility on the Saturday the day the resident eloped by the weekend supervisor. The weekend supervisor monitored the doors when she found out the gate was not working. S1/Administrator stated that the weekend supervisor contacted maintenance and if maintenance did not come then she would have come to the facility. She further indicated maintenance called her on the telephone and the issue was taken care of. If the issue was not taken care of then she would have come to the facility.

Based on record review and interview the facility failed to provide adequate supervision and monitoring to prevent a confused, wandering resident (#4) from eloping from the facility and crossing the street. The facility identified 15 residents (#4, & #9 through #22) as having wandering behaviors. The facility failed to: 1) verify that exit doors equipped with coded alert bracelet alarm systems were closing completely and working properly after being opened by visitors, staff, and/or contract workers on 7/14/12 after resident # 4 eloped from the facility 2) verify that the coded alert bracelet, secured to the extremity of residents identified as wanderers, correctly activated the exit door audible alarm when the resident went through the exit door on 7/14/12 after resident # 4 eloped from the facility and the audible alarm did not sound. 3) verify that the coded alert bracelet, secured on residents identified as wanderers, locked the closed exit doors when the resident approached the door armed with the alarm system on 7/14/12 after resident # 4 eloped from the facility through an exit door armed with the alarm system. 4) immediately conduct an investigation to determine how a confused, wandering resident ( #4) got out of the facility on 07/14/012 and crossed the road without facility staff being aware of her exit from the building. 5) verify and monitor the iron gate leading off the patio area to ensure it was secured and locked at all times, to prevent confused, wandering residents from leaving the facility grounds without staff knowledge after resident # 4 eloped on 7/14/12. 6) ensure facility and contractor staff were inserviced on resident safety in regard to the proper closure of facility exit doors equipped with the " coded alert bracelet " alarm system and the iron gate to prevent a wandering resident's elopement on 7/14/12. 7) have a system in place to monitor the correct operation of the " coded alert bracelet: " door alarm system. 8) immediately check the " coded alert bracelet door alarm system " to ensure it was functioning correctly on 7/14/12 after the exit door alarm on " a " hall did not lock and did not produce an audible alarm sound when A resident (#4) wearing a coded alert bracelet exited the facility building through the door on 7/14/12. 9) implement interventions to increase direct supervision of wandering residents on 7/14/12 after a resident eloped from the facility without staff knowledge. The immediate jeopardy (IJ) began on 7/14/12 for resident # 4, a confused resident with wandering behaviors, after he was discovered across the street from the facility by a staff member. At the time of the elopement, Resident #4 was wearing a " coded alert bracelet " device designed to lock the facility exit doors when the resident came in close proximity to any closed exit door equipped with the " Coded Alert Bracelet " alarm system. The resident's coded alert bracelet also was designed to sound an audible alarm if the exit door was open and the resident wearing the coded alert bracelet neared the door in order to alert staff of possible resident elopement or wandering out of the facility. Review of the 7/14/12 video surveillance revealed that the resident eloped through the exit door on " a " hall. After exiting the facility building, the resident went through an unsecured iron gate leading off the patio area, left the facility grounds, and crossed the street. Initially, facility staff were unaware how the resident exited the facility. The exit door alarm on " a " hall door did not lock and did not produce an audible alarm sound to alert staff of the possibility of resident elopement. The immediate jeopardy continued on 7/14/12 for resident # 4 and the other 15 residents (#4, & #9 through #22) identified by the facility as having wandering behaviors when resident # 4 was returned to the facility and the facility failed to immediately identify and implement interventions to prevent resident elopement from the facility. The IJ was lifted on 7/18/12 at 2:40pm, when an acceptable plan of removal was presented to the surveyors. The facility's plan revealed they locked the door where Resident #4 went out the facility's exit door, on hall ' a " , which then leads to an iron gate to the street. The system will be checked by the installation company, the safety ankle devices were checked on other residents at all other exits to ensure they were working correctly, signs were placed on all exit doors to ensure that visitors are aware to check with staff prior to letting resident's out the facility. The deficient practice remains at Scope/ Severity of level 2 (E), potential for more than minimum harm, pattern. Findings: Review of the facility's policy on Wandering Management, Monitoring System & Resident Elopement Protocol revealed, in part, the policy of the facility was that all residents are afforded adequate supervision to provide the safest environment possible. A missing resident shall be defined as a resident who has left the facility grounds without signing him/herself out. Further review revealed post elopement, the facility Quality Assurances /Improvement team shall review facility systems to evaluate if all systems are working properly. Review of the grievance Log dated 7/13/12 (Incident occurred on 7/14/12 a Saturday) revealed Resident #4 name and the grievance/concern was elopement, resident crossed the highway. Review of the Grievance/Incident report dated 7/14/12 revealed Elopement -Resident was observed crossing the street. The staff redirected the resident inside where she was evaluated for injury. The alarm was checked and ankle alarm was also tested . The documentation of facility follow/Up section revealed under the section titled what other action taken to resolve the incident was sign placed on doors not to assist with residents going in and out. To check with nursing staff first. Review of the facility's Incident Report Log dated 7/14/12 revealed Resident #4 was documented on for elopement and was found outside on sidewalk on 7/14/12 at 9:20am. Review of the Incident/Accident Report revealed it was dated 7/14/12 and Resident #4 was found outside the building at 9:20am. The resident was found outside on the sidewalk across the street from the facility. The resident was standing with hands behind back, had no complaints of pain and or injuries noted. Level of consciousness was confused and disoriented. Review of the facility's Accident and Incident and Grievance reports revealed no documentation of the facility's monitoring of the exit doors and iron gate to prevent the ongoing risk of elopement and/or was provided. In an interview on 7/17/12 at 10:35am, S1/Administrator stated that she was not finished with the investigation yet; she had five days to complete it and was still working on it to see what had happened. Review of the facility's Investigation follow-Up form revealed, in part, recommendations/new interventions, to make sure ankle safety device is on resident and working. Put signs up outside to inform all visitors to check with staff before allowing residents outside. The section titled Notification Summary revealed it was reported to Quality Assurance committee, family and doctor was notified. Review of Resident #4's Minimum Data Set (Assessment form) revealed it was a quarterly review assessment which was completed on 6/12/12 for Resident #4 ' s cognitive pattern. Resident #4 could not repeat words after first attempt, not able to report correct year, month, day of week, not able to recall sock, blue, and bed. Had short term and long term memory problems, was moderately impaired-decisions were poor: cues/supervision required. Review of a written statement per S6/RN Weekend Supervisor (who was working the day Resident #4 eloped) revealed it was not timed nor dated. The statement revealed a resident came to S6/RN and said that a resident came to her and said that Resident #4 went through the black iron gate off " a " hall because the gate was left open. S6/RN also put signs at every door for folks not to allow residents to exit without checking with staff. Also oriented staff to key (red fire box "b" & " c " hall nurse station) can be used to lock gate. Finally, S6/RN reminded yard man or maintenance men to ensure the gate is locked when job is finished. In an interview on 7/17/12 at 1:53pm, S4/ LPN stated that she was here the day Resident #4 eloped. She stated that she gave her (Resident #4) medication that day and was told she (Resident #4) crossed the street but 2 nursing assistants had already gotten her back into the facility, but she did not know which door she got out of. When she came back in her alarm was on her ankle and thinks maybe a family member let her out. She further stated that she checked her alarm and it was working. She stated the alarms are on all perimeters of the building. She stated that staff would be able to hear the alarm if the resident did go out through an open door. The alarm will keep alarming until someone puts the code in to shut it off. She said that the resident was asked why she went outside and the resident said she was going look for her mother. In an interview on 7/17/12 at 2:00pm, Resident #4 stated that she did not know how she left the building or why she was leaving the building. She was confused and was not cognitive enough to get an interview by the surveyor. Review of Resident #4's Nurses Notes dated 7/14/12 at 9:20am, revealed the resident was found across the street and 2 other Certified Nursing Assistants (C.N.A.) were going to get the resident. The resident was found across the street standing on sidewalk with hands behind her back saying, " I went to go see my mom ". Resident was last seen when medications were given to her. Observation on 7/18/12 at 9:05am by the surveyor revealed the street the resident had crossed had a posted speed limit of 35MPH. In an interview on 7/18/12 at 10:08am, Resident #23 stated that construction workers were working the day the resident eloped and she had witnessed them leaving the iron gate open which leads to the front of the street. In an interview on 7/18/12 at 10:15am, S5/Maintenance stated that there was constructions crews working at the facility on the day Resident #4 eloped from the building. He indicated he did not know if the construction crew had left the gate open or not and, he had explained to them about locking the gate up. He stated that he told them to make sure the gate was locked but there was no monitoring to ensure it was locked because it was on a Saturday. He further indicated that family members go out the gate at times too. In an interview on 7/19/12 at 10:25am, S2/DON stated that she was told that a guy was cutting the grass and perhaps he left the gate open but was not sure if that person did or not. She further stated that since the administrator was not here, she would look for more detailed information of an investigation since the surveyor informed her he was just presented with only a statement about one resident (#23) about the incident. In an interview on 7/18/12 at 11:00am, S1/Administrator indicated that family members do not go out the Iron Gate as maintenance had previously stated. She stated that we are still investigating how she eloped. She said that she thought the resident went out the front door and the surveillance video was not yet viewed by her. She was advised by the surveyor that the care plan revealed Resident #4 went out the back iron gate, but she stated was not aware of that yet. In an interview on 7/18/12 at 12:55pm, S5/Maintenance stated that there was a problem with the door Resident #4 took to exit out the facility. He stated he found out today the same door was not locking and he fixed the safety device system by hooking up wires to another port on the circuit so it would function properly but when he pressed on the door it would not lock. He thinks a storm on Friday (7/13/12) caused the system to quit working which allowed Resident #4 to exit the building. He further stated on Saturday 7/14/12 he called S6/RN Weekend Supervisor who found that the iron gate was not locked and told her how to reset the codes so the iron gate would lock. In an interview on 7/18/12 at 12:45pm, S7/Construction Worker, hired contractor, stated that he worked 7/14/12 and his staff at times takes garbage out the facility through the Iron Gate but made sure it was locked. Review of the security camera on 7/18/12 at 1:50pm by two surveyors revealed Resident #4 opened the facility's closed door near hall " a " at 9:18am and exited the building. Further review revealed at 9:23am the resident was brought back into the facility through another door per staff. Review of S5/Maintenance written statement dated 7/18/12 at 2:30pm revealed, in part, he talked to the weekend supervisor on the telephone how to lock the gate. On Monday, 7/16/12 (the following Monday) he checked the iron gate and it was locked. On 7/18/12 at 9:00am, S5/Maintenance discovered the wall panel for the back door where Resident #4 went out of had two ports blown out from the electrical surge and he rewired a fixed problem. He then locked the door down because ankle safety device would not be working at this time. In an interview on 7/18/12 at 4:00pm, S5/Maintenance stated that he was fishing at the time when the weekend supervisor called him about the back gate not locking. He said that the facility does not have a policy for him to come in and check on the safety device system to prevent wandering but it is understood that he should come in to check on the ankle safety device and fire alarm system. Review of a written statement presented on 7/18/12 at approximately 4:00pm revealed it was a statement per S6/Weekend Supervisor. This statement was not dated and/or timed. The statement revealed, in part, she (Weekend Supervisor) received a report from the 4 floor nurses. She was informed Resident #4 was found near the street by C.N.A who escorted her back into the facility. She immediately found Resident #4, provided and assessment and ensured her safety device was functioning properly. She determined it to be properly working. She then went to each door in the facility to verify that door locks were functioning correctly. Upon assessment of " a " hall patio, she determined that the gate was unlocked. She texted the administrator to inform her that the black iron gate off of " a " hall patio was unlocked and could not be locked. She (Administrator) texted me and said it should autolock but to call maintenance as soon as possible. She (Weekend Supervisor) immediately called maintenance and stayed on the phone as he (maintenance) gave her the instructions on now to reactivate the lock on the gate. I removed the key from " c " hall firebox and used the attached barrel key to reactivate the lock on the gate. She inserviced the four hall nurses (one of which was S4/LPN as interviewed above) of how to reactivate the lock by using the key from the firebox and the importance of ensuring the gate is locked at all times. She then posted a sign at every door in the facility stating not to let a resident exit the building unless checking with staff first. The signs were posted as a safety measure because it was undetermined how the resident exited the building. As she was posting signs, Resident #23 came to her and said that she thought Resident#4 had exited through the black iron gate from the patio on " a " hall. Review of S1/Administrator's written Statement dated July 18, 2012 revealed, in part, she was contacted by S4/LPN on July 14, 2012 and was told Resident #4 was found outside the facility crossing the road by a family. S4/LPN was instructed to put signs at all exit doors and talk with staff about not allowing visitors to let residents out the door. The weekend manager along with S4/LPN checked all doors to ensure they were working properly. Resident #4's alarm was also checked to ensure it was working properly. Review of S4/LPN written statement about the incident dated July 18, 2012, revealed, in part, the administrator was called about the Resident #4 found across the street. A head to toe assessment was done on the resident and tested the ankle safety device functioning as well as doors. The administrator informed S4/LPN to place signs on doors to inform visitors to check with staff before allowing any resident out of the doors. All instructions were followed through instantly and thoroughly per administrator request. In an interview on 7/18/12 at 4:15pm, S1/Administrator stated that maintenance was called to come to the facility on the Saturday the day the resident eloped by the weekend supervisor. The weekend supervisor monitored the doors when she found out the gate was not working. S1/Administrator stated that the weekend supervisor contacted maintenance and if maintenance did not come then she would have come to the facility. She further indicated maintenance called her on the telephone and the issue was taken care of. If the issue was not taken care of then she would have come to the facility.

Based on interview and record review the facility failed to ensure that residents were free of any significant medication errors for 1 (#96) of 43 stage 2 residents out of a facility census of 98. The facility failed to ensure: 1. Resident #96 was not given another resident's medication. 2. That nursing staff was able to correctly identify each resident before administering their medication. 3. The facility's system for identifying residents was being enforced. Resident #96 was in immediate jeopardy on 3/27/12 at 9:30 a.m when she received 21 medications ordered for another resident. The nurse did not make a positive identification of Resident #96 before administering the medications to the resident. Resident #96 received another resident's medication which included cardiac medication , antihypertensive medications and antidiabetic medications. The resident was transferred to the hospital where the Physician Progress Record/Note under Assessment and Plan revealed the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] and required intravenous fluids and monitoring for the effects of the medications. The resident remained in the hospital until 3/29/12. The immediate jeopardy ended on 3/27/12 at 12:20 p.m. when the ambulance left the facility and transported the resident to the hospital. This deficient practice continued at a actual harm for Resident #96 and a level 2 for all residents remaining in the facility who received medications. Findings: Resident #96 A review of the facility's policy and procedure on medication administration revealed in part the following: Resident Rights: The nurse should identify the residents by either a picture, name, or armband if available. A review of the clinical record for Resident #96 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set for the resident with an Assessment Reference Date of 2/24/12 revealed a BIMS score of 7 (Severely Impaired). An interview was held on 3/29/12 at 10:15 a.m. with S14LPN. She stated she was not working with Resident #96 on 3/27/12 when she gave her medications intended for another resident in error. S14LPN said Resident #96 was sitting in the front lobby in a wheelchair by the nurses' station. She said on 3/27/12 at 9:30 a.m. she prepared the following medications due for administration to another resident and gave them in error to Resident #96: [MEDICATION NAME] 200 mg (used to treat excessive sleepiness) [MEDICATION NAME] 40 mg (used to treat depression) [MEDICATION NAME] 0.125 mg (a heart medication) [MEDICATION NAME] 30 mg extended release (used to treat chest pain) Losartan Potassium 50 mg (used to treat high blood pressure) Pantoprazole 40 mg (used to treat reflux) Potassium Chloride 40 mEq Aspirin 81 mg [MEDICATION NAME] 15 mg (used to treat depression) [MEDICATION NAME] 100 mg (a stool softener) [MEDICATION NAME] 60 mg (used to treat depression) [MEDICATION NAME] 40 mg (a pill to decrease fluid) [MEDICATION NAME] 150 mg (prevents blood clotting) [MEDICATION NAME] 5 mg (used to treat diabetes) [MEDICATION NAME] 500 mg (used to treat diabetes) [MEDICATION NAME] 50 mg (used to treat high blood pressure) [MEDICATION NAME] 5 mg (used for overactive bladder) [MEDICATION NAME] 500 mg (an antibiotic) [MEDICATION NAME] 240 mg (used to control chest pain) Folic Acid 1 mg (a supplement) [MEDICATION NAME] 10 mg (used to treat high cholesterol) S14LPN said she usually asked the residents' their names prior to giving the medications, but on the morning of 3/27/12 she did not ask Resident #96 her name. She said she realized "sometime after 11:00 a.m." that she had given Resident #96 medications intended for another resident when she saw the resident in physical therapy who should have gotten the above medications. S14LPN stated when she realized she had made the error she found Resident #96 to find out her name. She saw Resident #96 in the hall sitting in a wheelchair. She said she asked S4LPN Resident #96's name and reported to S3ADON the medication error she had made. She said she did not tell S4LPN at that time she had made the medication error. S14LPN stated she pulled the MAR for the resident whose medicines she had given to Resident #96 in error and gave it to S3ADON. She revealed she did not chart the error on Resident #96's clinical record nor did she do any assessment of Resident #96 after the medication error. An interview was held on 3/29/12 at 11:45 a.m. with S4LPN. She stated she worked on 3/27/12 and was assigned Resident #96. She said she gave Resident #96 her routine medications around 9:00 a.m. on 3/27/12 as ordered which included the following: [MEDICATION NAME] 10 mg (used to treat [MEDICAL CONDITION]) [MEDICATION NAME] 30 mg (used to treat depression) [MEDICATION NAME] 15 mg (used to treat overactive bladder) [MEDICATION NAME] 20/12.5 mg (used to treat high blood pressure) [MEDICATION NAME] 1 scoop in water (a laxative) [MEDICATION NAME] 7.5 mg ( a pain medication) S4LPN continued to say that she recalled S14LPN asking her the name of Resident #96 who was sitting in the hallway in her wheelchair but she did not recall what time it was. She also said before lunch on 3/27/12, S3ADON brought Resident #96 to her and told her the resident had been given medications in error. S4LPN stated the doctor was notified of the resident getting 21 medications in error, an ambulance was called and the resident was sent out to the hospital at "around 11:00 a.m." on 3/27/12. On 3/29/12 at 1:10 p.m. an interview was held with S3ADON. She stated on 3/27/12, S14LPN reported she had given 21 medications in error to Resident #96. S3ADON said she reported the incident to S2CorporateNurse. She continued to say the resident was sent out to the hospital on [DATE] for monitoring related to the medication error. On 3/29/12 at 12:12 p.m. an interview was held with S2CorporateNurse. She stated S3ADON notified her of the medication error on Resident #96 on 3/27/12. She continued said the facility's policy for identification of resident's during medication administration was to have pictures of the residents on the MAR. S2CorporateNurse said it was good nursing practice to have the pictures on the MAR for resident identification. She continued to say she had found out on 3/27/12 pictures were not on all the MARs for resident identification. She also said the pictures had not been placed on the MARs until 3/29/12 at 12:00 p.m. A review of the MAR's were done on 3/29/12 at 11:45 a.m. There was no picture on the MAR indicated [REDACTED]. A review of the hospital's Emergency Department Physician Medical Record for Resident #96 revealed she arrived at the hospital on [DATE] at 12:32 p.m. Further review of the record revealed in part the following: History of Present Illness: The quality is acute. The severity is moderate. The duration is since this afternoon. The timing is abrupt. Patient is ...who lives at a nursing home, she is sent here for admission for observation after she was given multiple medications belonging to another resident; medications include hypoglycemic and antihypertensive. See nurse's notes for list of medicines. A review of the hospitals Physician Progress Record/Note revealed in part the following: Assessment and Plan: 1. [MEDICAL CONDITION]: Secondary to adverse medication effects. Will continue to monitor her blood pressure closely and continue to observe her overnight on the telemetry unit. Continue to decrease rate of intravenous fluids. 2. [MEDICAL CONDITION]: Slowly improving. continue to monitor. A review of the Emergency Department Nursing Medical Record dated 3/27/12 at 12:32 p.m. revealed in part the following: History of Present Illness: Complains of Ingestion ...EMT's report patient was given another patients medications in error this a.m. The wrong medications are as follows: [MEDICATION NAME] 150 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 5 mg, Potassium Chloride 40 mEq, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 240 mg, Folic Acid 1 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 1 gm. Aspirin 81 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 0.125 mg, [MEDICATION NAME] ER 30 mg, Losartan 50 mg. Patient also received her own morning medications ... Triage Vital Signs: 3/27/12 12:38 p.m. Temperature 98.2 BP: 89/53mmHG Pulse 56 Nursing Notes: 3/27/12 12:56 p.m. Blood Glucose performed; 70 mg/dl (Normal 70-110); MD notified. Medication, Intravenous (IV) Fluids ...Orders: 3/27/12 2:45 p.m. Normal Saline IV Solution 500 ml Rate: Wide open pump. Intake and Output: 3/27/12 3:11 p.m. IV 500 ml total Vital Signs: 3/27/12 1:06 p.m. BP 91/47 3/27/12 1:35 p.m. BP 98/55 Review of the Hospital Laboratory Results for Resident #96 revealed the following tests/blood work was obtained on the resident during her hospitalization : 3/27/12 at 12:29 p.m. 12-lead ECG: Results: Sinus [MEDICAL CONDITION]. 3/27/12 at 1:00 p.m. A Complete Blood Count, A Chemistry Panel, A [MEDICATION NAME] Time, An INR and a PTT Activity 3/27/12 at 2:48 p.m. [MEDICATION NAME] Level 3/28/12 at 4:07 a.m. A Complete Blood Count and a Chemistry Panel: 3/28/12 at 12:58 p.m. A hemoglobin and hematocrit

Based on interview and record review the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical mental and psychosocial well- being for 1 (#96) of 43 stage 2 residents with a facility census of 98. The facility failed to ensure: 1. Resident #96 was not given another resident's medication. 2. That nursing staff was able to correctly identify each resident before administering their medication. 3. The facility's system for identifying residents was being enforced. 4. The resident's photograph was placed in the MAR book. 5. The facility's policy for resident identification prior to medication administration was followed. Resident #96 was in an immediate jeopardy on 3/27/12 at 9:30 a.m. when she received 21 medications ordered for another resident. The nurse did not make a positive identification of Resident #96 before administering the medications to the resident. Resident #96 received another resident's medication which included cardiac medication , antihypertensive medications and antidiabetic medications. The resident was transferred to the hospital where the Physician Progress Record/Note under Assessment and Plan revealed the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] and required intravenous fluids and monitoring for the effects of the medications. The immediate jeopardy ended on 3/27/12 at 12:20 p.m. when the resident was transferred out of the facility to the hospital. This deficient practice continued at Actual Harm for Resident #96 and a level 2 for all residents remaining in the facility who received medications. Findings: Resident #96 A review of the facility's policy and procedure on medication administration revealed in part the following: Resident Rights: ...The nurse should identify the residents by either a picture, name, or armband if available... A review of the clinical record for Resident #96 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set for the resident with an Assessment Reference Date of 2/24/12 revealed a BIMS score of 7 (Severely Impaired). An interview was held on 3/29/12 at 10:15 a.m. with S14LPN. She stated she was not working with Resident #96 on 3/27/12 when she gave her medications intended for another resident in error. S14LPN said Resident #96 was sitting in the front lobby in a wheelchair by the nurses' station. She said on 3/27/12 at 9:30 a.m. she prepared the following medications due for administration to another resident and gave them in error to Resident #96: [MEDICATION NAME] 200 mg (used to treat excessive sleepiness) [MEDICATION NAME] 40 mg (used to treat depression) [MEDICATION NAME] 0.125 mg (a heart medication) [MEDICATION NAME] 30 mg extended release (used to treat chest pain) Losartan Potassium 50 mg (used to treat high blood pressure) Pantoprazole 40 mg (used to treat reflux) Potassium Chloride 40 mEq Aspirin 81 mg [MEDICATION NAME] 15 mg (used to treat depression) [MEDICATION NAME] 100 mg (a stool softener) [MEDICATION NAME] 60 mg (used to treat depression) [MEDICATION NAME] 40 mg (a pill to decrease fluid) [MEDICATION NAME] 150 mg (prevents blood clotting) [MEDICATION NAME] 5 mg (used to treat diabetes) [MEDICATION NAME] 500 mg (used to treat diabetes) [MEDICATION NAME] 50 mg (used to treat high blood pressure) [MEDICATION NAME] 5 mg (used for overactive bladder) [MEDICATION NAME] 500 mg (an antibiotic) [MEDICATION NAME] 240 mg (used to control chest pain) Folic Acid 1 mg (a supplement) [MEDICATION NAME] 10 mg (used to treat high cholesterol) S14LPN said she usually asked the residents' their names prior to giving the medications, but on the morning of 3/27/12 she did not ask Resident #96 her name. She said she realized "sometime after 11:00 a.m." that she had given Resident #96 medications intended for another resident when she saw the resident in physical therapy who should have gotten the above medications. S14LPN stated when she realized she had made the error she found Resident #96 to find out her name. She saw Resident #96 in the hall sitting in a wheelchair. She said she asked S4LPN Resident #96's name and reported to S3ADON the medication error she had made. She said she did not tell S4LPN at that time she had made the medication error. S14LPN stated she pulled the MAR for the resident whose medicines she had given to Resident #96 in error and gave it to S3ADON. She revealed she did not chart the error on Resident #96's clinical record nor did she do any assessment of Resident #96 after the medication error. An interview was held on 3/29/12 at 11:45 a.m. with S4LPN. She stated she worked on 3/27/12 and was assigned Resident #96. She said she gave Resident #96 her routine medications around 9:00 a.m. on 3/27/12 as ordered which included the following: [MEDICATION NAME] 10 mg (used to treat [MEDICAL CONDITION]) [MEDICATION NAME] 30 mg (used to treat depression) [MEDICATION NAME] 15 mg (used to treat overactive bladder) [MEDICATION NAME] 20/12.5 mg (used to treat high blood pressure) [MEDICATION NAME] 1 scoop in water (a laxative) [MEDICATION NAME] 7.5 mg ( a pain medication) S4LPN continued to say that she recalled S14LPN asking her the name of Resident #96 who was sitting in the hallway in her wheelchair but she did not recall what time it was. She also said before lunch on 3/27/12, S3ADON brought Resident #96 to her and told her the resident had been given medications in error. S4LPN stated the doctor was notified of the resident getting 21 medications in error, an ambulance was called and the resident was sent out to the hospital at "around 11:00 a.m." on 3/27/12. On 3/29/12 at 1:10 p.m. an interview was held with S3ADON. She stated on 3/27/12, S14LPN reported she had given 21 medications in error to Resident #96. S3ADON said she reported the incident to S2CorporateNurse. She continued to say the resident was sent out to the hospital on [DATE] for monitoring related to the medication error. On 3/29/12 at 12:12 p.m. an interview was held with S2CorporateNurse. She stated S3ADON notified her of the medication error on Resident #96 on 3/27/12. She continued said the facility's policy for identification of resident's during medication administration was to have pictures of the residents on the MAR. S2CorporateNurse said it was good nursing practice to have the pictures on the MAR for resident identification. She continued to say she had found out on 3/27/12 pictures were not on all the MARs for resident identification. She also said the pictures had not been placed on the MARs until 3/29/12 at 12:00 p.m. A review of the MAR's were done on 3/29/12 at 11:45 a.m. There was no picture on the MAR indicated [REDACTED]. A review of the hospital's Emergency Department Physician Medical Record for Resident #96 revealed she arrived at the hospital on [DATE] at 12:32 p.m. Further review of the record revealed in part the following: History of Present Illness: The quality is acute. The severity is moderate. The duration is since this afternoon. The timing is abrupt. Patient is ...who lives at a nursing home, she is sent here for admission for observation after she was given multiple medications belonging to another resident; medications include hypoglycemic and antihypertensive. See nurse's notes for list of medicines. A review of the hospitals Physician Progress Record/Note revealed in part the following: Assessment and Plan: 1. [MEDICAL CONDITION]: Secondary to adverse medication effects. Will continue to monitor her blood pressure closely and continue to observe her overnight on the telemetry unit. Continue to decrease rate of intravenous fluids. 2. [MEDICAL CONDITION]: Slowly improving. continue to monitor. A review of the Emergency Department Nursing Medical Record dated 3/27/12 at 12:32 p.m. revealed in part the following: History of Present Illness: Complains of Ingestion ...EMT's report patient was given another patients medications in error this a.m. The wrong medications are as follows: [MEDICATION NAME] 150 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 5 mg, Potassium Chloride 40 mEq, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 240 mg, Folic Acid 1 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 1 gm. Aspirin 81 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 0.125 mg, [MEDICATION NAME] ER 30 mg, Losartan 50 mg. Patient also received her own morning medications ... Triage Vital Signs: 3/27/12 12:38 p.m. Temperature 98.2 BP: 89/53mmHG Pulse 56 Nursing Notes: 3/27/12 12:56 p.m. Blood Glucose performed; 70 mg/dl (Normal 70-110); MD notified. Medication, Intravenous (IV) Fluids ...Orders: 3/27/12 2:45 p.m. Normal Saline IV Solution 500 ml Rate: Wide open pump. Intake and Output: 3/27/12 3:11 p.m. IV 500 ml total Vital Signs: 3/27/12 1:06 p.m. BP 91/47 3/27/12 1:35 p.m. BP 98/55 Review of the Hospital Laboratory Results for Resident #96 revealed the following tests/blood work was obtained on the resident during her hospitalization : 3/27/12 at 12:29 p.m. 12-lead ECG: Results: Sinus [MEDICAL CONDITION]. 3/27/12 at 1:00 p.m. A Complete Blood Count, A Chemistry Panel, A [MEDICATION NAME] Time, An INR and a PTT Activity 3/27/12 at 2:48 pm. [MEDICATION NAME] Level 3/28/12 at 4:07 a.m. A Complete Blood Count and a Chemistry Panel: 3/28/12 at 12:58 p.m. A hemoglobin and hematocrit

Based on observation, interview and record review the facility failed provide pharmaceutical services to ensure medications were accurately administered for 1 (#96) of 43 stage 2 residents reviewed with a facility census of 98. The facility failed to ensure: 1. Resident#96 was not administered another residents medication. 2. That nursing staff was able to correctly identify each resident before administering their medication. 3. The facility's system for identifying residents was being enforced. . Resident #96 was in immediate jeopardy on 3/27/12 at 9:30 a.m. when she received 21 medications ordered for another resident. The nurse did not make a positive identification of Resident #96 before administering the medications to the resident. Resident #96 received another resident's medication which included cardiac medication , antihypertensive medications and antidiabetic medications. The resident was transferred to the hospital where the Physician Progress Record/Note under Assessment and Plan revealed the resident had hypotension and bradycardia and required intravenous fluids and monitoring for the effects of the medications. The immediate jeopardy ended on 3/27/12 at 12:20 p.m. when the ambulance left the facility and transported the resident to the hospital. This deficient practice continued at Actual Harm for Resident#96 and a level 2 for all residents remaining in the facility who received medications. Findings: Resident #96 A review of the facility's policy and procedure on medication administration revealed in part the following: Resident Rights: ...The nurse should identify the residents by either a picture, name, or armband if available... A review of the facility ' s Policy and Procedure for Pharmaceutical Care in the Long-Term Care Setting revealed in part: d. Identify resident before administering medication. A review of the clinical record for Resident #96 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set for the resident with an Assessment Reference Date of 2/24/12 revealed a BIMS score of 7 (Severely Impaired). An interview was held on 3/29/12 at 10:15 a.m. with S14LPN. She stated she was not working with Resident #96 on 3/27/12 when she gave her medications intended for another resident in error. S14LPN said Resident #96 was sitting in the front lobby in a wheelchair by the nurses' station. She said on 3/27/12 at 9:30 a.m. she prepared the following medications due for administration to another resident and gave them in error to Resident #96: Provigil 200 mg (used to treat excessive sleepiness) Citalopram 40 mg (used to treat depression) Digoxin 0.125 mg (a heart medication) Isosorbide mononitrate 30 mg extended release (used to treat chest pain) Losartan Potassium 50 mg (used to treat high blood pressure) Pantoprazole 40 mg (used to treat reflux) Potassium Chloride 40 mEq Aspirin 81 mg Deplin 15 mg (used to treat depression) Colace 100 mg (a stool softener) Cymbalta 60 mg (used to treat depression) Lasix 40 mg (a pill to decrease fluid) Pradaxa 150 mg (prevents blood clotting) Glyburide 5 mg (used to treat diabetes) Metformin 500 mg (used to treat diabetes) Metoprolol 50 mg (used to treat high blood pressure) Oxybutynin 5 mg (used for overactive bladder) Ampicillin 500 mg (an antibiotic) Cardizem 240 mg (used to control chest pain) Folic Acid 1 mg (a supplement) Pravastatin 10 mg (used to treat high cholesterol) S14LPN said she usually asked the residents' their names prior to giving the medications, but on the morning of 3/27/12 she did not ask Resident #96 her name. She said she realized "sometime after 11:00 a.m." that she had given Resident #96 medications intended for another resident when she saw the resident in physical therapy who should have gotten the above medications. S14LPN stated when she realized she had made the error she found Resident #96 to find out her name. She saw Resident #96 in the hall sitting in a wheelchair. She said she asked S4LPN Resident #96's name and reported to S3ADON the medication error she had made. She said she did not tell S4LPN at that time she had made the medication error. S14LPN stated she pulled the MAR for the resident whose medicines she had given to Resident #96 in error and gave it to S3ADON. She revealed she did not chart the error on Resident #96's clinical record nor did she do any assessment of Resident #96 after the medication error. An interview was held on 3/29/12 at 11:45 a.m. with S4LPN. She stated she worked on 3/27/12 and was assigned Resident #96. She said she gave Resident #96 her routine medications around 9:00 a.m. on 3/27/12 as ordered which included the following: Namenda 10 mg (used to treat Alzheimer's disease) Cymbalta 30 mg (used to treat depression) Enablex 15 mg (used to treat overactive bladder) Prinzide 20/12.5 mg (used to treat high blood pressure) Miralax 1 scoop in water (a laxative) Lortab 7.5 mg ( a pain medication) S4LPN continued to say that she recalled S14LPN asking her the name of Resident #96 who was sitting in the hallway in her wheelchair but she did not recall what time it was. She also said before lunch on 3/27/12, S3ADON brought Resident #96 to her and told her the resident had been given medications in error. S4LPN stated the doctor was notified of the resident getting 21 medications in error, an ambulance was called and the resident was sent out to the hospital at "around 11:00 a.m." on 3/27/12. On 3/29/12 at 1:10 p.m. an interview was held with S3ADON. She stated on 3/27/12, S14LPN reported she had given 21 medications in error to Resident #96. S3ADON said she reported the incident to S2CorporateNurse. She continued to say the resident was sent out to the hospital on [DATE] for monitoring related to the medication error. On 3/29/12 at 12:12 p.m. an interview was held with S2CorporateNurse. She stated S3ADON notified her of the medication error on Resident #96 on 3/27/12. She continued to say the facility's policy for identification of resident's during medication administration was to have pictures of the residents on the MAR. S2CorporateNurse said it was good nursing practice to have the pictures on the MAR for resident identification. She continued to say she had found out on 3/27/12 pictures were not on all the MARs for resident identification. She also said the pictures had not been placed on the MARs until 3/29/12 at 12:00 p.m. A review of the MAR's were done 3/27/12 at 11:45 a.m. There was no picture on the MAR indicated [REDACTED]. A review of the hospital's Emergency Department Physician Medical Record for Resident #96 revealed she arrived at the hospital on [DATE] at 12:32 p.m. Further review of the record revealed in part the following: History of Present Illness: The quality is acute. The severity is moderate. The duration is since this afternoon. The timing is abrupt. Patient is ...who lives at a nursing home, she is sent here for admission for observation after she was given multiple medications belonging to another resident; medications include hypoglycemic and antihypertensive. See nurse's notes for list of medicines. A review of the hospitals Physician Progress Record/Note revealed in part the following: Assessment and Plan: 1. Hypotension: Secondary to adverse medication effects. Will continue to monitor her blood pressure closely and continue to observe her overnight on the telemetry unit. Continue to decrease rate of intravenous fluids. 2. Bradycardia: Slowly improving. continue to monitor. A review of the Emergency Department Nursing Medical Record dated 3/27/12 at 12:32 p.m. revealed in part the following: History of Present Illness: Complains of Ingestion ...EMT's report patient was given another patients medications in error this a.m. The wrong medications are as follows: Pradaxa 150 mg, Glyburide 5 mg, Metformin 500 mg, metoprolol 50 mg, Oxybutynin 5 mg, Potassium Chloride 40 mEq, Ampicillin 500 mg, Cardizem 240 mg, Folic Acid 1 mg, Pravastatin 10 mg, Carafate 1 gm. Aspirin 81 mg, Deplin 15 mg, Colace 100 mg, Cymbalta 60 mg, Lasix 40 mg, Provigil 200 mg, Celexa 40 mg, Digoxin 0.125 mg, Isosorbide ER 30 mg, Losartan 50 mg. Patient also received her own morning medications ... Triage Vital Signs: 3/27/12 12:38 p.m. Temperature 98.2 BP: 89/53mmHG Pulse 56 Nursing Notes: 3/27/12 12:56 p.m. Blood Glucose performed; 70 mg/dl (Normal 70-110); MD notified. Medication, Intravenous (IV) Fluids ...Orders: 3/27/12 2:45 p.m. Normal Saline IV Solution 500 ml Rate: Wide open pump. Intake and Output: 3/27/12 3:11 p.m. IV 500 ml total Vital Signs: 3/27/12 1:06 p.m. BP 91/47 3/27/12 1:35 p.m. BP 98/55 Review of the Hospital Laboratory Results for Resident #96 revealed the following tests/blood work was obtained on the resident during her hospitalization : 3/27/12 at 12:29 p.m. 12-lead ECG: Results: Sinus bradycardia. 3/27/12 at 1:00 p.m. A Complete Blood Count, A Chemistry Panel, A Prothrombin Time, An INR and a PTT Activity 3/27/12 at 2:48 p.m. Digoxin Level 3/28/12 at 4:07 a.m. A Complete Blood Count and a Chemistry Panel: 3/28/12 at 12:58 p.m. A hemoglobin and hematocrit

Based on record review and interview the facility failed to provide services according to accepted standards of clinical practice for 1 (#96) of 43 stage 2 residents reviewed out of a facility census of 98. The facility failed to: 1. Verify the correct identity of a resident prior to administering 21 medications (#96). 2. Ensure that nursing staff identified each resident before administering their ordered medication. 3. Ensure the facility's system for identifying residents was being enforced. 4. Promptly perform vital signs and an assessment on Resident #96 when it was discovered she had received 21 medications ordered for another resident that included cardiac medications, antihypertensive medications and antidiabetic medications. Resident #96 was in immediate jeopardy on 3/27/12 at 9:30 a.m. when she received 21 medications ordered for another resident. The nurse did not make a positive identification of Resident #96 before administering the medications to the resident. Resident #96 received another resident's medication which included cardiac medication, antihypertensive medications and antidiabetic medications. The resident was transferred to the hospital where the Physician Progress Record/Note under Assessment and Plan revealed the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] and required intravenous fluids and monitoring for the effects of the medications. The immediate jeopardy ended on 3/27/12 at 12:20 p.m. when the ambulance left the facility and transported the resident to the hospital. This deficient practice continued at actual harm for Resident #96 and a level 2 for all other residents remaining in the facility who received medications. Findings: Resident #96: According to the National Coordinating Council for Medication Error Reporting and Prevention, the Council recommends: 2. as one aspect of the overall medication use system, the following checks be performed immediately prior to medication administration: the right medication, in the right dose, to the right person, by the right route using the right dosage form, at the right time, with the right documentation. A review of the facility's policy and procedure on medication administration revealed in part the following: Resident Rights: The nurse should identify the residents by either a picture, name, or armband if available. A review of the clinical record for Resident #96 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set for the resident with an Assessment Reference Date of 2/24/12 revealed a BIMS score of 7 (Severely Impaired). An interview was held on 3/29/12 at 10:15 a.m. with S14LPN. She stated she was not working with Resident #96 on 3/27/12 when she gave her medications intended for another resident in error. S14LPN said Resident #96 was sitting in the front lobby in a wheelchair by the nurses' station. She said that at 9:30 a.m. on 3/27/12 she prepared the following medications due for administration to another resident and gave them in error to Resident #96: [MEDICATION NAME] 200 mg (used to treat excessive sleepiness) [MEDICATION NAME] 40 mg (used to treat depression) [MEDICATION NAME] 0.125 mg (a heart medication) [MEDICATION NAME] 30 mg extended release (used to treat chest pain) Losartan Potassium 50 mg (used to treat high blood pressure) Pantoprazole 40 mg (used to treat reflux) Potassium Chloride 40 mEq Aspirin 81 mg [MEDICATION NAME] 15 mg (used to treat depression) [MEDICATION NAME] 100 mg (a stool softener) [MEDICATION NAME] 60 mg (used to treat depression) [MEDICATION NAME] 40 mg (a pill to decrease fluid) [MEDICATION NAME] 150 mg (prevents blood clotting) [MEDICATION NAME] 5 mg (used to treat diabetes) [MEDICATION NAME] 500 mg (used to treat diabetes) [MEDICATION NAME] 50 mg (used to treat high blood pressure) [MEDICATION NAME] 5 mg (used for overactive bladder) [MEDICATION NAME] 500 mg (an antibiotic) [MEDICATION NAME] 240 mg (used to control chest pain) Folic Acid 1 mg (a supplement) [MEDICATION NAME] 10 mg (used to treat high cholesterol) S14LPN continued to say she usually asked the residents their names prior to giving the medications, but on the morning of 3/27/12 she did not ask Resident #96 her name. She then said she realized "sometime after 11:00 a.m." that she had given Resident #96 medications intended for another resident when she saw the resident in physical therapy who should have gotten the above medications. S14LPN stated when she realized she had made the error she found Resident #96 to find out her name. She saw Resident #96 in the hall sitting in a wheelchair. She said she asked S4LPN what Resident #96's name was and then reported to S3ADON the medication error she had made. She further said she did not tell S4LPN at that time she had made the medication error. S14LPN stated she pulled the MAR for the resident whose medicines she had given to Resident #96 in error and gave it to S3ADON. She revealed she did not chart the error on Resident #96's clinical record nor did she do any assessment of Resident #96 after the medication error. An interview was held on 3/29/12 at 11:45 a.m. with S4LPN. She stated she worked on 3/27/12 and was assigned Resident #96. She continued to say she gave Resident #96 her routine medications on 3/27/12 as ordered which included the following: [MEDICATION NAME] 10 mg (used to treat [MEDICAL CONDITION]) [MEDICATION NAME] 30 mg (used to treat depression) [MEDICATION NAME] 15 mg (used to treat overactive bladder) [MEDICATION NAME] 20/12.5 mg (used to treat high blood pressure) [MEDICATION NAME] 1 scoop in water (laxative) [MEDICATION NAME] 7.5 mg ( a pain medication) S4LPN continued to say that she recalled S14LPN asking her the name of Resident #96 who was sitting in the hallway in her wheelchair but she did not recall what time it was. She also said before lunch on 3/27/12, S3ADON brought Resident #96 to her and told her the resident had been given medications in error. S4LPN stated the doctor was notified of the resident getting 21 medications in error, an ambulance was called and the resident was sent out to the hospital at "around 11:00 a.m." on 3/27/12. On 3/29/12 at 1:10 p.m. an interview was held with S3ADON. She stated on 3/27/12, S14LPN reported she had given 21 medications in error to Resident #96. S3ADON said she reported the incident to S2Corporate Nurse. She continued to say the resident was sent out to the hospital on [DATE] for monitoring related to the medication error. On 3/29/12 at 12:12 p.m. an interview was held with S2Corporate Nurse. She stated S3ADON notified her of the medication error on Resident #96 on 3/27/12. She continued to say the facility's policy for identification of resident's during medication administration was to have pictures of the residents on the MAR. S2Corporate Nurse said it was good nursing practice to have the pictures on the MAR for resident identification. She continued to say she had found out on 3/27/12 pictures were not on all the MARs for resident identification. She also said the pictures had not been placed on the MARs until 3/29/12 at 12:00 p.m. A review of the MAR's were done on 3/27/12 at 11:45 a.m. There was no picture on the MAR indicated [REDACTED]. A review of the hospital's Emergency Department Physician Medical Record for Resident #96 revealed she arrived at the hospital on [DATE] at 12:32 p.m. Further review of the record revealed in part the following: History of Present Illness: The quality is acute. The severity is moderate. The duration is since this afternoon. The timing is abrupt. Patient is ...who lives at a nursing home, she is sent here for admission for observation after she was given multiple medications belonging to another resident; medications include hypoglycemic and antihypertensive. See nurse's notes for list of medicines. A review of the hospitals Physician Progress Record/Note revealed in part the following: Assessment and Plan: 1. [MEDICAL CONDITION]: Secondary to adverse medication effects. Will continue to monitor her blood pressure closely and continue to observe her overnight on the telemetry unit. Continue to decrease rate of intravenous fluids. 2. [MEDICAL CONDITION]: Slowly improving. continue to monitor... A review of the Emergency Department Nursing Medical Record dated 3/27/12 at 12:32 p.m. revealed in part the following: History of Present Illness: Complains of Ingestion ...EMT's report patient was given another patients medications in error this a.m. The wrong medications are as follows: [MEDICATION NAME] 150 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 5 mg, Potassium Chloride 40 mEq, [MEDICATION NAME] 500 mg, [MEDICATION NAME] 240 mg, Folic Acid 1 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 1 gm. Aspirin 81 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 0.125 mg, [MEDICATION NAME] ER 30 mg, Losartan 50 mg. Patient also received her own morning medications ... Triage Vital Signs: 3/27/12 12:38 p.m. Temperature 98.2 BP: 89/53 mmHG Pulse 56 Nursing Notes: 3/27/12 12:56 p.m. Blood Glucose performed; 70 mg/dl (Normal 70-110); MD notified. Medication, Intravenous (IV) Fluids ...Orders: 3/27/12 2:45 p.m. Normal Saline IV Solution 500 ml Rate: Wide open pump. Intake and Output: 3/27/12 3:11 p.m. IV 500 ml total Vital Signs: 3/27/12 1:06 p.m. BP 91/47 3/27/12 1:35 p.m. BP 98/55 Review of the Hospital Laboratory Results for Resident #96 revealed the following tests/blood work was obtained on the resident during her hospitalization : 3/27/12 at 12:29 p.m. 12-lead ECG: Results: Sinus [MEDICAL CONDITION]. 3/27/12 at 1:00 p.m. A Complete Blood Count, A Chemistry Panel, A [MEDICATION NAME] Time, An INR and a PTT Activity 3/27/12 at 2:48 p.m. [MEDICATION NAME] Level 3/28/12 at 4:07 a.m. A Complete Blood Count and a Chemistry Panel: 3/28/12 at 12:58 p.m. A hemoglobin and hematocrit

Based on record reviews and interviews, the facility failed to ensure that services were provided according to professional standards of care for 1 of 5 sampled residents receiving wound care (#1). On 12/21/11, a Podiatrist treated Resident #1's left great toe. The podiatrist mistakenly wrote an order to treat the right great toe instead of the left great toe. Resident #1 was in Immediate Jeopardy after the 12/21/11 visit when the facility nurses failed to provide needed care and services. From 12/21/11 until 01/04/12, the dressing the Podiatrist applied to Resident #1's left great toe was not removed. For two weeks, no one assessed this wound, consulted with the Podiatrist regarding his order, changed the dressing, or provided treatment. The left great toe was not visually assessed from 12/21/11 until 01/04/12. On 01/04/12, the left great toe was black in color, gangrenous, and had an odor. The immediate jeopardy ended for Resident #1 when the resident was transferred to the hospital on [DATE]. The deficient practice continues for Resident #1 at isolated actual harm. Resident #1's left great toe was amputated on 01/06/12 and the resident experienced pain after the amputation. The deficient practice remains at a pattern of potential for more than minimal harm (scope and severity E) for any resident who has a dressing applied during a doctor's visit. The facility failed to put a system in place with quality assurance to ensure nurses were clinically supervised to ensure dressings were changed. From 12/21/11 until 01/04/12, the staff the facility assigned to care for Resident #1 were unable or unprepared to provide the following needed care and services and there was no intervention by S1/DON or S4/ADON to ensure the following needed care and services were provided: 1. observation and assessment of the left great toe; 2. conduct head to toe assessments as per Facility Wound Care Policies and Procedures. 3. failure to assess the resident's left ankle, tibia, and fibula when the resident complained of pain to these areas; 4. failed to transcribe the 12/21/11 podiatrist order to the treatment administration record; 5. change the dressings to the left great toe; 6. assessing both feet and consulting with the physician regarding a discrepancy of which toe was treated by the podiatrist and which toe required treatments by the facility; 7. clinical supervision of the Treatment nurse and floor nurses to ensure a dressing did not remain on a resident's left great toe for 15 days; 8. clinical supervision of the CNAs to ensure they reported to nursing and/or supervisors when a dressing remained on a resident's left great toe for 15 days. Findings: Review of the Facility Wound Care Policies and Procedures revealed, in part: Pressure Ulcer Prevention Program. Procedure: 4. All residents will have a head to toe assessment completed on a weekly basis by a licensed nurse to identify any skin breakdown. The results of this assessment will be documented in the resident's medical record. 5. If a pressure ulcer/skin breakdown is identified, the following will be done - The licensed nurse will complete a thorough assessment of the affected area. The assessment must include size, stage, location, drainage and odor. The licensed nurse will notify the physician and the family. Treatment will be initiated per physician orders. The resident's plan of care will be updated to reflect interventions. The interdisciplinary team will be notified so that appropriate referrals may be made to the dietitian, therapy, etc. The licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The DON or designee will track and monitor pressure ulcers weekly. Resident #1: Review of the medical record revealed the resident was a [AGE] year-old female admitted to the facility 04/08/02. The resident had the [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 12/21/11 at 14:30 (2:30 pm) revealed, in part, the resident complained of pain to touch to left great toe and bruising was noted around the nail bed. The resident had an appointment scheduled and was seen by a Podiatrist. Review of the Podiatrist visit dated 12/21/11 revealed, in part, Location: Integument over the dorsal aspect of the right 1st digit. Patient complains of moderate sharp and aching pains to ingrown toenail borders, redness, drainage and swelling to toenail borders, irritation present to integument over the dorsal aspect of the right 1st digit. Additional Objective Findings: Removed right hallux nail plate and noted mal odor eminating from proximal nail fold. No purulent drainage. Review of a Physician's Telephone Order dated 12/21/11 revealed, [MEDICATION NAME] 875 mg one by mouth twice a day for 10 days. Nursing to cleanse wound to right big toe with normal saline and apply [MEDICATION NAME] ointment and gauze dressing daily. Review of Nurse's Notes dated 12/21/11 at 16:30 (4:30 pm) revealed the resident returned from the Podiatrist and was up in wheelchair. The resident's left great toe nail was cut by the Podiatrist. The resident had new orders noted for [MEDICATION NAME] 875mg. The nurse also documented that she spoke to the DON. Documentation failed to reveal the nurse addressed the physician's documentation and order for the great toe on the right foot and facility documentation of the wound on the left foot great toe. Documentation failed to reveal that the nurse contacted the physician to clarify the discrepancy or examined the resident's great toe on the right and left foot. Review of Nurse's Notes from 12/22/11 through 12/29/11 revealed no documented evidence the resident's left great toe was assessed. Review of Nurse's Notes dated 12/30/11 at 8:00 am revealed, in part, the resident complained of pain to the left ankle, tibia, and fibula. The nurse documented Tylenol 325 mg was given and an x-ray was ordered. Further review revealed no documented evidence the resident's left great toe was assessed. Review of the December 2011 Treatment Administration Record revealed no documented evidence the resident received any wound care treatments. Further review revealed a nurse initialed that a weekly skin check was performed on 12/27/11 and no skin problems were found. Review of Nurse's Notes from 12/31/11 through 01/03/12 revealed no documented evidence the resident's left great toe was assessed. Review of Nurse's Notes dated 01/04/12 at 1:30 pm revealed, in part, the treatment nurse asked for assistance with resident due to [MEDICATION NAME] (bandage) around left great toe being difficult to remove. Blue [MEDICATION NAME] moistened with normal saline to loosen, able to get [MEDICATION NAME] loose enough to unravel, gauze around toe stuck to skin. Saturated with normal saline to undo, treatment order written by Podiatrist for removal of right great toe nail, treatment needed to be to left great toe, resident's toe black after removing [MEDICATION NAME] and gauze. At 3:10 pm the nurse documented the resident was out to physician's office for appointment. Review of Nurse's Notes dated 01/04/12 at 4:15 pm revealed after the physician assessed the resident's left great toe the physician recommended direct admit to hospital. Review of Nurse's Notes dated 01/07/12 at 4:15 pm revealed it was reported to the nurse that the physician amputated the resident's entire left great toe. Review of the Hospital History and Physical with an admitted [DATE] revealed, in part, Chief Complaint: Gangrene to left great toe. Impression and Plan: Dry gangrene to her left hallux. She is scheduled to have her left toe amputated per podiatry. In interview on 01/30/12 at 1:54 pm, S3/RN Treatment Nurse indicated no treatments were done on Resident #1 in December 2011 and she did not know who Resident #1 was until 01/02/12. S3/RN Treatment Nurse indicated Resident #1 had an order dated 12/21/11 to cleanse the right great toe, but this order was not transcribed to the treatment administration record until January 2012. S3/RN Treatment Nurse indicated no treatments were done to the resident's left great toe from 12/21/11 through 01/04/12. S3/RN Treatment Nurse indicated she started treating the right great toe on 01/02/12. S3/RN Treatment Nurse said the right great toe had only a small scab and nothing that really required treatment. S3/RN Treatment Nurse said, on 01/04/12, she decided to observe Resident #1's left great toe. S3/RN Treatment Nurse indicated this was the first day she observed the left great toe. S3/RN Treatment Nurse indicated the dressing around the left great toe was difficult to remove and was stuck to the skin. S3/RN Treatment Nurse indicated it took about 20 minutes to remove the dressing off the left great toe. S3/RN Treatment Nurse indicated the left toe was black, gangrenous, and had an odor. In interview on 01/30/12 at 1:08 pm, S2/DON indicated Resident #1 complained of pain to her left great toe on 12/21/11 and was sent to the podiatrist. S2/DON indicated on 12/21/11, the podiatrist mistakenly wrote an order to treat the right great toe instead of the left great toe. S2/DON indicated the facility failed to transcribe the 12/21/11 podiatrist order to the treatment administration record. S2/DON indicated this error was noted when the January 2012 physician's orders [REDACTED]. S2/DON indicated no one at the facility questioned the dressing on the left toe and the dressing was not removed or changed until 01/04/12. S2/DON indicated the resident was sent on 01/04/12 to the hospital because of the condition of the left great toe and the toe was amputated.

Based on record reviews and interviews, the facility failed to ensure residents maintained their highest level of well-being regarding wounds for 1 of 5 sampled residents receiving wound care (#1). On 12/21/11, a Podiatrist treated Resident #1's left great toe. The podiatrist mistakenly wrote an order to treat the right great toe instead of the left great toe. Resident #1 was in Immediate Jeopardy after the 12/21/11 visit when the facility nurses failed to provide needed care and services. From 12/21/11 until 01/04/12, the dressing the Podiatrist applied to Resident #1's left great toe was not removed. For two weeks, no one assessed this wound, consulted with the Podiatrist regarding his order, changed the dressing, or provided treatment. The left great toe was not visually assessed from 12/21/11 until 01/04/12. On 01/04/12, the left great toe was black in color, gangrenous, and had an odor. The immediate jeopardy ended for Resident #1 when the resident was transferred to the hospital on [DATE]. The deficient practice continues for Resident #1 at isolated actual harm. Resident #1's left great toe was amputated on 01/06/12 and the resident experienced pain after the amputation. The deficient practice remains at a pattern of potential for more than minimal harm (scope and severity E) for any resident who has a dressing applied during a doctor's visit. The facility failed to put a system in place with quality assurance to ensure nurses were clinically supervised to ensure dressings were changed. From 12/21/11 until 01/04/12, the staff the facility assigned to care for Resident #1 were unable or unprepared to provide the following needed care and services and there was no intervention by S1/DON or S4/ADON to ensure the following needed care and services were provided: 1. observation and assessment of the left great toe; 2. conduct head to toe assessments as per Facility Wound Care Policies and Procedures. 3. failure to assess the resident's left ankle, tibia, and fibula when the resident complained of pain to these areas; 4. failed to transcribe the 12/21/11 podiatrist order to the treatment administration record; 5. change the dressings to the left great toe; 6. assessing both feet and consulting with the physician regarding a discrepancy of which toe was treated by the podiatrist and which toe required treatments by the facility; 7. clinical supervision of the Treatment nurse and floor nurses to ensure a dressing did not remain on a resident's left great toe for 15 days; 8. clinical supervision of the CNAs to ensure they reported to nursing and/or supervisors when a dressing remained on a resident's left great toe for 15 days. Findings: Review of the Facility Wound Care Policies and Procedures revealed, in part: Pressure Ulcer Prevention Program. Procedure: 4. All residents will have a head to toe assessment completed on a weekly basis by a licensed nurse to identify any skin breakdown. The results of this assessment will be documented in the resident's medical record. 5. If a pressure ulcer/skin breakdown is identified, the following will be done - The licensed nurse will complete a thorough assessment of the affected area. The assessment must include size, stage, location, drainage and odor. The licensed nurse will notify the physician and the family. Treatment will be initiated per physician orders. The resident's plan of care will be updated to reflect interventions. The interdisciplinary team will be notified so that appropriate referrals may be made to the dietitian, therapy, etc. The licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The DON or designee will track and monitor pressure ulcers weekly. Resident #1: Review of the medical record revealed the resident was a [AGE] year-old female admitted to the facility 04/08/02. The resident had the [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 12/21/11 at 14:30 (2:30 pm) revealed, in part, the resident complained of pain to touch to left great toe and bruising was noted around the nail bed. The resident had an appointment scheduled and was seen by a Podiatrist. Review of the Podiatrist visit dated 12/21/11 revealed, in part, Location: Integument over the dorsal aspect of the right 1st digit. Patient complains of moderate sharp and aching pains to ingrown toenail borders, redness, drainage and swelling to toenail borders, irritation present to integument over the dorsal aspect of the right 1st digit. Additional Objective Findings: Removed right hallux nail plate and noted mal odor eminating from proximal nail fold. No purulent drainage. Review of a Physician's Telephone Order dated 12/21/11 revealed, [MEDICATION NAME] 875 mg one by mouth twice a day for 10 days. Nursing to cleanse wound to right big toe with normal saline and apply [MEDICATION NAME] ointment and gauze dressing daily. Review of Nurse's Notes dated 12/21/11 at 16:30 (4:30 pm) revealed the resident returned from the Podiatrist and was up in wheelchair. The resident's left great toe nail was cut by the Podiatrist. The resident had new orders noted for [MEDICATION NAME] 875mg. The nurse also documented that she spoke to the DON. Documentation failed to reveal the nurse addressed the physician's documentation and order for the great toe on the right foot and facility documentation of the wound on the left foot great toe. Documentation failed to reveal that the nurse contacted the physician to clarify the discrepancy or examined the resident's great toe on the right and left foot. Review of Nurse's Notes from 12/22/11 through 12/29/11 revealed no documented evidence the resident's left great toe was assessed. Review of Nurse's Notes dated 12/30/11 at 8:00 am revealed, in part, the resident complained of pain to the left ankle, tibia, and fibula. The nurse documented Tylenol 325 mg was given and an x-ray was ordered. Further review revealed no documented evidence the resident's left great toe was assessed. Review of the December 2011 Treatment Administration Record revealed no documented evidence the resident received any wound care treatments. Further review revealed a nurse initialed that a weekly skin check was performed on 12/27/11 and no skin problems were found. Review of Nurse's Notes from 12/31/11 through 01/03/12 revealed no documented evidence the resident's left great toe was assessed. Review of Nurse's Notes dated 01/04/12 at 1:30 pm revealed, in part, the treatment nurse asked for assistance with resident due to [MEDICATION NAME] (bandage) around left great toe being difficult to remove. Blue [MEDICATION NAME] moistened with normal saline to loosen, able to get [MEDICATION NAME] loose enough to unravel, gauze around toe stuck to skin. Saturated with normal saline to undo, treatment order written by Podiatrist for removal of right great toe nail, treatment needed to be to left great toe, resident's toe black after removing [MEDICATION NAME] and gauze. At 3:10 pm the nurse documented the resident was out to physician's office for appointment. Review of Nurse's Notes dated 01/04/12 at 4:15 pm revealed after the physician assessed the resident's left great toe the physician recommended direct admit to hospital. Review of Nurse's Notes dated 01/07/12 at 4:15 pm revealed it was reported to the nurse that the physician amputated the resident's entire left great toe. Review of the Hospital History and Physical with an admitted [DATE] revealed, in part, Chief Complaint: Gangrene to left great toe. Impression and Plan: Dry gangrene to her left hallux. She is scheduled to have her left toe amputated per podiatry. In interview on 01/30/12 at 1:54 pm, S3/RN Treatment Nurse indicated no treatments were done on Resident #1 in December 2011 and she did not know who Resident #1 was until 01/02/12. S3/RN Treatment Nurse indicated Resident #1 had an order dated 12/21/11 to cleanse the right great toe, but this order was not transcribed to the treatment administration record until January 2012. S3/RN Treatment Nurse indicated no treatments were done to the resident's left great toe from 12/21/11 through 01/04/12. S3/RN Treatment Nurse indicated she started treating the right great toe on 01/02/12. S3/RN Treatment Nurse said the right great toe had only a small scab and nothing that really required treatment. S3/RN Treatment Nurse said, on 01/04/12, she decided to observe Resident #1's left great toe. S3/RN Treatment Nurse indicated this was the first day she observed the left great toe. S3/RN Treatment Nurse indicated the dressing around the left great toe was difficult to remove and was stuck to the skin. S3/RN Treatment Nurse indicated it took about 20 minutes to remove the dressing off the left great toe. S3/RN Treatment Nurse indicated the left toe was black, gangrenous, and had an odor. In interview on 01/30/12 at 1:08 pm, S2/DON indicated Resident #1 complained of pain to her left great toe on 12/21/11 and was sent to the podiatrist. S2/DON indicated on 12/21/11, the podiatrist mistakenly wrote an order to treat the right great toe instead of the left great toe. S2/DON indicated the facility failed to transcribe the 12/21/11 podiatrist order to the treatment administration record. S2/DON indicated this error was noted when the January 2012 physician's orders [REDACTED]. S2/DON indicated no one at the facility questioned the dressing on the left toe and the dressing was not removed or changed until 01/04/12. S2/DON indicated the resident was sent on 01/04/12 to the hospital because of the condition of the left great toe and the toe was amputated.