Every finding on record at Heritage Manor South

Based on record reviews and interview, the facility failed to develop an individualized care plan for 2 (#4, #5) of 6 sampled residents reviewed. The facility failed:to develop a care plan for urinary tract infections for Resident #4, andto develop a care plan for stage IV pressure ulcer for Resident #5 Findings:Resident #4Review of Resident #4's medical record revealed an admit date of 01/13/2022 with the following diagnoses, including in part: kidney disease with stage 1 through stage IV chronic kidney disease, type 2 diabetes mellitus, urinary tract infection site not specified and nocturnal enuresis.Review of Resident #4's medical record failed to reveal a care plan for urinary tract infections.Review of Resident #4's Nurse Practitioner progress notes revealed in part:02/19/2026: Status post hospitalization from 02/12/2026 - 02/16/2026 for .urinary tract infection.03/02/2026 - Status post hospitalization from 02/23/2026 - 03/01/2026 for .urinary tract infection.03/10/2026 - Status post hospitalization from 03/03/2026 - 03/06/2026 for sepsis .urinary tract infection.Resident #5Review of Resident #5's medical record revealed an admit date of 03/15/2018 with the following diagnoses, including in part: Stage IV pressure ulcer sacrum.Review of Resident #5's medical record failed to reveal a care plan for stage IV sacrum pressure ulcer.Review of Resident #5's surgical and wound care notes revealed in part: 03/25/2026: Wound 1 Bilateral Sacrococcyx, Pressure Injury, Stage IV. During an interview on 03/31/2026 at 9:59 a.m. S1 Assessment Registered Nurse acknowledged Resident #4 was not care planned for urinary tract infections and Resident #5 was not care planned for a stage IV sacrum pressure ulcer and should have been.

Based on observations, record reviews and interviews the facility failed to ensure residents who were unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 5 (#4, #31, #45, #69, #100) of 5 residents reviewed for activities of daily living out of a total final sample of 37. The facility failed to ensure Residents #4, #31, #45, #69, and #100 fingernails were cleaned and trimmed. Findings:Resident #4Review of Resident #4's medical record revealed an admit date of 01/15/2013 with diagnoses that include in part type 2 diabetes mellitus with diabetic neuropathy, primary generalized (Osteo) arthritis, Schizophrenia and lack of coordination.Review of Resident #4's quarterly MDS assessment dated [DATE] revealed in part Resident #4 had a BIMS score of 15 indicating Resident #4 was cognitively intact. During an interview on 01/12/2026 at 9:00 a.m. Resident #4 reported he wanted his nails cut and cleaned and staff kept telling him the nurse will do it because he is diabetic. Observation on 01/12/2026 at 9:00 a.m. revealed Resident #4's fingernails were long past the end of his fingertips with brown and black substance underneath. Observation on 01/13/2026 at 9:50 a.m. revealed Resident #4's fingernails were long past end of his fingertips with brown and black substance underneath. During an interview on 01/13/2026 at 9:50 a.m. Resident #4 reported they still haven't come to cut or clean my fingernails yet. Resident #31 Review of Resident #31's medical record revealed an admit date of 03/23/2022 with diagnoses that include in part rheumatoid arthritis with rheumatoid factor, type 2 diabetes mellitus without complications, and lack of coordination. Review of Resident #31's annual MDS assessment dated [DATE] revealed in part Resident #31 had a BIMS score of 15 indicating Resident #31 was cognitively intact. Observation on 01/12/2026 at 8:00 a.m. revealed Resident #31's fingernails were long past end of her fingertips with brown substance underneath. During an interview on 01/13/2026 at 9:30 a.m. Resident #31 reported I'm diabetic so the nurse is supposed to cut my fingernails and I wish she would because they are jagged. During an interview on 01/13/2026 at 9:35 a.m. S4 CNA reported she could not cut Resident #31's fingernails because Resident #31 was a diabetic and a nurse had to do it. S4 CNA confirmed Resident #31's fingernails were long and jagged and needed to be cut. Resident #45 Review of Resident #45's medical record revealed an admit date of 05/23/2019 with diagnoses that include in part diabetes mellitus with diabetic neuropathy, chronic systolic (congestive) heart failure, hallucinations, and other lack of coordination. Review of Resident #45's quarterly MDS assessment dated [DATE] revealed in part Resident #45 had a BIMS score of 10 indicating moderate cognitive impairment. Observation on 01/12/2026 at 8:40 a.m. revealed Resident #45's fingernails were long past the end of fingertips with brown substance underneath. During an interview on 01/12/2026 at 8:40 a.m. Resident #45 reported he needed the nurse to cut and clean his fingernails. Observation on 01/13/2026 at 9:30 a.m. revealed Resident #45's fingernails were long past the end of fingertips with brown substance underneath. Resident #69 Review of Resident #69's record revealed an admit date of 07/16/2025 with diagnoses that include in part: type 2 diabetes mellitus without complications, schizoaffective disorder, unspecified, and paranoid schizophrenia. Review of Resident #69's quarterly MDS assessment dated [DATE] revealed in part a BIMS score of 11 indicating moderate impairment. Observation on 01/12/2026 at 8:30 a.m. revealed Resident #69's fingernails were long and jagged past fingertips with black substance underneath. During an interview on 01/12/2026 at 8:30 a.m. Resident #69 reported he would like to have his fingernails cut and cleaned. Observation on 01/13/2026 at 9:39 a.m. revealed Resident #69's fingernails were long and jagged past end of fingertips with black and brown substance underneath. During an interview on 01/13/2026 at 9:39 a.m. Resident #69 reported he needs his fingernails cut and cleaned and it hasn't been done in a long time. Resident #100Review of Resident #100's medical record revealed an admit date of 04/08/2021 with diagnoses that include in part hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, unspecified dementia, depression, and cognitive communication deficit. Review of Resident #100's quarterly MDS assessment dated [DATE] revealed in part a BIMS score of 07 indicating severely impaired cognition.Observation on 01/12/2026 at 9:30 a.m. revealed Resident #100's fingernails were long past fingertips, jagged with brown substance underneath. During an interview on 01/12/2026 at 9:30 a.m. Resident #100 reported my fingernails need to be cut. Observation on 01/13/2026 at 9:30 a.m. revealed Resident #100's fingernails were long past tips of fingers with yellow, and black substance underneath. During an interview on 01/13/2026 at 9:45 a.m. S2 LPN confirmed residents #4, #31, #45, #69, and #100 were diabetic and a nurse should cut the resident's fingernails. During an interview on 01/13/2026 at 10:00 a.m. S1 DON confirmed Residents #4, #31, #45, #69, and #100's were diabetics. S1 DON further confirmed Residents #4, #31, #45, #69, and #100's fingernails were long, dirty and should have been cleaned and cut by the nurse.

Based on record review and interviews the facility failed to ensure assessments were accurate for 1 (#13) of 37 residents reviewed for MDS assessments. The facility failed to ensure Resident #13's medication was accurately assessed. Findings:Review of Resident #13's record revealed an admit date of 08/29/2024 and failed to reveal Resident #13 was diagnosed with diabetes. Review of Resident #13's physician orders failed to reveal Resident #13 had an order for insulin. Review of Resident #13's quarterly MDS assessment dated [DATE] revealed in part, Resident received 1 injection of insulin every 7 days. During an interview on 01/14/2026 at 10:45 a.m. S2 LPN confirmed Resident #13 is not a diabetic and does not receive insulin. During an interview on 01/14/2026 at 10:50 a.m. S1 DON reviewed Resident #13's record and confirmed Resident #13 is not a diabetic and does not receive insulin. During an interview on 01/14/2026 at 11:00 a.m. S3 MDS reviewed Resident #13's record, confirmed Resident #13 is not a diabetic, does not receive insulin and the MDS medication section had been coded incorrectly.

Based on record review and interviews the facility failed to ensure residents received adequate supervision to prevent elopement for 1 (#1) of 3 (#1, #2, #3) sampled residents at risk for elopement. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 12/09/2025. It was determined to be a Past noncompliance Citation. Findings: Review of Resident #1's record revealed an admission date of 10/27/2025 and a discharge to a behavioral hospital on [DATE]. Diagnoses included, in part, Parkinson's disease without dyskinesia without mention of fluctuations, dementia, depression, Alzheimer's disease unspecified, essential hypertension, atherosclerotic heart disease, and delusional disorders. Review of Resident #1's 11/03/2025 admission MDS (Minimum Data Set) revealed Resident #1 had a BIMS (Brief Interview Mental Status) score of 06, indicating a severe cognitive impairment. Review of Resident #1's Care Plan revealed Resident #1 was care planned for security bracelet which was initiated on 11/11/2025 and an actual elopement on 11/30/2025 when Resident #1 left the facility through a window in an office that had a malfunctioning door lock. Interventions included an admission to ___ _____ Behavioral on 12/01/2025, a change in lock codes of offices with window access, one on one supervision, and resident was moved to the secure memory care unit on 12/01/2025. Review of Resident #1's progress notes revealed:-11/30/2025 at 2:51 p.m. - . Resident was not in her room, CNA (unspecified Certified Nursing Assistant) states that she just walked with her about 10-15 minutes ago down the hall. Writer walked to Hall E to see if resident was on Hall B or Hall E hall and she was not. CNA's found resident's walker on Hall E smoking patio. Writer reviewed the cameras and at 1:21 p.m. writer noted resident going into the MDS office then 5-10 minutes later the CNA checked in the office for the resident and did not see her. Writer never seen resident come back out of the MDS office. CNA was driving searching for resident and found resident at _______ (convenience store) at 2:07 p.m. on _________ Rd. CNA brought resident back. Full head to toe assessment complete and only skin tear noted to right arm with steri strips in place and another skin tear to right arm with bandage in place, these were old skin tears. Writer asked resident how she got out and she began smiling and stated I'm not going to tell you my secret. Resident was placed on the Memory care unit for safety.-12/01/2025 at 1:56 p.m. - New order to send resident to ___ _____ Behavior.-12/01/2025 at 4:42 p.m. - Left facility ambulating with walker, left in ___ ____ Behavior van at 2:15 p.m. Review of 11/30/2025 facility video footage with S2 ADON (Assistant Director of Nursing) revealed:From Hall A hall camera:-1:19 p.m. - Resident #1 was initially seen on Hall A near the staff breakroom hugging S12 CNA and S12 CNA and Resident #1 proceeded to walk away from the camera, all the way down to the far end of Hall A door which led to door that entered Hall E where MDS office was located. S12 CNA seen going into a room on the left at the end of the Hall A while Resident #1 continued on down the hallway.-1:20 p.m. - Resident #1 seen going through door at the far end of Hall A to Hall E where the MDS office was located. From Hall E camera:-1:20 p.m. - Resident #1 was seen coming through door from Hall A to Hall E and attempted to open the door to outside across from the Hall A door without success, then attempted to open mechanical closet door next to the outside door and it was locked, then attempted to open the door to outside again, but was unable to open it. -1:21 p.m. - Resident #1 proceeded past 3 windows and turned toward the MDS office and was able to open the door, without any difficulty, and entered the office. Resident #1 did not exit the MDS office door. During an interview on 12/10/2025 at 9:55 a.m. S3 DON (Director of Nursing) reviewed Resident #1's record and confirmed Resident #1's wanderguard was initiated on 11/11/2025. During an interview on 12/10/2025 at 10:43 a.m. S3 DON confirmed the windows in offices with windows leading outside the facility and the windows in therapy gym did not have stops to limit how far the windows would open before the 11/30/2025 incident. Further reported she had worked the day of the 11/30/2025 incident and upon check of the MDS office lock right after the incident, the keypad door lock was found to be unlocked. During an interview on 12/10/2025 at 11:53 a.m. S2 ADON reported when she went to give Resident #1's medications on 11/30/2025 at 1:30pm, Resident #1 was not in her room and upon review of video footage, Resident #1 was seen entering the MDS office at 1:21 p.m. S2 ADON further confirmed Resident #1 was found and returned to the facility on [DATE] at 2:07 p.m During an interview on 12/11/2025 at 12:50 p.m. S1 Administrator confirmed she had been made aware on 11/30/2025 that Resident #1 had exited the building through a window in the MDS office on a Sunday when the office would have been locked and the MDS nurse reported she had locked the door. S1 Administrator further reported a system was already in place that had been followed upon Resident #1's elopement and actions had been put in place since the 11/30/2025 incident for correction with a completion date of 12/02/2025. During the survey, it was determined the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility as evidenced by onsite observations, interviews and record reviews. The facility implemented the following actions with a completion date of 12/02/20251. Corrective actions for the resident affected include:a. Immediate elopement procedures were enacted to locate Resident #1. Facility conducted a facility-wide search to include inside/outside, facility grounds and the immediate surrounding area.b. Staff member located Resident #1 at a convenience store, which was 0.9 miles (per google maps) down the road on the same side of road as the facility. Staff member called and informed ward clerk and drove Resident #1 back to the facility.c. Camera footage was reviewed and Resident #1 was observed walking the hall and seen opening an unlocked office, went in and was not seen leaving the office. Upon return, Resident #1 had reported she exited through a window in that office, then closed the window behind her. d. MD (Medical Doctor) and Resident #1's RP (Responsible Party) were notified.e. Resident #1 was assessed and no negative outcome was found.f. Resident #1 was placed under 1:1 supervision until it was determined SCU (Secure Care Unit) was appropriate at this time for Resident #1.g. Resident #1 was sent out to a behavioral hospital the day after the incident and had not returned to the facility. 2. Residents at risk to be affected include residents assessed as an elopement risk and/or any resident who has been assessed for need of a security bracelet. Corrective actions for those residents include: Staff with offices were in-serviced about making sure office doors are closed and locked when unoccupied. All staff were educated on elopement policy beginning 11/30/2025 and continued until all staff were educated. Wandering drills completed to include all staff across all shift beginning on 11/30/2025. Wanderguard system was checked by maintenance.3. The system changes the facility plans to put into place to prevent recurrence include: An audit was conducted of all windows and doors to ensure windows do not open past 6 inches and doors are locking properly on 12/01/2025. Office doors with coded (keypad) locks that have a window that has access to non-fenced-in areas were changed to keyed locks on 11/30/2025.4. The facility plans to monitor its performance to ensure the results are sustained by: Follow-up tools for locked unoccupied office doors and monitoring residents for exit seeking behaviors were developed and implemented on 12/01/2025. QA (Quality Assurance) meeting to meet weekly to discuss findings. Validation of Plan of Correction:Review of Correction Binder provided by the facility revealed wanderguard system checks had been conducted, resident rooms had been checked for window stops, and wandering drills were being conducted. Further monitoring of doors for being locked, monitoring for window door stops, and monitoring for exit seeking behaviors was being conducted as per the plan. Correction Binder further revealed QA meetings have been conducted on 12/01/2025 and 12/08/2025 thus far and included discussion of monitoring findings. Observation of office doors with windows to the outside were noted to have keyed entry. Observation on 12/09/2025 at 8:45 a.m. revealed the memory care unit had keypad entry and common areas had strip of wood screwed inside of each window to limit how far the windows would open. During an interview on 12/09/2025 at 2:55 p.m. S4 CNA and S5 CNA reported they had received training in regard to elopement and completed a test after the training that had to be passed. Observations conducted on 12/09/2025 from 3:30 p.m. to 3:45 p.m. revealed multiple windows were noted to have hex screws inserted which, when opened limited the window opening; windows in the MDS office, hallway outside MDS office, therapy, and the dining area on rehab hall had stops in place on them so the windows would only open approximately 6 inches. During an interview on 12/10/2025 at 8:56 a.m. S10 Housekeeping reported she had received training in regard to residents who wander/elope recently after a resident had recently had eloped. Further reported appropriate action to take if a resident was found to be missing. During an interview on 12/10/2025 at 10:10 a.m. S6 CNA reported she had received an in-service in regard to elopement after the incident and had to pass a test after the in-service. During an interview on 12/10/2025 at 10:49 a.m. S7 RN/MDS and S8 MDS reported they had been in-serviced regarding locking office doors and elopement of residents and had taken a test regarding elopement of residents after the in-service. Further reported anytime they leave the office, they made sure the office door was locked. Further added a screw had been put in their windows to limit how far the windows could open. During an interview on 12/10/2025 at 11:05 a.m. S9 Maintenance reported after a recent elopement incident in which a resident went out the window, he had changed all the keypad office locks with windows to the outside of the building to keyed locks and had put screws in windows of every office with windows leading outside the building so the windows could not be opened more than 6 inches. S9 Maintenance further reported he had recently received training in regard to resident elopements that included a test.Observations of the following rooms were conducted on 12/11/2025 between 8:57 a.m. and 9:15 a.m. and windows were noted to have stops in place that limited the window opening to approximately 6 inches:-Rooms 103, 111, 117, 204, 207, 206, 308, 313, 316, 402, 408, 410, 411, 501, 503, and 511.-Windows in hallway on Hall E-Therapy on Hall E-Dining room on Hall E During an interview on 12/11/2025 at 9:15 a.m. S11 LPN (Licensed Practical Nurse) reported she worked in the memory care unit and had recently received training in regard to wandering/elopement policy and reported appropriate action to take if a resident could not be found.

Based on record review and interview the facility failed to ensure a comprehensive person-centered care plan had been developed and implemented for 1 (#3) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure a care plan had been developed and implemented to reflect Resident #1/Resident #1's RP's (Responsible Party) wishes for code status of DNR (Do Not Resuscitate). Review of Resident #3's medical record revealed an admission date of [DATE] with diagnoses including, part, chronic obstructive pulmonary disease (COPD), unspecified severe protein-calorie malnutrition, anemia unspecified, essential (primary) hypertension, anxiety disorder, depression unspecified, and pain unspecified. Review of Resident #3's [DATE] Significant Change MDS (Minimum Data Set) revealed a BIMS (Brief Interview Mental Status) of 99, which indicated Resident #3 was unable to complete the interview. Review of Resident #3's physician orders revealed a [DATE] order for Do Not Resuscitate. Review of Resident #3's medical record revealed a [DATE] Advance Directive Consent obtained from Resident #3's RP with selection of DNR code status.Review of Resident #3's current care plan revealed a care plan initiated on [DATE] for Full code with interventions that included: if cardiac arrest occurs, initiate CPR; respect resident/family wishes; and review and update code status with resident/family as needed. During an interview on [DATE] at 8:11 a.m. S3 MDS (Minimum Data Set) Nurse and S4 MDS Nurse reviewed Resident #3's medical record and care plan and reported Resident #3 was care planned for full code and should have been care planned for DNR.

Based on record reviews and interviews the facility failed to ensure a grievance investigation and resolution had been conducted and documented as per facility policy for 1 (#1) of 3 (#1, #2, #3) sampled residents.Review of facility Grievances - Residents policy with latest revision date of 05/2024 revealed, in part:All residents are to be encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff and other resident's and other concerns regarding their facility stay, in the event that they have a need to make a concern known. The following outlines the process: . Family members, visitors or others may also present grievances on behalf of residents. Grievances may also be made anonymously using the suggestion box. The facility shall make prompt efforts to resolve the grievances. The Social Worker or Social Service Designee has been appointed by the Administrator to . to receive concerns, grievances and recommendations by residents, or any group or individual designated by the resident and his/her representative. Concerns which cannot be promptly resolved shall be treated as a grievance. These grievances shall be directed to the appropriate Department Head and/or Administrator for investigation and follow-up according to the following procedure:o Upon receipt of a grievance/complaint the staff receiving the complaint will report to their supervisor, grievance official, or will initiate the Grievance/Complaint Form NS-795. An investigation led by the Administrator based on the allegations will be set forth. NS-795 will be completed electronically in the electronic health record.o The Administrator and his/her designees will conduct an impartial investigation of the allegations and will discuss the findings and recommendations within five (5) work days of receiving the complaint, with the complainant, The Resident has the right to review the grievance and obtain a written decision regarding the grievance.o In all grievance cases, the resident and/or legal representative will be informed of the result of the investigation, the recommendations made by the investigating parties, and of the action(s) contemplated by the Administrator. Reports shall be maintained electronically for a minimum of 3 years. Review of Resident #1's medical record revealed an initial admission date of 12/03/2024 with diagnoses including, in part, rheumatoid arthritis, type 2 diabetes mellitus, essential hypertension, Alzheimer's disease unspecified, anxiety disorder unspecified, bipolar disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, and mood disorder due to known physiological condition with mixed features. Review of 06/13/2025 Significant Change MDS (Minimum Data Set) revealed BIMS (Brief Interview for Mental Status) should not have been conducted as resident is rarely/never understood. Review of a 04/01/2025 at 11:25 a.m. grievance/complaint report revealed a family member had reported: (1) Resident #1's sheets looked dirty, even when they are clean; (2) Had received a call from the 2pm to 10pm nurse on 3/31/2025 at 4pm with report that Resident #1's stomach hurt and the nurse reported being unsure if Resident #1 had eaten or not and family member brought food and reported Resident #1 ate as if starving; and (3) Resident #1 was soaking wet and had to change him and today Resident #1 still had on the same clothing Resident #1 was put in yesterday. Further review of the Grievance/Complaint report failed to reveal evidence an investigation had been conducted and resolution communicated. During an interview on 07/16/2025 at 3:55 p.m. S1 DON (Director of Nursing) reviewed the 04/01/2025 grievance/complaint form and confirmed an investigation and resolution had not been documented. During an interview on 07/17/2025 at 11:57 a.m. S2 SSD (Social Services Director) reported she had recorded the 04/01/2025 complaint from Resident #1's family member, forwarded the complaint to nursing and laundry and did not document any investigation or resolution. S2 SSD further confirmed there was no evidence an investigation for the 04/01/2025 complaint had been done and no evidence the complainant had been notified of the resolution.

Based on record review, observations and interviews the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#62, #81) out of 30 sampled residents reviewed. The facility failed to develop a care plan for Resident #62's diabetic wound and failed to obtain a physician order for Resident #81 to receive oxygen therapy. Findings: Resident #62 Review of Resident #62's medical record revealed an admitted [DATE] with diagnoses that included, in part, type 2 diabetes mellitus, diabetic ulcer, absence of right leg below knee, dementia, essential (primary) hypertension, impetigo, and peripheral vascular disease. Review of Resident #62's Physician Orders revealed an order dated 08/30/2024 to cleanse diabetic ulcer to left great toe with wound cleanser, pat dry, apply medi-honey and cover with bandage every Tues, Thurs, and Sat until resolved. May be changed as needed for soilage/dislodgement - every day shift every Tue, Thu, Sat and every 1 hour as needed. Review of Resident #62's 08/20/2024 Quarterly MDS (Minimum Data Set) revealed Resident #62 had a BIMS (Brief Interview Mental Status) of 07, which indicated severe cognitive impairment. Review of Resident #62's medical record revealed weekly wound assessments had been conducted for a diabetic wound to left dorsum-1st digit (Hallux) that was acquired in-house. Review of Resident #62's care plan failed to reveal a care plan had been developed for Resident #62's diabetic foot ulcer-left dorsum-1st digit (Hallux). During an interview on 10/30/2024 at 3:13 p.m. S4 MDS Coordinator reviewed Resident #62's care plan and acknowledged a care plan for Resident #62's diabetic wound had not been developed and should have been. 40193 Resident #81 Review of Resident #81's medical record revealed an admitted [DATE] with the following diagnoses, including in part: chronic pulmonary obstructive disease/unspecified, edema/unspecified, and shortness of breath. Review of Resident #81's Physicians Orders failed to reveal an order for continuous oxygen via nasal cannula at 3 liters per minute (LPM). Review of Resident #81's Nurse Practitioner Progress Note dated 10/10/2024 revealed a history of present illness: .He is dependent on oxygen at 3 Liters . Observation on 10/28/2024 at 8:15 a.m. revealed Resident #81 sitting up in wheelchair in room and noted nasal cannula with continuous oxygen in progress at 3LPM. Further observation revealed humidifier bottle and tubing dated 10/28/2024. During an interview on 10/29/2024 at 2:45 p.m. Resident #81 reported he does wear his oxygen. Observation on 10/30/2024 at 8:55 a.m. revealed Resident #81 lying in bed with continuous oxygen via nasal cannula in place at 3LPM. During an interview on 10/30/2024 at 1:00 p.m. S6 Licensed Practical Nurse (LPN) confirmed Resident #81 does wear his oxygen. During an interview on 10/30/2024 at 10:25 a.m. S2 DON (Director of Nursing) confirmed Resident #81 does use oxygen sometimes and did not know why he did not have an order for oxygen but should have.

Based on record review and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (#62) of 30 sampled residents by failing to administer a full course of antibiotic as ordered by the physician. Findings: Review of Resident #62's medical record revealed an admitted [DATE] with diagnoses that included, in part, type 2 diabetes mellitus, diabetic ulcer, absence of right leg below knee, dementia, essential (primary) hypertension, impetigo, and peripheral vascular disease. Review of Resident #62's 08/20/2024 Quarterly MDS (Minimum Data Set) revealed Resident #62 had a BIMS (Brief Interview Mental Status) of 07, which indicated severe cognitive impairment. Review of Resident #62's physician orders revealed a 09/20/2024 order, with an end date of 09/27/2024 for Amoxicillin-Pot Clavulanate Tablet 875-125mg (milligram) - give 1 tablet by mouth every 12 hours for wound infection for 7 days. Review of Resident #62's September 2024 MAR (Medication Administration Record) revealed: Amoxicillin-Pot Clavulanate Tablet 875-125mg (1 tablet every 12 hours) - 8:00 p.m. doses for 9/20, 09/21, and 09/22/2024 and 8:00 a.m. doses for 09/21 and 09/22/2024 were left blank, indicating 5 missed doses of the medication. During an interview on 10/30/2024 at 1:30 p.m. S2 DON (Director of Nursing) reviewed Resident #62's September 2024 MAR and reported the Amoxicillin-Pot Clavulanate doses for 8:00 p.m. on 09/20, 09/21, and 09/22/2024 and doses for 8:00 a.m. on 09/21 and 09/22/2024 were blank and the full course was not administered.

Based on observations, record reviews, and interviews, the facility failed to ensure residents were free of accident hazards by failing to ensure bed rails were securely attached to the bed for 5 (#70, #54, #49, #40, and #8) of 6 (#70, #54, #49, #40, #8, and #201) residents reviewed for accident hazards. Findings: Resident #70 Review of Resident #70's record revealed an admitted [DATE] and diagnoses including: unspecified dementia unspecified severity with other behavioral disturbance, post-traumatic stress disorder, unspecified mood disorder, bipolar disorder current episode manic severe with psychotic features, edema, and pain. The resident resided on the facility's secure memory care unit. Review of Resident #70's most currently completed MDS (Minimum Data Set) Assessments with an ARD (Assessment Reference Date) of 08/13/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) Score of 9 out of 15 indicating moderately impaired cognition. Further review revealed the resident was independent requiring no set up or physical help from staff for bed mobility, transfer, eating, and toilet use. Observation on 10/28/2024 at 9:35 a.m. revealed Resident #70 lying in bed with bilateral quarter metal bed rails in place on the upper half bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. During an interview on 10/28/2024 at 9:35 a.m., Resident #70 stated he used the rails to help position himself and to help himself sit up. Observation on 10/29/2024 at 10:18 a.m. revealed Resident #70's bed had bilateral quarter metal bed rails attached to the upper half of the bed. The right rail was loose when moved toward and away from the mattress. The left rail was very loose when moved toward and away from the mattress and freely moved toward the foot of the bed so that it turned a full 90 degrees. During an interview on 10/29/2024 at 10:18 a.m., Resident #70 asked the surveyor what they were doing. When told the surveyor was looking at the rails on his bed, and told him they were kind of loose, he replied yeah I know. That's why I don't use them, I'm afraid I'll fall. Resident #54 Review of Resident #54's most recently completed comprehensive MDS assessments with ARD of 08/06/2024 revealed the resident had a BIMS score of 15 out of 15 indicating he was cognitively intact. Observation on 10/28/2024 at 10:25 a.m. revealed Resident #54 had bilateral quarter metal bed rails in place on the upper half of the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. During an interview on 10/28/2024 at 10:25 a.m. Resident #54 reported he used the rails to help position himself in the bed. Observation on 10/29/2024 at 10:30 a.m. revealed resident lying in his bed. Further observation revealed the resident's bed had bilateral quarter metal bed rails attached to the upper half of the bed. Both rails were loose and freely moved back and forth and toward and away from the mattress. During an interview on 10/29/2024 at 10:30 a.m. Resident #54 reported he used the rails to pull himself up in the bed, but they were pretty loose. Resident #54 further indicated the staff only checked on the rails at his request, but it had been a while since he had mentioned the rails being loose to any staff member. Resident #49 Review of Resident #49's record revealed an admitted [DATE] and diagnoses including: neuroleptic induced parkinsonism, vascular dementia severe with mood disturbance, depression, unspecified mood disorder, alcohol dependence with alcohol-induced persisting dementia, insomnia, idiopathic peripheral autonomic neuropathy, generalized muscle weakness, anxiety disorder, impulse disorder, unspecified pain, unspecified abnormalities of gait and mobility, unspecified lack of coordination. The resident resided on the facility's secure memory care unit. Review of Resident #49's most recently completed comprehensive MDS assessments with ARD of 08/06/2024 revealed the resident had a BIMS score of 10 out of 15 indicating moderately impaired cognition. Further review revealed Resident #49 was independent with setup help only for eating, required supervision with one person physical assist for toilet use; supervision with one person physical assist for bed mobility and transfer. Observation on 10/28/2024 at 9:33 a.m. revealed Resident #49's bed had bilateral quarter metal bed rails in place on the upper half of the bed in the raised position. The rail to the right side was loose and moved back and forth and side to side when pulled. During an interview on 10/28/2024 at 9:33 a.m., Resident #49 reported he used the rails to help position himself in the bed. Observation on 10/29/2024 at 10:14 a.m. revealed Resident #49's bed had bilateral quarter metal bed rails attached to the upper half of the bed. Both rails were loose and freely moved back and forth and toward and away from the mattress. Resident #40 Review of Resident #40's record revealed an admitted [DATE] and diagnoses including: neurocognitive disorder with Lewy Bodies, vascular dementia, bipolar disorder, and generalized muscle weakness. The resident resided on the facility's secure memory care unit. Review of Resident #40's most recently completed comprehensive MDS assessments with ARD of 09/18/24 revealed the resident's BIMS interview was not conducted due to the resident being rarely/never understood. Further review revealed the resident had a short-term memory problem and severely impaired cognitive skills for daily decision making. Observation on 10/28/2024 at 9:41 a.m. revealed Resident #40's bed had bilateral quarter metal bed rails in place to the upper half of the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. Observation on 10/29/2024 at 10:20 a.m. revealed Resident #40's bed had bilateral quarter metal bed rails attached to the upper half of the bed. The left rail was in the down position. The right rail was loose and moved freely toward and away from the mattress and moved back and forth toward the head and foot of the bed when pulled on. Resident #8 Review of Resident #8's record revealed an admitted [DATE] and diagnoses including: unspecified dementia with behavioral disturbance, unspecified convulsions, bipolar disorder, persistent mood disorder, major depressive disorder, insomnia, generalized muscle weakness, anxiety disorder. The resident resided on the facility's secure memory care unit. Review of Resident #8's most recently completed comprehensive MDS assessments with ARD of 10/08/2024 revealed the resident's BIMS interview was not conducted due to the resident being rarely/never understood. Further review revealed Resident #8 had a short-term memory problem and severely impaired cognitive skills for daily decision making. Observation on 10/28/2024 at 9:25 a.m. revealed Resident #8 lying in bed with bilateral quarter metal bed rails in place to the upper half of the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. Observation on 10/29/2024 at 10:16 a.m. revealed Resident #8 lying in her bed with bilateral quarter metal bed rails attached to the upper half of the bed. The resident's upper body was leaning up against the right bed rail. Further observation revealed both rails were loose and moved toward and away from the mattress, and moved back and forth toward the head and foot of the bed when pulled on. Observations beginning on 10/29/2024 at 3:58 p.m. with S7 CNA (Certified Nursing Assistant) on the secure dementia care unit revealed Resident #70, #49, #40, and #8's bed rails were loose and freely moveable. During an interview on 10/29/2024 beginning at 3:58 p.m. S7 CNA confirmed Resident #70, #49, #40, and #8's bed rails were loose and should not be. Observations beginning on 10/29/2024 at 4:00 p.m. with S8 CNA revealed Resident #54's bed had had bilateral quarter metal side rails attached to the upper half of the bed that were loose and freely moveable. During an interview on 10/29/2024 at 4:00 p.m. S8 CNA confirmed Resident #54's bed rails were loose and should not be. Observations beginning on 10/29/2024 at 4:04 p.m. with S3 ADON (Assistant Director of Nursing) revealed Resident #70, #49, #40, #8 and #54's beds had had bilateral quarter metal bed rails attached to the upper half of the bed that were loose and freely moveable. During an interview on 10/29/2024 beginning at 4:04 p.m. S3 ADON confirmed Resident #70, #49, #40, #8 and #54's bed rails were loose and freely moveable and should not be. During an interview on 10/29/2024 at 4:08 p.m. S2 DON (Director of Nursing) reported the maintenance department was responsible for checking the bed rails to ensure they were firmly attached and functioning properly. S2 DON further reported she did not know if maintenance checks were done on a routine basis or only when problems were reported. During an interview on 10/29/2024 at 4:33 p.m. S9 Maintenance reported he only inspected bed rails when staff turned in a work order reporting an issue. S9 Maintenance reported he did not conduct regular routine maintenance on the bed rails.

Based on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails. The facility failed to ensure: residents were assessed for risks associated with the use of bed rails (side rails) and/or safety devices, informed consent was obtained from resident/resident representative prior to installation of bed rails, evidence of monitoring and supervision during the use of bed rails, and/or scheduled maintenance was conducted according to manufacturer's recommendations for any bed rails in use for 12 (#5, #8, #14, #29, #31, #40, #49, #54, #57, #64, #70, #201) of 12 residents reviewed for bed rails. Findings: Review of the facility's Restraints and Safety Devices policy with a revision date of October of 2022 revealed in part: It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints not required to treat the resident's medical symptoms. Restraints may not be used for the convenience of the nursing staff or as punishment to the resident. Physical Restraint Definition Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, restricts freedom of movement or normal access to one's body. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This is not determined by a type of device or method, but can only be determined on an individual basis by evaluating the effect it has on the resident. Do not focus on the type, intent or the reason behind the use to determine if it should be classified as a restraint, focus on the effect. The Restraint Device Worksheet helps to make the determination of whether the device is a restraint or not. If it is determined not to be a restraint, it is a device. If the device being used could be considered a restraint, the Device/Physical Consent shall be completed. Residents must be screened for use of approved restraints to meet their particular needs. Side rail usage should also be reviewed. If necessary, use side rail covers or bolster to prevent the resident's body from going under or through side rails if side rails are used. The facility must attempt to use an appropriate alternatives prior to installing a side rail. If used, the facility must assess the resident for risk of entrapment, review the risks and benefits with the resident or resident representative, obtain informed consent prior to installation, ensure bed dimensions are appropriate for the resident's size and weight, and follow manufacturer's directions for installing and maintaining side rails. Resident #5 Review of Resident #5's medical record revealed an admitted [DATE] with diagnoses including but not limited to: quadriplegia unspecified, communicating hydrocephalus, morbid (severe) obesity due to excess calories, muscle weakness (generalized), aphasia, cerebral palsy, spastic quadriplegia, cerebral palsy, and profound intellectual disabilities. Review of Resident #5's comprehensive care plan revealed Resident #5's current safety devices and special equipment included approaches of quarter bed rails X 2 and wheelchair. Review of Resident #5's medical record failed to reveal documentation of monitoring and supervision provided during use of bed rails. Observation on 10/29/2024 at 8:07 a.m. revealed Resident #5 was awake in bed with head of bed slightly elevated and bed rails were up on both sides of upper bed. Observation on 10/29/2024 at 1:19 p.m. revealed Resident #5 was asleep in bed with head of bed elevated and bed rails were up on both sides of upper bed. During an interview on 10/29/2024 at 3:48 p.m. S11 LPN (Licensed Practical Nurse) observed Resident #5's bed rails and reported the rails were always up when she was in bed. Resident #8 Review of Resident #8's record revealed an admitted [DATE] and diagnoses including: unspecified dementia with behavioral disturbance, unspecified convulsions, bipolar disorder, persistent mood disorder, major depressive disorder, insomnia, generalized muscle weakness, anxiety disorder. The resident resided on the facility's secure memory care unit. Review of Resident #8's most recently completed comprehensive MDS (minimum data set) assessments with ARD (assessment reference date) of 10/08/2024 revealed the resident's BIMS (brief interview mental status) interview was not conducted due to the resident being rarely/never understood. Further review revealed Resident #8 had a short-term memory problem and severely impaired cognitive skills for daily decision making. Review of Resident #8's record failed to reveal a consent for the use of bed rails. Observation on 10/28/2024 at 9:25 a.m. revealed Resident #8 lying in bed with bilateral quarter metal side rails in place to the upper half of the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. Observation on 10/29/2024 at 10:16 a.m. revealed Resident #8 lying in her bed with bilateral quarter metal side rails attached to the upper half of the bed. The resident's upper body was leaning up against the right side rail. Further observation revealed both rails were loose and moved toward and away from the mattress, and moved back and forth toward the head and foot of the bed when pulled on. During an interview on 10/30/2024 at 8:15 a.m. S2 DON (Director of Nursing) confirmed a consent for the use of bed rails had not been obtained for Resident #8 prior to the use of the rails and should have been. Resident #14 Review of Resident #14's medical record revealed an admitted [DATE] with following diagnoses, including but not limited to: acquired absence of left leg below knee, acquired absence of right leg above knee, hereditary and idiopathic neuropathy, morbid (severe) obesity, chronic systolic (congestive) heart failure, primary generalized (osteo) arthritis, other lack of coordination, and muscle wasting and atrophy of unspecified site. Review of Resident #14's comprehensive care plan revealed: Potential for injury related to the use of quarter side rails. Bed rails up X2 when in bed for bed mobility and positioning. Quarter side rails up X 2 when in bed, and safety device/restraint assessment quarterly and prn (as needed). Review of Resident #14's medical record failed to reveal documentation of monitoring and supervision had been provided during use of bed rails. Observation on 10/28/2024 at 3:06 p.m. revealed Resident #14's bed rails were up on both sides of upper bed. Observation on 10/29/2024 at 3:48 p.m. with S11 LPN revealed Resident #14 was in bed with head of bed elevated and bed side rails were up on both sides of upper bed. During an interview on 10/29/2024 at 3:48 p.m. S11 LPN reported Resident #14 usually had both upper bed rails up and preferred them to stay up. Resident #29 Review of Resident #29's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: spondylosis of the lumbar region, delusional disorder and anxiety disorder. Review of Resident #29's comprehensive care plan revealed, in part: Resident #29 had a potential for injury related to the use of quarter side rails up X 2 when in bed for bed mobility and repositioning. Review of Resident #29's medical record revealed an incomplete Device/Physical Restraint Consent dated 09/03/2024, which failed to indicate whether the resident consented to side rails. Further review of Resident #29's medical record failed to reveal documentation of monitoring and supervision provided during the use of side rails. Observation on 10/28/2024 at 8:15 a.m. revealed Resident #29 asleep in bed with bilateral upper quarter side rails in use. Observation on 10/28/2024 at11:15 a.m. revealed Resident #29 awake in bed with bilateral upper quarter side rails in use. During an interview on 10/28/2024 at 11:15 a.m. Resident #29 reported she uses the left side rail to help get out of bed. During an interview on 10/29/2024 at 3:50 p.m. S10 LPN reported Resident #29's upper quarter side rails are kept in a raised position. During an interview on 10/29/2024 at 4:30 p.m. S2 DON acknowledged Resident #29's Device/Physical Restraint Consent was incomplete. Resident #31 Review of Resident #31's medical record revealed an admitted [DATE] with diagnoses including but not limited to: type 2 diabetes mellitus with diabetic chronic kidney disease, acute systolic (congestive) heart failure, atherosclerotic heart disease, muscle wasting and atrophy of unspecified site, insomnia, other lack of coordination, secondary Parkinsonism unspecified, history of falling, and bipolar disorder. Review of Resident #31's comprehensive care plan revealed Resident #31's current safety devices and special equipment included approaches of quarter side rails X 2 and wheelchair. Review of Resident #31's medical record failed to reveal documentation of monitoring and supervision provided during use of bed rails. Observation on 10/28/2024 at 3:23 p.m. revealed Resident #31 was lying in bed with head of bed slightly elevated and bed rails were up on both sides of the upper bed. During an interview on 10/29/2024 at 3:48 p.m. S11 LPN observed Resident #31's side rails and confirmed bed rails were up on both sides of upper bed and Resident #31 preferred them to stay up. Resident #40 Review of Resident #40's record revealed an admitted [DATE] and diagnoses including: neurocognitive disorder with Lewy Bodies, vascular dementia, bipolar disorder, and generalized muscle weakness. The resident resided on the facility's secure memory care unit. Review of Resident #40's most recently completed comprehensive MDS assessments with ARD of 09/18/2024 revealed the resident's BIMS interview was not conducted due to the resident being rarely/never understood. Further review revealed the resident had a short-term memory problem and severely impaired cognitive skills for daily decision making. Review of Resident #40's Nurse Data Collection and Screening dated 09/18/2024 revealed in part: section B. Restraint Necessity/Positioning Device: device in use=yes, device=side/bed rail, alteration in safety awareness, severe impairment of mental status, bed mobility=independent with an enabler; type of bed/side rail-quarter bed rail/assist bed rail. Further review revealed section #3 Bed/side rails have been inspected and evaluated to identify and remove potential fall, entrapment, or entanglement hazards and is appropriate for resident needs after considering all relevant risk factors was left blank. Observation on 10/28/2024 at 9:41 a.m. revealed Resident #40's bed had bilateral quarter metal side rails in place to the upper half of the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. Observation on 10/29/2024 at 10:20 a.m. revealed Resident #40's bed had bilateral quarter metal side rails attached to the upper half of the bed. The left rail was in the down position. The right rail was loose and moved freely toward and away from the mattress and moved back and forth toward the head and foot of the bed when pulled on. During an interview on 10/30/2024 at 8:15 a.m. S2 DON confirmed Resident #40's bed rail assessment dated [DATE] did not include an inspection and evaluation to identify and remove potential fall, entrapment, or entanglement hazards and should have. Resident #49 Review of Resident #49's record revealed an admitted [DATE] and diagnoses including: neuroleptic induced parkinsonism, vascular dementia severe with mood disturbance, depression, unspecified mood disorder, alcohol dependence with alcohol-induced persisting dementia, insomnia, idiopathic peripheral autonomic neuropathy, generalized muscle weakness, anxiety disorder, impulse disorder, unspecified pain, unspecified abnormalities of gait and mobility, unspecified lack of coordination. The resident resided on the facility's secure memory care unit. Review of Resident #49's most recently completed comprehensive MDS assessments with ARD of 08/06/2024 revealed the resident had a BIMS score of 10 out of 15 indicating moderately impaired cognition. Further review revealed Resident #49 was independent with setup help only for eating, required supervision with one person physical assist for toilet use; supervision with one person physical assist for bed mobility and transfer. Review of Resident #49's record failed to reveal a consent for the use of bed rails. Review of Resident #49's comprehensive care plan failed to reveal any interventions related to the use of side rails. Review of Resident #49's Nurse Data Collection and Screening form dated 08/06/2024 revealed in part: Restraint Necessity/Positioning device: The question Does the resident currently have a device in use of being considered? Devices may include but not limited to bed/side rails, lap buddy, table, recliner, seatbelt, mittens, position change alarm etc. was marked No. Further review revealed no assessment of risks associated with the use of the bed rails had been completed. Observation on 10/28/2024 at 9:33 a.m. revealed Resident #49's bed had bilateral quarter metal side rails in place on the upper half of the bed in the raised position. The rail to the right side was loose and moved back and forth and side to side when pulled. During an interview on 10/28/2024 at 9:33 a.m., Resident #49 reported he used the rails to help position himself in the bed. Observation on 10/29/2024 at 10:14 a.m. revealed Resident #49's bed had bilateral quarter metal side rails attached to the upper half of the bed. Both rails were loose and freely moved back and forth and toward and away from the mattress. During an interview on 10/30/2024 at 8:43 a.m. S2 DON confirmed Resident #49 did not have a consent for the use of bed rails, was not care planned for the use of bed rails, and had not been evaluated for the risks associated with the use of bed rails. S2 DON further reported Resident #49 had bed rails in use and should not have. Resident #54 Review of Resident #54's most recently completed comprehensive MDS assessments with ARD of 08/06/2024 revealed the resident had a BIMS score of 15 out of 15 indicating he was cognitively intact. Observation on 10/28/2024 at 10:25 a.m. revealed Resident #54 had bilateral quarter metal side rails in place on the upper half of the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. During an interview on 10/28/2024 at 10:25 a.m. Resident #54 reported he used the rails to help position himself in the bed. During an interview on 10/29/2024 beginning at 4:04 p.m. S3 ADON (Assistant Director of Nursing) confirmed Resident #54's bed rails were loose and freely moveable and should not be. Resident #57 Review of Resident 57's medical record revealed a re-entry date of 04/05/2024 with the following diagnoses, including but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, vascular dementia, severe with other behavioral disturbance, and general anxiety disorder. Review of Resident #57's comprehensive care plan on 10/29/2024 revealed in part: Resident #57s current safety devices and special equipment included bolster device and quarter bed rails x 2. Review of Resident #57's medical record failed revealed an undated Device/Physical Restraint Consent. Review of Resident #57's medical record revealed the Quarterly Nurse Data Collection and Screening assessment dated [DATE] failed to assess Resident #57 for the use of a bolster device. Further review of Resident #57's medical record failed to reveal documentation of monitoring and supervision provided during use of side rails. Observation on 10/28/2024 at 8:30 a.m. revealed Resident #57 asleep in bed with bilateral upper quarter bed rails in use with bolster devices strapped to the resident side of each rail. Observation on 10/28/2024 at 11:00 a.m. revealed Resident #57 asleep in bed with bilateral upper quarter bed rails and bolster devices in use. Observation on 10/29/2024 at 10:30 a.m. revealed Resident #57 asleep in bed with bilateral upper quarter bed rails and bolster devices in use. During an interview on 10/29/2024 at 3:50 p.m., S10 LPN reported Resident #57's upper quarter bed rails stay up and she was not sure why both bed rails and bolsters were in use. During an interview on 10/29/2024 at 4:30 p.m. S2 DON acknowledged Resident #57's Device/Physical Restraint Consent was not dated and was incomplete. During an interview on 10/30/2024 at 8:45 a.m. S2 DON reviewed Resident #57's 09/16/2024 Assessment for Restraint Necessity dated 09/16/2024 and acknowledged Resident #57 had not been assessed for bolster device usage. S2DON acknowledged Resident #57 had a bolster device in use and should not have. Resident #64 Review of Resident #64's medical record revealed an admitted [DATE] with diagnoses that included, in part, unspecified diastolic (congestive) heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic obstructive pulmonary disease, iron deficiency anemia, primary generalized (osteo) arthritis, unspecified dementia, post-traumatic stress disorder, chronic kidney disease stage 4, muscle weakness (generalized), other lack of coordination, and unspecified pain. Review of Resident #64's comprehensive care plan revealed: Resident #64's current safety devices and special equipment included approaches of quarter bed rails X 2 and wheelchair. Review of Resident #64's medical record failed to reveal documentation of monitoring and supervision provided during use of bed rails. Observation on 10/28/2024 at 12:02 p.m. revealed Resident #64 was in bed with head of bed elevated and bed rails were up on both sides of upper bed. Observation on 10/29/2024 at 1:17 p.m. revealed Resident #64 was lying in bed with head of bed elevated and bed rails were up on both sides of upper bed. During an interview on 10/29/2024 at 3:44 p.m. S11 LPN observed Resident #64 and reported Resident #64 usually kept his both of his upper bed rails up and preferred them to stay up to make it easier to maneuver in bed. Resident #70 Review of Resident #70's record revealed an admitted [DATE], and diagnoses including: Unspecified dementia unspecified severity with other behavioral disturbance, post-traumatic stress disorder, unspecified mood disorder, bipolar disorder current episode manic severe with psychotic features, edema, and pain. The resident resided on the facility's secure memory care unit. Review of Resident #70's most currently completed MDS Assessments with an ARD of 8/13/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) Score of 9 out of 15 indicating moderately impaired cognition. Further review revealed the resident was independent requiring no set up or physical help from staff for bed mobility, transfer, eating, and toilet use. Review of Resident #70's comprehensive care plan failed to reveal any interventions related to the use of bed rails. Review of Resident #70's Nurse Data Collection and Screening form dated 08/13/2024 revealed in part: Restraint Necessity/Positioning device: The question Does the resident currently have a device in use of being considered? Devices may include but not limited to bed/side rails, lap buddy, table, recliner, seatbelt, mittens, position change alarm etc. was marked No. Further review revealed no assessment of risks associated with the use of the bed rails had been completed. Observation on 10/28/2024 at 9:35 a.m. revealed Resident #70 lying in bed on the locked dementia care unit. Bilateral quarter metal side rails were in place on the bed in the raised position. The rail to right side was loose and moved back and forth and side to side when pulled. During an interview on 10/28/2024 at 9:35 a.m., Resident #70 stated he used the rails to help position himself and to help himself sit up. Observation on 10/29/2024 at 10:18 a.m. revealed Resident #70's bed had bilateral quarter metal bed rails attached to the upper half of the bed. The right rail was loose when moved toward and away from the mattress. The left rail was very loose when moved toward and away from the mattress and freely moved toward the foot of the bed so that it turned a full 90 degrees. During an interview on 10/30/2024 at 8:43 a.m. S2 DON confirmed Resident #70's care plan did not include the use of bed rails/safety device. S2 DON further confirmed Resident #70 had not been assessed quarterly for the risks associated with the use of the bed rails and should have been. Resident #201 Review of Resident #201's record an admitted [DATE] and diagnoses including: fracture of unspecified parts of lumbosacral spine and pelvis subsequent encounter for fracture with routine healing, schizoaffective disorder bipolar type, depression, muscle wasting and atrophy unspecified site, cognitive communication deficit, mood disorder, unspecified abnormalities of gait and mobility, lack of coordination, generalized muscle weakness, unspecified dementia. The resident resided on the facility's secure memory care unit. Review of Resident #201's most recently completed comprehensive MDS assessments with ARD of 08/20/2024 revealed the resident had a BIMS score of 6 out of 15 indicating severely impaired cognition. Observation on 10/29/2024 at 10:12 a.m. revealed Resident #201 lying in bed with bilateral quarter metal side rails attached to the upper half of the bed. Observation on 10/29/2024 at 3:58 p.m. revealed Resident #201's bed had bilateral quarter metal side rails attached to the upper half of the bed. During an interview on 10/29/2024 at 4:08 p.m. S2 DON reported a consent should be obtained from all residents or the residents' responsible parties prior to the installation or use of bed rails or other safety devices, even if not considered a restraint. S2 DON further reported a resident/device assessment should be conducted at least quarterly, and the use of the device should be included in the resident's care plan. S2 DON also reported the maintenance department was responsible for checking the bed rails to ensure they were firmly attached and functioning properly, but she did not know if checks were done on a routine basis or only when problems were reported. During an interview on 10/29/2024 at 4:33 p.m. S9 Maintenance reported he only inspected bed rails when staff turned in a work order reporting an issue. S9 Maintenance reported he did not conduct regular routine maintenance on the bed rails. S9 Maintenance further reported he did not know what the manufacturer recommendations were regarding the maintenance of the rails but he could look them up. During an interview on 10/30/2024 at 9:26 a.m. S9 Maintenance reported he did not have the manufacturer's recommendations for the installation and/or maintenance of the metal side rails. S9 Maintenance stated the rails come loose all the time. S9 Maintenance further confirmed he did not conduct regular scheduled maintenance checks on the bed rails, but only inspected them when staff reported an issue to him. During an interview on 10/30/2024 at 1:30 p.m. S1 Administrator reported he did not have the manufacturer's information and guidance for the metal bed rails in use at the facility, and did not know what the manufacturer's recommendations were for the scheduled maintenance of the rails. During an interview on 10/30/2024 at 4:10 p.m. S2 DON and S12 Corporate Nurse reported no residents with side rails up were being monitored for the use of side rails. 40015 44414

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 4 (#28, #34, #79, #87) out of 6 (#28, #34, #49, #70, #79, #87) residents review for unnecessary medications. The facility failed to: 1. Monitor Resident #28 for edema, 2. Monitor Resident #34 for edema and bleeding, 3. Monitor Resident #79 for edema and bleeding, and 4. Monitor Resident #87 for bleeding. Findings: Resident #28 Review of Resident #28's medical record revealed an admitted [DATE] with the following diagnoses, including in part: acute on chronic congestive heart failure (CHF), essential (primary) hypertension, end stage renal disease, chronic kidney disease/stage 3 unspecified, and dependence on dialysis. Review of Resident #28's Physician's Orders revealed an order dated 08/01/2024 for Bumetanide tablet 1 mg (milligram) give 1 tablet by mouth one time a day related to CHF. Review of Resident #28's October 2024 tasks in electronic health record failed to reveal edema was monitored every shift on the following days: 1-5, 7, 9-13, 15-20, 24, 25, 26, 28, and 29th. During an interview on 10/30/2024 at 11:50 a.m. S2 DON (Director of Nursing) acknowledged Resident #28 was not monitored every shift for edema and should have been. Resident #34 Review of Resident #34's medical record revealed an admitted [DATE] with the following diagnoses, including in part: chronic obstructive pulmonary disease/unspecified, CHF, and edema/unspecified. Review of Resident #34's Comprehensive Care Plan revealed: Resident is on diuretic therapy related to CHF - monitor/document/report prn (as needed) adverse reactions to diuretic therapy .Potential for altered blood pressure - monitor for and document any edema. Notify MD (Medical Direcdtor). Potential for abnormal bleeding and bruising - observe for signs and symptoms of abnormal bleeding - tarry stool, coffee ground emesis, nose bleed, excessive/unexplained bruising . Review of Resident #34's Physician's Order dated 08/01/2024 for Torsemide oral tablet 20 mg give 20 mg by mouth one time a day for edema and Apixaban tablet 5 mg give 1 tablet orally two times a day. Review of Resident #34's October 2024 tasks in the electronic health record failed to reveal edema was monitored every shift on the following days: 1-5, 7, 9-14, 16-20, 22-26, 28 and 29th. Further review of the tasks failed to reveal bleeding was monitored every shift on the following days: 1-5, 7, 9-14, 16-20, 22-26, 28 and 29th. During an interview on 10/30/2024 at 11:50 a.m. S2 DON acknowledged Resident #34 was not monitored every shift for edema and bleeding and should have been. Resident #79 Review of Resident #79's medical record revealed an admitted [DATE] with the following diagnoses, including in part: anxiety disorder, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and acute kidney failure. Review of Resident #79's Physician's Orders revealed an order dated 08/28/2024 for Eliquis tablet 5 mg by mouth two times a day and Furosemide tablet 40 mg by mouth one time a day. Review of Resident #79's October 2024 tasks in electronic health record failed to reveal edema was monitored every shift on the following days: 1, 4, 6-11, and 13-29th. Further review of the tasks failed to reveal bleeding was monitored every shift on the following days: 1, 4, 6-11, and 13-29th. During an interview on 10/30/2024 at 2:35 p.m. S3 ADON (Assistant Director of Nursing) acknowledged Resident #79 had not been monitored every shift for edema and bleeding and should have been. Resident #87 Review of Resident #87's medical record revealed an admitted [DATE] with the following diagnoses, including in part: dyskinesia, neurocognitive disorder with lewy bodies, and major depressive disorder, Review of Resident #87's Physician's Orders revealed an order dated 10/14/2024 for Eliquis tablet 5 mg by mouth two times a day. Review of Resident #87's October 2024 tasks in electronic health record failed to reveal bleeding was monitored every shift on the following days: 1-2, 4, 6, 9-11, 13-20, 23, and 25-28th. During an interview on 10/30/2024 at 2:35 p.m. S2 ADON acknowledged Resident #87 had not been monitored every shift for bleeding and should have been. 44414

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary psychotropic medications for 3 (#34, #79, #87) out of 6 (#28, #34, #49, #70, #79, #87) residents review for unnecessary medications. The failed to monitor Residents #34, #79, and #87 for psychotropic side effects and behaviors. Findings: Resident #34 Review of Resident #34's medical record revealed an admitted [DATE] with the following diagnoses, including in part: anxiety disorder due to known physiological condition, mood disorder due to known physiological condition/unspecified, insomnia/unspecified, and major depressive disorder/recurrent/moderate. Review of Resident #34's Physician's Orders dated 09/13/2024 for Zoloft oral tablet give 150 mg (milligram) by mouth one time a day for major depressive disorder (MDD), 09/10/2024 for Busprione HCL (hydrochloride) tablet give 7.5 mg orally three times a day for anxiety, 08/01/2024 for Duloxetine HCL enteric coated pellets capsule 60 mg orally two times a day for behavior - withdrawn, and 08/01/2024 for Bupropion HCL tablet ER (extended release) 24 hr (hour) 150 mg give 1 tablet orally one time a day for behavior - withdrawn. Review of Resident #34's October 2024 tasks in the electronic health record failed to reveal side effects were monitored every shift on the following days: 1-5, 7, 9-14, 16-20, 22-26, 28 and 29th. Further review of the tasks failed to reveal behaviors were monitored every shift on the following days: 1-5, 7, 9-14, 16-20, 22-26, 28 and 29th. During an interview on 10/30/2024 at 11:50 a.m. S2 DON (Director of Nursing) acknowledged Resident #34 was not monitored every shift for psychotropic side effects and behaviors and should have been. Resident #79 Review of Resident #79's medical record revealed an admitted [DATE] with the following diagnoses, including in part: anxiety disorder, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and acute kidney failure. Review of Resident #79's Physician's Orders revealed an order dated 08/28/2024 for Buspirone tablet 5 mg by mouth two times a day and Trazadone tablet 50 mg by mouth at bedtime. Further review revealed an order dated 10/15/2024 for Mirtazapine tablet 7.5 mg by mouth at bedtime for depression Review of Resident #79's October 2024 tasks in electronic health record failed to reveal side effects and behaviors were monitored every shift on the following days: 1, 4, 6-11, and 13-29th. During an interview on 10/30/2024 at 2:35 p.m. S3 ADON (Assistant Director of Nursing) acknowledged Resident #79 had not been monitored every shift psychotropic side effects and behaviors and should have been. Resident #87 Review of Resident #87's medical record revealed an admitted [DATE] with the following diagnoses, including in part: dyskinesia, neurocognitive disorder with lewy bodies, and major depressive disorder. Review of Resident #87's Physician's Orders revealed orders dated 10/17/2024 for Sertraline tablet 100 mg by mouth one time a day, 05/21/2024 Alprazolam tablet 0.25 mg by mouth one time a day and 07/30/2024 Quetiapine Fumarate tablet 150 mg by mouth at bedtime. Review of Resident #87's October 2024 tasks in electronic health record failed to reveal side effects and behaviors were monitored every shift on the following days: 1-2, 4, 6, 9-11, 13-20, 23, and 25-28th. During an interview on 10/30/2024 at 2:35 p.m. S3 ADON acknowledged Resident #87 had not been monitored every shift for psychotropic side effects and behaviors and should have been. 44414

Based on record review and interview the facility failed to inform in writing 1 (#151) of 3 residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Protection Notification of changes in their liability. Findings: Review of the facility's SNF Beneficiary Protection Notification Review revealed the facility initiated Resident #151's discharge from Medicare Part-A Services when the benefit days were not exhausted. A written NOMNC (Notice of Medicare Non-Coverage) or ABN (Advance Beneficiary Notice) was not given to Resident #151 or his RP (responsible party). Review of the facility's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage read in part the following: Beginning on 10/10/2024 you may have to pay out of pocket for this care if you do not have other insurance that may cover theses costs. Additional Information: On 10/28/2024 at 1:08 p.m., you_________ (the Resident Representative's name) were contacted by telephone at _________ Contact#, by S5 Account Manager to discuss details of this notice. During an interview on 10/28/2024 at 4:30 p.m., S5 Account Manager reported a written NOMNC or ABN were not provided to Resident #151 or his RP. S5 Account Manager reported she should have notified Resident #151or his RP earlier in October and she did not.

Based on record reviews and interviews, the facility failed to ensure the medical record reflected an accurate advance directive preference for 1 (#44) of 1 resident investigated for advanced directives. Findings: Review of Resident #44's electronic medical record header indicated a code status of Cardiopulmonary Resuscitation (CPR). Review of Resident #44's record revealed a facility form titled Resident/Family Consent for Cardiopulmonary Resuscitation indicated a code status of CPR. Review of Resident #44's record revealed a physician's order dated [DATE] for Code Status Do Not Resuscitate (DNR). Further review of Resident #44's record failed to reveal documentation of a LaPOST (Louisiana Physician Orders for Scope of Treatment). During an interview on [DATE] at 4:25 p.m. S2 ADON (Assistant Director of Nursing) reviewed Resident #44's records and acknowledged there was not documentation of accurate advanced directive preference. During an interview on [DATE] at 4:30 p.m. S1 DON (Director of Nursing) reviewed Resident #44's records and acknowledged there was not documentation of accurate advanced directive preference.

Based on record reviews, observations, and interview the facility failed to ensure a cover/cap was applied to the male tip of a feeding tube line when removed from a gastrostomy tube for 2 (Residents #2, #76) of 3 (Residents #2, #72, #76) residents reviewed for tube feeding. Findings: Resident #2 Record review of Resident # 2's diagnoses revealed the following, in part: - Gastrostomy status - Dysphagia - Type 2 diabetes. Record review of Resident #2's physician orders for November 2023 revealed the following , in part: - Tube feeding formula Diabetisource 1.2 Kcal (Kilocalories) at 60cc (cubic centimeters)/hour times 20 hours per day to deliver 1440 calories, 72 grams protein, 979ml (milliliters) total volume. Off at 7:00 a.m. and on at 11:00 a.m. - NPO (nothing by mouth). Review of Resident #2's MDS (minimum data set) dated 09/20/2023 revealed the following, in part: - Section C showed a BIMS (brief interview of mental status) of 00, which would indicate the resident had severely impaired cognition. - Section K showed nutritional approaches were per feeding tube. Observation on 11/27/2023 at 9:10 a.m. revealed Resident #2's feeding tube was disconnected from the resident's gastrostomy tube. The male tip of the feeding tube line that connects to the resident's gastrostomy was not capped and was hanging over the pole above the feeding pump, open to air. Observation on 11/28/2023 at 8:15 a.m. revealed Resident #2's feeding tube was disconnected from the resident's gastrostomy tube. The male tip of the feeding tube line that connects to the resident's gastrostomy was not capped and was hanging over the pole above the feeding pump, open to air. Observation on 11/29/2023 at 7:50 a.m. revealed Resident #2's feeding tube was disconnected from the resident's gastrostomy tube. The male tip of the feeding tube line that connects to the resident's gastrostomy was not capped and was hanging over the pole above the feeding pump, open to air. During an interview on 11/29/2023 at 10:20 a.m., S1DON verified the tip of the feeding tube line was open to air after being removed from Resident #2's gastrostomy tube on 11/29/2023 at 7:00 a.m. S1DON further indicated the tip of the feeding line should have been capped after removal. Resident #76 Record review of Resident # 76's diagnoses revealed the following, in part: - Dysphagia - Gastrostomy status - Type 2 diabetes Record review of Resident #76's physician orders for November 2023 revealed the following, in part: - NPO - Tube feeding formula Diabetisource 1.2Kcal at 75cc/hour times 20 hours per day to deliver 1800 calories, 90 grams protein, 1500ml total volume. Off at 7:00 a.m. and on at 11:00 a.m. Record review of Resident #76's MDS dated [DATE] included: - Section C showed a BIMS score of 00, which would indicate the resident had severely impaired cognition. - Section K showed nutritional approaches were per feeding tube. Observation on 11/27/2023 at 9:05 a.m. revealed Resident #76's feeding tube was disconnected from the resident's gastrostomy tube. The male tip of the feeding tube line that connects to the resident's gastrostomy was not capped and was hanging over the pole above the feeding pump, open to air. Observation on 11/28/2023 at 8:10 a.m. revealed Resident #76's feeding tube was disconnected from the resident's gastrostomy tube. The male tip of the feeding tube line that connects to the resident's gastrostomy was not capped and was hanging over the pole above the feeding pump, open to air. Observation on 11/29/2023 at 7:45 a.m. revealed Resident #76's feeding tube was disconnected from the resident's gastrostomy tube. The male tip of the feeding tube line that connects to the resident's gastrostomy was not capped and was hanging over the pole above the feeding pump, open to air. During an interview on 11/29/2023 at 10:15 a.m., S1DON verified the tip of the feeding tube line was open to air after being removed from Resident #76's gastrostomy tube on 11/29/2023 at 7:00 a.m. S1DON further indicated the tip of the feeding line should have been capped after removal.

Based on record review, observations, and interviews the facility failed to ensure a resident's BiPap (bilevel positive airway pressure) machine was in working order for a resident to receive BiPap at bedtime per physician orders for 1 (Resident #29) of 1 (Resident #29) resident reviewed for respiratory care. Findings: Record review of Resident #29's diagnoses revealed the following, in part: - Acute or chronic systolic congestive heart failure. - Acute respiratory failure with hypoxia - Type 2 diabetes - Morbid obesity - COPD (chronic obstructive pulmonary disease) - Acute and chronic respiratory failure with hypercapnia Record review of Resident #29's physician orders for November 2023 revealed the following, in part: - Oxygen at 2 liters per minute per nasal cannula continuous. - BiPap to be worn daily with two liter nasal cannula at bedtime, settings 12/5/40%. Record review of Resident #29's MDS (minimum data set) dated 10/17/2023 revealed the following, in part: - Section C showed a BIMS (brief interview of mental status) of 15, which would indicate the resident was cognitively intact. - Section O showed the resident received oxygen therapy. Record review of Resident #29's MAR (medication administration record) for November 2023 revealed the following, in part: - BiPap to be worn daily with 2 lpm (liters per minute) per NC (nasal cannula) at bedtime, was marked as completed every day this month on 11/1-28/2023. During an interview on 11/27/23 at 11:13 a.m., Resident #29 indicated she had not worn her BiPap at night time because the power cord was missing and her mask was laying on the floor. Resident #29 further indicated she had not worn her BiPap for several weeks. Observation at this time revealed Resident #29's BiPap mask was laying on the floor under the resident's bed and the power cord for the BiPap machine was not seen. Observation on 11/28/2023 at 8:45 a.m. revealed Resident #29's BiPap mask was laying on the floor under the resident's bed and the power cord for the BiPap machine was not seen. Observation on 11/29/2023 at 8:15 a.m. revealed Resident #29's BiPap mask was laying on the floor under the resident's bed and the power cord for the BiPap machine was not seen. During an interview on 11/29/2023 at 1:25 p.m., Resident #29 indicated she thought the power cord went missing when they moved her to another room. During an interview on 11/29/2023 at 9:00 a.m., S1 DON (Director of Nursing) indicated she was unaware Resident # 29's power cord was missing for her BiPap machine. S1 DON reviewed the MAR from November 2023 and indicated the nurses should put a N indicating not completed in the slot for Resident #29's BiPap machine if they did not apply the BiPap for the resident. S1DON verified the problem should have been resolved, and Resident #29 should have been receiving her BiPap per physician orders.

Based on record review and interviews the facility failed to ensure neurological checks were completed for 1(#41) out of 1 resident reviewed for vision (communication-sensory). Findings: During an interview on 11/27/2023 at 12:05 p.m. Resident #41 reported she just woke up and was not able to see about a month ago. Resident #41 reported her vision was very poor and she could not see. Review of Resident #41's diagnosis revealed dry eye syndrome of unspecified lacrimal gland. Review of Resident #41's October 28, 2023 Physician orders revealed neurological checks every 4 hours for 72 hours after complaints of sudden decrease in vision. Review of Resident #41's Neurological Observations form revealed neurological checks started on 10/28/2023 and ended on 10/31/2023. Review of Resident #41's Neurological Observations failed to reveal neurological checks were done on 10/29/2023 at 12:00 p.m., 10/29/2023 at 4:00 p.m., 10/29/2023 at 8:00 p.m., 10/31/2023 at 12:00 a.m., and 10/31/2023 at 4:00 a.m. During an interview on 10/29/2023 at 1:30 p.m. S1 DON (Director of Nursing) reviewed Resident #41's electronic health record and Neurological Observations form and confirmed neurological checks were not completed on 10/29/2023 at 12:00 p.m., 10/29/2023 at 4:00 p.m., 10/29/2023 at 8:00 p.m., 10/31/20223 at 12:00 a.m., and 10/31/2023 at 4:00 a.m.

Based on record reviews and interviews, the facility failed to ensure a comprehensive care plan had been developed and implemented for 1 (#55) out of 24 total sampled residents. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #55 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of Resident #55's medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - an order dated 11/02/2022 for [MEDICATION(S)] 300mg (milligram) capsule-Give 300mg by mouth twice daily for 14 days for [CONDITION(S)] (Urinary Tract Infection) - an order dated 9/27/2022 for [MEDICATION(S)] 100mg capsule-Give 1 capsule by mouth once daily for [CONDITION(S)] prevention Review of Resident #55's current Care Plan failed to reveal problems and approaches for [CONDITION(S)]. During an interview on 11/15/2022 at 2:30 P.M. S4 MDS (Minimum Data Set) Assessment Nurse reviewed Resident #55's care plan and acknowledged Resident #55 was not care plan for [CONDITION(S)] and should be. During an interview on 11/16/2022 at 9:55 A.M. Resident #55 reported she was on an antibiotic for a [CONDITION(S)] and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record reviews and interviews, the facility failed to ensure a resident's assessment accurately reflected the resident's discharge disposition for 1 (#96) of 2 (#95, #96) residents whose discharge assessments were reviewed. Findings: Review of resident #96's medical record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #96's discharge MDS (Minimum Data Set) dated 9/16/2022 indicated resident #96's discharge was a planned discharge to an acute hospital with no return anticipated. Review resident #96's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/16/2022 at 11:55 am. S1 DON (Director of Nurses) confirmed resident #96 was discharged to home and not to an acute care hospital. During an interview on 11/16/2022 at 12:20 pm. S3 MDS Assessment Nurse confirmed resident #96 was discharged to home and resident #96's MDS indicated resident #96 was discharged to an acute hospital in error.

Based on observation, interview, and record review the facility failed to ensure that a resident's enteral (tube) feeding was properly labeled for 1 (#16) of 1 (#16) resident investigated for tube feeding. This deficient practice had the potential to affect 5 residents in the facility who received tube feedings according to the Resident Census and Conditions of Residents dated 11/14/22. Findings: Review of the facility's policy for Gastrostomy/Jejunostomy/Tube revealed: . Enteral (Tube) Feeding Pump General Instructions: . Label formula container with resident's name, room, date, starting time, rate at milliliters/hour, and initials of licensed staff preparing feeding. Review of Resident #16's current physician order, dated 6/14/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 11/14/22 at 10:15 a.m. with S2 LPN (Licensed Practical Nurse) revealed Resident #16's [MEDICATION(S)] 1.5 Cal tube feeding bag was not labeled with a starting time. During an interview on 11/14/2022 at 10:17 a.m. S2 LPN observed Resident #16's [MEDICATION(S)] 1.5 Cal tube feeding bag and confirmed the bag was not labeled with the starting time and should have been. S2 LPN further reported the bag had to be changed every 24 hours and the labeled time would let staff know when to change the bag.

Based on observations, record reviews, interviews, and review of the facility's Policy and Procedures the facility failed to ensure adequate supervision was provided for 1 (#1) of 12 (#1, #2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) sampled residents who were determined to be at risk for elopement out of a total sample of 15 that resulted in actual harm when resident #1 eloped from the facility and suffered heat exhaustion, dehydration, and acute renal failure. The facility further failed to ensure adequate supervision was provided for 11 of 11 (#2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) residents at risk for elopement currently residing in the facility, not in the locked unit, out of a total sample of 15. The facility failed to: 1. Ensure staff assessed resident #1 for the presence of a wander guard bracelet upon his readmission to the facility from a local emergency roiagnom on [DATE] prior to placing him on the general unit. 2. Ensure staff followed the facility's Nursing Intervention Communication Form Policy dated January 2012 for identification of nursing interventions, i.e. security bracelet, that did not require a physician's orders [REDACTED]. 3. Ensure staff followed the facility's Elopement/Wandering-Residents at Risk Policy revised May 2011 to implement the appropriate protective measures to help guard against a resident wandering from the facility on 7/30/12 when a resident assessed as being an elopement risk on 7/12/12 returned to the facility and no interventions were put in place to prevent elopement from the facility. 4. Increase supervision of a confused, wandering resident (#1) assessed as being an elopement risk, after he returned from a local emergency roiagnom on [DATE] and was placed on the general floor of the facility without a wander guard bracelet. 5. Ensure 2 of 8 facility exit doors on the general unit, accessible by the residents identified as being wanderers by the facility, and who resided on the general unit, were protected by the wander guard system. 6. Ensure 4 of 8 facility exit doors on the general unit, accessible by the residents identified as being wanderers by the facility, and who resided on the general unit, alarmed to alert staff of a resident wearing a wander guard bracelet attempting to exit the facility after the keypad code was entered by visitors and/or staff and the door was opened. The Immediate Jeopardy began for resident #1 on 7/30/12 at 7:42 p.m. when he returned to the facility from a local emergency room and the admitting nurse failed to assess resident #1 for the presence of a wander guard security bracelet. The LPN also failed to immediately place a wander guard bracelet on resident #1 on 7/30/12 prior to admitting him to a room on the general unit. Resident #1 eloped on 7/31/12 at approximately 9:00 a.m. The facility is located on a highly traveled road near a large Supercenter retail store. The Immediate Jeopardy ended for resident #1 when he was found on 7/31/12 at approximately 7:00 p.m. and transported to a local hospital where he was admitted for treatment of [REDACTED]. The Immediate Jeopardy continued for residents #2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 when it was determined the facility had 2 of 9 exit doors with no wander guard alarm system and 4 of 9 exit doors that negated the wander guard alarm system when the key code was entered to open the doors. These 6 exit doors were readily accessible by the eleven residents, identified by the facility as elopement risks, who resided on the general unit. S1 Administrator, S2 DON, and S3 Corporate Nurse were notified on 8/2/12 at 4:45 p.m. of the Immediate Jeopardy situation regarding the actual elopement of resident #1 that began on 7/30/12 at 7:42 p.m. S1 Administrator, S2 DON, and S3 Corporate Nurse were also notified of the continued Immediate Jeopardy for the remaining 11 residents identified as elopement risk residing on the general unit at the facility due to an ineffective wander guard system. The facility's Plan of Removal was documented as follows: 1. Code changed to all exit doors immediately-All staff/family members must use the front door entrance/exit only. Charge nurse, DON, Administrator are the only employees with door code access with strict instructions per Administrator to not give code out to any employees/families. Facility in essence put in lock down. Door/Alarm Specialist on site 8/3/12 at 7:30 a.m. retrofitting current door alarm panels to include advance security feature. This feature will alarm at any time a resident with a security bracelet passes through an open exit door. This work will be completed by 4:00 p.m. 8/3/12. 2. Residents at risk for elopement and currently with security bracelet has the potential to be affected. 3. In-serviced nursing staff on q 15 minute observation of 11 residents with security bracelets to continue until permanent change/upgrade made to secure care system. Code changed to all exit doors with only charge nurse, Administrator, and DON having knowledge of the new code as in-serviced by the Administrator. In-serviced nursing staff regarding assessment of residents upon return from hospital to ensure appropriate interventions implemented for resident at risk for elopement. Residents determined to require a security bracelet and unable to obtain for any reason-notify Administrator/DON immediately and assign 1:1 until bracelet obtained. 4. Administrator to ensure that code is remaining secured until retrofit is completed on all doors-DON/designee to do random direct resident observations of the 11 residents with security bracelets-direct observation of residents will continue until permanent change/upgrade made to secure care system. DON/designee to review documentation on readmissions and direct observation of that resident to ensure interventions, if warranted, were implemented. The facility's Plan of Removal was accepted on 8/3/12 at 2:30 p.m. The Immediate Jeopardy was lifted on 8/3/12 at 3:10 p.m. after observations and record reviews revealed the Plan of Removal had been implemented and functioning and after all exit doors were tested and functioned properly with the wander guard bracelets. The deficient practice continued at a scope and severity of third level isolated. Findings: Review of the facility's Elopement/Wandering-Residents at Risk Policy (May 2011) revealed the following: Purpose: To identify residents who have a potential to wander from the facility. To implement the appropriate protective measures to help guard against a resident wandering from the facility. Policy and Procedure: 1. On admission/readmission, and in the observation period of each MDS and when resident has a significant change in condition, the nursing staff will screen each resident for elopement risk.... Observation on 8/1/12 at 1:10 p.m. revealed the 300 Hall exit door on the south end of the facility was closed and locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. Observation on 8/1/12 at 1:15 p.m. revealed an exit door on the side hall between the 200 Hall and main dining room that was locked with a key pad alarm, but no wander guard sensor was observed at this door. Further observation revealed another door at the end of the side hall that was locked with a key pad alarm and the red armed light was on. A wander guard sensor strip was observed on the wall by the door. Observation on 8/1/12 at 1:17 p.m. revealed an exit door in the main dining room that was locked with a key pad alarm and had a wander guard sensor attached to the wall by the door. Observation on 8/1/12 at 1:20 p.m. revealed an exit door in the northwest corner of the 500 Hall that was locked with a key pad alarm, but no wander guard sensor was observed at this door. Observation on 8/1/12 at 1:22 p.m. revealed an exit door in the northeast corner of the 500 Hall that was locked with a key pad alarm and the red armed light was on. A wander guard sensor was attached to the wall by the door. Observation on 8/1/12 at 1:23 p.m. revealed a door located between the 500 Hall and 100 Hall that was locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. Observation on 8/1/12 at 1:24 p.m. revealed the front door of the facility had a key pad alarm, but was unlocked for entrance and exit of the facility. Further observation revealed a wander guard sensor was attached to the wall by the front door. Observation on 8/1/12 at 1:26 p.m. revealed an exit door on a side hall off of the 400 Hall that was locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. During an interview on 8/1/12 at 1:30 p.m. S4 CNA stated resident #1 previously resided on the locked unit, but was moved to the 200 Hall. S4 CNA stated she was not sure exactly when the move occurred. S4 CNA stated resident #1 was still in the locked unit on Sunday 7/29/12 when she got off work at 2:00 p.m. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Depressive Disorder, Alzheimer's Disease, and Anxiety. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] from home with orders to admit to facility on regular diet, TB Test, and start meds Prozac 20 mg po daily and Exelon Patch 4.6 mg q day. Further review of resident #1's medical record revealed the following: A Physician's Telephone Order dated 7/6/12-Apply wander guard to promote safety and monitor exiting behaviors with a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/19/12-Vistaril 50 mg capsule give 1 tablet po q hs. No diagnosis listed. A Physician's Telephone Order dated 7/21/12-Risperdal 1 mg tablet one po bid for a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/23/12-Seroquel 50 mg tablet give 1 po q hs for a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/26/12-Geodon 20 mg vial give 10 mg IM q 6 hours prn agitation. A Physician's Telephone Order dated 7/30/12-Lorazepam 0.5 mg tablet give 1 tablet po tid prn anxiety/agitation. Exelon 3 mg capsule give 1 po bid with no diagnosis listed. Rozerem 8 mg tablet give 1 po prn at hs with no diagnosis listed. Review of resident #1's Admission MDS with ARD 7/13/12 revealed the following: Section C-Cognitive Patterns: Resident was assessed as 1 (behavior continuously present, does not fluctuate) for Inattention and Disorganized Thinking. Section D-Mood: Resident was assessed 1/2 (yes/7-11 days) for trouble falling or staying asleep, or sleeping too much, trouble concentrating on things, and moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around a lot more than usual. Section E-Behavior: Resident was assessed as having delusions. Resident was assessed as having behavioral symptoms not directed towards others having occurred 1 to 3 days. Resident was assessed as having behaviors that significantly interfere with his care and interfere with participation in activities or social interactions. Resident was assessed as having behaviors that significantly intrude on the privacy or activity of others and significantly disrupts care of living environment. Resident was assessed as 3 (behavior of this type occurred daily) for Wandering. Resident was assessed 1 (yes) for does wandering place resident at significant risk of getting to a potentially dangerous place and does wandering significantly intrude on the privacy or activities of others. Section G-Functional Status: Resident was assessed 1/0 (Supervision/No set up help) for walk in corridor, locomotion on unit, and locomotion off unit. Section N-Medications: Resident was assessed as having received an antidepressant 7 of the last 7 days of the assessment. Review of resident #1's Elopement Risk Screening dated 7/12/12 revealed resident was cognitively impaired, had Alzheimer's Disease and Depression, was able to ambulate independently, and wandered aimlessly. Resident was assessed as an elopement risk with the following comments: Resident wanders and paces constantly due to Alzheimer's Disease. He is independently ambulatory with no aids used. He is confused daily and thinks he is at work. A wander guard bracelet has been applied for safety due to high risk for elopement. Review of resident #1's plan of care revealed a problem onset 7/6/12 for Wanders/Potential for Elopement with a [DIAGNOSES REDACTED]. Review of resident #1's electronic nurse's notes dated 7/6/12 revealed an entry at 8:00 p.m.-Resident is confused and wanders up and down hallways. Resident has to be redirected constantly. Resident speech is also confused. Secure bracelet in place at this time. Will continue to monitor. Review of resident #1's electronic nurse's notes dated 7/7/12 revealed an entry at 4:26 a.m.-Resident rested quietly in bed approximately 30 minutes, resident has since then been up ambulating throughout the facility. Has to be redirected due to confusion, he mumbles to himself when ambulating. Resident thinks he is working on a job and has swept floors and wiped tables all night ....Wanderguard in place to right ankle. Review of resident #1's electronic nurse's notes dated 7/8/12 revealed an entry at 1:27 p.m.-Resident up in dining room cleaning tables, has not slept over night, he has been walking the halls this morning going in and out of rooms looking for things to do. Review of resident #1's electronic nurse's notes dated 7/17/12 revealed an entry at 2:34 p.m.-Resident did more wandering than usual today. Looking in residents rooms on the 300 Hall and redirected back to dining room. Later found going in and out of rooms on 200 Hall stating he was looking for 70th street and asking how to get there. Placed on Alzheimer's unit to see how he responds there. Will monitor. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 12:41 a.m.-Wandering throughout facility while on 200 hall, resident urinating on floor as he walked. Assisted to room. Wanderguard in place. All staff alerted to monitor resident for elopement precautions. Resident sleeps for very short periods of time and gets up wandering in and out of others rooms and shaking exit doors. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 4:37 a.m.-Resident placed 1:1 monitoring and has been unsuccessfully redirected several times. Resident going from exit door to exit door pushing and kicking mumbling he needs to go to Union Street. Wanderguard in place. Resident removed from other resident's rooms .... Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 2:35 p.m.-Resident removed from the unit, he has done well and not attempted to leave at all. He is involved with activities and other events going on. He has not been wandering on other halls. He has not been resistant to staff. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 8:59 p.m.-Late entry-Resident wanders hallways all evening. Redirected to room many times. Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 4:33 a.m.-Resident observed standing by exit doors trying to escape. Stands by doors at times waiting on someone to open door such as staff or visitor so that he may get out once door is opened. Resident has been awake all night ambulating throughout facility. Observed pulling at Wanderguard on ankle, when asked what he was doing, he replied that he was trying to break that thing off his leg so he could get it off. Redirected many times, but unsuccessful .... Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 2:57 p.m.-Resident has not slept any this shift and night shift stated he only slept about 10 minutes. Physician notified to see if he would order something, awaiting call back. Resident has not attempted to leave facility, but requires redirection to his room or dining room. Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 8:46 p.m.-Resident wandering hall this evening mumbling to self. Physician called with new order for Vistaril 50 mg 1 po q hs. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 4:29 a.m.-Resident received Vistaril 50 mg po last night on 2 p-10 p shift. Resident rested quietly in bed all night with no distress. Aroused to verbal stimuli, denies pain ....No wandering observed this shift. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 12:38 p.m.-Resident wasn't as anxious today, always wants to help somebody. Requires cues for directions to room and dining room for meals. Very cooperative with staff and no abnormal behaviors noted. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 6:50 p.m.-No adverse side effects from new med Vistaril. Resident has not done much wandering today. Review of resident #1's electronic nurse's notes dated 7/21/12 revealed an entry at 4:49 p.m.-Resident up wandering hall, going into other resident's room, also going to exits and trying to leave and becoming agitated when staff attempts to redirect. Review of resident #1's electronic nurse's notes dated 7/21/12 revealed an entry at 5:57 p.m.-Physician notified of residents wandering in/out of other rooms, resisting care, agitation, and blocking exit doors. Staff x2 had to redirect resident from exit doors. Orders to send resident to Alzheimer's unit, Risperdal 1 mg po bid and Geodon 20 mg IM now prn agitation. RP notified of new room and new med orders ....IM injection of Geodon given to right deltoid. No signs/symptoms of adverse reaction noted after injection. No vital signs obtained due to agitation. Will continue to monitor. Review of resident #1's electronic nurse's notes dated 7/22/12 revealed an entry at 10:35 p.m.-11:00 a.m. resident appears to be adjusting in secure unit. Ate meals in dining room. Redirection needed, but allows staff to redirect. No agitation at this time. Up ad lib wandering noted in/out other rooms at times. Review of resident #1's electronic nurse's notes dated 7/22/12 revealed an entry at 10:38 p.m.-Resident in room and caused flood in bathroom. Toilet overflowed. Water cleaned up then resident placed in bed. Remained in bed throughout remainder of shift. Review of resident #1's electronic nurse's notes dated 7/23/12 revealed an entry at 3:23 p.m.-Physician's office called with new order to discontinue Risperdal and start Seroquel 50 mg 1 po q hs. RP notified. Review of resident #1's electronic nurse's notes dated 7/24/12 revealed an entry at 1:29 p.m.-Resident's family here at this time and wants resident off Seroquel. Physician office called and notified of family concerns. Review of resident #1's electronic nurse's notes dated 7/24/12 revealed an entry at 1:44 p.m.-Resident moved to Dementia unit for exiting behavior. Wander guard discontinued at this time. Review of resident #1's electronic nurse's notes dated 7/26/12 revealed an entry at 9:16 p.m.-(2:45 p.m.)Resident pacing up and down hall talking to people who are not there. Physician notified and Geodon 10 mg IM given. (4:00 p.m.)-Sitting on side of bed with covers over his head .... Review of resident #1's electronic nurse's notes dated 7/28/12 revealed an entry at 9:57 a.m.-Resident out on pass with sister. Sister stated resident may be back on Monday morning. Review of resident #1's electronic nurse's notes dated 7/29/12 revealed an entry at 9:21 p.m.-(9:25 a.m.)Resident returned to facility with daughter. Daughter stated she wanted resident off of Seroquel or get it decreased. Explained the Seroquel was keeping him from being agitated. Daughter insisted resident was calm and she did not want him on the medication. Daughter returned the medications that resident took out on pass and the resident's Seroquel had not been given the night before. Resident walked back to Secure unit where he resided. Approximately 5:00 p.m. was called to unit per CNA. Resident was attempting to fight other residents and yelling and cursing to get out of his momma's house. CNAs between residents to protect other residents from resident #1. Nurses stat called to unit with response from other nurses and staff. Resident charged at the male nurse and hit him in the abdomen. Continued cursing and threatening to kill everyone. 911 notified and DON called. Resident taken to local ER via police. Physician notified. Review of resident #1's electronic nurse's notes dated 7/30/12 revealed an entry at 7:42 p.m.-Resident returned to facility per stretcher in stable condition to room 208 A. No agitation or abnormal behaviors noted ....Will continue to monitor for aggressive behaviors. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 4:53 a.m.-Resident rested quietly in bed in his room throughout the shift. No behavioral issues noted at this time. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 12:13 p.m.-Resident was very cooperative this a.m. except he would not take his medication that was offered three different ways. He never got upset, just refused it. He was assisted to dining room where he ate 100% of breakfast and after finishing he sat there and talked with other residents. Went down the hall for 10-15 minutes and when returned to front of nurse's station resident was standing at the other doorway by the piano. At approximately 9:00 a.m. resident could not be found. An overhead announcement was made to alert staff to look everywhere for him. Some staff went outside and some left in cars to try and locate him. 911 was notified. Family and physician were notified. Staff continues to look for resident. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 1:46 p.m.-Resident is still not in facility at this time. Review of resident #1's plan of care revealed it was revised to include resident was moved to dementia unit on 7/21/12 and the wander guard was discontinued on 7/22/12. Review of the facility's Incident Log revealed an incident on 7/29/12 that resident #1 had physical contact with staff and an incident on 7/31/12 where resident #1 wandered from the grounds. Review of the facility's OTIS Log revealed documentation of an ongoing OTIS investigation regarding resident #1's elopement from the facility. During an interview on 8/2/12 at 11:15 a.m. S5 LPN (called the facility to speak with me) stated resident #1 was readmitted to the facility at 7:42 p.m. on 7/30/12 and she was the admitting nurse. S5 LPN stated resident #1 was on the locked unit and was sent out to the hospital over the weekend due to his behaviors. S5 LPN stated S2 DON called her on 7/30/12 and let her know resident #1 was going to be returning to the facility and was going to be admitted to room 208 A on the general floor. S5 LPN stated resident #1 did not have a wander guard bracelet on and she did not have an order for [REDACTED]. S5 LPN stated S2 DON informed her if resident #1 became combative again to just call 911 and have resident sent back to the hospital. S5 LPN stated she took care of resident #1 before he was moved to the locked unit and he wandered frequently and tried getting out the door at times, so she knew to monitor him for elopement and resident #1 never left his room. S5 LPN stated she offered resident his evening medications and he refused them and pulled the covers over his head and stayed in bed until she left at 10:00 p.m. During an interview on 8/2/12 at 11:45 a.m. S2 DON stated a physician's orders [REDACTED]. S2 DON was asked for a copy of the facility standing orders. S2 DON on 8/2/12 at 12:20 p.m. provided the facility's Nursing Intervention Communication Form Policy with the following information: This is a reference list of items that are nursing interventions and may not require a physician order. The list included security bracelet. S2 DON stated this is the standing orders for the facility she had mentioned. During an interview on 8/2/12 at 1:00 p.m. S6 LPN stated on the morning of 7/31/12 resident #1 was wandering and looking in the dining area and she assisted him to his seat. S6 LPN stated resident #1 ate 100 % of his breakfast and was talking to other residents. S6 LPN stated she went to finish passing medications on the 300 Hall and when she came back up the hall resident #1 was standing at the dining room door by the piano. S6 LPN stated that was the last time she saw him and it was around 8:50 a.m. S6 LPN stated she was on the 200 Hall when S13 Activity Assistant Director came to place a wander guard bracelet on resident #1 and he was not in his room. S6 LPN stated they made the announcement and all staff went to search rooms, bathrooms, all doors, searched outside the grounds, and some staff drove down the street to look for him. S6 LPN stated S7 LPN had mentioned seeing resident #1 on the 500 Hall right after she saw him at 8:50 a.m. in the dining room. S6 LPN stated resident #1 had been readmitted the day before and when she came to work that morning, he did not have a wander guard bracelet in place. S6 LPN stated she did not know why resident was not placed back on the locked unit. S6 LPN stated they kept an eye on resident #1 and the staff knew to watch him closely because he was an elopement risk, but he was not 1 on 1. S6 LPN stated when resident was first admitted on [DATE] she placed a wander guard bracelet on him. During an interview on 8/2/12 at 1:15 p.m. S7 LPN stated resident #1 came back to the 500 Hall and she didn't know who he was. S7 LPN stated she asked if she could help him and he mumbled so she called up front and spoke with S9 CNA Supervisor. S7 LPN stated she was informed the resident on her hall was resident #1 and that S9 CNA Supervisor was getting ready to put a wander guard bracelet on him. S7 LPN stated resident #1 walked down by the therapy department and it looked like he was talking to someone. S7 LPN stated she was called to a resident's room and then she heard the call that a resident was missing. S7 LPN stated a family member came in a few minutes after that and she asked did they see anyone in a blue shirt and the family told her someone was walking down the street out front. S7 LPN stated she did not see how resident #1 got out of the facility. During an interview on 8/2/12 at 1:30 p.m., with S1 Administrator, S2 DON, and S3 Corporate Nurse, DON stated resident #1 came back to the facility on [DATE] between 7:00 and 8:00 p.m. S2 DON stated the hospital tried to send resident #1 back earlier in the day on 7/30/12, but they were not able to meet his needs and were scared for the other residents so her and S1 Administrator tried to find other placement for him. S2 DON stated they were not able to find placement and the hospital was adamant resident #1 was going to be sent back to the facility and after much discussion it was determined the residents on the Alzheimer's unit were too vulnerable to deal with resident #1's behaviors so they agreed to place resident #1 on the 200 Hall so he could be monitored by both nurse's stations. S2 DON stated S5 LPN was instructed to place a wander guard on resident #1, but she did not place the wander guard bracelet. S1 Administrator stated S5 LPN wrote a statement that she did not check resident #1 for a wander guard bracelet because he previously had one in place and she thought he still had it on. S1 Administrator stated later on S5 LPN said she did not put the wander guard bracelet on him because she was afraid of him. S1 Administrator stated S5 LPN was suspended for not placing the wander guard bracelet on resident #1 and was going to be terminated for not doing what S2 DON told her to do. When asked which door resident #1 eloped from, S1 Administrator stated it was determined by cameras and last known location that resident #1 left out of the northeast door on the 500 Hall that was always locked. S1 Administrator stated a lot of family come visit at that time of morning and a visitor stated they saw a person meeting resident #1's description in the area of the northeast door. S1 Administrator further stated when the fire rescue came with the blood hounds, the dogs picked up resident #1's trail at the northeast exit door. S1 Administrator stated resident #1 walked up the street and was caught on video camera from a Supercenter retail store and was found in a neighborhood by the Supercenter retail store about an 1/8 mile from the facility. S1 Administrator stated resident #1 was found at 7:00 p.m. and he went to check on the resident with local police and EMS. S1 Administrator stated resident #1 was taken by EMS to a local hospital and was admitted and transferred to the behavioral unit. During an interview on 8/2/12 at 1:45 p.m. S1 Administrator stated resident #1 was an admit from home and the physician assessed him in the office and then admitted resident #1 to the facility. S1 Administrator stated when resident #1 was admitted he had a wander guard bracelet placed for monitoring. S2 DON stated resident was moved to the locked unit on 7/21/12 and the wander guard bracelet was removed at that time. Review of a written statement dated 7/31/12 and signed by S5 LPN revealed the following: Resident returned to facility at 7:42 p.m. Resident was in fetal position in bed when writer got to him and attempted to give meds. Resident pushed hand out stated, "No" and covered head. Resident had wander guard in place when on floor and did not know that the wander guard had been removed due to resident was on secure unit before hospital return. Review of a written statement dated 7/30/12 and signed by S2 DON revealed the following: 5:47 p.m.-With no other option, but to accept resident #1 back, we determined resident would not go back on the unit due to the vulnerable condition of the residents on the dementia unit, and the recent violent episode. Also, we thought that the small space and activity may have agitated resident #1. Room 208 is between two nurse's stations for better observation of the resident so staff could monitor closely. Resident had not previously attempted to leave the facility, but in his fragile state we decided to place a wander guard to alert staff to any exiting behaviors.... 6:00 p.m.-S5 LPN called and notified that resident #1 would be returning tonight. He was to go into room 208, a wander guard placed upon arrival, and to call 911 if he became physically violent. S5 LPN verbalized understanding. A list was obtained from the unit clerk of residents who were elopement risk and had wander guard bracelets in place as of the list printed on 8/2/12 at 10:45 a.m. During an interview on 8/2/12 at 3:00 p.m. the Administrator was provided with the list of 11 residents who were elopement risk with wander guard bracelets in place and asked if the list was current. S1 Administrator reviewed the list and signed and dated it as being correct. During an interview on 8/2/12 at 4:45 p.m. S1 Administrator asked how it was determined

Based on observations, record reviews, interviews, and review of the facility's Policy and Procedures the facility failed to be administered in a manner that used resources effectively and efficiently for 1 (#1) of 12 (#1, #2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) sampled residents who were determined to be at risk for elopement out of a total sample of 15 that resulted in actual harm when resident #1 eloped from the facility and suffered heat exhaustion, dehydration, and acute [MEDICAL CONDITION]. The facility further failed to be administered in a manner that used resources effectively and efficiently for 11 of 11 (#2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) residents at risk for elopement currently residing in the facility, not in the locked unit, out of a total sample of 15. Administration failed to: 1. Have a system in place to ensure nursing staff assessed and implemented protective measures for residents residing on the general unit who had been assessed as being at risk for elopement. 2. Have a system in place to increase supervision of a confused, wandering resident (#1) assessed as being an elopement risk, after he returned from a local emergency roiagnom on [DATE] and was placed on the general floor of the facility without a wander guard bracelet. 3. Have a system in place to ensure 4 of 8 facility exit doors on the general unit, accessible by the residents identified as being wanderers by the facility, and who resided on the general unit, alarmed to alert staff of a resident wearing a wander guard bracelet attempting to exit the facility after the keypad code was entered by visitors and/or staff and the door was opened. 4. Have a system in place to ensure 2 of 8 facility exit doors on the general unit, accessible by the residents identified as being wanderers by the facility, and who resided on the general unit, were protected by the wander guard system. 5. Have a system of staff supervision and monitoring to ensure the licensed practical nurse followed orders delegated by the Director of Nurses and applied a wander guard bracelet for a resident assessed as an elopement risk on 7/12/12 (#1). The Immediate Jeopardy began for resident #1 on 7/30/12 at 7:42 p.m. when he returned to the facility from a local emergency room and the admitting nurse failed to assess resident #1 for the presence of a wander guard security bracelet. The LPN also failed to immediately place a wander guard bracelet on resident #1 on 7/30/12 prior to admitting him to a room on the general unit. Resident #1 eloped on 7/31/12 at approximately 9:00 a.m. The facility is located on a highly traveled road near a large Supercenter retail store. The Immediate Jeopardy ended for resident #1 when he was found on 7/31/12 at approximately 7:00 p.m. and transported to a local hospital where he was admitted for treatment of [REDACTED]. The Immediate Jeopardy continued for residents #2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 when it was determined the facility had 2 of 9 exit doors with no wander guard alarm system and 4 of 9 exit doors that negated the wander guard alarm system when the key code was entered to open the doors. These 6 exit doors were readily accessible by the eleven residents identified by the facility as elopement risks, who resided on the general unit. S1 Administrator, S2 DON, and S3 Corporate Nurse were notified on 8/2/12 at 4:45 p.m. of the Immediate Jeopardy situation regarding the actual elopement of resident #1 that began on 7/30/12 at 7:42 p.m. S1 Administrator, S2 DON, and S3 Corporate Nurse were also notified of the continued Immediate Jeopardy for the remaining 11 residents identified as elopement risk residing on the general unit at the facility due to an ineffective wander guard system. The facility's Plan of Removal was documented as follows: 1. Code changed to all exit doors immediately-All staff/family members must use the front door entrance/exit only. Charge nurse, DON, Administrator are the only employees with door code access with strict instructions per Administrator to not give code out to any employees/families. Facility in essence put in lock down. Door/Alarm Specialist on site 8/3/12 at 7:30 a.m. retrofitting current door alarm panels to include advance security feature. This feature will alarm at any time a resident with a security bracelet passes through an open exit door. This work will be completed by 4:00 p.m. 8/3/12. 2. Residents at risk for elopement and currently with security bracelet has the potential to be affected. 3. In-serviced nursing staff on q 15 minute observation of 11 residents with security bracelets to continue until permanent change/upgrade made to secure care system. Code changed to all exit doors with only charge nurse, Administrator, and DON having knowledge of the new code as in-serviced by the Administrator. In-serviced nursing staff regarding assessment of residents upon return from hospital to ensure appropriate interventions implemented for resident at risk for elopement. Residents determined to require a security bracelet and unable to obtain for any reason-notify Administrator/DON immediately and assign 1:1 until bracelet obtained. 4. Administrator to ensure that code is remaining secured until retrofit is completed on all doors-DON/designee to do random direct resident observations of the 11 residents with security bracelets-direct observation of residents will continue until permanent change/upgrade made to secure care system. DON/designee to review documentation on readmissions and direct observation of that resident to ensure interventions, if warranted, were implemented. The facility's Plan of Removal was accepted on 8/3/12 at 2:30 p.m. The Immediate Jeopardy was lifted on 8/3/12 at 3:10 p.m. after observations and record reviews revealed the Plan of Removal had been implemented and functioning and after all exit doors were tested and functioned properly with the wander guard bracelets. The deficient practice continued at a scope and severity of third level isolated. Findings: Review of the facility's Elopement/Wandering-Residents at Risk Policy (May 2011) revealed the following: Purpose: To identify residents who have a potential to wander from the facility. To implement the appropriate protective measures to help guard against a resident wandering from the facility. Policy and Procedure: 1. On admission/readmission, and in the observation period of each MDS and when resident has a significant change in condition, the nursing staff will screen each resident for elopement risk.... Observation on 8/1/12 at 1:10 p.m. revealed the 300 Hall exit door on the south end of the facility was closed and locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. Observation on 8/1/12 at 1:15 p.m. revealed an exit door on the side hall between the 200 Hall and main dining room that was locked with a key pad alarm, but no wander guard sensor was observed at this door. Further observation revealed another door at the end of the side hall that was locked with a key pad alarm and the red armed light was on. A wander guard sensor strip was observed on the wall by the door. Observation on 8/1/12 at 1:17 p.m. revealed an exit door in the main dining room that was locked with a key pad alarm and had a wander guard sensor attached to the wall by the door. Observation on 8/1/12 at 1:20 p.m. revealed an exit door in the northwest corner of the 500 Hall that was locked with a key pad alarm, but no wander guard sensor was observed at this door. Observation on 8/1/12 at 1:22 p.m. revealed an exit door in the northeast corner of the 500 Hall that was locked with a key pad alarm and the red armed light was on. A wander guard sensor was attached to the wall by the door. Observation on 8/1/12 at 1:23 p.m. revealed a door located between the 500 Hall and 100 Hall that was locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. Observation on 8/1/12 at 1:24 p.m. revealed the front door of the facility had a key pad alarm, but was unlocked for entrance and exit of the facility. Further observation revealed a wander guard sensor was attached to the wall by the front door. Observation on 8/1/12 at 1:26 p.m. revealed an exit door on a side hall off of the 400 Hall that was locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. During an interview on 8/1/12 at 1:30 p.m. S4 CNA stated resident #1 previously resided on the locked unit, but was moved to the 200 Hall. S4 CNA stated she was not sure exactly when the move occurred. S4 CNA stated resident #1 was still in the locked unit on Sunday 7/29/12 when she got off work at 2:00 p.m. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITIONS], and Anxiety. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] from home with orders to admit to facility on regular diet, TB Test, and start meds [MEDICATION NAME] 20 mg po daily and [MEDICATION NAME] Patch 4.6 mg q day. Further review of resident #1's medical record revealed the following: A Physician's Telephone Order dated 7/6/12-Apply wander guard to promote safety and monitor exiting behaviors with a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/19/12-[MEDICATION NAME] 50 mg capsule give 1 tablet po q hs. No diagnosis listed. A Physician's Telephone Order dated 7/21/12-[MEDICATION NAME] 1 mg tablet one po bid for a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/23/12-[MEDICATION NAME] 50 mg tablet give 1 po q hs for a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/26/12-[MEDICATION NAME] 20 mg vial give 10 mg IM q 6 hours prn agitation. A Physician's Telephone Order dated 7/30/12-[MEDICATION NAME] 0.5 mg tablet give 1 tablet po tid prn anxiety/agitation. [MEDICATION NAME] 3 mg capsule give 1 po bid with no diagnosis listed. [MEDICATION NAME] 8 mg tablet give 1 po prn @ hs with no diagnosis listed. Review of resident #1's Admission MDS with ARD 7/13/12 revealed the following: Section C-Cognitive Patterns: Resident was assessed as 1 (behavior continuously present, does not fluctuate) for Inattention and Disorganized Thinking. Section D-Mood: Resident was assessed 1/2 (yes/7-11 days) for trouble falling or staying asleep, or sleeping too much, trouble concentrating on things, and moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around a lot more than usual. Section E-Behavior: Resident was assessed as having [MEDICAL CONDITION]. Resident was assessed as having behavioral symptoms not directed towards others having occurred 1 to 3 days. Resident was assessed as having behaviors that significantly interfere with his care and interfere with participation in activities or social interactions. Resident was assessed as having behaviors that significantly intrude on the privacy or activity of others and significantly disrupts care of living environment. Resident was assessed as 3 (behavior of this type occurred daily) for Wandering. Resident was assessed 1 (yes) for does wandering place resident at significant risk of getting to a potentially dangerous place and does wandering significantly intrude on the privacy or activities of others. Section G-Functional Status: Resident was assessed 1/0 (Supervision/No set up help) for walk in corridor, locomotion on unit, and locomotion off unit. Section N-Medications: Resident was assessed as having received an antidepressant 7 of the last 7 days of the assessment. Review of resident #1's Elopement Risk Screening dated 7/12/12 revealed resident was cognitively impaired, had [MEDICAL CONDITION] and Depression, was able to ambulate independently, and wandered aimlessly. Resident was assessed as an elopement risk with the following comments: Resident wanders and paces constantly due to [MEDICAL CONDITION]. He is independently ambulatory with no aids used. He is confused daily and thinks he is at work. A Wanderguard bracelet has been applied for safety due to high risk for elopement. Review of resident #1's plan of care revealed a problem onset 7/6/12 for Wanders/Potential for Elopement with a [DIAGNOSES REDACTED]. Review of resident #1's electronic nurse's notes dated 7/6/12 revealed an entry at 8:00 p.m.-Resident is confused and wanders up and down hallways. Resident has to be redirected constantly. Resident speech is also confused. Secure bracelet in place at this time. Will continue to monitor. Review of resident #1's electronic nurse's notes dated 7/7/12 revealed an entry at 4:26 a.m.-Resident rested quietly in bed approximately 30 minutes, resident has since then been up ambulating throughout the facility. Has to be redirected due to confusion, he mumbles to himself when ambulating. Resident thinks he is working on a job and has swept floors and wiped tables all night ....Wanderguard in place to right ankle. Review of resident #1's electronic nurse's notes dated 7/8/12 revealed an entry at 1:27 p.m.-Resident up in dining room cleaning tables, has not slept over night, he has been walking the halls this morning going in and out of rooms looking for things to do. Review of resident #1's electronic nurse's notes dated 7/17/12 revealed an entry at 2:34 p.m.-Resident did more wandering than usual today. Looking in residents rooms on the 300 Hall and redirected back to dining room. Later found going in and out of rooms on 200 Hall stating he was looking for 70th street and asking how to get there. Placed on Alzheimer's unit to see how he responds there. Will monitor. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 12:41 a.m.-Wandering throughout facility while on 200 hall, resident urinating on floor as he walked. Assisted to room. Wanderguard in place. All staff alerted to monitor resident for elopement precautions. Resident sleeps for very short periods of time and gets up wandering in and out of others rooms and shaking exit doors. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 4:37 a.m.-Resident placed 1:1 monitoring and has been unsuccessfully redirected several times. Resident going from exit door to exit door pushing and kicking mumbling he needs to go to Union Street. Wanderguard in place. Resident removed from other resident's rooms .... Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 2:35 p.m.-Resident removed from the unit, he has done well and not attempted to leave at all. He is involved with activities and other events going on. He has not been wandering on other halls. He has not been resistant to staff. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 8:59 p.m.-Late entry-Resident wanders hallways all evening. Redirected to room many times. Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 4:33 a.m.-Resident observed standing by exit doors trying to escape. Stands by doors at times waiting on someone to open door such as staff or visitor so that he may get out once door is opened. Resident has been awake all night ambulating throughout facility. Observed pulling at Wanderguard on ankle, when asked what he was doing, he replied that he was trying to break that thing off his leg so he could get it off. Redirected many times, but unsuccessful .... Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 2:57 p.m.-Resident has not slept any this shift and night shift stated he only slept about 10 minutes. Physician notified to see if he would order something, awaiting call back. Resident has not attempted to leave facility, but requires redirection to his room or dining room. Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 8:46 p.m.-Resident wandering hall this evening mumbling to self. Physician called with new order for [MEDICATION NAME] 50 mg 1 po q hs. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 4:29 a.m.-Resident received [MEDICATION NAME] 50 mg po last night on 2-10 shift. Resident rested quietly in bed all night with no distress. Aroused to verbal stimuli, denies pain ....No wandering observed this shift. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 12:38 p.m.-Resident wasn't as anxious today, always wants to help somebody. Requires cues for directions to room and dining room for meals. Very cooperative with staff and no abnormal behaviors noted. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 6:50 p.m.-No adverse side effects from new med [MEDICATION NAME]. Resident has not done much wandering today. Review of resident #1's electronic nurse's notes dated 7/21/12 revealed an entry at 4:49 p.m.-Resident up wandering hall, going into other resident's room, also going to exits and trying to leave and becoming agitated when staff attempts to redirect. Review of resident #1's electronic nurse's notes dated 7/21/12 revealed an entry at 5:57 p.m.-Physician notified of residents wandering in/out of other rooms, resisting care, agitation, and blocking exit doors. Staff x2 had to redirect resident from exit doors. Orders to send resident to Alzheimer's unit, [MEDICATION NAME] 1 mg po bid and [MEDICATION NAME] 20 mg IM now prn agitation. RP notified of new room and new med orders ....IM injection of [MEDICATION NAME] given to right deltoid. No signs/symptoms of adverse reaction noted after injection. No vital signs obtained due to agitation. Will continue to monitor. Review of resident #1's electronic nurse's notes dated 7/22/12 revealed an entry at 10:35 p.m.-11:00 a.m. resident appears to be adjusting in secure unit. Ate meals in dining room. Redirection needed, but allows staff to redirect. No agitation at this time. Up ad lib wandering noted in/out other rooms at times. Review of resident #1's electronic nurse's notes dated 7/22/12 revealed an entry at 10:38 p.m.-Resident in room and caused flood in bathroom. Toilet overflowed. Water cleaned up then resident placed in bed. Remained in bed throughout remainder of shift. Review of resident #1's electronic nurse's notes dated 7/23/12 revealed an entry at 3:23 p.m.-Physician's office called with new order to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 50 mg 1 po q hs. RP notified. Review of resident #1's electronic nurse's notes dated 7/24/12 revealed an entry at 1:29 p.m.-Resident's family here at this time and wants resident off [MEDICATION NAME]. Physician office called and notified of family concerns. Review of resident #1's electronic nurse's notes dated 7/24/12 revealed an entry at 1:44 p.m.-Resident moved to Dementia unit for exiting behavior. Wander guard discontinued at this time. Review of resident #1's electronic nurse's notes dated 7/26/12 revealed an entry at 9:16 p.m.-(2:45 p.m.)Resident pacing up and down hall talking to people who are not there. Physician notified and [MEDICATION NAME] 10 mg IM given. (4:00 p.m.)-Sitting on side of bed with covers over his head .... Review of resident #1's electronic nurse's notes dated 7/28/12 revealed an entry at 9:57 a.m.-Resident out on pass with sister. Sister stated resident may be back on Monday morning. Review of resident #1's electronic nurse's notes dated 7/29/12 revealed an entry at 9:21 p.m.-(9:25 a.m.)Resident returned to facility with daughter. Daughter stated she wanted resident off of [MEDICATION NAME] or get it decreased. Explained the [MEDICATION NAME] was keeping him from being agitated. Daughter insisted resident was calm and she did not want him on the medication. Daughter returned the medications that resident took out on pass and the resident's [MEDICATION NAME] had not been given the night before. Resident walked back to Secure unit where he resided. Approximately 5:00 p.m. was called to unit per CNA. Resident was attempting to fight other residents and yelling and cursing to get out of his momma's house. CNAs between residents to protect other residents from resident #1. Nurses stat called to unit with response from other nurses and staff. Resident charged at the male nurse and hit him in the abdomen. Continued cursing and threatening to kill everyone. 911 notified and DON called. Resident taken to local ER via police. Physician notified. Review of resident #1's electronic nurse's notes dated 7/30/12 revealed an entry at 7:42 p.m.-Resident returned to facility per stretcher in stable condition to room [ROOM NUMBER] A. No agitation or abnormal behaviors noted ....Will continue to monitor for aggressive behaviors. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 4:53 a.m.-Resident rested quietly in bed in his room throughout the shift. No behavioral issues noted at this time. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 12:13 p.m.-Resident was very cooperative this a.m. except he would not take his medication that was offered three different ways. He never got upset, just refused it. He was assisted to dining room where he ate 100% of breakfast and after finishing he sat there and talked with other residents. Went down the hall for 10-15 minutes and when returned to front of nurse's station resident was standing at the other doorway by the piano. At approximately 9:00 a.m. resident could not be found. An overhead announcement was made to alert staff to look everywhere for him. Some staff went outside and some left in cars to try and locate him. 911 was notified. Family and physician were notified. Staff continues to look for resident. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 1:46 p.m.-Resident is still not in facility at this time. Review of resident #1's plan of care revealed it was revised to include resident was moved to dementia unit on 7/21/12 and the wander guard was discontinued on 7/22/12. Review of the facility's Incident Log revealed an incident on 7/29/12 that resident #1 had physical contact with staff and an incident on 7/31/12 where resident #1 wandered from the grounds. Review of the facility's OTIS Log revealed documentation of an ongoing OTIS investigation regarding resident #1's elopement from the facility. During an interview on 8/2/12 at 11:15 a.m. S5 LPN (called the facility to speak with me) stated resident #1 was readmitted to the facility at 7:42 p.m. on 7/30/12 and she was the admitting nurse. S5 LPN stated resident #1 was on the locked unit and was sent out to the hospital over the weekend due to his behaviors. S5 LPN stated S2 DON called her on 7/30/12 and let her know resident #1 was going to be returning to the facility and was going to be admitted to room [ROOM NUMBER] A on the general floor. S5 LPN stated resident #1 did not have a wander guard bracelet on and she did not have an order for [REDACTED].#1 before he was moved to the locked unit and he wandered frequently and tried getting out the door at times, so she knew to monitor him for elopement and resident #1 never left his room. S5 LPN stated she offered resident his evening medications and he refused them and pulled the covers over his head and stayed in bed until she left at 10:00 p.m. During an interview on 8/2/12 at 11:45 a.m. S2 DON stated a physician's orders [REDACTED]. S2 DON was asked for a copy of the facility standing orders. S2 DON on 8/2/12 at 12:20 p.m. provided the facility's Nursing Intervention Communication Form Policy with the following information: This is a reference list of items that are nursing interventions and may not require a physician order. The list included security bracelet. S2 DON stated this is the standing orders for the facility she had mentioned. During an interview on 8/2/12 at 1:00 p.m. S6 LPN stated on the morning of 7/31/12 resident #1 was wandering and looking in the dining area and she assisted him to his seat. S6 LPN stated resident #1 ate 100 % of his breakfast and was talking to other residents. S6 LPN stated she went to finish passing medications on the 300 hall and when she came back up the hall resident #1 was standing at the dining room door by the piano. S6 LPN stated that was the last time she saw him and it was around 8:50 a.m. S6 LPN stated she was on the 200 hall when S13 Activity Assistant Director came to place a wander guard bracelet on resident #1 and he was not in his room. S6 LPN stated they made the announcement and all staff went to search rooms, bathrooms, all doors, searched outside the grounds, and some staff drove down the street to look for him. S6 LPN stated S7 LPN had mentioned seeing resident #1 on the 500 hall right after she saw him at 8:50 a.m. in the dining room. S6 LPN stated resident #1 had been readmitted the day before and when she came to work that morning, he did not have a wander guard bracelet in place. S6 LPN stated she did not know why resident was not placed back on the locked unit. S6 LPN stated they kept an eye on resident #1 and the staff knew to watch him closely because he was an elopement risk, but he was not 1 on 1. S6 LPN stated when resident was first admitted on [DATE] she placed a wander guard bracelet on him. During an interview on 8/2/12 at 1:15 p.m. S7 LPN stated resident #1 came back to the 500 hall and she didn't know who he was. S7 LPN stated she asked if she could help him and he mumbled so she called up front and spoke with S9 CNA Supervisor. S7 LPN stated she was informed the resident on her hall was resident #1 and that S9 CNA Supervisor was getting ready to put a wander guard bracelet on him. S7 LPN stated resident #1 walked down by the therapy department and it looked like he was talking to someone. S7 LPN stated she was called to a resident's room and then she heard the call that a resident was missing. S7 LPN stated a family member came in a few minutes after that and she asked did they see anyone in a blue shirt and the family told her someone was walking down the street out front. S7 LPN stated she did not see how resident #1 got out of the facility. During an interview on 8/2/12 at 1:30 p.m., with S1 Administrator, S2 DON, and S3 Corporate Nurse, DON stated resident #1 came back to the facility on [DATE] between 7:00 and 8:00 p.m. S2 DON stated the hospital tried to send resident #1 back earlier in the day on 7/30/12, but they were not able to meet his needs and were scared for the other residents so her and S1 Administrator tried to find other placement for him. S2 DON stated they were not able to find placement and the hospital was adamant resident #1 was going to be sent back to the facility and after much discussion it was determined the residents on the Alzheimer's unit were too vulnerable to deal with resident #1's behaviors so they agreed to place resident #1 on the 200 hall so he could be monitored by both nurse's stations. S2 DON stated S5 LPN was instructed to place a wander guard on resident #1, but she did not place the wander guard bracelet. S1 Administrator stated S5 LPN wrote a statement that she did not check resident #1 for a wander guard bracelet because he previously had one in place and she thought he still had it on. S1 Administrator stated later on S5 LPN said she did not put the wander guard bracelet on him because she was afraid of him. S1 Administrator stated S5 LPN was suspended for not placing the wander guard bracelet on resident #1 and was going to be terminated for not doing what S2 DON told her to do. When asked which door resident #1 eloped from, S1 Administrator stated it was determined by cameras and last known location that resident #1 left out of the northeast door on the 500 hall that was always locked. S1 Administrator stated a lot of family come visit at that time of morning and a visitor stated they saw a person meeting resident #1's description in the area of the northeast door. S1 Administrator further stated when the fire rescue came with the blood hounds, the dogs picked up resident #1's trail at the northeast exit door. S1 Administrator stated resident #1 walked up the street and was caught on video camera from a Supercenter retail store and was found in a neighborhood by the Supercenter retail store about an 1/8 mile from the facility. S1 Administrator stated resident #1 was found at 7:00 p.m. and he went to check on the resident with local police and EMS. S1 Administrator stated resident #1 was taken by EMS to a local hospital and was admitted and transferred to the behavioral unit. During an interview on 8/2/12 at 1:45 p.m. S1 Administrator stated resident #1 was an admit from home and the physician assessed him in the office and then admitted resident #1 to the facility. S1 Administrator stated when resident #1 was admitted he had a wander guard bracelet placed for monitoring. S2 DON stated resident was moved to the locked unit on 7/21/12 and the wander guard bracelet was removed at that time. Review of a written statement dated 7/31/12 and signed by S5 LPN revealed the following: Resident returned to facility at 7:42 p.m. Resident was in fetal position in bed when writer got to him and attempted to give meds. Resident pushed hand out stated, "No" and covered head. Resident had wander guard in place when on floor and did not know that the wander guard had been removed due to resident was on secure unit before hospital return. Review of a written statement dated 7/30/12 and signed by S2 DON revealed the following: 5:47 p.m.-With no other option, but to accept resident #1 back, we determined resident would not go back on the unit due to the vulnerable condition of the residents on the dementia unit, and the recent violent episode. Also, we thought that the small space and activity may have agitated resident #1. room [ROOM NUMBER] is between two nurse's stations for better observation of the resident so staff could monitor closely. Resident had not previously attempted to leave the facility, but in his fragile state we decided to place a wander guard to alert staff to any exiting behaviors.... 6:00 p.m.-S5 LPN called and notified that resident #1 would be returning tonight. He was to go into room [ROOM NUMBER], a wander guard placed upon arrival, and to call 911 if he became physically violent. S5 LPN verbalized understanding. A list was obtained from the unit clerk of residents who were elopement risk and had wander guard bracelets in place as of the list printed on 8/2/12 at 10:45 a.m. During an interview on 8/2/12 at 3:00 p.m. the Administrator was provided with the list of 11 residents who were elopement risk with wander guard bracelets in place and asked if the list was current. S1 Administrator reviewed the list and signed and dated it as being correct. During an interview on 8/2/12 at 4:45 p.m. S1 Administrator asked how it was determined supervision was not increased and was informed resident #1 did not have a wander guard bracelet in place, was not being monitored 1 on 1, and he eloped from the facility. S1 Administrator and S2 DON agreed resident #1 should have been 1 on 1 and was not. Observation on 8/2/12 at 4:50 p.m., with S1 Administra

Based on observation, record reviews, interviews, review of the facility's Policy and Procedures, and review of the RN and LPN Scopes of Practice, the facility failed to ensure nursing professional standards of quality were provided for 1 (#1) of 12 (#1, #2, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) residents reviewed who were determined to be at risk for elopement out of a total sample of 15 that resulted in actual harm when resident #1 eloped from the facility and suffered heat exhaustion, dehydration, and acute [MEDICAL CONDITION]. The facility failed to: 1. Ensure resident #1 was assessed for the presence of a wander guard bracelet upon readmission to the facility, from a local emergency roiagnom on [DATE], by the licensed practical nurse. 2. Ensure the license practical nurse followed orders delegated by the Director of Nurses and applied a wander guard bracelet for a resident assessed as being at risk for elopement (#1). 3. Ensure the licensed practical nurse followed the facility's Nursing Intervention Communication Form Policy (January 2012) for identification of nursing interventions, i.e. security bracelet, that did not require a physician's orders [REDACTED]. 4. Ensure the licensed practical nurse followed the facility's Elopement/Wandering-Residents at Risk Policy revised May 2011 to implement the appropriate protective measures to help guard against a resident wandering from the facility on 7/30/12 when a resident assessed as being an elopement risk on 7/12/12 returned to the facility and no interventions were put in place to prevent elopement from the facility. 5. Ensure the licensed practical nurse increased supervision of a confused, wandering resident (#1) assessed as being an elopement risk, after he returned from a local emergency roiagnom on [DATE] and was placed on the general floor of the facility without a wander guard bracelet. 6. Ensure the Director of Nursing supervised the licensed practical nurse to ensure the delegated task was completed. The Immediate Jeopardy began for resident #1 on 7/30/12 at 7:42 p.m. when he returned to the facility from a local emergency room and the admitting nurse failed to assess resident #1 for the presence of a wander guard security bracelet. The LPN also failed to immediately place a wander guard bracelet on resident #1 on 7/30/12 prior to admitting him to a room on the general unit. Resident #1 eloped on 7/31/12 at approximately 9:00 a.m. The facility is located on a highly traveled road near a large Supercenter retail store. The Immediate Jeopardy ended for resident #1 when he was found on 7/31/12 at approximately 7:00 p.m. and transported to a local hospital where he was admitted for treatment of [REDACTED]. S1 Administrator, S2 DON, and S3 Corporate Nurse were notified on 8/2/12 at 4:45 p.m. of the Immediate Jeopardy situation regarding the actual elopement of resident #1 that began on 7/30/12 at 7:42 p.m. The facility's Plan of Removal was documented as follows: 1. Code changed to all exit doors immediately-All staff/family members must use the front door entrance/exit only. Charge nurse, DON, Administrator are the only employees with door code access with strict instructions per Administrator to not give code out to any employees/families. Facility in essence put in lock down. Door/Alarm Specialist on site 8/3/12 at 7:30 a.m. retrofitting current door alarm panels to include advance security feature. This feature will alarm at any time a resident with a security bracelet passes through an open exit door. This work will be completed by 4:00 p.m. 8/3/12. 2. Residents at risk for elopement and currently with security bracelet has the potential to be affected. 3. Inserviced nursing staff on q 15 minute observation of 11 residents with security bracelets to continue until permanent change/upgrade made to secure care system. Code changed to all exit doors with only charge nurse, Administrator, and DON having knowledge of the new code as inserviced by the Administrator. Inserviced nursing staff regarding assessment of residents upon return from hospital to ensure appropriate interventions implemented for resident at risk for elopement. Residents determined to require a security bracelet and unable to obtain for any reason-notify Administrator/DON immediately and assign 1:1 until bracelet obtained. 4. Administrator to ensure that code is remaining secured until retrofit is completed on all doors-DON/designee to do random direct resident observations of the 11 residents with security bracelets-direct observation of residents will continue until permanent change/upgrade made to secure care system. DON/designee to review documentation on readmissions and direct observation of that resident to ensure interventions, if warranted, were implemented. The facility's Plan of Removal was accepted on 8/3/12 at 2:30 p.m. The Immediate Jeopardy was lifted on 8/3/12 at 3:10 p.m. after observations and record reviews revealed the Plan of Removal had been implemented and functioning and after all exit doors were tested and functioned properly with the wander guard bracelets. The deficient practice continued at a scope and severity of third level isolated. Findings: Review of the Louisiana State Board of Practical Nurse Examiners (http://www.lsbpne.com/scope_of_practice.htm) revealed the following: The practice of practical nursing is defined in Section 961 of Chapter 11, Louisiana Revised Statutes of 1950. According to this law, practical nursing is the performance, for pay, of acts in the care, treatment or observation of the ill and for the maintenance of the health of others and the promotion of health care. Practical nurses may train and/or supervise other nurses, and subordinate personnel. They may also instruct patients. A licensed practical nurse must practice under the direction of one of the following: licensed physician, optometrist, dentist, psychologist, or registered nurse. A licensed practical nurse may perform duties consistent with his/her educational preparation. The licensed practical nurse may also, with appropriate training (which is approved by this Board, and documented), perform additional specified acts which are authorized by the Board of Practical Nurse Examiners when directed to do so by the licensed physician, optometrist, dentist, psychologist, or registered nurse. LPNs must possess the knowledge, skill, and ability to perform their duties, therefore, scope of practice comes down to the competency of the individual LPN. The following are some of the tasks (those most frequently inquired about) an LPN may perform when the above conditions are met: bullet point 16-Perform "head to toe" physical assessment. Review of the Louisiana State Board of Nursing website revealed the Delegation Decision-Making Process from the Registered Nurse to the Licensed Practical Nurse (http://www.lsbn.state.la.us/Portals/1/Documents/DelegationTree.pdf) with the following information: In Louisiana, R.S. 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for the implementation of the statutory mandate. The term "delegating nursing interventions" is defined and criteria are provided for all delegatory activities, for delegation to licensed practical nurses, and for delegation to unlicensed nursing personnel. The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures. Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse's responsibility and accountability. Review of the facility's Elopement/Wandering-Residents at Risk Policy revealed the following: Purpose: To identify residents who have a potential to wander from the facility. To implement the appropriate protective measures to help guard against a resident wandering from the facility. Policy and Procedure: 1. On admission/readmission, and in the observation period of each MDS and when resident has a significant change in condition, the nursing staff will screen each resident for elopement risk.... Observation on 8/1/12 at 1:10 p.m. revealed the 300 Hall exit door on the south end of the facility was closed and locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. Observation on 8/1/12 at 1:15 p.m. revealed an exit door on the side hall between the 200 Hall and main dining room that was locked with a key pad alarm, but no wander guard sensor was observed at this door. Further observation revealed another door at the end of the side hall that was locked with a key pad alarm and the red armed light was on. A wander guard sensor strip was observed on the wall by the door. Observation on 8/1/12 at 1:17 p.m. revealed an exit door in the main dining room that was locked with a key pad alarm and had a wander guard sensor attached to the wall by the door. Observation on 8/1/12 at 1:20 p.m. revealed an exit door in the northwest corner of the 500 Hall that was locked with a key pad alarm, but no wander guard sensor was observed at this door. Observation on 8/1/12 at 1:22 p.m. revealed an exit door in the northeast corner of the 500 Hall that was locked with a key pad alarm and the red armed light was on. A wander guard sensor was attached to the wall by the door. Observation on 8/1/12 at 1:23 p.m. revealed a door located between the 500 Hall and 100 Hall that was locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. Observation on 8/1/12 at 1:24 p.m. revealed the front door of the facility had a key pad alarm, but was unlocked for entrance and exit of the facility. Further observation revealed a wander guard sensor was attached to the wall by the front door. Observation on 8/1/12 at 1:26 p.m. revealed an exit door on a side hall off of the 400 Hall that was locked with a key pad alarm and the red armed light was on. Further observation revealed a wander guard sensor attached to the wall next to the door with a warning to not use the pink transmitter and only use the white transmitter. During an interview on 8/1/12 at 1:30 p.m. S4 CNA stated resident #1 previously resided on the locked unit, but was moved to the 200 Hall. S4 CNA stated she was not sure exactly when the move occurred. S4 CNA stated resident #1 was still in the locked unit on Sunday 7/29/12 when she got off work at 2:00 p.m. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITIONS], and Anxiety. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] from home with orders to admit to facility on regular diet, TB Test, and start meds [MEDICATION NAME] 20 mg po daily and [MEDICATION NAME] Patch 4.6 mg q day. Further review of resident #1's medical record revealed the following: A Physician's Telephone Order dated 7/6/12-Apply wander guard to promote safety and monitor exiting behaviors with a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/19/12-[MEDICATION NAME] 50 mg capsule give 1 tablet po q hs. No diagnosis listed. A Physician's Telephone Order dated 7/21/12-[MEDICATION NAME] 1 mg tablet one po bid for a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/23/12-[MEDICATION NAME] 50 mg tablet give 1 po q hs for a [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/26/12-[MEDICATION NAME] 20 mg vial give 10 mg IM q 6 hours prn agitation. A Physician's Telephone Order dated 7/30/12-[MEDICATION NAME] 0.5 mg tablet give 1 tablet po tid prn anxiety/agitation. [MEDICATION NAME] 3 mg capsule give 1 po bid with no diagnosis listed. [MEDICATION NAME] 8 mg tablet give 1 by mouth as needed at bedtime with no diagnosis listed. Review of resident #1's Admission MDS with ARD 7/13/12 revealed the following: Section C-Cognitive Patterns: Resident was assessed as 1 (behavior continuously present, does not fluctuate) for Inattention and Disorganized Thinking. Section D-Mood: Resident was assessed 1/2 (yes/7-11 days) for trouble falling or staying asleep, or sleeping too much, trouble concentrating on things, and moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around a lot more than usual. Section E-Behavior: Resident was assessed as having [MEDICAL CONDITION]. Resident was assessed as having behavioral symptoms not directed towards others having occurred 1 to 3 days. Resident was assessed as having behaviors that significantly interfere with his care and interfere with participation in activities or social interactions. Resident was assessed as having behaviors that significantly intrude on the privacy or activity of others and significantly disrupts care of living environment. Resident was assessed as 3 (behavior of this type occurred daily) for Wandering. Resident was assessed 1 (yes) for does wandering place resident at significant risk of getting to a potentially dangerous place and does wandering significantly intrude on the privacy or activities of others. Section G-Functional Status: Resident was assessed 1/0 (Supervision/No set up help) for walk in corridor, locomotion on unit, and locomotion off unit. Section N-Medications: Resident was assessed as having received an antidepressant 7 of the last 7 days of the assessment. Review of resident #1's Elopement Risk Screening dated 7/12/12 revealed resident was cognitively impaired, had [MEDICAL CONDITION] and Depression, was able to ambulate independently, and wandered aimlessly. Resident was assessed as an elopement risk with the following comments: Resident wanders and paces constantly due to [MEDICAL CONDITION]. He is independently ambulatory with no aids used. He is confused daily and thinks he is at work. A Wanderguard bracelet has been applied for safety due to high risk for elopement. Review of resident #1's plan of care revealed a problem onset 7/6/12 for Wanders/Potential for Elopement with a [DIAGNOSES REDACTED]. Review of resident #1's electronic nurse's notes dated 7/6/12 revealed an entry at 8:00 p.m.-Resident is confused and wanders up and down hallways. Resident has to be redirected constantly. Resident speech is also confused. Secure bracelet in place at this time. Will continue to monitor. Review of resident #1's electronic nurse's notes dated 7/7/12 revealed an entry at 4:26 a.m.-Resident rested quietly in bed approximately 30 minutes, resident has since then been up ambulating throughout the facility. Has to be redirected due to confusion, he mumbles to himself when ambulating. Resident thinks he is working on a job and has swept floors and wiped tables all night ....Wanderguard in place to right ankle. Review of resident #1's electronic nurse's notes dated 7/8/12 revealed an entry at 1:27 p.m.-Resident up in dining room cleaning tables, has not slept over night, he has been walking the halls this morning going in and out of rooms looking for things to do. Review of resident #1's electronic nurse's notes dated 7/17/12 revealed an entry at 2:34 p.m.-Resident did more wandering than usual today. Looking in residents rooms on the 300 Hall and redirected back to dining room. Later found going in and out of rooms on 200 Hall stating he was looking for 70th street and asking how to get there. Placed on Alzheimer's unit to see how he responds there. Will monitor. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 12:41 a.m.-Wandering throughout facility while on 200 hall, resident urinating on floor as he walked. Assisted to room. Wander guard in place. All staff alerted to monitor resident for elopement precautions. Resident sleeps for very short periods of time and gets up wandering in and out of others rooms and shaking exit doors. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 4:37 a.m.-Resident placed 1:1 monitoring and has been unsuccessfully redirected several times. Resident going from exit door to exit door pushing and kicking mumbling he needs to go to Union Street. Wander guard in place. Resident removed from other resident's rooms .... Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 2:35 p.m.-Resident removed from the unit, he has done well and not attempted to leave at all. He is involved with activities and other events going on. He has not been wandering on other halls. He has not been resistant to staff. Review of resident #1's electronic nurse's notes dated 7/18/12 revealed an entry at 8:59 p.m.-Late entry-Resident wanders hallways all evening. Redirected to room many times. Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 4:33 a.m.-Resident observed standing by exit doors trying to escape. Stands by doors at times waiting on someone to open door such as staff or visitor so that he may get out once door is opened. Resident has been awake all night ambulating throughout facility. Observed pulling at wander guard on ankle, when asked what he was doing, he replied that he was trying to break that thing off his leg so he could get it off. Redirected many times, but unsuccessful .... Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 2:57 p.m.-Resident has not slept any this shift and night shift stated he only slept about 10 minutes. Physician notified to see if he would order something, awaiting call back. Resident has not attempted to leave facility, but requires redirection to his room or dining room. Review of resident #1's electronic nurse's notes dated 7/19/12 revealed an entry at 8:46 p.m.-Resident wandering hall this evening mumbling to self. Physician called with new order for [MEDICATION NAME] 50 mg 1 po q hs. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 4:29 a.m.-Resident received [MEDICATION NAME] 50 mg po last night on 2-10 shift. Resident rested quietly in bed all night with no distress. Aroused to verbal stimuli, denies pain ....No wandering observed this shift. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 12:38 p.m.-Resident wasn't as anxious today, always wants to help somebody. Requires cues for directions to room and dining room for meals. Very cooperative with staff and no abnormal behaviors noted. Review of resident #1's electronic nurse's notes dated 7/20/12 revealed an entry at 6:50 p.m.-No adverse side effects from new med [MEDICATION NAME]. Resident has not done much wandering today. Review of resident #1's electronic nurse's notes dated 7/21/12 revealed an entry at 4:49 p.m.-Resident up wandering hall, going into other resident's room, also going to exits and trying to leave and becoming agitated when staff attempts to redirect. Review of resident #1's electronic nurse's notes dated 7/21/12 revealed an entry at 5:57 p.m.-Physician notified of residents wandering in/out of other rooms, resisting care, agitation, and blocking exit doors. Staff x2 had to redirect resident from exit doors. Orders to send resident to Alzheimer's unit, [MEDICATION NAME] 1 mg po bid and [MEDICATION NAME] 20 mg IM now prn agitation. RP notified of new room and new med orders ....IM injection of [MEDICATION NAME] given to right deltoid. No signs/symptoms of adverse reaction noted after injection. No vital signs obtained due to agitation. Will continue to monitor. Review of resident #1's electronic nurse's notes dated 7/22/12 revealed an entry at 10:35 p.m.-11:00 a.m. resident appears to be adjusting in secure unit. Ate meals in dining room. Redirection needed, but allows staff to redirect. No agitation at this time. Up ad lib wandering noted in/out other rooms at times. Review of resident #1's electronic nurse's notes dated 7/22/12 revealed an entry at 10:38 p.m.-Resident in room and caused flood in bathroom. Toilet overflowed. Water cleaned up then resident placed in bed. Remained in bed throughout remainder of shift. Review of resident #1's electronic nurse's notes dated 7/23/12 revealed an entry at 3:23 p.m.-Physician's office called with new order to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 50 mg 1 po q hs. RP notified. Review of resident #1's electronic nurse's notes dated 7/24/12 revealed an entry at 1:29 p.m.-Resident's family here at this time and wants resident off [MEDICATION NAME]. Physician office called and notified of family concerns. Review of resident #1's electronic nurse's notes dated 7/24/12 revealed an entry at 1:44 p.m.-Resident moved to Dementia unit for exiting behavior. Wander guard discontinued at this time. Review of resident #1's electronic nurse's notes dated 7/26/12 revealed an entry at 9:16 p.m.-(2:45 p.m.)Resident pacing up and down hall talking to people who are not there. Physician notified and [MEDICATION NAME] 10 mg IM given. (4:00 p.m.)-Sitting on side of bed with covers over his head .... Review of resident #1's electronic nurse's notes dated 7/28/12 revealed an entry at 9:57 a.m.-Resident out on pass with sister. Sister stated resident may be back on Monday morning. Review of resident #1's electronic nurse's notes dated 7/29/12 revealed an entry at 9:21 p.m.-(9:25 a.m.)Resident returned to facility with daughter. Daughter stated she wanted resident off of [MEDICATION NAME] or get it decreased. Explained the [MEDICATION NAME] was keeping him from being agitated. Daughter insisted resident was calm and she did not want him on the medication. Daughter returned the medications that resident took out on pass and the resident's [MEDICATION NAME] had not been given the night before. Resident walked back to Secure unit where he resided. Approximately 5:00 p.m. was called to unit per CNA. Resident was attempting to fight other residents and yelling and cursing to get out of his momma's house. CNAs between residents to protect other residents from resident #1. Nurses stat called to unit with response from other nurses and staff. Resident charged at the male nurse and hit him in the abdomen. Continued cursing and threatening to kill everyone. 911 notified and DON called. Resident taken to local ER via police. Physician notified. Review of resident #1's electronic nurse's notes dated 7/30/12 revealed an entry at 7:42 p.m.-Resident returned to facility per stretcher in stable condition to room [ROOM NUMBER] A. No agitation or abnormal behaviors noted ....Will continue to monitor for aggressive behaviors. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 4:53 a.m.-Resident rested quietly in bed in his room throughout the shift. No behavioral issues noted at this time. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 12:13 p.m.-Resident was very cooperative this a.m. except he would not take his medication that was offered three different ways. He never got upset, just refused it. He was assisted to dining room where he ate 100% of breakfast and after finishing he sat there and talked with other residents. Went down the hall for 10-15 minutes and when returned to front of nurse's station resident was standing at the other doorway by the piano. At approximately 9:00 a.m. resident could not be found. An overhead announcement was made to alert staff to look everywhere for him. Some staff went outside and some left in cars to try and locate him. 911 was notified. Family and physician were notified. Staff continues to look for resident. Review of resident #1's electronic nurse's notes dated 7/31/12 revealed an entry at 1:46 p.m.-Resident is still not in facility at this time. Review of the facility's Incident Log revealed an incident on 7/29/12 that resident #1 had physical contact with staff and an incident on 7/31/12 where resident #1 wandered from the grounds. Review of the facility's OTIS Log revealed documentation of an ongoing OTIS investigation regarding resident #1's elopement from the facility. During an interview on 8/2/12 at 11:15 a.m. S5 LPN (called the facility to speak with me) stated resident #1 was readmitted to the facility at 7:42 p.m. on 7/30/12 and she was the admitting nurse. S5 LPN stated resident #1 was on the locked unit and was sent out to the hospital over the weekend due to his behaviors. S5 LPN stated S2 DON called her on 7/30/12 and let her know resident #1 was going to be returning to the facility and was going to be admitted to room [ROOM NUMBER] A on the general floor. S5 LPN stated resident #1 did not have a wander guard bracelet on and she did not have an order for [REDACTED].#1 before he was moved to the locked unit and he wandered frequently and tried getting out the door at times, so she knew to monitor him for elopement and resident #1 never left his room. S5 LPN stated she offered resident his evening medications and he refused them and pulled the covers over his head and stayed in bed until she left at 10:00 p.m. During an interview on 8/2/12 at 11:45 a.m. S2 DON stated a physician's orders [REDACTED]. S2 DON was asked for a copy of the facility standing orders. S2 DON on 8/2/12 at 12:20 p.m. provided the facility's Nursing Intervention Communication Form Policy with the following information: This is a reference list of items that are nursing interventions and may not require a physician order. The list included security bracelet. S2 DON stated this is the standing orders for the facility she had mentioned. During an interview on 8/2/12 at 1:00 p.m. S6 LPN stated on the morning of 7/31/12 resident #1 was wandering and looking in the dining area and she assisted him to his seat. S6 LPN stated resident #1 ate 100 % of his breakfast and was talking to other residents. S6 LPN stated she went to finish passing medications on the 300 hall and when she came back up the hall resident #1 was standing at the dining room door by the piano. S6 LPN stated that was the last time she saw him and it was around 8:50 a.m. S6 LPN stated she was on the 200 hall when S13 Activity Assistant Director came to place a wander guard bracelet on resident #1 and he was not in his room. S6 LPN stated they made the announcement and all staff went to search rooms, bathrooms, all doors, searched outside the grounds, and some staff drove down the street to look for him. S6 LPN stated S7 LPN had mentioned seeing resident #1 on the 500 hall right after she saw him at 8:50 a.m. in the dining room. S6 LPN stated resident #1 had been readmitted the day before and when she came to work that morning, he did not have a wander guard bracelet in place. S6 LPN stated she did not know why resident was not placed back on the locked unit. S6 LPN stated they kept an eye on resident #1 and the staff knew to watch him closely because he was an elopement risk, but he was not 1 on 1. S6 LPN stated when resident was first admitted on [DATE] she placed a wander guard bracelet on him. During an interview on 8/2/12 at 1:15 p.m. S7 LPN stated resident #1 came back to the 500 hall and she didn't know who he was. S7 LPN stated she asked if she could help him and he mumbled so she called up front and spoke with S9 CNA Supervisor. S7 LPN stated she was informed the resident on her hall was resident #1 and that S9 CNA Supervisor was getting ready to put a wander guard bracelet on him. S7 LPN stated resident #1 walked down by the therapy department and it looked like he was talking to someone. S7 LPN stated she was called to a resident's room and then she heard the call that a resident was missing. S7 LPN stated a family member came in a few minutes after that and she asked did they see anyone in a blue shirt and the family told her someone was walking down the street out front. S7 LPN stated she did not see how resident #1 got out of the facility. During an interview on 8/2/12 at 1:30 p.m., with S1 Administrator, S2 DON, and S3 Corporate Nurse, DON stated resident #1 came back to the facility on [DATE] between 7:00 and 8:00 p.m. S2 DON stated the hospital tried to send resident #1 back earlier in the day on 7/30/12, but they were not able to meet his needs and were scared for the other residents so her and S1 Administrator tried to find other placement for him. S2 DON stated they were not able to find placement and the hospital was adamant resident #1 was going to be sent back to the facility and after much discussion it was determined the residents on the Alzheimer's unit were too vulnerable to deal with resident #1's behaviors so they agreed to place resident #1 on the 200 hall so he could be monitored by both nurse's stations. S2 DON stated S5 LPN was instructed to place a wander guard on resident #1, but she did not place the wander guard bracelet. S1 Administrator stated S5 LPN wrote a statement that she did not check resident #1 for a wander guard bracelet because he previously had one in place and she thought he still had it on. S1 Administrator stated later on S5 LPN said she did not put the wander guard bracelet on him because she was afraid of him. S1 Administrator stated S5 LPN was suspended for not placing the wander guard bracelet on resident #1 and was going to be terminated for not doing what S2 DON told her to do. When asked which door resident #1 eloped from, S1 Administrator stated it was determined by cameras and last known location that resident #1 left out of the northeast door on the 500 hall that was always locked. S1 Administrator stated a lot of family come visit at that time of morning and a visitor stated they saw a person meeting resident #1's description in the area of the northeast door. S1 Administrator further stated when the fire rescue came with the blood hounds, the dogs picked up resident #1's trail at the northeast exit door. S1 Administrator stated resident #1 walked up the street and was caught on video camera from a Supercenter retail store and was found in a neighborhood by the Supercenter retail store about an 1/8 mile from the facility. S1 Administrator stated resident #1 was found at 7:00 p.m. and he went to check on the resident with local police and EMS. S1 Administrator stated resident #1 was taken by EMS to a local hospital and was admitted and transferred to the behavioral unit. During an interview on 8/2/12 at 1:45 p.m. S1 Administrator stated resident #1 was an admit from home and the physician assessed him in the office and then admitted resident #1 to the facility. S1 Administrator stated when resident #1 was admitted he had a wander guard bracelet placed for monitoring. S2 DON stated resident was moved to the locked unit on 7/21/12 and the wander guard bracelet was removed at that time. Review of a written statement dated 7/31/12 and signed by S5 LPN revealed the following: Resident returned to facility at 7:42 p.m. Resident was in fetal position in bed when writer got to him and attempted to give meds. Resident pushed hand out stated, "No" and covered head. Resident had wander guard in place when on floor and did not know that the wander guard had been removed due to resident was on secure unit before hospital return. Review of a written statement dated 7/30/12 and signed by S2 DON revealed the following: 5:47 p.m.-With no oth