Every finding on record at Hermitage Care and Rehabilitation Center

Based on observation, interview, and review of facility policy, the facility failed to store food in accordance with professional standards for food service safety. Observation revealed refrigerated foods were not dated, labeled, and/or discarded in a timely manner. Those failures had the potential to affect 86 of 87 residents in the facility who consumed food from the kitchen. The findings include: Review of the facility policy, Food Storage, Cold Foods, revised ,d+[DATE], revealed, all Time Temperature Control (TCS) for safety foods, frozen and refrigerated, would be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Review of the facility's, Food Storage and Retention Guide, dated 2017, revealed, ready to eat prepared foods, such as leftovers, deli salads, and cut produce, when refrigerated at 41 degrees Fahrenheit (F) or less was good up to seven days and poultry or seafood, once thawed, was one-two (,d+[DATE]) days. Observation on [DATE] at 10:27 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), revealed two large ziploc bags of raw chicken breasts stored in a container that was dated [DATE]; one large bag of chopped meat that the CDM identified as chicken, not sealed with no label or date; and a large bag of deli meat (ham), dated [DATE] with a use by date of [DATE]. Continued observation of the freezer revealed a ziploc bag with seven frozen hamburger patties that were not not labeled or dated. Further observation of an upright freezer revealed it contained a plastic bag labeled italian sausage that was dated [DATE]. In interview with the CDM and the Dietary District Manager on [DATE] at 8:41 AM, the CDM stated the process for labeling stored foods was items were to have a label identifying what the item was, an opened date and a use by date. She stated foods could be dated for seven days. The CDM said she expected staff to label and date all food items before placing them in the coolers. She reported all staff were responsible for labeling and dating items as well as checking the coolers. The CDM further stated outcomes for residents eating out of date or expired foods could be be nausea and vomiting. In interview with the Director of Nursing (DON) and the Administrator on [DATE] at 1:09 PM, the DON stated her expectations for the kitchen was for them to follow their guidelines for labeling and dating food items. She stated an outcome for residents was they could become sick with stomach issues. The Administrator stated he did not have any different expectation than the DON.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide oxygen therapy according to the care plan for one (1) of three (3) sampled residents (Resident #1). The findings include: Review of the facility policy titled, Comprehensive Care Plans, not dated, revealed the facility provides person-centered care as it focuses on the resident as the center of control and supports each resident in making his/her own choices. The policy further revealed each resident's Comprehensive Care plan is designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Record review revealed the facility readmitted Resident #1 on 09/25/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. Review of the Physician's Order, dated (MONTH) (YEAR), revealed an order to administer oxygen at three (3) liters per minute (lpm) per nasal cannula to keep oxygen saturation above ninety percent (90 %). Review of Resident #1's Comprehensive Care Plan, dated 10/03/18 revealed an intervention to administer oxygen as ordered; however, interview with Resident #1 on 10/16/18 at 4:40 PM, revealed there were times the aides removed his/her oxygen while assisting him/her to the bathroom because the tubing was not long enough. Resident #1 stated he/she has breathing problems and can became short of breath easily. He/she stated after his/her daughter complained to the nursing staff, the staff put longer oxygen tubing in use so it could be worn while in the bathroom. Interview with Certified Nurse Aide (CNA) #1 on 10/16/18 at 4:18 PM, and CNA #2 on 10/17/18 at 12:50 PM revealed they would remove Resident #1's oxygen when they assisted him/her to the bathroom because the oxygen tubing was not long enough. Interview with the Director of Nursing (DON) on 10/17/18 at 2:35 PM, revealed there were oxygen supplies available to extend the oxygen tubing for residents requiring continuous oxygen while in the bathroom. She stated she expected staff to follow the residents care plan and she was not aware the nurse aides were taking the resident to the bathroom without his/her oxygen in use. She stated she did not provide education due to not being aware

Based on interview, record review, and facility policy review, it was determined the facility failed to provide oxygen therapy according to the physician's order and care plan for one (1) of three (3) sampled residents. The findings include: Review of the facility policy, Oxygen Administration, not dated, revealed in order to administer oxygen safely supplies and equipment should be gathered and to place appropriate oxygen devices on the resident (ie. mask, nasal cannula and/or nasal catheter). Record review revealed the facility readmitted Resident #1 on 09/25/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. Review of the Physician's Order, dated (MONTH) (YEAR), revealed an order to administer oxygen at 3 liters per minute (lpm) per nasal cannula to keep oxygen saturation above ninety (90) percent. Review of Resident #1's Comprehensive Care Plan, dated 10/03/18 revealed an intervention to administer oxygen as ordered and check oxygen saturation levels as needed. Interview with Resident #1 on 10/16/18 at 4:40 PM, revealed there were times when the aides had removed his/her oxygen while assisting him/her to the bathroom because the tubing was not long enough and they would leave him/her telling him/her to push the call light when done. Resident #1 stated he/she has breathing problems and can became short of breath easily. He/she stated after his/her daughter complained to the nursing staff put longer oxygen tubing in use so it could be worn while in the bathroom. Interview with Certified Nurse Aide (CNA) #1 on 10/16/18 at 4:18 PM, revealed she had assisted Resident #1 to the bathroom on a couple of occasions in which the residents oxygen was taken off because the oxygen tubing was not long enough. She further stated she stayed with the resident during this time and Resident #1 had no complaints of shortness of breath. She further stated Resident #1 now has long tubing so he/she can keep the oxygen on at all times. Interview with CNA #2 on 10/17/18 at 12:50 PM, revealed she had removed Resident #1's oxygen while assisting him/her to the bathroom because the oxygen tubing was not long enough. She further stated she stayed with the resident and Resident #1 had no signs of distress. Interview with the Director of Nursing (DON) on 10/17/18 at 2:35 PM, revealed there were oxygen supplies available to extend the oxygen tubing for residents requiring continuous oxygen while in the bathroom. She stated she expected staff to follow the physician's orders. She revealed she was not aware the nurse aides were taking the resident to the bathroom without his/her oxygen in use so no education had been provided to the staff.

Based on observation, interview and review of the facility policy and procedure, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Dietary Aide #1 was observed touching his clothing and not washing his hands during the meal service. Review of the Census and Condition dated 08/07/18 revealed seventy-six (76) of seventy-six (76) residents received their food from the kitchen. The findings include: Review of the facility policy and procedure titled, Handwashing and Glove Use, last revised (MONTH) 2014, revealed guidelines for handwashing and glove use are used to promote safe and sanitary conditions throughout the dietary department. Further review of the policy revealed employees should wash their hands following contact with any unsanitary surface i.e touching hair, sneezing, opening doors, etc Observation of a lunch meal, on 08/07/18 at 11:30 AM , revealed Dietary Aide #1 touched and pulled up his pants, with ungloved hands, then touched clean plates and towels and placed food into the clean dishes. Continued observation revealed he did not wash his hands after touching his clothing and prior to touching the clean dishes. Interview with Dietary Aide #1 on 8/08/18 at 9:30 AM, revealed he knew he should have washed his hands after touching his clothing and prior to touching clean plates because his hands were considered soiled after touching contaminated items. Interview with the Dietary Manager on 08/08/18 at 9:23 AM, revealed if staff's hands become contaminated by touching unclean objects such as their clothes, they should wash their hands prior to touching clean items such as plates during meal service.

Based on interview, record review and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for one (1) of nineteen (19) sampled residents (Resident #43), and one (1) resident not in the selected sample (Resident #77). Record review for Resident #43 and Resident #77, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of resident transfers. The finding include: Review of the facility policy titled, Transfer/Discharge Notice, last reviewed 12/06/16, revealed before the transfer or discharge occurs, the facility will notify the resident and, the resident's representative of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. Send a copy of the transfer or discharge notice to a representative of the Office of the State Long Term Care Ombudsman. The facility's notice will include an explanation of the right of appeal to transfer to the State as well as the name, address, and phone number of the State Long-Term Care Ombudsman, and the facility will send a copy of the transfer or discharge notice to a representative of the State Long-Term Care Ombudsman. According to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. 1. Record review revealed the facility admitted Resident #43 on 10/25/13 with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Anxiety Disorder, and Type two (2) Diabetes. Review of a Physician Order dated 06/12/18, revealed to send to emergency room (ER) for evaluation and treatment. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the local hospital. 2. Record review revealed the facility admitted Resident #77 on 02/25/18, with [DIAGNOSES REDACTED]. Review of a Physician Order dated 05/10/18, revealed Resident #77 was to be discharged home with Home Health to follow up. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the local hospital. Interview with the Business Office Manager (BOM) on 08/08/18 at 3:55 PM, revealed she was not aware she was required to notify a representative of the State Ombudsman office when a resident was transferred out of the facility. She stated she only notified a representative of the State Ombudsman office when they have involuntary discharges. Interview with the facility Administrator on 08/08/18 at 4:00 PM, revealed he was not aware the facility was to notify a representative of the Office of the State Long-Term Care Ombudsman office when a resident was transferred out. He was only aware the facility needed to make a representative of the State Ombudsman office aware of all involuntary discharges. He revealed he had recently had a conversation with the local Ombudsman regarding involuntary discharge notifications, and the local Ombudsman informed him she did not want a notification after every single involuntary discharge just to keep a list of the involuntary discharges and send the list of involuntary discharges to her periodically. Further interview at 4:49 PM, revealed after reading the interpretative guidance of F-623 and after our discussion regarding the new regulation, he did see that the Ombudsman's office was to be notified of all discharges, and not just involuntary discharges.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure medication administration met professional standards of quality for one (1) of nineteen (19) sampled residents (Resident #10). Observation on 08/07/18 of a medication cart revealed a syringe containing a dose of reconstituted [MEDICATION NAME][MEDICATION NAME] had not been administered. The findings include: Review of the facility policy, Medication Administration General Guidelines, last revised (MONTH) (YEAR), revealed medications are to be administered at the time they are prepared and medications are administered in accordance with written orders of the prescriber. Further review of the policy revealed medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Record review revealed the facility admitted Resident #10 on 06/18/16, with [DIAGNOSES REDACTED]. Review of Resident #10's Physicians Orders dated (MONTH) (YEAR), revealed an order for [REDACTED]. Observation of a medication care on A Hall, on 08/08/18 at 2:15 PM, revealed a syringe of reconstituted [MEDICATION NAME][MEDICATION NAME] milligram (MG) in the top drawer for Resident #10. Interview with Licensed Practical Nurse (LPN) #1 on 08/07/18 at 2:15 PM, revealed the resident should have received the injection earlier but was gone to Bingo and she did not want to interrupt the resident in activities. She stated medications are to be given an hour before or an hour after and she should have administered when the medication was prepared. Interview with the Pharmacist on 08/09/18 at 8:59 AM, revealed according to the manufacturers guidelines as long as [MEDICATION NAME][MEDICATION NAME] given within six (6) hours of reconstitution, there are no known effects. Interview with the Director of Nursing (DON) on 08/09/18 at 2:18 PM, revealed she expected the medications to be given as ordered and an hour before/after the scheduled time.

Based on interview and record review, it was determined the facility failed to report an allegation of misappropriation of resident property to the appropriate state agencies per facility policy. On [DATE], an anonymous caller reported to the Administrator that he/she had seen empty residents' narcotic medication cards at the Director of Nursing's (DON's) home, however, the Administrator failed to report the allegation to the appropriate State Agency per facility policy. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Property, not dated, revealed the facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of a crime as defined in this policy and if so he/she or the Director of Nursing will notify State agencies according to State reporting procedures within two (2) hours. Interview with the Administrator, on [DATE] at 1:45 PM and [DATE] at 2:30 PM, revealed she received a telephone call on [DATE] from an anonymous caller who reported they saw empty narcotic medication cards of residents in the Director of Nursing's (DON) home. The Administrator stated she began an investigation into the allegation and had the DON escorted from the facility by the maintenance man and the marketing manager. She revealed she contacted the city police but did not report the allegation to the State Agency because they could only determine that the signature cards for three (3) deceased residents were missing.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care according to each resident's written plan of care related to oxygen (O2) administration for one (1) of six (6) sampled residents (Resident #10). Resident #10 was care planned to receive O2 as ordered (O2 at three {3} liters a minute {LPM}); however, observations on 06/14/17 at 8:52 AM revealed the resident's O2 concentrator was set on 1.5 LPM, and observation at 9:26 AM revealed the O2 concentrator was set on four (4) LPM. The findings include: Review of the facility policy, Care-Plans-Comprehensive, dated 09/21/16, revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan interventions are implemented after consideration of the resident's problem areas and their causes. Record review revealed the facility admitted Resident #10 on 03/06/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/26/17, revealed the facility assessed Resident #10's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for [MEDICAL CONDITION] Condition, last updated 05/18/17, revealed to administer Resident #10's O2 as ordered and review of the June 2017 Physician's Orders revealed to administer O2 therapy at three (3) liters per nasal cannula. However, observations on 06/14/17 revealed Resident #10 concentrator was set on 1.5 LPM at 8:52 AM, and set at four (4) LPM at 9:26 AM; with nasal cannula in place. Resident #10 stated someone had come into his/her room and told her/him that his/her oxygen was on 1.5 LPM and should be on three (3) or four (4) LPM. The resident stated the person then changed the setting. Interview with the Activity Director on 06/14/17 at 12:23 PM revealed she changed the concentrator from 1.5 LPM to four (4) LPM at 9:00 AM that day because when she made rounds she identified the concentrator was on the wrong setting according to the rounding acuity sheet which stated it should be at four (4) LPM. Interview with Licensed Practical Nurse (LPN) #1, on 06/14/17 at 9:17 AM, and Registered Nurse (RN) #3 on 06/15/17 at 2:36 PM, revealed nurses are to follow the plan of care to provide care for the residents. Interview with the Assistant Director of Nursing (ADON) who is the acting Director of Nursing (DON), on 06/15/17 at 2:50 PM, and the Administrator on 06/14/17 at 2:10 PM, revealed they expected staff to follow the care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide one (1) of six (6) sampled resident the proper care and treatment related to oxygen (O2) administration (Resident #10). Resident #10 had Physician Orders for O2 at three (3) liters per minute (LPM) per nasal cannula and was care planned to administer O2 as ordered. However, observations on 06/14/17 revealed Resident #10's O2 concentrator was set at three (3) liters a minute (LPM) at 8:52 AM; and, the O2 concentrator was set at four (4) LPM at 9:26 AM. The findings include: Review of the facility policy titled, Oxygen Administration, dated 04/26/17 revealed the purpose of the procedure is to provide guidelines for safe oxygen administration. Further review revealed before administering oxygen, staff should turn on the oxygen per the physician's order, and ensure the proper flow of oxygen is being administered. Record review revealed the facility admitted Resident #10 on 03/06/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/26/17, revealed the facility assessed Resident #10's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Further review of the MDS revealed the resident was extensive assist of two (2) staff for bed mobility, dependent on staff for transfers, and the resident was receiving O2. Review of the Comprehensive Care Plan for [MEDICAL CONDITION] Condition, dated 03/27/17 and last updated 05/18/17, revealed Resident #10 required O2 via nasal cannula and to administer O2 as ordered. Review of the June 2017 Physician's Orders revealed to administer O2 therapy at three (3) liters per nasal cannula continuously for [DIAGNOSES REDACTED]. Review of the June 2017 Treatment Administration Record revealed Oxygen Therapy at three (3) liters per nasal cannula continuously, check on day shift and night shift. Further review revealed licensed staff had initial Resident #10 was receiving O2 at three (3) LPM on 06/13/17 night shift and 06/14/17 days shift. Observation on 06/14/17 at 8:52 AM revealed Resident #10's concentrator was set on 1.5 LPM instead of three (3) LPM as ordered, and the nasal cannula was in place. Interview with Resident #10 at the time revealed his/her oxygen should be set on three (3) or four (4). Observation with LPN #1, on 06/14/17 at 9:26 AM of Resident #10's concentrator revealed the concentrator was set on four (4) LPM. The resident stated that someone had come into his/her room and stated that his/her oxygen was on 1.5 LPM and should be on three (3) or four (4) and stated she changed it for him/her. Interview with the Facility Nurse Consultant on 06/14/17 at 11:26 AM revealed the Activity Director, who is also a Certified Nurse Aide (CNA), had changed the O2 settings to four (4) LPM. Interview with the Activity Director, on 06/14/17 at 12:23 PM, revealed as a department head she was responsible to check on a select number of residents in the facility twice a day for oxygen settings, call lights and hydration within reach, and other needs. She stated Resident #10's O2 concentrator was not on the right setting at 1.5 LPM when she made rounds around 9:00 AM on 06/14/17, according to the rounding acuity sheet provided to the department heads. She stated the acuity sheet revealed the resident was to be on four (4) LPM of O2 per nasal cannula; therefore, she changed the settings to four (4). She revealed she then went to look in the chart to ensure the resident was on the correct setting but could not find the order so she looked for the resident's nurse but she was not at the desk so she found the scheduler nurse in the hall. She stated she asked the scheduler nurse to assist her with finding the correct order for O2 and the Scheduler nurse stated the correct LPM was three (3). She revealed she went back to change the O2 concentrator and the concentrator had already been changed to three (3) liters. She stated she was not sure who changed the setting back. She further stated it was okay for the Department Heads to turn oxygen settings up or down but to notify the nurse of the change. Further interview with the Activity Director, on 06/15/17 at 10:10 AM revealed she had been shown how to adjust the ball on the oxygen concentrator by the nurses on the unit but she had not received any formal training regarding how to adjust oxygen settings. She stated that changing the settings on the concentrator is not within the scope of practice of the CNA and she should get the nurse to adjust the settings. Interviews on 06/15/17 with CNA #1 at 10:00 AM, CNA #2 at 10:07 AM, and CNA #3 at 2:29 PM, revealed the CNAs are not allowed to adjust the liter flow settings for O2 and if an issue is found to notify the nurse. Interview with Licensed Practical Nurse (LPN) #1, on 06/14/17 at 9:17 AM, revealed according to physician's orders Resident #10's O2 should be on three (3) LPM. She stated the nurses check the oxygen concentrators to ensure the correct setting once every shift; however, she had not had time to check Resident #10's concentrator yet for 7:00 AM - 7:00 PM. Interview with Registered Nurse #3 on 06/15/17 at 2:36 PM revealed she worked night shift on 06/13/17 and got off from work at 7:00 AM on 06/14/17. She stated she checked Resident #10 O2 at 10:30 PM on 06/13/17 and the resident's O2 settings were at three (3) LPM when she changed him/her from a nasal cannula to his/her [MEDICAL CONDITION] machine. She revealed at around 5:00 AM on 06/14/17 she changed out the resident's cannula because the cannula was clogged up due to water condensation from the humidifier. She then stated she did not check the liter flow at that time as she was in a hurry making her final rounds before she left for the day. She stated she could have bumped the concentrator while switching the resident back over to the nasal cannula as there was tight quarters in the room. She revealed that CNAs are not to adjust the meter flow as it is considered a medication. Interview with the Assistant Director of Nursing (ADON) who is the acting Director of Nursing (DON), on 06/15/17 at 2:50 PM revealed she expected staff to follow the care plan and physician's orders when the O2 was administered. She stated when the Activity Director told the nurse that the O2 liter flow was not accurate, the nurse should have followed up on the concentrator to ensure the correct setting. Interview with the Administrator, on 06/14/17 at 2:10 PM, revealed CNAs do not normally change O2 settings even if in the leadership role. She stated the CNA should have come to the nurse with the discrepancy and not have changed the liter flow, which is what the facility instructs. She revealed she does not accept CNAs changing the liter flow on the concentrators. She further stated the Administrator updates the acuity rounding sheets with changes; however, the information is not concrete and if staff have questions, they should consult the nurse.

Based on interview, record review, review of the facility's investigation, and review of the facility's policy and procedures, it was determined the facility failed to implement the care plan interventions for four (4) of eighteen (18) sampled residents (Resident #18, Resident # 10, Resident #7, and Resident #8 ), and one (1) unsampled resident (Resident A), not in the selected sample. On 03/25/15, Resident #18 was care planned for exit seeking behaviors and potential elopement with interventions for staff to ensure there was an audible monitoring system to alert staff of exit seeking behavior and to monitor the resident for tailgating when visitors were in the building. However, on 04/05/16, Resident #18 allegedly followed family members out an exit door at the back of the facility to the parking lot without staff's knowledge, due to a visitor silencing the alarm. In addition, staff failed to implement the care plan for Resident #10 related to applying [MEDICATION NAME] (skin protectors) daily; for Resident #7 and Unsampled Resident A related to nail care, and Resident #8 related to administering medication according to the physician order. The facility's failure to implement the care plan related to potential elopement, has caused, or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/28/16 and determined to exist on 04/05/16. The facility was notified of the Immediate Jeopardy on 04/28/16. An acceptable Allegation of Compliance (AoC) was received on 04/29/16 alleging the removal of the Immediate Jeopardy on 04/30/16. The State Survey Agency validated, on 05/05/16, the Immediate Jeopardy was removed on 04/30/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, Care Plans-Comprehensive, last reviewed 06/01/15, revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs should be developed for each resident. Care plan interventions should be implemented after consideration of the resident's problem areas and their causes. Interventions should address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes. 1. Record review revealed the facility admitted Resident #18, on 03/10/16 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) assessment, dated 01/28/16, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for Risk for Elopement, dated 03/25/15 and last revised on 02/17/16, revealed Resident #18 was independent with ambulation and had exit seeking behaviors. Interventions included for staff to monitor the resident for tailgating visitors out the exit doors; to have an audible monitoring system to alert staff of exit seeking behaviors; and, to have a wanderguard bracelet applied to the resident's ankle to alert staff of exit seeking behaviors. Review of the facility's investigation, dated 04/05/16, revealed Resident #18 exited the back door of the facility on E-Hall without staff knowledge and was found approximately thirty (30) feet from the building in the back parking lot. Housekeeping Aide #1 brought the resident back into the facility. Further review of the investigation revealed the visitors had access to the door alarm codes and allegedly, as they were exiting the facility, the door was held open too long, which caused the alarm to go off. As the visitors had the code and were able to silence the alarm staff did not hear the alarm. Staff was unaware Resident #18 followed the visitors out of the building. The visitors having access to the door codes prevented the staff from monitoring to ensure residents did not tailgate visitors out the exit doors and the audible monitoring system to alert staff the resident was exiting the building, as care planned. Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide #2 at 2:00 PM, SRNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training related to monitoring residents who wandered and elopement, as well as door alarms. The staff stated if a door alarm sounded, staff was to go to the door and check the perimeters all around the door inside and out. However, further interview revealed prior to this incident they were allowed to give out the door codes to everyone except residents. Interview with the Director of Nursing (DON) and Administrator, on 04/27/16 at 2:25 PM, revealed they expected staff to follow care plan interventions related to monitoring Resident #18 for tailgating visitors out of the facility and to ensure the audible monitoring system alerted staff to ensure an elopement did not occur. 2. Record review revealed the facility admitted Resident #8 on 11/12/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/14/16, revealed the facility assessed Resident #8's cognition as moderately impaired with a BIMS score of eleven (11) which indicated the resident was interviewable. In addition, the resident required extensive assistance with transferring, dressing, hygiene and bathing; and, was wheelchair bound. Review of the Comprehensive Care Plan risk for signs and symptoms of adverse side effects related to use of [MEDICAL CONDITION] medication, dated 10/07/14, revealed an intervention to administer medication as prescribed by the physician. Review of the physician's orders [REDACTED]. However, observation of a skin assessment while Resident #8 was receiving a shower, on 04/28/16 at 11:00 AM, revealed there were two (2) Rivastigmine 9.5 mg/24 hr [MEDICATION NAME]es on the resident's anterior chest. One of the patches was dated 04/27/16 and one was dated 04/28/16. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/16 at 11:15 AM, revealed she neglected to follow the care plan and remove the old Rivastigmine [MEDICATION NAME] dated 04/27/16 before applying the new patch which left two (2) patches on the resident's anterior chest. Interview with DON, on 04/28/16 at 3:30 PM revealed he/she expected the nursing staff to follow the care plan which stated to follow the physician's orders [REDACTED]. 3. Record review revealed the facility admitted Unsampled Resident #A, on 03/09/15, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 04/06/16, revealed the facility assessed Unsampled Resident A's cognition with a BIMS score of ninety-nine (99), indicating the resident was not interviewable and he/she required extensive assistance of one (1) staff for personal hygiene. Review of the Comprehensive Care Plan for Activity of Daily Living (ADL) deficit, dated 03/20/15, revealed an intervention to provide assistance/supervision to meet the resident's needs for all ADLs; however, observation on 04/26/16 at 8:30 AM and 04/27/16 at 9:15 AM, revealed Unsampled Resident A's finger nails with a brown substance underneath them. Interview with the DON, on 04/27/16 at 4:10 PM, revealed she expected the staff to follow the care plan for each resident. 4. Record review revealed the facility admitted Resident #7 on 06/29/10 with diagnoses, which included [MEDICAL CONDITION], Anxiety, and [MEDICAL CONDITION] Disease. Review of the Annual MDS assessment, dated 01/20/16, revealed the facility assessed Resident #7's cognition as moderately impaired with a BIMS score of zero (00), indicating Resident #7 was not interviewable. Further review revealed the facility had assessed Resident #7 to require extensive assistance with Activities of Daily Living (ADLs) Review of the Comprehensive Care Plan, last revised 06/04/16, revealed the resident was assessed to be at risk for behavior problems related to resident gets easily annoyed with staff and peers. Further review revealed an intervention to encourage resident to allow staff to keep fingernails trimmed. Observation of Resident #7, on 04/27/16 at 8:30 AM, revealed the resident's fingernails were very long and visibly dirty with a dark brown substance visible under all the fingernails of the resident's right hand; and, also under the resident's thumb nail of the left hand. Interviews with LPN #3, on 04/27/16 at 8:50 AM, revealed when asked about the appearance of Resident #7's fingernails replied, I see them. She stated, The resident can be very combative and we can only do what (he/she) will allow us to do. Interview with CNA #2, on 04/27/16 at 3:20 PM, and CNA #1, on 04/28/16 at 1:00 PM, revealed the resident was not always cooperative with letting staff provide nail care. They stated they try to do them on shower days and report to the nurse if the resident refuses. CNA #2 stated the dark substance could possibly be bowel movement (BM), or dried food. She stated it has been maybe a month since the resident let her trim his/her fingernails. Interview with the Administrator, on 04/28/16 at 3:00 PM, revealed Resident #7 refuses care quite often and sometimes it was hard to get it done. She further stated she would expect the staff to follow the resident's comprehensive plan of care and provide the care that was needed for the resident. 5. Record review revealed the facility admitted Resident #10 on 09/20/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/08/16, revealed the facility assessed Resident #10's cognition as intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of the Comprehensive Care Plan for at risk for developing skin break down, last updated on 04/26/16, and review of the Nurse Aide Care Plan, dated April 2016, revealed [MEDICATION NAME] (leg protectors) to bilateral legs. However, observations on 04/26/16 at 9:30 AM, 11:30 AM, 2:30 PM, and 4:10 PM, revealed Resident #10 was wearing short white socks, with no evidence of [MEDICATION NAME] stockings in place. Interview with Resident #10, on 04/28/16 at 9:15 AM, revealed he/she could not recall the last time he/she wore the stockings. He/She stated the areas on his/her legs were healed and he/she used to wear the stockings all the time. Interview with CNA #1, on 04/28/16 at 9:50 AM, revealed she has been employed at the facility since last October and had never placed stockings on the resident until today. She stated she was unaware the [MEDICATION NAME] were on Resident #10's care plan. CNA #1 stated she did sign off on the CNA Care Plan at the end of every shift and it must have been an oversight on her part. Interview with CNA #5, on 04/27/16 at 9:00 AM, revealed she has been employed here since 01/29/16 and to her knowledge Resident #10 has never worn [MEDICATION NAME] or any special type of stockings. Further interview revealed, she was the one stiff responsible to assist Resident #10 up in the morning and it must have been an oversight on her part. Interview with Registered Nurse (RN) #2, on 04/27/16 at 9:15 AM, revealed it was the nurses' responsibility to verify the stockings were on the resident, as per the care plan. Interview with the DON, on 04/28/16 at 10:30 AM, revealed she expected the staff to review the resident's nursing plan of care and provide care accordingly. She stated the nurse aide plan of care should guide the aides on how to provide care for the residents, and when they sign off on that plan of care they were saying they provided that care. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 no longer resides in the facility. The family decided to take him/her home. Resident #18 received a nursing assessment, dated 04/05/16, completed by Registered Nurse (RN) #3 with no injuries noted or other physical harm. The Power of Attorney was notified of the elopement on 04/05/16 at approximately 9:30 AM, as well as the resident's physician at 9:00 AM. 2. The resident was placed immediately on 1:1 supervision on 04/05/16 after being brought back into the facility and remained 1:1 throughout his/her stay at the facility. 3. An Elopement Risk Evaluation was completed on 04/05/16 by the DON and RN #3 and Resident #18 continued to be identified as an elopement risk. 4. The DON and Licensed Nurses completed Elopement Risk Evaluations on all current residents on 04/05/16 and 04/06/16 with no other residents being identified at risk. Two (2) residents were identified as no longer being a wander risk. Their care plans, CNA Care Plans, Behavior Management Plans, and physician's orders [REDACTED]. 5. The facility's elopement book was updated by the Social Services Director with changes made to the book. The two (2) residents, who were assessed to no longer be at risk, were removed from the book. 6. New signs were placed at the exit doors on 04/05/16, reminding staff and visitors to be mindful of residents when entering and exiting the building and to not allow or assist a resident out of the facility without staff knowledge. 7. A letter was placed in the facility's admission packet, on 04/05/16, to inform family members and other visitors to be mindful of residents attempting to exit the facility, when they were entering or exiting the facility. 8. Education was provided to 100% of staff on 04/05/16 to 04/11/16, related to what to do if a door alarm sounded. Education was provided to 100% of staff by the Staff Development Coordinator (SDC) and Human Resources Director (HRD) related to elopement/wandering as well as the missing resident policy and procedures and what to do if a door alarm sounded and monitoring of exit seeking residents. A posttest was administered to test employees knowledge of the training with a 100 % pass rate. (No agency staff). 9. An elopement drill (Code Green) was held by Plant Operations. 10. The Maintenance Director checked all three (3) exit doors on 04/05/16, with the code box on them, and determined the doors were functioning properly and this was and remained ongoing. All wander guards in use were tested with a pass rate for all. 11. The Plant Operations Supervisor tested all wander guards on 04/05/16 with a pass rate for all. 12. A Quality Assessment Performance Improvement (QAPI) meeting was held on 04/06/16, which consisted of the Quality Assurance members with the following issues discussed: Missing Resident policy and Elopement/Wandering Policy. 13. The facility implemented an action plan for all door alarms to be changed on 04/28/16 after notification of the Immediate Jeopardy. All door alarm codes were reset/changed on 04/28/16, by the Plant Operations Manager to ensure visitors would have to ask a staff member to enter the code before they could exit the facility. 14. Staff education was conducted on 04/28/16 and 04/29/16, by the Director of Nursing, Assistant Director of Nursing, Registered Nurse Managers, LPN Charge Nurses, Human Resources Director, Business Office Manager, Assistant Business Office Manager, and Plant Operations, regarding the door codes that were changed on all exit doors. 100% of staff were educated related to not giving the codes to anyone including visitors, vendors, or residents and they must walk a visitor to the door and key in the code for them without the visitor visualizing the code. 15. A Door Observation Tool was implemented, on 04/29/16, with continued observations by three (3) staff members daily, seven (7) days a week for two (2) weeks, then by three (3) staff daily five (5) days a week for four (4) weeks, then by three (3) staff for three (3) days a week for four (4) weeks, then by three (3) staff members weekly for six (6) weeks. 16. The door code policy was revised on 04/28/16 to include staff to not give the code to any visitors. 17. A Quality Assurance meeting was held on 05/04/16 to ensure ongoing monitoring was occurring to address the following: Elopement/Wandering Program Policy and Procedure as well as the process and who was responsible; analyze and identify opportunities for quality improvement; Provide oversight of quality and compliance performance; and, Identify and communicate best practices and lessons learned. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #18's Nursing Assessment, dated 04/05/16, revealed the resident was assessed with [REDACTED]. 2. Review of Resident #18's 1:1 Monitoring Forms revealed the resident was immediately placed on 1:1 supervision on 04/05/16, after being brought back into the facility and remained on 1:1 until he/she was discharged on [DATE]. 3. Review of Resident #18's Elopement Risk Evaluation, dated 04/05/16, revealed a new assessment had been completed with Resident #18 being identified as an elopement risk. 4. Review of Elopement Assessments, dated 04/05/16 and 04/06/16, revealed all residents who were at risk for elopement had new elopement risk assessments completed with two (2) residents being removed from the list based on a new assessment and no longer a wander risk. The assessments were completed by the DON and licensed nursing staff. The residents, who were previously identified as elopement risk, were assessed to still be at risk and all care plans including Comprehensive and CNA, Behavior Management Plans and Physician order [REDACTED]. 5. Review of the facility's elopement book revealed changes made to the book included removing two (2) residents from the book who were identified as no longer being at risk. Further review revealed the book included photo and a description of each resident who had been identified at risk. 6. Tour of the facility revealed new signs had been placed at the exit doors on 04/05/16 asking visitors to be mindful of residents when entering and exiting the building and to not allow or assist a resident out of the facility without staff knowledge. 7. Review of the Admission Packet revealed a letter had been placed, as of 04/05/16, to ask family members and other visitors to be mindful of residents attempting to exit the facility, when they were entering or exiting the facility. 8. Review of inservice records, dated 04/05/16 to 04/11/16, revealed 100% of staff was educated on what to do if a door alarm sounds. Review of education revealed 100% of staff was educated by the Staff Development Coordinator (SDC) and Human Resources Director related to elopement/wandering as well as the missing resident policy and procedures and what to do if a door alarm sounded and monitoring of exit seeking residents. A posttest was administered to test employees' knowledge of the training with a 100% pass rate (No agency staff). Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide # 2 at 2:00 PM, CNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training related to monitoring wandering residents for elopement as well as door alarms. They stated a Code Green drill was conducted to train staff if a door alarm sounded, and staff was to go to the door and check the perimeters all around the door inside and out. 9. Review of inservice sign in records, revealed elopement drills (Code Green) were held on 04/05/16 through 04/07/16. 10. Review of the logbook documentation for 04/05/16, revealed the Maintenance Director checked all three (3) doors with the code box on them, and determined the doors were functioning properly and this check remained ongoing. 11. Review of an audit, completed by the Plant Operations, dated 04/05/16, revealed all wander guards in use were tested with a pass rate for all. 12. Review of a QAPI meeting minutes, dated 04/06/16, revealed the meeting consisted of the Quality Assurance members and the following topic was discussed: Missing Resident Policy and Elopement/Wandering Policy. 13. Review of the facility's action plan, after notification of IJ on 04/28/16, revealed all door alarm codes were reset/changed on 04/28/16, by Plant Operations to ensure visitors would have to be accompanied by staff to exit. Interview with the Plant Operations Manager, on 04/28/16 at 8:17 AM, revealed he had been educated on not providing the door alarm codes to any visitors after the elopement on 04/05/16. 14. Review of all staff education conducted on 04/28/16 and 04/29/16, by the Director of Nursing, Assistant Director of Nursing, Registered Nurse Managers, LPN Charge Nurses, Human Resources Director, Business Office Manager, Assistant Business Office Manager, and Plant Operations, revealed the door codes were changed on all exit doors. Staff was educated to not give the codes to anyone including visitors, vendors, or residents. Staff must walk a visitor to the door and key in the code for them without the visitor visualizing the code. Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide #2 at 2:00 PM, CNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training to keep the door codes confidential, punch in the code for visitors, and to not give it to them because they could silence it without staff's knowledge, leaving residents at risk for elopement. 15. Review of the Door Observation Tool revealed monitoring was started on 04/29/16, with continued observations by three (3) staff members daily for seven (7) days a week for two (2) weeks, then daily for five (5) days a week for four (4) weeks, then three (3) days a week for four (4), then weekly x six (6) weeks. The observations were being done by the facility stakeholders staff with no specific person identified as responsible. Interviews with staff that were observing, confirmed the dates and times of interviews. 16. Review of policies revealed the door code policy was revised on 04/28/16 to include not giving the code to any visitors. 17. Review of a QA Meeting minutes, dated 05/04/16, revealed ongoing monitoring was occurring to address the following Elopement/Wandering Program Policy and Procedure as well as the process and who was responsible; Analyze and identify opportunities for quality improvement; Provide oversight of quality and compliance performance; and, Identify and communicate best practices and lessons learned. Interviews on 04/27/16 with the MDS Coordinator at 11:08 AM, the DON at 2:45 PM, and the Administrator, at 2:45 PM, revealed they had been a part of the QA meetings to discuss the ongoing monitoring of the door alarms and the wandering/elopement risks policies.

Based on observation, interview, record review, review of the facility's policy and procedure, review of the Standard Features of the 1000DE Wandering Resident Locking System, and review of the facility investigation, it was determined the facility failed to have an effective system in place to ensure adequate supervision was provided to prevent an elopement for one (1) of eighteen (18) sampled residents (Resident #18). On 04/05/16, Resident #18 exited the back door of the facility on E-Hall without staff knowledge. Resident #18 was found approximately thirty (30) feet from the building in the back parking lot. Housekeeping Aide #1 brought the resident back into the facility. The visitors had access to the door alarm codes and allegedly, as they were exiting the facility, the door was held open too long which caused the alarm to go off. The visitors were able to silence the code causing staff to be unaware of Resident #18 following them out of the building. The facility's failure to ensure the alarm system was effective to prevent elopements for residents who wandered, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/28/16 and determined to exist on 04/05/16. The facility was notified of the Immediate Jeopardy on 04/28/16. An acceptable Allegation of Compliance (AoC) was received on 04/29/16 alleging the removal of the Immediate Jeopardy on 04/30/16. The State Survey Agency validated, on 05/05/16, the Immediate Jeopardy was removed on 04/30/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, Elopement/Wandering, not dated, revealed the facility should maintain resident safety by identifying residents who were at risk for wandering/elopement behavior. An elopement/wandering assessment will be completed upon admission, located in the nursing admission information packet, and quarterly thereafter. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. A wandering/elopement assessment notebook containing pictures and pertinent demographic information will be maintained by social services and kept at the nurses' stations. Updates will be completed at least quarterly. Review of the Standard Features of the 1000DE Wandering Resident Locking System, dated 04/25/11, revealed the standard mode of operation allowed free access of staff members and visitors, however, it quietly locked when a monitored wandering resident approached the door. Once the resident left the monitored door, the door would unlock and make it accessible for visitors and staff to exit and enter. The primary reset code was used to reset an alarm condition or escort a monitored resident through a door without creating an alarm condition in normal mode. In the Advanced Security Mode, the reset code would not allow access through a door and only staff members should have access to the code and it should not be given to family members or visitors. Only staff members should be allowed to reset a code to escort a resident out of the facility per the guidelines. Record review revealed the facility admitted Resident #18 on 03/10/15, with diagnoses, which included Non-Alzheimer's Dementia. Review of an Annual Minimum Data Set (MDS) assessment, dated 01/28/16, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. In addition, the resident was assessed as having poor safety awareness and to be independent with ambulation with no assistance required. Review of Nursing Communication Forms revealed on 12/04/15, Resident #18 was experiencing increased anxiety and exit seeking behaviors and followed a visitor out the first door to the lobby, but did not make it to the exit door to the outside of the building. Additionally, on 12/28/15, the resident was noted at the back door causing it to alarm and had to be redirected back in the facility. Further review revealed, on 01/05/16, the resident attempted to exit the back door and opened the door, but was redirected. Review of an Elopement Risk Assessment, dated 03/12/15, revealed Resident #18 was assessed to be an elopement risk related to impaired cognition, independence with ambulation, poor decision making skills, wanders oblivious to safety needs, and had the ability to exit the facility. Review of the Comprehensive Care Plan for Risk for Elopement, dated 03/25/15 and last revised 02/17/16, revealed Resident #18 was independent with ambulation and had exit seeking behaviors with an intervention to monitor for tailgating visitors out exit doors. The care plan was revised on 02/17/16 related to a wander guard bracelet applied to the resident's ankle to alert staff of his/her exit seeking behaviors. Review of the facility's investigation, dated 04/05/16, revealed Resident #18 was seen by the Business Office Manager in the dining room where breakfast was being served and he/she refused to eat at that time. Between 8:00 AM and 8:05 AM, the resident was seen in the front lobby by the Business Office Manager and was encouraged to come back to the dining room for breakfast. At approximately 8:06 AM, on 04/05/16, Resident #18 was observed by Housekeeping Aide #1 to be outside the facility in the back parking lot, approximately thirty (30) feet from the building. The facility determined the resident followed family members out the back door and the family members allegedly reset the alarm when it sounded by entering the code to the door alarm, unaware a resident had followed them out of the facility. Interview with Certified Nurse Aide (CNA) #9, on 04/27/16 at 12:03 PM, revealed she witnessed Resident #18 at the back door of the facility at approximately 7:00 AM and redirected the resident to the Gallery Dining Room where she took him/her over to the windows to sit for breakfast. CNA #9 stated she was documenting in the Kiosk located near the back door, when she heard the door alarm sounding and noticed Resident #18 and Housekeeping Aide #1 standing outside in the back parking lot attempting to get in the back door. She stated during the morning of 04/05/16, family members were in and out of the back door of the facility visiting a dying family member and she assumed the resident followed the family members out the back door. Interview with Housekeeping Aide #1, on 04/26/16 at 4:30 PM, revealed she pulled into the back parking lot at approximately 8:05 AM on 04/05/16, and noticed Resident #18 standing approximately thirty (30) feet from the building in a parking space. She stated she got out of her car and approached the resident and convinced him/her to go back inside the facility at approximately 8:12 AM. Interview with the MDS Coordinator, on 04/27/16 at 11:08 AM, revealed she was one of the first to hear the back door alarm sound and when she came out of her office, she could see Resident #18 and Housekeeping Aide #1 outside the back exit door attempting to enter the building. She stated she went to the door to open it and had to have the resident and aide step away from the door so she could open the door related to the resident's alarm prohibiting the door from being opened. Review of the Nursing Assessment, dated 04/05/16, (no time), revealed Resident #18 was assessed after being brought back into the facility and his/her body temperature was ninety-eight point two (98.2) degrees Fahrenheit (F) which was considered within normal limits and no injuries were noted. Review of the weather for 04/05/16, at approximately 7:50 AM, revealed the outside temperature was thirty-six (36) degrees F with a wind chill factor of twenty-eight (28) degrees F. Resident #18 was reported to have been dressed in slacks, top, sweater, shoes, and socks. Interview with the Maintenance Director, on 04/28/16 at 2:20 PM, revealed he had only changed the door codes one (1) time in fourteen (14) years because there had not been a reason to change the codes until 04/05/16 when Resident #18 exited the building. He stated after the codes were changed, staff continued to give the code to visitors. Interview with the Director of Nursing (DON) and Administrator, on 04/27/16 at 2:45 PM, revealed there was no policy related to not giving the door alarm codes to visitors. She stated they did give the codes to visitors for their convenience; otherwise, visitors would have to wait each time for a staff member to punch in the code causing them to have to wait to exit the building and taking staff away from resident care each time someone needed to exit the building. The DON stated she felt it was appropriate to give the codes out for visitors' convenience. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 no longer resides in the facility. The family decided to take him/her home. Resident #18 received a nursing assessment, dated 04/05/16, completed by Registered Nurse (RN) #3 with no injuries noted or other physical harm. The Power of Attorney was notified of the elopement on 04/05/16 at approximately 9:30 AM, as well as the resident's physician at 9:00 AM. 2. The resident was placed immediately on 1:1 supervision on 04/05/16 after being brought back into the facility and remained 1:1 throughout his/her stay at the facility. 3. An Elopement Risk Evaluation was completed on 04/05/16 by the DON and RN #3 and Resident #18 continued to be identified as an elopement risk. 4. The DON and Licensed Nurses completed Elopement Risk Evaluations on all current residents on 04/05/16 and 04/06/16 with no other residents being identified at risk. Two (2) residents were identified as no longer being a wander risk. Their care plans, CNA Care Plans, Behavior Management Plans, and physician's orders [REDACTED]. 5. The facility's elopement book was updated by the Social Services Director with changes made to the book. The two (2) residents, who were assessed to no longer be at risk, were removed from the book. 6. New signs were placed at the exit doors on 04/05/16, reminding staff and visitors to be mindful of residents when entering and exiting the building and to not allow or assist a resident out of the facility without staff knowledge. 7. A letter was placed in the facility's admission packet, on 04/05/16, to inform family members and other visitors to be mindful of residents attempting to exit the facility, when they were entering or exiting the facility. 8. Education was provided to 100% of staff on 04/05/16 to 04/11/16, related to what to do if a door alarm sounded. Education was provided to 100% of staff by the Staff Development Coordinator (SDC) and Human Resources Director (HRD) related to elopement/wandering as well as the missing resident policy and procedures and what to do if a door alarm sounded and monitoring of exit seeking residents. A posttest was administered to test employees knowledge of the training with a 100 % pass rate. (No agency staff). 9. An elopement drill (Code Green) was held by Plant Operations. 10. The Maintenance Director checked all three (3) exit doors on 04/05/16, with the code box on them, and determined the doors were functioning properly and this was and remained ongoing. All wander guards in use were tested with a pass rate for all. 11. The Plant Operations Supervisor tested all wander guards on 04/05/16 with a pass rate for all. 12. A Quality Assessment Performance Improvement (QAPI) meeting was held on 04/06/16, which consisted of the Quality Assurance members with the following issues discussed: Missing Resident policy and Elopement/Wandering Policy. 13. The facility implemented an action plan for all door alarms to be changed on 04/28/16 after notification of the Immediate Jeopardy. All door alarm codes were reset/changed on 04/28/16, by the Plant Operations Manager to ensure visitors would have to ask a staff member to enter the code before they could exit the facility. 14. Staff education was conducted on 04/28/16 and 04/29/16, by the Director of Nursing, Assistant Director of Nursing, Registered Nurse Managers, LPN Charge Nurses, Human Resources Director, Business Office Manager, Assistant Business Office Manager, and Plant Operations, regarding the door codes that were changed on all exit doors. 100% of staff were educated related to not giving the codes to anyone including visitors, vendors, or residents and they must walk a visitor to the door and key in the code for them without the visitor visualizing the code. 15. A Door Observation Tool was implemented, on 04/29/16, with continued observations by three (3) staff members daily, seven (7) days a week for two (2) weeks, then by three (3) staff daily five (5) days a week for four (4) weeks, then by three (3) staff for three (3) days a week for four (4) weeks, then by three (3) staff members weekly for six (6) weeks. 16. The door code policy was revised on 04/28/16 to include staff to not give the code to any visitors. 17. A Quality Assurance meeting was held on 05/04/16 to ensure ongoing monitoring was occurring to address the following: Elopement/Wandering Program Policy and Procedure as well as the process and who was responsible; analyze and identify opportunities for quality improvement; Provide oversight of quality and compliance performance; and, Identify and communicate best practices and lessons learned. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #18's Nursing Assessment, dated 04/05/16, revealed the resident was assessed with [REDACTED]. 2. Review of Resident #18's 1:1 Monitoring Forms revealed the resident was immediately placed on 1:1 supervision on 04/05/16, after being brought back into the facility and remained on 1:1 until he/she was discharged on [DATE]. 3. Review of Resident #18's Elopement Risk Evaluation, dated 04/05/16, revealed a new assessment had been completed with Resident #18 being identified as an elopement risk. 4. Review of Elopement Assessments, dated 04/05/16 and 04/06/16, revealed all residents who were at risk for elopement had new elopement risk assessments completed with two (2) residents being removed from the list based on a new assessment and no longer a wander risk. The assessments were completed by the DON and licensed nursing staff. The residents, who were previously identified as elopement risk, were assessed to still be at risk and all care plans including Comprehensive and CNA, Behavior Management Plans and Physician order [REDACTED]. 5. Review of the facility's elopement book revealed changes made to the book included removing two (2) residents from the book who were identified as no longer being at risk. Further review revealed the book included photo and a description of each resident who had been identified at risk. 6. Tour of the facility revealed new signs had been placed at the exit doors on 04/05/16 asking visitors to be mindful of residents when entering and exiting the building and to not allow or assist a resident out of the facility without staff knowledge. 7. Review of the Admission Packet revealed a letter had been placed, as of 04/05/16, to ask family members and other visitors to be mindful of residents attempting to exit the facility, when they were entering or exiting the facility. 8. Review of inservice records, dated 04/05/16 to 04/11/16, revealed 100% of staff was educated on what to do if a door alarm sounds. Review of education revealed 100% of staff was educated by the Staff Development Coordinator (SDC) and Human Resources Director related to elopement/wandering as well as the missing resident policy and procedures and what to do if a door alarm sounded and monitoring of exit seeking residents. A posttest was administered to test employees' knowledge of the training with a 100% pass rate (No agency staff). Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide # 2 at 2:00 PM, CNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training related to monitoring wandering residents for elopement as well as door alarms. They stated a Code Green drill was conducted to train staff if a door alarm sounded, and staff was to go to the door and check the perimeters all around the door inside and out. 9. Review of inservice sign in records, revealed elopement drills (Code Green) were held on 04/05/16 through 04/07/16. 10. Review of the logbook documentation for 04/05/16, revealed the Maintenance Director checked all three (3) doors with the code box on them, and determined the doors were functioning properly and this check remained ongoing. 11. Review of an audit, completed by the Plant Operations, dated 04/05/16, revealed all wander guards in use were tested with a pass rate for all. 12. Review of a QAPI meeting minutes, dated 04/06/16, revealed the meeting consisted of the Quality Assurance members and the following topic was discussed: Missing Resident Policy and Elopement/Wandering Policy. 13. Review of the facility's action plan, after notification of IJ on 04/28/16, revealed all door alarm codes were reset/changed on 04/28/16, by Plant Operations to ensure visitors would have to be accompanied by staff to exit. Interview with the Plant Operations Manager, on 04/28/16 at 8:17 AM, revealed he had been educated on not providing the door alarm codes to any visitors after the elopement on 04/05/16. 14. Review of all staff education conducted on 04/28/16 and 04/29/16, by the Director of Nursing, Assistant Director of Nursing, Registered Nurse Managers, LPN Charge Nurses, Human Resources Director, Business Office Manager, Assistant Business Office Manager, and Plant Operations, revealed the door codes were changed on all exit doors. Staff was educated to not give the codes to anyone including visitors, vendors, or residents. Staff must walk a visitor to the door and key in the code for them without the visitor visualizing the code. Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide #2 at 2:00 PM, CNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training to keep the door codes confidential, punch in the code for visitors, and to not give it to them because they could silence it without staff's knowledge, leaving residents at risk for elopement. 15. Review of the Door Observation Tool revealed monitoring was started on 04/29/16, with continued observations by three (3) staff members daily for seven (7) days a week for two (2) weeks, then daily for five (5) days a week for four (4) weeks, then three (3) days a week for four (4), then weekly x six (6) weeks. The observations were being done by the facility stakeholders staff with no specific person identified as responsible. Interviews with staff that were observing, confirmed the dates and times of interviews. 16. Review of policies revealed the door code policy was revised on 04/28/16 to include not giving the code to any visitors. 17. Review of a QA Meeting minutes, dated 05/04/16, revealed ongoing monitoring was occurring to address the following Elopement/Wandering Program Policy and Procedure as well as the process and who was responsible; Analyze and identify opportunities for quality improvement; Provide oversight of quality and compliance performance; and, Identify and communicate best practices and lessons learned. Interviews on 04/27/16 with the MDS Coordinator at 11:08 AM, the DON at 2:45 PM, and the Administrator, at 2:45 PM, revealed they had been a part of the QA meetings to discuss the ongoing monitoring of the door alarms and the wandering/elopement risks policies.

Based on interview and review of the facility Quality Assurance policy, it was determined the facility failed to ensure the Quality Assessment and Assurance Committee develops and implements appropriate plans of action to correct identified quality deficiencies related to one (1) of eighteen (18) sampled resident (Resident #18) eloping from the facility. The facility determined Resident #18 eloped from the facility due to visitors knowing the code to the door, which enabled them to silence the alarm and prevent staff from knowing when the resident had exited the building behind them. The facility failed to put an action plan in place to address the visitors having access to the code to the alarm and disarming it. The facility's failure to ensure its Quality Assurance Committee develops an action plan to correct the quality deficiency, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/28/16 and determined to exist on 04/05/16. The facility was notified of the Immediate Jeopardy on 04/28/16. An acceptable Allegation of Compliance (AoC) was received on 04/29/16 alleging the removal of the Immediate Jeopardy on 04/30/16. The State Survey Agency validated, on 05/05/16, the Immediate Jeopardy was removed on 04/30/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, Quality Assurance, not dated, revealed members of the committee included the Administrator, Director of Nursing, Assistant Directors of Nursing, Medical Director, Social Service Director, Business Office Manager, Dietary Manager, Maintenance Director, Activities Director, Rehab Services Manager, Minimum Data Set (MDS) Coordinator, Human Resources Director, and the Staff Development Coordinator. Quality Assurance is a program designed to ensure that care practices are applied, are being met, and are exceeding expected outcomes-the Quality Assurance Committee evaluates the care and quality of life of our residents. The Committee meets monthly (usually the 2nd Wednesday of each month) to find the cause of a problem and develop a plan to correct it. Review of the facility's investigation, dated 04/05/16, revealed the facility identified Resident #18 exited the E-Hall (back) door of the facility after he/she allegedly followed visitors out the door after the visitors silenced the door alarm after the door had been held open for too long. The facility determined that the visitors knowing the door codes caused them to silence the alarm, which prevented the staff from knowing Resident #18 had exited the building which placed the resident at risk for injury. However, review of staff education, dated 04/05/16, revealed 100% of staff was educated on the door alarm procedures and elopement, which included staff members were not to shout out the door alarm code to visitors, family members, or vendors to prevent residents from hearing the code. However, the education did not address the fact the facility had identified the visitors knowing the code had enabled them to turn off the alarm so staff was not aware the resident had exited the building. Interview with Certified Nurse Aide (CNA) #11, on 04/28/16 at 1:47 PM, revealed she had received education after Resident #18 had eloped related to Code Green (code used when a resident is missing) with a posttest given requiring 100% pass rate. She stated she gave the visitors codes to the doors (after Resident #18 had eloped and after receiving the education) and was told it was appropriate to do so. Interview with Activity Assistant #1, on 04/28/16 at 1:50 PM, revealed staff was allowed to give the codes to visitors as long they did not yell it down the hallway for residents to hear. Interview with CNA #7, on 04/28/16 at 2:02 PM, revealed she was educated related to the door codes having been changed and stated employees and family members may know the door codes, but not residents. Interview with Licensed Practical Nurse (LPN) #3, on 04/28/16 at 2:05 PM, revealed she was recently educated on giving door alarm codes to visitors. She stated staff should not yell the codes out so residents could hear them. However, if a resident was not around she would give the code to visitors; LPN #3 stated she was told this in the training. Interview with the Director of Nursing, on 04/27/16 at 2:45 PM, revealed she felt it was appropriate for the visitors to have the code to the doors for their convenience. She stated otherwise, staff would have to be pulled away from their duties every time someone needed to exit the facility. Interview with the Administrator, on 04/27/16 at 2:45 PM, revealed there was no policy related to not giving out the door codes or changing the door codes. She stated signs were placed to alert visitors to be aware of wandering, exit seeking residents. Further interview, on 04/28/16 at 3:03 PM, revealed the code had been changed twice in seven (7) months because an alert resident knew the code. She stated staff was educated on discretely entering the code and were told to not yell out the code. Interview (Post Survey) with the Administrator, on 05/17/16 at 11:54 AM, revealed a QA meeting was held on 04/06/16, the day after Resident # 18 eloped and the fact that a family member knew the code to the exit door was the root cause of the resident exiting the facility unattended. The Plan of Correction from the QA meeting included to change all of the door codes and educate staff to enter the door codes to allow visitors to exit but staff were not specifically told to not give out the codes to visitors. The door codes were changed on 04/05/16; however, staff had not been told not give out the door codes. The door codes were changed again on 04/28/16 to ensure no visitor had access to the door codes and staff was re-educated to not give out the door codes to anyone. The codes were to continue to be changed monthly with ongoing monitoring. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 no longer resides in the facility. The family decided to take him/her home. Resident #18 received a nursing assessment, dated 04/05/16, completed by Registered Nurse (RN) #3 with no injuries noted or other physical harm. The Power of Attorney was notified of the elopement on 04/05/16 at approximately 9:30 AM, as well as the resident's physician at 9:00 AM. 2. The resident was placed immediately on 1:1 supervision on 04/05/16 after being brought back into the facility and remained 1:1 throughout his/her stay at the facility. 3. An Elopement Risk Evaluation was completed on 04/05/16 by the DON and RN #3 and Resident #18 continued to be identified as an elopement risk. 4. The DON and Licensed Nurses completed Elopement Risk Evaluations on all current residents on 04/05/16 and 04/06/16 with no other residents being identified at risk. Two (2) residents were identified as no longer being a wander risk. Their care plans, CNA Care Plans, Behavior Management Plans, and physician's orders [REDACTED]. 5. The facility's elopement book was updated by the Social Services Director with changes made to the book. The two (2) residents, who were assessed to no longer be at risk, were removed from the book. 6. New signs were placed at the exit doors on 04/05/16, reminding staff and visitors to be mindful of residents when entering and exiting the building and to not allow or assist a resident out of the facility without staff knowledge. 7. A letter was placed in the facility's admission packet, on 04/05/16, to inform family members and other visitors to be mindful of residents attempting to exit the facility, when they were entering or exiting the facility. 8. Education was provided to 100% of staff on 04/05/16 to 04/11/16, related to what to do if a door alarm sounded. Education was provided to 100% of staff by the Staff Development Coordinator (SDC) and Human Resources Director (HRD) related to elopement/wandering as well as the missing resident policy and procedures and what to do if a door alarm sounded and monitoring of exit seeking residents. A posttest was administered to test employees knowledge of the training with a 100 % pass rate. (No agency staff). 9. An elopement drill (Code Green) was held by Plant Operations. 10. The Maintenance Director checked all three (3) exit doors on 04/05/16, with the code box on them, and determined the doors were functioning properly and this was and remained ongoing. All wander guards in use were tested with a pass rate for all. 11. The Plant Operations Supervisor tested all wander guards on 04/05/16 with a pass rate for all. 12. A Quality Assessment Performance Improvement (QAPI) meeting was held on 04/06/16, which consisted of the Quality Assurance members with the following issues discussed: Missing Resident policy and Elopement/Wandering Policy. 13. The facility implemented an action plan for all door alarms to be changed on 04/28/16 after notification of the Immediate Jeopardy. All door alarm codes were reset/changed on 04/28/16, by the Plant Operations Manager to ensure visitors would have to ask a staff member to enter the code before they could exit the facility. 14. Staff education was conducted on 04/28/16 and 04/29/16, by the Director of Nursing, Assistant Director of Nursing, Registered Nurse Managers, LPN Charge Nurses, Human Resources Director, Business Office Manager, Assistant Business Office Manager, and Plant Operations, regarding the door codes that were changed on all exit doors. 100% of staff were educated related to not giving the codes to anyone including visitors, vendors, or residents and they must walk a visitor to the door and key in the code for them without the visitor visualizing the code. 15. A Door Observation Tool was implemented, on 04/29/16, with continued observations by three (3) staff members daily, seven (7) days a week for two (2) weeks, then by three (3) staff daily five (5) days a week for four (4) weeks, then by three (3) staff for three (3) days a week for four (4) weeks, then by three (3) staff members weekly for six (6) weeks. 16. The door code policy was revised on 04/28/16 to include staff to not give the code to any visitors. 17. A Quality Assurance meeting was held on 05/04/16 to ensure ongoing monitoring was occurring to address the following: Elopement/Wandering Program Policy and Procedure as well as the process and who was responsible; analyze and identify opportunities for quality improvement; Provide oversight of quality and compliance performance; and, Identify and communicate best practices and lessons learned. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #18's Nursing Assessment, dated 04/05/16, revealed the resident was assessed with [REDACTED]. 2. Review of Resident #18's 1:1 Monitoring Forms revealed the resident was immediately placed on 1:1 supervision on 04/05/16, after being brought back into the facility and remained on 1:1 until he/she was discharged on [DATE]. 3. Review of Resident #18's Elopement Risk Evaluation, dated 04/05/16, revealed a new assessment had been completed with Resident #18 being identified as an elopement risk. 4. Review of Elopement Assessments, dated 04/05/16 and 04/06/16, revealed all residents who were at risk for elopement had new elopement risk assessments completed with two (2) residents being removed from the list based on a new assessment and no longer a wander risk. The assessments were completed by the DON and licensed nursing staff. The residents, who were previously identified as elopement risk, were assessed to still be at risk and all care plans including Comprehensive and CNA, Behavior Management Plans and Physician order [REDACTED]. 5. Review of the facility's elopement book revealed changes made to the book included removing two (2) residents from the book who were identified as no longer being at risk. Further review revealed the book included photo and a description of each resident who had been identified at risk. 6. Tour of the facility revealed new signs had been placed at the exit doors on 04/05/16 asking visitors to be mindful of residents when entering and exiting the building and to not allow or assist a resident out of the facility without staff knowledge. 7. Review of the Admission Packet revealed a letter had been placed, as of 04/05/16, to ask family members and other visitors to be mindful of residents attempting to exit the facility, when they were entering or exiting the facility. 8. Review of inservice records, dated 04/05/16 to 04/11/16, revealed 100% of staff was educated on what to do if a door alarm sounds. Review of education revealed 100% of staff was educated by the Staff Development Coordinator (SDC) and Human Resources Director related to elopement/wandering as well as the missing resident policy and procedures and what to do if a door alarm sounded and monitoring of exit seeking residents. A posttest was administered to test employees' knowledge of the training with a 100% pass rate (No agency staff). Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide # 2 at 2:00 PM, CNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training related to monitoring wandering residents for elopement as well as door alarms. They stated a Code Green drill was conducted to train staff if a door alarm sounded, and staff was to go to the door and check the perimeters all around the door inside and out. 9. Review of inservice sign in records, revealed elopement drills (Code Green) were held on 04/05/16 through 04/07/16. 10. Review of the logbook documentation for 04/05/16, revealed the Maintenance Director checked all three (3) doors with the code box on them, and determined the doors were functioning properly and this check remained ongoing. 11. Review of an audit, completed by the Plant Operations, dated 04/05/16, revealed all wander guards in use were tested with a pass rate for all. 12. Review of a QAPI meeting minutes, dated 04/06/16, revealed the meeting consisted of the Quality Assurance members and the following topic was discussed: Missing Resident Policy and Elopement/Wandering Policy. 13. Review of the facility's action plan, after notification of IJ on 04/28/16, revealed all door alarm codes were reset/changed on 04/28/16, by Plant Operations to ensure visitors would have to be accompanied by staff to exit. Interview with the Plant Operations Manager, on 04/28/16 at 8:17 AM, revealed he had been educated on not providing the door alarm codes to any visitors after the elopement on 04/05/16. 14. Review of all staff education conducted on 04/28/16 and 04/29/16, by the Director of Nursing, Assistant Director of Nursing, Registered Nurse Managers, LPN Charge Nurses, Human Resources Director, Business Office Manager, Assistant Business Office Manager, and Plant Operations, revealed the door codes were changed on all exit doors. Staff was educated to not give the codes to anyone including visitors, vendors, or residents. Staff must walk a visitor to the door and key in the code for them without the visitor visualizing the code. Interviews on 04/28/16, with Certified Nurse Aide (CNA) #10 at 1:45 PM, CNA #11 at 1:47 PM, the Activity Director at 1:50 PM, the Activity Assistant at 1:52 PM, Housekeeping Aide #2 at 2:00 PM, CNA #7 at 2:02 PM, and Licensed Practical Nurse (LPN) #3 at 2:05 PM, revealed they had received training to keep the door codes confidential, punch in the code for visitors, and to not give it to them because they could silence it without staff's knowledge, leaving residents at risk for elopement. 15. Review of the Door Observation Tool revealed monitoring was started on 04/29/16, with continued observations by three (3) staff members daily for seven (7) days a week for two (2) weeks, then daily for five (5) days a week for four (4) weeks, then three (3) days a week for four (4), then weekly x six (6) weeks. The observations were being done by the facility stakeholders staff with no specific person identified as responsible. Interviews with staff that were observing, confirmed the dates and times of interviews. 16. Review of policies revealed the door code policy was revised on 04/28/16 to include not giving the code to any visitors. 17. Review of a QA Meeting minutes, dated 05/04/16, revealed ongoing monitoring was occurring to address the following Elopement/Wandering Program Policy and Procedure as well as the process and who was responsible; Analyze and identify opportunities for quality improvement; Provide oversight of quality and compliance performance; and, Identify and communicate best practices and lessons learned. Interviews on 04/27/16 with the MDS Coordinator at 11:08 AM, the DON at 2:45 PM, and the Administrator, at 2:45 PM, revealed they had been a part of the QA meetings to discuss the ongoing monitoring of the door alarms and the wandering/elopement risks policies.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored and served under sanitary conditions. The facility failed to keep accurate temperature logs of the freezers; remove outdated food from the refrigerators; and, use proper handwashing when handling foods. Review of the Census and Condition, dated 04/26/16 revealed seventy-nine (79) of eighty-one (81) residents received their meals from the kitchen. The findings include: Review of the facility's policy titled, Food Storage revealed scoops must be provided and kept covered in a protected area near the container. Food should be stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Temperatures for the freezer should be zero degrees or below and must be recorded daily. Further review revealed any expired or outdated food products should be discarded. Most fruits and vegetables should be used within three (3) to five (5) days. Review of the Kitchen Handwashing and Glove Use Policy #132, last revised 02/01/14, revealed antimicrobial hand gel cannot be used in place of proper handwashing techniques with soap and warm water. Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances i.e. chicken to fresh fruit, and following contact with any unsanitary surface i.e. touching hair, sneezing, opening door, etc. Observations during the initial tour of the kitchen, on 04/26/16 at 9:57 AM with the Registered Dietician Assistant revealed the following: 1. There were two (2) ice scoops lying on top of the cart uncovered and the tray holding the ice scoops was dirty and dusty. 2. There were no thermometers in the double freezer and single freezer in the storage room. 3. There was one (1) carton of buttermilk with a use by date of 04/17/16 in the milk refrigerator. 4. In the vegetable and fruit fridge, there was a package of lettuce that was opened on 04/20/16, a box of grapes opened 03/30/16, and five (5) cucumbers dated 04/18/16. 5. There were five (5) bags of Hoagie Buns with no use by date. 6. There were five (5) individual packages of bologna in the refrigerator with no use by date or date thawed. Review of facility policy titled Handwashing and Glove Use, revealed gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching ready to eat food. 7. Observation of the tray line, on 04/26/16 at 11:00 AM revealed Cook #10 and Dishwasher #11 prepared food trays without gloves. Cook #10 touched the food with his bare hands and at one point left the line, went into the dining room and returned to the tray line without washing his hands. Interview with Cook #10, on 04/26/16 at 3:25 PM, revealed he should have used proper handwashing during preparation and handling of food, as per policy. He stated he also should have used gloves when serving food to ensure his bare hands did not touch the food. 8. Observation on 04/26/16 at 11:15 AM revealed Dishwasher #11 was working the tray line, left the line with the first food cart and five (5) minutes later returned, touched the arms of the Surveyor and went immediately back to the line and picked up tongs and condiments as she filled the trays. She did not wash her hands after returning. Interview with Dishwasher #11, on 04/26/16 at 3:30 PM, revealed she should have followed the facility's policy and used proper handwashing techniques when handling food and when returning from other areas and before returning to the food service area. Interview with the Registered Dietitian, on 04/26/16 at 3:40 PM, revealed she expected staff to use proper handwashing techniques as stated in the policy. When asked about outdated foods, she stated she expected all foods to be dated when opened and to be discarded per policy. She stated there should be thermometers in the freezers.

Based on observation, interview, record review, facility guidelines, review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, and review of Perry & Potter Eighth (8th) Edition, Clinical Nursing Skills and Techniques, it was determined the facility failed to ensure services provided met professional standards of quality for two (2) of eighteen (18) sampled residents (Residents #10 and #8). Resident #8 had a physician's orders [REDACTED]. However, observation during Resident #8's shower on 04/28/16 at 11:00 AM revealed there was one (1) patch on Resident #8's left anterior chest, dated 04/27/16; and, one (1) patch on his/her right anterior chest, dated 04/28/16. In addition, Resident #10 had a physician's orders [REDACTED].#10 was not wearing [MEDICATION NAME] stockings. The findings include: Review of the KBN AOS #14 Patient Care Orders, last revised October 2010, revealed the administration of medication/treatment prescribed by a physician or advanced practice registered nurse should be followed. Review of the facility's policy titled Medication Administration Guidelines, dated December 2012, revealed medications should be administered in accordance with written orders of the prescriber. Review of the Perry & Potter 8th Edition, Clinical Nursing Skills and Techniques, pages 507 and 508, revealed to apply [MEDICATION NAME]es and if the old patch is present, remove it and clean area. Be sure to check between skinfolds for patch. Failure to remove old patch can result in overdose. Many patches are small, clear, or flesh colored and can be easily hidden between skinfolds. Cleaning removes traces of previous patch. 1. Record review revealed the facility admitted Resident #8 on 11/12/13, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. However, observation of Resident #8 on 04/28/16 at 10:30 AM, revealed there was one (1) patch on Resident #8's left anterior chest, dated 04/27/16; and, one (1) patch on his/her right anterior chest, dated 04/28/16. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/16 at 11:15 AM, revealed she had neglected to remove the Rivastigmine [MEDICATION NAME], dated 04/27/16, before placing the patch dated 04/28/16. Interview with the Director of Nursing (DON), on 04/28/16 at 3:30 PM, revealed she expected the nurses administering [MEDICATION NAME]es to follow physician orders [REDACTED]. Interview with Resident #8's Physician (facility Medical Director), on 04/28/16 at 2:45 PM, revealed he expected the nurse to follow the written orders and to remove the old patch before a new patch was applied. 2. Record review revealed the facility admitted Resident #10 on 09/20/14 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the April 2016 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. However, observations on 04/26/16 at 9:30 AM, 11:30 AM, 2:30 PM, and 4:10 PM, revealed Resident #10 was wearing short white socks, with no evidence of [MEDICATION NAME] stockings in place. In addition, interviews with Certified Nurse Aide (CNA) #1 on 04/28/16 at 9:50 AM, and CNA #5, on 04/27/16 at 9:00 AM, revealed they had not applied the [MEDICATION NAME] to Resident #10 since they started working with him/her in October 2015 and January 2016 respectively. Interview with Resident #10, on 04/28/16 at 9:15 AM, revealed he/she did not recall the last time he/she had worn the stockings. Interview with Registered Nurse (RN) #2, on 04/27/16 at 9:15 AM, revealed Resident #10's physician's orders [REDACTED]. This physician's orders [REDACTED]. She stated it was the nurse ' s responsibility to verify that the stockings were on the resident then sign off on the MAR, but evidently, that had not been the case. Interview with the DON, on 04/28/16 at 10:30 AM, revealed she would expect the staff to review and follow the resident's physician's orders [REDACTED].

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming for one (1) of eighteen (18) sampled residents (Resident #7) and one (1 ) unsampled resident (Resident #A). Resident #7 and Unsampled Resident A were assessed to require assistance with ADLs; however, observation revealed Resident #7 and Unsampled Resident A had long untrimmed fingernails with visible dark substances under the nails. The findings include: Review of the facility's policy and procedure titled, Nail Grooming, not dated, revealed regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and, as necessary. 1. Record review revealed the facility admitted Resident #7 on 06/29/10, with [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment, dated 01/20/16, revealed the facility assessed Resident #7's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 00, indicating Resident #7 was not interviewable. Further review revealed the facility had assessed Resident #7 to require the extensive assistance with Activities of Daily Living (ADLs). Review of a Skin Assessment, dated 10/26/15, revealed Resident #7 had an open area to the lower portion of buttocks related to scratching the area. Further review of resident's plan of care revealed an intervention, dated 10/24/15, to keep fingernails trimmed and filed with a healed date of 11/20/15. Review of the Comprehensive Care Plan for ADL Self Care Deficit, last revised 03/04/16, revealed interventions for staff to provide assistance/supervision to meet the resident's needs for all ADLs. Further review revealed the resident was assessed to be at risk for behavior problems related to resident gets easily annoyed with staff and peers. Further review revealed an intervention to encourage resident to allow staff to keep fingernails trimmed. Observation of Resident #7, on 04/27/16 at 8:30 AM, revealed the resident was sitting at the breakfast table eating toast. The resident's fingernails were very long and visibly dirty. Further observation revealed a dark brown substance visible under all the nails of the resident's right hand, and under the resident's thumbnail of the left hand. Interview with Licensed Practical Nurse (LPN) #3, on 04/27/16 at 8:50 AM, revealed she could see the condition of the resident's nails. She stated the resident could be very combative and We can only do what (he/she) will allow us to do. Review of Resident #7's April 2016 Behavior/Intervention Monthly flow sheet revealed the resident had behaviors of refusal of care and medication. However, there was no documented evidence the resident had refused any care. Interview with Certified Nurse Aide (CNA) #2, on 04/27/16 at 3:20 PM, revealed staff try to trim the resident's nails when he/she gets a shower and whenever needed. She stated they report to the charge nurse when they were not able to trim them. CNA #2 stated the dark substance could possibly be bowel movement (BM) or dried food. She stated it had been maybe a month since the resident let her trim his/her fingernails. Interview with CNA #1, on 04/28/16 at 1:00 PM, revealed Resident #7 could be difficult and staff has to talk with him/her prior to starting a task to determine the resident's mood. She stated staff has tried to trim the resident's nails and typically do that on shower days, as it was easier to clean them than to clip them. Interview with Registered Nurse (RN) #2, on 04/27/16 at 3:30 PM, revealed staff try to trim and clean the resident's fingernails but he/she was combative and resisted care being provided. She stated the resident feeds himself/herself. RN #2 stated she thought it could be food under the resident's nails. She stated the staff reported to her when they were not able to trim the resident's nails and an attempt was made at that time but they were not always successful. Interview with Director of Nursing (DON), on 04/28/16 at 10:00 AM, revealed it was the CNA's responsibility to trim nails during the bath. She stated the CNAs should report to the charge nurse if they were unable to trim them during shower. The DON stated Resident #7 could be combative and resistant to care. She stated she thought the substance under the resident's fingernails was probably food. The DON stated the nurses have tried to trim the resident's fingernails without success. 2. Record review revealed the facility admitted Unsampled Resident #A, on 03/16/15, with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 04/06/16, revealed the facility assessed Unsampled Resident A's cognition as severely impaired as he/she was unable to complete the BIMS which indicated the resident was not interviewable. In addition, the resident required extensive assist of one (1) staff for personal hygiene and grooming. Review of the Comprehensive Care Plan for an Activity of Daily Living (ADL) Deficit, dated 03/20/15, revealed staff should provide assistance/supervision to meet the resident's needs for all ADLs. Observation of Unsampled Resident #A, on 04/26/16 at 8:30 AM and on 04/27/16 at 9:15 AM, revealed the resident's finger nails had a brown substance underneath them. Interview with the DON, on 04/27/16 at 4:10 PM, revealed she expected staff to ensure the resident's nails were clean.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure necessary treatment and services were provided to promote healing and prevent infection of pressure sores for one (1) of eighteen (18) sampled residents (Resident #3). Observation of wound care, on 04/27/16 at 10:50 AM, revealed Registered Nurse (RN) #2 removed a soiled wound dressing with gloves on and did not change gloves and wash her hands until RN #4 told her she should wash her hands. Further observation revealed RN #2 cleaned Resident #3's heel and allowed the heel to lie back on the soiled pillow before applying a clean dressing to the area. The findings include: Review of the facility's policy and procedure titled, Dressing, Soiled/Contaminated, not dated, revealed soiled/contaminated dressings must be handled in a safe sanitary manner and must be disposed of appropriately. Gloves must be worn when staff change a dressing/or when handling items contaminated with blood, body fluids, or potentially infective materials. Review of policy titled, Standard Precautions, last revised 08/2007, revealed staff should change gloves, as necessary, during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one). Record review revealed the facility admitted Resident #3, on 03/10/15 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 04/09/16, revealed a Brief Interview of Mental Status (BIMS) score of ninety-nine (99), which indicated the resident's cognition was severely impaired. Review of the Comprehensive Care Plan, dated 04/27/16, revealed Resident #3 had a Suspected Deep Tissue Injury (STDI) to the right heel and was to receive wound care per physician's orders [REDACTED].>Observation of wound care, on 04/27/16 at 10:50 AM, revealed RN #2, with the assistance of RN #4, provided wound care to Resident #3's right heel. Review of a pressure ulcer record, dated 04/22/16, revealed the resident's right heel had a suspected deep tissue injury measuring approximately 5.0 centimeters (cm) length by 4.0 cm width by <.1 cm deep. During wound care, RN #2 removed the soiled dressing from the right heel with gloved hands and proceeded to open the gauze that was to be used to cleanse the area, with the soiled gloves. RN #2 did not change gloves or wash her hands until RN #4 told her she should. Further observation revealed after RN #2 cleaned the resident's heel, she allowed the heel to rest on a soiled pillow, resulting in recontamination of the heel surface. She applied the new dressing without cleansing the heel again. Interview with RN #2, on 04/27/16 at 3:45 PM, revealed she was aware of the need to change her gloves and wash her hands after contaminating them before returning to wound care. She stated she should have cleansed the resident's heel after allowing it to touch the soiled pillow before applying a clean dressing. Interview with RN #4, on 04/27/16 at 3:36 PM, revealed she expected RN #2 to change her gloves and wash her hands after removing a soiled dressing. Interview with the Director of Nursing (DON), on 04/27/16 at 4:10 PM, revealed she expected the nurses to change gloves and wash their hands after removing a soiled dressing from a wound. She stated the RN should have cleaned the wound if it became contaminated prior to applying a clean dressing.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure a resident who was incontinent of urine was provided appropriate treatment and services to prevent urinary tract infections for one (1) of eighteen (18) sampled residents (Resident #6). Certified Nurse Aide (CNA) #3 failed to wash her hands and change gloves during incontinent care after cleaning feces from the resident buttock area and before applying barrier cream for Resident #6. The findings include: Review of the facility's policy entitled, Standard Precautions, last revised August 2007, revealed change gloves, as necessary, during care of a resident to prevent cross contamination from one body site to another (when moving from dirty site to a clean site). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident wash hands immediately to avoid transfer of microorganisms to other residents or environments. Record review revealed the facility admitted Resident #6 on 12/13/11 with diagnoses, which included Hypertension, [MEDICAL CONDITIONS], Depression, Contracture of Muscles, and Abnormal Posture. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/21/16, revealed the facility assessed Resident #6 to be frequently incontinent. Review of the Comprehensive Care Plan, associated with incontinence of bowel and bladder, last revised on 03/30/16, revealed to check and change every two (2) hours and as needed (PRN). Review of the Nurse Aide Care Plan for April 2016, revealed Resident #6 was total care and incontinent of bowel and bladder Observation of Resident #6's incontinent care provided by CNA #3, on 04/27/16 at 10:50 AM, revealed after providing perineal care for Resident #6, CNA #3 used the same glove to provide perineal care, remove feces, apply barrier cream, pull at the resident's gown and repositioned him/her. Interview with CNA #3, on 11:15 AM, revealed she should have changed gloves after providing perineal care, in order to prevent the spread of infection. She stated, It was just a lazy habit she had gotten into, and if the gloves were not visibly soiled she did not think about changing them. She stated she should have changed gloves and washed her hands when going from front to back. CNA #3 stated she should change gloves and wash her hands then provide care to the resident as needed. Interview with the Director of Nursing (DON), on 04/28/16 at 10:30 AM, revealed she would expect all staff to change gloves and wash hands multiple times when providing incontinent care and after care to help prevent the increased chance of Urinary Tract Infections.

Based on observation, interview and review of the facility's Skin Management and Prevention policy and Certified Nurse Aide (CNA) Skin Care Alert Policy, it was determined the facility failed to ensure the care plan was implemented for one (1) of seventeen (17) sampled residents (Resident #4). A CNA identified a newly acquired Deep Tissue Injury (DTI) on Resident #4 and failed to report the injury to the nurse. The findings include: Review of the facility's policy for Skin Management and Prevention, dated August 2013, revealed on bath and shower days, CNAs will complete total skin observations. If a new skin issue is identified, the CNA will report it to the charge nurse and a copy of the form will be given to the Assistant Director of Nursing (ADON) or designee. Review of the CNA Skin Care Alert policy, dated July 2009, revealed the CNAs must complete this document on all residents on shower days and anytime a change was noted or observed on the resident's skin. The CNA should give the skin sheet to a nurse immediately. Record review revealed the facility admitted Resident #4 on 09/24/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for At Risk for Skin Breakdown, dated 06/17/13, revealed the nurse should be notified immediately of any new areas of skin breakdown, redness, blisters, bruises, and/or any discoloration noted during the bath or daily care. Observation of a skin assessment for Resident #4, on 03/12/14 at 2:35 PM, revealed a three (3) centimeter (cm) by four (4) cm DTI to the resident's left hip area. Interview with Registered Nurse #1, revealed this was not noticed on the last skin assessment completed on 03/07/14, and it had not been reported by the CNAs. Interview with CNA #1, on 03/12/14 at 3:20 PM, revealed she had been instructed to turn Resident #4 every hour, due to the resident's skin being fragile and the resident's declining condition. The CNA stated when she bathed the resident on 03/11/14 she identified the DTI to the left buttocks. The CNA stated she had been off work for two (2) days, prior to 03/11/14, and was unaware this was a new area so she did not fill out the CNA Skin Care Alert or report this to the Charge Nurse. Interview with the Assistant Director of Nursing (ADON,) on 03/12/14 at 4:15 PM, revealed she would have expected Resident #4's DTI to have been reported immediately.

Based on observation, interview and review of the facility's policy titled, "Medication Administration/Administering Medications (Licensed Staff), it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of seventeen (17) sampled residents (Resident #4). The facility failed to ensure the "right" Intravenous Fluids (IVF) ordered by the physician were administered to Resident #4. The findings include: Review of the facility's policy titled, "Medication Administration-Administering Medications (Licensed Staff)", effective December 2010, revealed medications should be brought to the bedside, the label read three (3) times prior to the administration of the medication and checked again after administration. The five (5) rights should be reviewed during the preparation and administration process to include the right medication, right dosage, right resident, right time and right route. Interview with the Administrator, on 03/27/14 at 4:05 PM, revealed she was not sure what professional standards of practice were used to develop the facility's policy and procedure. Record review revealed the facility readmitted Resident #4 on 09/24/12 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. However, observation of Resident #4, on 03/12/14 at 8:57 AM, revealed [MEDICATION NAME] 5% Water (D5W) was being administered at 75 ml/hr per pump; with 400 ml of a 1000 ml bag having been administered. Further observation revealed there was no label on the IVF bag to indicate the right medication, right dosage, right resident, right time, and right route. Interview with Registered Nurse (RN) #1, on 03/12/14 at 10:00 AM, revealed the IVF hanging was D5W at 75 ml/hr and the nurse should have hung D5 1/2 NS. Interview with the Assistant Director of Nursing (ADON), on 03/12/14 at 10:07 AM, revealed D5W was being administered at 75 ml/hr and the nurse should have administered D5 1/2 NS. The ADON stated the risk of D5W hanging was increased sugar content to the resident. Interview the Director of Nursing (DON), on 03/13/14 at 2:17 PM, revealed IVFs should be administered per physician's orders [REDACTED].

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure a resident who was identified as having a pressure sore received the necessary treatment and services to promote healing for one (1) of seventeen (17) sampled residents (Resident #4). Resident #4 was identified as having a Deep Tissue Injury (DTI) and the staff failed to report it to the nurse so the physician and family could be notified, the wound could be monitored, and appropriate treatment could be obtained. The findings include: Review of the facility's policy for Skin Management and Prevention, dated August 2013, revealed on bath and shower days, Certified Nurse Aide (CNA) will complete total skin observations. If a new skin issue is identified, the CNA will report it to the Charge Nurse and a copy of the form will be given to the Assistant Director of Nursing (ADON) or designee. Review of the CNA Skin Care Alert policy, dated July 2009, revealed the CNAs must complete this document on all residents on shower days and anytime a change was noted or observed on the resident's skin. The CNA should give the skin sheet to a nurse immediately. Review of the facility's Pressure Ulcer Management policy, dated 12/2010, revealed when a wound was identified the nurse must measure the size, depth, presence or absence of odor, drainage, and appearance of the periphery/surrounding skin and document findings. The wound must be assessed and measured at least weekly, the physician and responsible party must be notified, and if new orders received they must be initiated. Record review revealed the facility admitted Resident #4 on 09/24/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/26/14, revealed the facility assessed the resident's cognition as moderately impaired; the resident was totally dependent on staff for all Activities of Daily Living (ADLs), was incontinent of bowel and bladder, and at risk for skin breakdown. Review of the Comprehensive Care Plan for At Risk for Skin Breakdown, dated 06/17/13, revealed interventions to turn and reposition the resident every two (2) hours, provide incontinent care and apply barrier cream as needed, complete weekly skin checks and the nurse should be notified immediately of any new areas of skin breakdown, redness, blisters, bruises, and/or any discoloration noted during the bath or daily care and report any new areas to the physician. Observation of a skin assessment for Resident #4, on 03/12/14 at 2:35 PM, revealed a three (3) centimeter (cm) by four (4) cm DTI to the resident's left hip area. Review of Resident #4's last skin assessment documentation, dated 03/07/14, revealed there was no DTI identified to the resident's left hip area. Interview with CNA #1, on 03/12/14 at 3:20 PM, revealed she had bathed the resident on 03/11/14 and had identified the DTI to the left buttocks. The CNA stated she was not aware this was a new area and did not report the area to the Charge Nurse. She stated she had been instructed to turn Resident #4 every hour, due to the resident's skin being fragile and the resident's declining condition. Interview with the Assistant Director of Nursing (ADON), on 03/12/14 at 4:15 PM, revealed she would have expected Resident #4's DTI to have been reported immediately so the physician could be notified to see if treatment was needed and staff could monitor the area.

Based on observation, interview, and review of the facility's Abuse/Neglect policy and procedure, the facility's investigation, facesheets, Minimum Data Set (MDS) assessments, police report, and Nurses' Notes, it was determined the facility failed to ensure two (2) of four (4) sampled residents (Resident #1 and Resident #2) were free from abuse. Certified Nursing Assistant (CNA) #1 spilled urine in Resident #1's bed, did not change the bed, then left the window open when it was a cold night. On another occasion, CNA #1 manipulated Resident #1's leg into a position by crossing his/her legs to put on shoes causing the resident pain. Interview with the resident revealed the CNA pushed his/her leg which caused his/her right foot to hit the floor, pulled his/her right leg up by the pant leg, placed it back on the resident's left knee, got in his/her face and said, "That doesn't hurt now does it?" Interview with Resident #1's family member revealed he/she was informed by the resident that CNA #1 had been saying the resident was stupid and crazy. Resident #1 also became anxious and had difficulty sleeping. Additionally, CNA #1 grabbed Resident #2 by his/her arms causing bruising to the resident's bilateral arms. Resident #2 began having tearful episodes after the incident and required pharmaceutical intervention. The findings include: Review of the facility's policy titled, "ABUSE, NEGLECT AND MISAPPROPRIATION", last revised 03/2013, revealed verbal, sexual, physical and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property are prohibited. 1. Record review revealed the facility admitted Resident #1 on 12/09/13 with [DIAGNOSES REDACTED]. The resident was admitted for short term rehabilitation and the plan was for the resident to return home. Review of the Admission MDS assessment, dated 12/16/13, revealed the facility assessed Resident #1's cognition as cognitively intact with a Brief Interview Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. The facility assessed the resident as requiring extensive assistance with transfers and dressing. Review of the facility's Investigation Summary, revealed on 12/30/13 at 2:30 PM, Resident #1's family member reported to the facility Resident #1 had disclosed dissatisfaction with the care provided by CNA #1 during the previous night and on another night. Further review of the Investigation Summary revealed on one occasion (date uncertain), CNA #1 had spilled urine from a bed pan onto the resident's bed and refused to clean it up resulting in Resident #1 sleeping in a wet bed that night. That same evening, the CNA refused to close an open window in the resident's room which resulted in the resident being wet and cold. In addition, on the morning of 12/30/13, CNA #1 became impatient and smacked Resident #1 on the hand stating he/she was taking too long to put on his/her socks and shoes. CNA #1 made Resident #1 cross his/her legs placing the right ankle on the left knee causing Resident #1 pain. Resident #1 told CNA #1 he/she felt pain and the doctor had instructed him/her not to position his/her legs in that manner due to recent hip surgery. CNA #1 argued back saying the doctor was wrong. The report revealed CNA #1 then pushed the resident's elevated foot causing it to drop to the floor. CNA #1 then pulled the cuff on the resident's right pant leg physically manipulating Resident #1 to cross his/her legs stating "see that didn't hurt anything did it?" Observation, on 01/15/14 at 1:30 PM, revealed Resident #1 was dressed in pants, a blouse and shoes. Interview with the resident, at this time, revealed several days back, CNA #1 had spilled urine from a bedpan onto the bed and did not change the bed linens. The resident stated the window was open and CNA #1 refused to close it. Resident #1 stated CNA #1 said it was closed, but he/she knew it was open as he/she could see some greeting cards blowing in the breeze and he/she was cold. In addition, Resident #1 revealed on 12/30/13, CNA #1 made him/her cross his/her legs to put on shoes. Resident #1 went on to explain that the doctor had instructed him/her not to do that as it would cause his/her hip to "pop out". Resident #1 stated the CNA then pushed his/her leg causing the right foot to hit the floor, the CNA then pulled the resident's right leg up by the pant leg placing it back on the left knee and got in his/her face and said, "That doesn't hurt now does it?" Resident #1 stated it made him/her "feel bad" when it happened and that he/she couldn't sleep at night until he/she knew CNA #1 was not going to come back to work. Interview with the Director of Nursing (DON), on 01/15/14 at 4:20 PM, revealed Resident #1's family members reported to her that CNA #1 left Resident #1's bed wet with urine and the window open. The family told the DON that it was twenty three (23) degrees (Farenheit) outside that night. The resident's family reported Resident #1 was crying and told them CNA #1 had slapped his/her hand and snatched his/her shoes from his/her hand. The family stated the CNA made the resident cross his/her legs, then moved the resident's legs, causing the resident's right leg to drop to the floor, then picked up his/her right leg by the pant cuff and manipulated the resident's right leg to cross. The CNA then looked the resident in the face and said "see, now that didn't hurt anything did it?" The facility initiated an investigation immediately. The facility suspended CNA #1. The allegation was substantiated and CNA #1 was terminated. Review of a Nurse's Note, dated 01/03/14 (no time) written by Registered Nurse (RN) #1, revealed "Resident more at ease today, I spoke with (him/her) about (his/her) restless nights. (He/she) stated (the alleged abuser's name), and I assured (him/her) that (he/she) was not going to have to contend with the alleged abuser any more and that the matter is being dealt with in the appropriate manner. (He/she) stated relief and was in a good mood today". Further review of the Nurse's Notes revealed no documented evidence the resident had restless or sleepless behaviors prior to the incident on 12/30/13. Interview with RN #1, on 01/16/14 at 1:45 PM, revealed he went to speak with Resident #1 after seeing documentation on a Situation/Background/Assessment or Appearance/Request (SBAR) Communication form that the resident was not sleeping. He stated he talked with Resident #1 who said he/she "was pretty scared" and was having trouble sleeping. RN #1 stated the resident called CNA #1 by name, and identified this CNA as the person he/she was afraid of. He ensured the resident was safe and all had been taken care of, and the resident seemed more at ease. Interview with Resident #1's family member, on 01/16/14 at 10:00 AM, revealed Resident #1 informed the family member on 12/30/13 that CNA #1 had been saying he/she was stupid and crazy and had made Resident #1 cross his/her legs. Resident #1 also told the family member of an incident when CNA #1 spilled urine on the bed and left it and had refused to close an opened window at the time. The family member stated Resident #1 had a good memory and was scared of CNA #1 hurting his/her leg. Resident #1 would stay awake worried about CNA #1 coming into his/her room, but now he/she feels better since he/she was told CNA #1 would never be back. Review of a Police Report, obtained on 01/17/14, revealed the time of the occurrence was 12/30/13 at approximately 5:00 AM. Resident #1's statements were in corroboration with the facility's allegation and Resident #1 was visually upset about the incident as he/she cried when he/she was giving the Officer his/her statement. Interview with the investigating Police Officer, on 01/17/14 at 3:25 PM, revealed Resident #1 had said CNA #1 was mentally abusive and disrespectful. Further interview with the Police Officer revealed the resident was crying during their interview. 2. Record review revealed the facility admitted Resident #2 on 02/24/12 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 10/05/13, revealed the facility assessed the resident's cognition as moderately impaired with a BIMS score of ten (10). The resident required extensive assistance with transfers, dressing and grooming and had a hearing impairment. The resident was alert, oriented, could express needs and wants, was cooperative with care and had no behaviors. On 12/30/13, during the facility's investigation of alleged abuse of Resident #1, Resident #2 was interviewed. Resident #2 also alleged rough treatment from CNA #1 that caused bruising to his/her bilateral arms. Resident #2 told facility staff that CNA #1 had caused bruising to his/her arms that morning when she got the resident up for the day. During the interview, the resident stated, "I don't know what I ever did to make her mad at me". The facility identified bruising on the resident's bilateral forearms that was purple in color and circular in shape measuring 7 (seven) centimeters (cm) by 5 (five) cm on the right arm; and, 5 (five) cm by 6 (six) cm on the left arm. According to staff observations, Resident #2 began to have tearful episodes after the experience with CNA #1 on 12/30/13. Review of a physician's orders [REDACTED].#2's tearfulness. Review of a [MEDICAL CONDITION] Medication Consent form, dated 12/31/13, revealed the targeted behavior was "crying". Resident #2 had no previous [DIAGNOSES REDACTED]. Psychiatric services were declined by the resident's family on 01/04/14. Observation, on 01/15/14 at 2:00 PM, revealed Resident #2 was sitting in a low seated wheelchair. Interview with the resident, at this time, revealed on 12/30/13, he/she was half asleep when CNA #1 "just grabbed me (demonstrated with clinched fists) like she was shaking something, it was my body". Resident #2 stated his/her arms were sore but better now. The resident stated he/she did not know why CNA #1 was mad at him/her. Further observation revealed the resident had quarter sized, faint greenish faded circular areas on both forearms. An additional observation, on 01/21/14 at 1:00 PM, revealed Resident #2 sitting in a wheel chair looking out the window by the facility dining room. The resident was tearful at the time but insisted he/she was fine. The resident stated twice "I'm fine, its nothing" and "It's ok, I'm fine". He/she did not want to talk at the time. Interview with the DON, on 01/15/14 at 4:20 PM, revealed Resident #2 was interviewed on 12/30/13 during a facility investigation regarding an abuse allegation of Resident #1. Resident #2 cried and continued to cry when interviewed. Resident #2 stated CNA #1 had grabbed his/her arms and the resident did not know why the CNA was mad at him/her. The DON talked with Resident #2 on 12/31/13. Resident #2 had informed the DON that his/her call light was on the floor so CNA #1 yelled at him/her for calling out. The resident stated the CNA grabbed him/her by the arms and told him/her to shut up. The resident told CNA #1 she did not have to be so rough. The DON said Resident #2 had visible discolorations on both the right and left forearms. Further interview revealed the marks were red and purple and circular in shape. The police were notified and investigated the incident on 12/31/13. The Police Officers stated the discolorations on Resident #2's arms were "grab marks". Further interview with the DON, on 01/16/14 at 7:30 AM, revealed Resident #2 had cried and continued to cry when he/she talked with about the incident on 12/30/13. The Physician was notified and a new order for [MEDICATION NAME] 25 mg daily (antidepressant) was ordered. Review of a Police Report, obtained on 01/17/14, revealed the date and time of occurrence was on 12/30/13 at approximately 5:00 AM. Further review of the Police Report revealed, evidence listed as: Officer observed bruises in question which were located in the same area of both the left and right arm. Both bruises were the same color and seemed to be consistent with Resident #2's arms being held down. The Police Officer submitted photos taken of the victim for evidence. Interview with the investigating Police Officer, on 01/17/14 at 3:25 PM, revealed Resident #2 had stated he/she was sleepy that morning (12/30/13) and CNA #1 was agitated and grabbed him/her by the arms. The officer stated he saw bruises on both arms in the same location and the bruising coincided with grabbing. Interview with the Administrator, on 01/21/14 at 11:30 AM, revealed there were red flags noted from the facility's investigation and he could not say for certain CNA #1 did what was alleged but he certainly did not want her as an employee.

Based on interview, record review, and facility policy and procedures review, it was determined the facility failed to have an effective system in place to ensure residents received the necessary care and treatment to ensure continuous Oxygen (O2) was provided, for one (1) of three (3) sampled residents (Resident #1). The hospital provided the facility with a packet on [DATE], four days prior to the resident's admission, which included Resident #1's face sheet, history and profile, nursing and therapy notes to review to determine if the facility could meet the residents' care needs. The facility accepted Resident #1 for admission and was notified on [DATE] at 12:22 PM, the resident was scheduled to be discharged at 1:00 PM. The facility admitted Resident #1 on [DATE] at approximately 1:30 PM with [DIAGNOSES REDACTED]. After the Emergency Medical Technicians (EMT) transported the resident to the facility and discontinued the resident's O2 from the portable tank, the facility failed to ensure an O2 concentrator was in the room to administer the resident's O2 at five (5) L via NC. Resident #1 was without O2 for approximately ten (10) minutes when staff entered the resident's room at 1:40 PM and found the resident pale and diaphoretic (sweating). The resident was able to make eye contact but could not speak and O2 was applied at six (6) liters, per nasal cannula. At 1:45 PM, the resident was unresponsive with no carotid pulse or respirations and a Code was called. Emergency Services (911) was called and the resident was intubated at 2:02 PM and transferred to the hospital at 2:11 PM. The resident was placed on a ventilator and remained unresponsive. Resident #1 expired at the hospital, on [DATE] at 9:00 PM. The facility's failure to have an effective system in place to ensure newly admitted residents received the necessary care and services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], the Immediate Jeopardy was removed on [DATE], as alleged. The scope and severity was lowered to a "D" at 42 CFR 485.25 Quality of Care F 328 while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Oxygen Administration Policy, dated [DATE], revealed the procedural steps, for administering O2 for a resident, were to check the physician's orders [REDACTED]. A reserve O2 tank should be available to provide continuity of care. The licensed staff member was to connect the humidifier, if applicable, and attach the nasal cannula or O2 mask to the resident, check the liter flow, assess the resident's respirations, and observe the resident at regular intervals. A review of the facility's "Job Description for Admission Nurse", undated, revealed the "Admission Nurse's essential duties and responsibilities included ensuring that all necessary equipment and medications were available, prior to the resident's arrival". A review of e-mails between the hospital and facility revealed on [DATE] at 10:13 AM, the hospital made the facility aware Resident #1 preferred to be discharged to this facility as he/she had stayed there before. On [DATE] at 10:15 AM, the hospital [MEDICAL CONDITION] sent an e-mail to the facility indicating the resident would be ready today ([DATE]). An e-mail, dated [DATE], at 12:22 PM from the hospital revealed the resident was scheduled to leave at 1:00 PM. A record review revealed Resident #1 was admitted to the facility on [DATE] at approximately 1:30 PM, with [DIAGNOSES REDACTED]. A review of the admission orders [REDACTED].) However, interview and record review revealed O2 was not administered to the resident continuously after the resident arrived to the facility. A review of the facility's Nursing Admission Form for Resident #1, dated [DATE], revealed at 1:40 PM the O2 concentrator was taken to the resident's room and the resident was observed to be "cyanotic with shallow breathing." O2 was applied at 6 L per N/C. At 1:45 PM, the Admitting/Charge Nurse, Licensed Practical Nurse (LPN) #2, was unable to obtain a pulse or blood pressure and a Code Blue was initiated. A review of the Emergency Code Documentation, revealed the Code was started, on [DATE] at 1:45 PM, by LPN #2, when the LPN identified the resident had no pulse, respirations or blood pressure. Oxygen was administered, per Ambu bag, at 1:45 PM and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was started and the 911 call was made, at 1:50 PM. The physician was notified at 1:50 PM and the family was notified at 1:55 PM. EMS arrived at 1:57 PM. The resident was intubated at 2:02 PM. Intravenous Fluids (IVF) were started at 2:04 PM with Normal Saline, [MEDICATION NAME] and [MEDICATION NAME] administered and the resident was transferred at 2:11 PM, by the EMTs to the emergency room (ER). A review of the ambulance records and the hospital records revealed the resident arrived at the hospital at 2:23 PM in [MEDICAL CONDITION], was defibrillated and converted to Sinus [MEDICAL CONDITION] a pulse rate of 172 beats an hour. The resident was placed on the ventilator and experienced stable vital signs but remained unresponsive. The family made the decision to withdraw life support after an Electroencephalogram (EEG) showed no active brain waves and the resident expired on [DATE] at approximately 9:00 PM. An interview, on [DATE] at 4:40 PM, with EMT #1, who assisted with delivering the resident to the facility, on the first EMS run, on [DATE] at 1:30 PM, revealed there were two people in the room when they entered the resident's room and the EMT stated she told them the resident needed an O2 concentrator, as there was not one in the room. The EMT stated she went to E Wing Nurses Station, left a packet with the physician orders, told the nurse the resident was on O2 at 5 L, and had the nurse sign the Ambulance Run Sheet. The EMT stated the resident had O2 administered per nasal cannula, and at some point the EMT's partner had taken the resident off O2 and met the EMT in the hall with the stretcher, to leave the facility. The EMT stated she was unaware the resident was not on O2 when they left the building. An interview, [DATE] at 2:40 PM, with Paramedic #1, who assisted the EMT to deliver Resident #1 to the facility, on [DATE] at 1:30 PM, revealed Resident #1 was receiving 5 L of oxygen via a portable O2 tank when the resident arrived at the facility. The Paramedic stated he noticed there was no concentrator in the room and the EMT left the resident's room, to find the nurse. The Paramedic stated he was under the impression someone was bringing O2 and he disconnected the portable oxygen tank. An interview with the Assistant Director of the Ambulance Service, on [DATE] at 12:40 PM, revealed if O2 was involved, the EMTs were required to wait until a portable O2 tank or concentrator was available. He revealed a report was to be given to the nurses, as well as the hospital records packet, and the the ambulance record sheet was to be signed, before the EMTs left the building. He stated the O2 should have been only off momentarily, two to three minutes, during change over. A review of the Transfer Discharge Form from the hospital, dated [DATE], revealed at 12:42 PM, LPN #1 was called for report and informed of Resident #1's status. The "short medical history" part of the form, revealed the resident had [DIAGNOSES REDACTED].) An interview with LPN #1, on [DATE] at 12:40 PM and on [DATE] at 11:50 AM, revealed she was filling out admission paperwork for Resident #1, when the resident was escorted into the facility, on a stretcher through the West door by the ambulance staff. The LPN stated the hospital's Registered Nurse (RN) phoned the facility and reported the pending transfer to her. Per the report she received, the resident had a [DIAGNOSES REDACTED]. After getting report, from the RN at the hospital, she gave report to the Charge Nurse, LPN #2. She stated she overheard LPN #2, stating she had to go get the O2 concentrator and LPN #1 went back to her office. An interview with LPN #2, on [DATE] at 1:24 PM, revealed she was on the phone with a physician, receiving orders for another resident, when she saw the EMTs enter the facility, through the West door. However, she was not sure if this resident was her admission because the EMTs never stopped at the desk and proceeded down the hallway with the resident. The LPN stated she told Certified Nurse Aide (CNA) #1 to follow the EMTs, to see if this was the new admission. An interview with CNA #1, on [DATE] at 11:51 AM, revealed the CNA was made aware of Resident #1's transfer to the facility from the hospital, on [DATE], by LPN #2. The CNA went to the resident's room to ensure the resident had a call light in reach, knew how to use the call light, and to introduce herself. She stated there was no one else in the room and the resident complained of being hot and requested a fan. The CNA noted the resident had an O2 cannula but there was no concentrator in the room, and the O2 tubing was lying on the resident's bed. She stated the CNAs did not have access to the locked Medication Room, where the O2 concentrators were stored, and only the charge nurses and medication nurses had keys. The CNA went down the hall and told LPN #2 the resident was not hooked up to an O2 concentrator, and stated the LPN was "in the middle of getting report." The LPN acknowledged the CNA by saying "OK," but continued getting report from LPN #1. The CNA stated she remembered the ambulance driver telling LPN #2 the resident was on five (5) liters of O2, right before he left. Further interview with LPN #2, on [DATE] at 1:24 PM, revealed "everything happened simultaneously that day". The LPN stated CNA #1 was at the desk and stated the resident needed O2, the EMTs were at the nursing desk to state the resident needed O2 at 5 liters, and LPN #1 was at the desk to give her report." LPN #2 stated she was not aware the EMTs had not ensured the resident was on O2 prior to leaving the facility. When she entered the room, the resident's nasal cannula was on the resident's nose and the O2 tubing was laying on the bed, not connected, as there was no concentrator in the room. The LPN revealed she went to the A Hall, to get a concentrator from the Medication Room and when she returned, the resident was breathing shallow, was pale, diaphoretic and made eye contact but did not speak. The LPN stated she placed the resident on O2 at "6 liters," was unable to feel a carotid pulse and requested the CNA to get LPN #1 and the crash cart. Further interview with CNA #1, on [DATE] at 11:51 AM revealed when she came out of another resident's room "five to ten minutes later," she saw LPN #2 rolling the O2 concentrator down the hallway. She then heard LPN #2 calling out for the CNA to get LPN #1, who went in the resident's room and a Code Blue was called. The CNA got the crash cart and stepped back out of the way. Further interview with LPN #1, on [DATE] at 12:40 PM and on [DATE] at 11:50 AM, revealed CNA #1 came and got her and stated Resident #1 didn't look right." LPN #1 stated she went to the resident's room and noted the nasal cannula was connected to the concentrator and the resident's head of the bed was 45 degrees, "or more." She stated Resident #1 was experiencing periods of Apneic Breathing, or slowing and stopping breaths, was unresponsive, and his/her skin was cool to touch. LPN #1 stated she administered a sternal rub, to check for a response, and the resident didn't respond. The LPN stated she could not feel a carotid pulse and a Code Blue was called. LPN #1 revealed CNA #1 brought the crash cart, the resident was positioned on a back board, and CPR was started. An interview with the facility's Admissions Nurse, LPN #3, on [DATE] at 10:55 AM, revealed the hospital sent her a packet on [DATE] which included Resident #1's face sheet, History and Profile, nursing notes and therapy notes. The Admission Nurse stated the referral information for Resident #1, sent by the hospital, specified the need for O2 therapy. She stated it was her responsibility to review the admission packets, prior to the resident's admission, and to ensure the resident had the necessary equipment available upon admission and to set-up the resident's room, in anticipation of the admission, to include having an O2 concentrator in the room, prior to the resident's arrival. However, she was not working on [DATE] and was unable to state who was responsible to carry out her job duties, when she was not at work. Per interview, she would have expected someone to have made the O2 available, prior to the resident being admitted . An interview with the Director of Nursing (DON) on [DATE] at 1:10 PM and on [DATE] at 12:16 PM, revealed part of the Admissions Nurse's responsibilities was to prepare the resident's room for the admission, to include any needed equipment and an O2 concentrator, if needed. If the Admissions Nurse was not available, on the day of the admission, it was the Charge Nurses responsibility to ensure that the room was prepped for the resident. In regards to the report called to LPN #1, on ,[DATE]//13 at 12:42 PM and the resident's arrival to the facility at 1:30 PM, the DON revealed LPN #1 failed to immediately report the expected transfer in a timely manner, so the room could be ready with the O2 concentrator, when the resident arrived. The DON revealed in addition to the concentrators in the Medication Rooms, in Section One (1), which includes Halls A,B and C and Section Two (2,) which includes Halls D and E, there were portable O2 tanks, on the crash carts, in these same areas. An interview with the Administrator, on [DATE] at 5:00 PM, revealed the Administrator was aware of the resident's pending transfer, on [DATE]; however, he was not aware the resident required continuous O2 therapy and "unfortunately, was out of the facility, when he/she was admitted ." An interview, on [DATE] at 12:29 PM with the Resident #1's physician, who is also the Medical Director, revealed he would have expected the O2 to have been available, administered as ordered, and stated the ten or so minutes the resident went without O2 "almost undoubtedly" contributed to his/her death, as the resident had "never been without O2." The facility implemented the following actions to remove the Immediate Jeopardy: -All residents requiring O2 therapy were assessed , on [DATE], by the Nursing Administrative Team (Assistant Director of Nursing, Staff Development Coordinator, Medical Records, Assistant Medical Records, Restorative Nurse, Suite 72 Nurse-Admission Nurse, and Minimum Data Set Coordinators 1 and 2), to ensure residents were stable and ensure any PRN orders have equipment available at bedside. - On [DATE], all residents with Special Needs were reassessed by the Nursing Administrative Team, to ensure the residents were stable and nursing care was provided, as ordered, to include: Residents with nebulizer treatments; inhalers; enteral and [MEDICATION NAME] therapy; injections; prosthesis; colostomies and foot care. Prior to any resident with special needs being admitted to the facility, the Staff Development Coordinator (SDC) will reeducate the staff on the care of a resident with these special needs. - On [DATE], the Admissions Director and/or the Suite 72 Nurse (Admissions Nurse) the Medical Records Assistant-LPN will call the hospital discharge planner and confirm the acceptance of a transfer once the facility has been made the facility of choice for transfer and admission. The Admission Coordinator and the Suite 72 Nurse will complete the Preadmission Worksheet to ensure the resident's room is set-up with the needed equipment, prior to the resident's arrival to the facility. The Admissions Nurse will do a final audit of the room, once discharge orders are received. The hospital transfer report is to be managed only by the Admissions Nurse, Back-up Admissions Nurse or admitting nurse. No room numbers will be provided to the hospital or ambulance service, in order to ensure the ambulance service stops at the desk to inquire a room number. The Admitting Nurse must follow the ambulance attendants to the resident's room and assess the resident to ensure the resident is stable and has the needed equipment, prior to signing the Ambulance Run Report. The Manager of Case Management, at the hospital was made aware of the new admission policies at the facility, to enhance communication between the entities and ensure a safe transfer for the resident. -Inservices for Administrative Nurses were conducted by the DON, on [DATE] and [DATE], regarding taking the hospital report, on a transferring resident, when a Charge Nurse is unavailable. The nurse taking report must immediately meet with the Charge Nurse and provide them with the information from the hospital to ensure the room is set- up and ready for the admission. -Inservices were provided for all disciplines, in each department, by the Staff Development Coordinator, on [DATE] and [DATE], regarding the new transfer and admissions guidelines. New employee training regarding the new transfer procedure will be included in the orientation process. - Monitoring and audits were performed regarding new admissions and the room set-up with correct equipment; medication rooms for the availability of the O2 concentrators and other special needs equipment; rounds were completed twice a day to audit the treatment records to ensure the O2 and special needs services are being provided and is ongoing. -The Quality Assurance Committee met [DATE] and [DATE] to review action plans, regulatory concerns, and team assignments to ensure compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: A review of the facility's inservice, conducted on [DATE], revealed all licensed staff was inserviced on the new admission policy. Interviews on [DATE], from 3:05 PM until 3:50 PM, with the Social Worker, Physical Therapist, CNA, two RNs, Dietary Aide and the Maintenance Assistant, revealed the staff members had been inserviced on the above policies. Record reviews to expand and extend the survey, for Residents #4 through #11, revealed no concerns. An observation of four residents receiving treatments for [MEDICAL CONDITION] care, foot care, gastrostomy care and respiratory care revealed no concerns. An interview with the DON and Administrator, on [DATE] at 2:55 PM, revealed resident's on oxygen and nebulizer treatments had been reviewed with no concerns. All oxygen orders were clarified as continuous or as needed. A review of Residents #4 through #11's charts was completed and orders, treatments and care plans, were verified with no concerns. A review of the audits and monitoring tools for tracking the effectiveness of the implemented programs, revealed no concerns and verified the monitoring of oxygen, nebulizer treatments and special needs for five consecutive days (,[DATE]-,[DATE],) with no concerns. Further interview with the Administrator and the DON revealed they would ensure the the audits and monitoring would continue, as stated in the plan of correction.

Based on observation, interview and record review, it was determined the facility failed to provide care according to the written plan of care for two residents (#1 and #4 ), in the selected sample of 18 residents. The facility failed to provide adequate supervision to Resident #4 as directed on the Comprehensive Care Plan to prevent repeated falls. On 01/27/12, Resident #4 was admitted to the facility with a history of falls at home. The Plans of Care for January, March, and April identified falls on 01/31/12, 03/18/12, 04/16/12, and 04/17/12, with the initiated interventions related to alarms and observations of the resident. On 03/30/12, Resident #4 sustained a [MEDICAL CONDITION] which required surgical intervention as a result of a fall where the resident was left unattended in his/her room. On 04/06/12, Resident #4 was readmitted to the facility and determined at high risk for falls. Resident #4 suffered additional unobserved falls on 04/16/12 and on 04/17/12 where staff continued to not follow the care leaving the resident unattended while up in the wheelchair in the residents room. The facility failed to implement care plan interventions for Resident #1 to prevent accidents and/or injury for the resident. The facility assessed the resident at high risk for falls and developed care plan interventions to address the risk for falls; however, the facility failed to follow the planned interventions and provide the assistive devices deemed appropriate to prevent accidents and/or injuries to Resident #1. Findings include: An interview with the Director of Nursing (DON), on 04/20/12 at 4:00 PM, revealed the facility did not have a policy and procedure that specifically addressed the implementation of the care plan. 1. A record review revealed the facility admitted Resident #4 on 01/27/12 with [DIAGNOSES REDACTED]. A review of the Discharge/Transfer form, dated 01/27/12, revealed activity limitations needed with falls precautions. A review of the Interim Plan of Care, dated 01/27/12, revealed Resident #4 was at risk for falls. A review of the Admission Interim Plan of Care, dated 01/27/12, revealed the facility assessed Resident #4 at risk for falls with interventions to include verbal reminders not to ambulate alone, his/her bed to be in the lowest position, assistance with transfers and ambulation as needed, and observe for any unsafe actions and intervene as needed. A review of the admission Minimum Data Set (MDS) assessment, dated 02/03/12, revealed the facility assessed Resident #4 at risk for falls with a history of falls prior to admission to the facility, and the resident required extensive assistance for walking within his/her room and did not walk in the corridors during the time of the MDS evaluation. A review of the Comprehensive Care Plan for falls, dated 02/03/12, revealed interventions to provide a personal body alarm to be on at all times and a pressure bed alarm on while Resident #4 was in the bed. Further review of the Comprehensive Care Plan revealed an update, on 03/16/12, to discontinue the intervention of a personal alarm on at all times. A review of the Care Plan for "head injury from fall", dated 03/18/12, revealed the facility developed interventions for staff to encourage Resident #4 to be in the lobby for observation and to not be left unattended while up in the wheelchair. A review of the Plan of Care for "head injury from fall", dated 03/18/12, was updated on 03/23/12 and documented their knowledge that the resident refused to leave alarms on, takes them off and hides them; however, maintained these interventions to prevent falls. A review of physician's orders [REDACTED]. A review of the "Fall/Change in Functional Status," dated 03/30/12, revealed a CNA found Resident #4 sitting on the floor in his/her room and was unattended. The facility assessed the resident for injuries and found a skin tear on the left elbow and Resident #4 was complaining of hip pain. An interview with CNA #8, on 04/19/12 at 3:00 PM, revealed the fall on 03/30/12 occurred during the supper meal while Resident #4 was alone in his/her room. CNA #8 stated she found the Resident #4 sitting on the floor. Interview with RN #5, on 04/20/12 at 9:10 AM, revealed she was called from the dining room to find that Resident #4 had fallen. RN #5 found the resident sitting in the wheelchair and complaining of hip pain. RN #5 reported the alarms were sounding when Resident #4 fell and staff reported they found him/her sitting in the floor of his/her room alone. The facility did not identify that Resident #4's care plan was not being followed as the resident was left unattended in his/her room and was not in the lobby. A review of the physician's orders [REDACTED].#4 had sustained a left [MEDICAL CONDITION]. Resident #4 was transferred to the emergency room for surgical repair on 03/31/12. A review of the "Admission information," dated 04/06/12 at 6:00 PM, revealed Resident #4 was admitted to the facility after surgical repair of the left [MEDICAL CONDITION] sustained in the facility on 03/30/12. The facility assessed the resident to be at high risk for falls. A review of the Interim Plan of Care, dated 04/06/12, revealed the interventions for falls included the bed be in the lowest position, verbal reminders not to ambulate alone, assistance with transfers and ambulation as needed, observe for unsteady gait, dizziness, and intervene as needed, and pressure bed alarms and chair alarms. There were no interventions to address Resident #4's demonstrated ability to remove the alarms or the need for increased supervision due to the resident's history of falls at the facility. A review of the Care Plan for "resident fell ", dated 04/16/12, revealed an intervention for the resident to be in the lobby while up in the wheelchair and the resident was non-compliant with the alarms and will not stay off hip. A review of the "Fall/Change in Functional Status," dated 04/16/12, revealed Resident #4 was found sitting on the floor in his/her room. The assessment revealed no apparent injury was sustained. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed the fall was unobserved so it must be treated as a fall. An interview with CMT #3, on 04/20/12 at 10:30 AM, revealed Resident #4 was found sitting on the floor in his/her room alone. There was no evidence that the facility identified that staff was not following the care plan related to the resident was to be in the lobby while up in the wheelchair and not be left unattended while in the room. A review of the Care Plan, dated 04/17/12, revealed the facility initiated no interventions related to the prevention of further falls. A review of the "Fall/Change in Functional Status," dated 04/17/12, revealed two (2) unobserved falls within a one and a half (1.5) hour time period. The record revealed Resident #4 was found sitting in the floor of his/her room unattended. The resident was assisted back into the wheelchair, the alarms were turned off, and the RN #5 left Resident #4 alone in the room. The facility did not follow the care plan intervention of using the pressure chair alarm in that the alarm was turned off after the resident was assisted back into the wheelchair. In addition, the facility did not follow the care plan intervention of resident to be in the lobby when in the wheelchair. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed Resident #4 was alone in the room when the chair and bed alarms sounded. The resident was found sitting in the floor, was returned to the wheelchair, and RN #5 left the room. RN #5 stated, upon her return, she found Resident #4 on the opposite side of the bed, on hands and knees, trying to pull the bed control cord from the bed frame. The resident was unattended and the fall was not observed. An interview with CNA #7, on 04/20/12 at 12:40 PM, revealed, CNA #7 found Resident #4 in his/her room alone after the chair alarm sounded on 04/17/12. CNA #7 revealed Resident #4 was taken for activities but would leave the activity and self-propel back to his/her room unassisted. Supervision after the falls included taking the resident out of the room while in the wheelchair and parking the resident's wheelchair at the nurse's station, but he/she always wanted to return to the room to be alone. An observation, on 04/18/12 at 11:40 AM, revealed Resident #4 was in bed with his/her eyes closed and was unattended. On 04/19/12 at 8:55 AM, the resident was returned to the room from physical therapy and was in his/her wheelchair. The facility staff provided Resident #4 with activities and left the resident alone in the room. An observation, on 04/19/12 at 2:00 PM and at 2:30 PM, found Resident #4 laying in the bed unattended with his/her eyes closed. The personal body alarm was attached to the resident's clothing and the bed alarm activation light was blinking. The resident was unattended. An observation, on 04/20/12 at 1:30 PM, revealed Resident #4 was observed in the bed with a personal body alarm in place. The pressure bed alarm activation light was not blinking and the staff was notified. The resident was unattended. An observation, on 04/20/12 at 4:25 PM, revealed Resident #4 was sitting in his/her wheelchair in the doorway of his/her room in a forward drooped position with his/her eyes closed. The resident did not respond to a verbal greeting. An interview with CMT #3 revealed Resident #4 received [MEDICATION NAME] 5/325 mg for pain at 11:00 AM, and received [MEDICATION NAME] for anxiety at 12:00 PM. At 4:33 PM, Resident #4 remained in the wheelchair in his/her the doorway of his/her room. His/her posture was more erect at that time. The resident responded to a verbal greeting by lifting his/her head and opening his/her glassy eyes. His/her mouth fell open from a relaxed jaw, but no verbal response was given. The Director of Nursing (DON), on 04/20/12 at 3:10 PM, revealed the facility had staffing to ensure adequate supervision was provided for Resident #4 to keep him/her safe. The DON stated if the nursing staff was busy, she could notify other facility departments, such as activities or the chaplain, to attend to the resident. The DON stated Resident #4 cannot be forced to stay at the nurse's station and the staff cannot keep the resident on one-to-one supervision, as the staff had to take care of other residents. The DON reported the facility ensured the safety of Resident #4 the same way as they do for all residents by moving around the facility and ensuring whereabouts of the residents. Another method of ensuring safety, reported by the DON, was "team tackling" and described this method as part of internal audits and the review of different topics each day. However, the DON was unable to provide evidence that the facility had identified their failure to ensure interventions developed to prevent recurrence of falls was implemented. These failures continued even after the resident sustained [REDACTED]. 2. A record review revealed the facility admitted Resident #1 on 10/17/07 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 02/02/12, revealed the facility assessed Resident #1 as cognitively intact and requiring minimal assistance of one staff for ambulation. A review of the Falls assessment, dated 02/02/12, revealed the facility assessed Resident #1 at high risk for falls. A review of the Comprehensive Care Plan for falls, dated 02/06/12, revealed the facility developed interventions for Resident #1 to have a personal alarm in place at all times while in the wheelchair and a pressure alarm in place when in the bed. Observations, on 04/18/12 at 10:30 AM, 3:50 PM, 4:35 PM and 4:55 PM, and on 04/19/12 at 9:30 AM, 10:55 AM, 11:40 AM and 1:50 PM, revealed Resident #1 was up in his/her wheelchair with no alarm on the chair. Observations of the resident's bed revealed there was no pressure alarm in place. An observation and an interview with LPN #1, on 04/19/12 at 10:10 AM, revealed Resident #1 was up in the wheelchair with no alarm on the chair, and when the nurse checked the resident's bed, there was no pressure alarm under the sheet in the bed. She stated Resident #1 was supposed to have a clip alarm on his/her wheelchair and a pressure alarm on the bed. She was unable to provide an explanation as to why the alarms were not in place. Interviews with CNA #4 and CNA #5, on 04/20/12 at 9:15 AM and 10:25 AM, respectively, revealed Resident #1 should have had a chair alarm and bed alarm; however, they were unable to provide an explanation as to why the alarms were not in place. An interview with the DON, on 04/20/12 at 4:00 PM, revealed Resident #1's alarms should have been on the wheelchair and the bed. Interview with the Director of Nursing (DON), on 04/20/12 at 3:10 PM, revealed the process for evaluation of effective interventions was to determine why an intervention was not in place, to educate and coach the staff. Further evaluation of interventions for Resident #4 were monitored weekly through clinical meetings, Interdisciplinary Team meetings, and "at risk" meetings. The team talked about behaviors on a daily basis and with any change in condition.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to provide assistive devices or supervision to prevent accidents and/or injury for two residents (#1 and #4), in the selected sample of eighteen residents. The facility failed to provide adequate supervision for Resident #4 to prevent falls and/or other injuries and failed to ensure interventions implemented were effective in preventing falls for the residents. The facility assessed Resident #4 as a high risk for falls due to his/her history of falls. The resident sustained [REDACTED]. On 01/31/12, Resident #4 sustained a skin tear. On 03/18/12, the resident sustained [REDACTED]. On 03/30/12, Resident #4 suffered a hip fracture as a result of the fall. The facility's incident investigations failed to identify causal factors of the falls to prevent recurrence. The facility failed to identify that staff was not implementing the care plan related to supervision and failed to identify that the resident was agitated by the alarms. The facility continued to utilize interventions despite having knowledge that the resident was known to remove and hide the alarms that were placed by the facility to monitor the resident's movement and would propel him/herself back to the resident's room without staff supervision after staff placed the resident in the lobby. The facility continued these interventions failing to determine their ineffectiveness and failing to implement new interventions to prevent fall recurrence. This failure led to the residents continued fall occurrences on 04/16/12, and twice on 04/17/12 placing the resident at further risk for falls with potential for injuries. The facility failed to provide assistive devices to prevent accidents and/or injury for Resident #1. The facility assessed the resident at high risk for falls and developed care plan interventions to address the risk for falls. The facility failed to follow the planned interventions and provide the assistive devices deemed appropriate to prevent accidents and/or injuries to Resident #1. Findings include: A review of the facility's policy and procedures for "Falls," dated 12/10, revealed it was the intent of this facility to provide residents with assistance and supervision in an effort to avoid falls and minimize injury and complications that may result from a resident falling. A review of the facility's Incident Reporting policy and procedure, dated 12/10, revealed the facility shall ensure that each resident shall receive adequate supervision and assistive devices that shall reduce accidents. 1. A record review revealed the facility admitted Resident #4 on 01/27/12 with [DIAGNOSES REDACTED]. A review of the Discharge/Transfer form, dated 01/27/12, revealed Activity Limitations included falls precautions. A review of the Interim Plan of Care, dated 01/27/12, revealed the facility identified Resident #4 was at risk for falls. Interventions included verbal reminders not to ambulate alone, his/her bed to be in the lowest position, assistance with transfers and ambulation as needed, and observe for any unsafe actions and intervene as needed. A review of the "Incident Accident Tracking Log," dated 01/31/12 at 10:00 AM, revealed Resident #4 turned off the pressure alarm, got out of bed, stumbled and fell , which resulted in a skin tear to the right arm. A review of the Plan of Care, dated 01/31/12, revealed the facility initiated an intervention conducting neurological checks and clean the steri strips applied to the skin tear on right arm. A Plan of Care entry on 03/07/12 identified the skin tear as healed. A review of the Admission Minimum Data Set (MDS) assessment, dated 02/03/12, revealed the facility assessed Resident #4 as at risk for falls with a history of falls prior to admission to the facility. The resident required extensive assistance for walking in his/her room, but did not walk in the corridors at the time of the MDS evaluation. A review of the Comprehensive Care Plan for falls, dated 02/03/12, revealed interventions included a personal alarm on at all times and a pressure bed alarm on while in the bed. Further review of the Comprehensive Care Plan for falls, dated 02/03/12, and updated on 03/16/12, revealed the intervention for the personal alarm was discontinued. A review of the "Fall/Change in Functional Status," dated 03/18/12 at 6:30 AM, revealed Resident #4 had an unobserved fall which resulted in a hematoma, 7 centimeter (cm) by 4 cm laceration injury to the back of his/her head, and a bruise on the left thumb. The resident stated he/she fell on the floor. A review of the "Incident Accident Tracking Log," dated 03/18/12 at 6:30 AM, revealed Resident #4 attempted to go to the bathroom unassisted and fell , hitting his/her head. An interview with Certified Nurse Aide (CNA) #6, on 04/20/12 at 10:00 AM, revealed Resident #4 did not like to request assistance and frequently went to the bathroom unassisted. The alarm sounded on 03/18/12, but the resident was already up and trying to get to the bathroom by the time staff arrived. An interview with RN #4, on 04/20/12 at 1:45 PM, revealed Resident #4 was moved to a room closer to the nurse's desk on 03/18/12 to enable the facility staff to closely monitor the resident.The facility initiated an intervention for Resident #4 to be out in the lobby while up due to the resident removing alarms and hiding them in drawers. A review of the Plan of Care, dated 03/18/12, revealed interventions included to encourage Resident #4 to be in up in the lobby for observation and not to be left unattended while up in the wheelchair. A review of the "Fall/Change in Functional Status," dated 03/30/12, revealed a CNA found Resident #4 sitting in the floor of his/her room unattended. The resident stated he/she was trying to walk from the bathroom to the bedroom, reached for the door jam, missed it, and fell to the floor. The facility assessed for injuries and found a skin tear on the left elbow, as well as a complaint of hip pain. A review of the "Incident Accident Tracking Log," dated 03/30/12 at 6:30 PM, revealed Resident #4 was trying to go to the bathroom unassisted after he/she disconnected the alarms. An interview with CNA #8, on 04/19/12 at 3:00 PM, revealed the fall, on 03/30/12, occurred during the dinner meal while Resident #4 was in his/her room alone. CNA #8 described the routine for CNAs during mealtime was to "patrol" the hallway while residents ate meals in their rooms. She passed Resident #4's room and observed him/her sitting on the floor. The resident reported he/she reached for the door jam and fell backwards onto his/her bottom. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed she was assisting in the dining room and was notified that Resident #4 fell . RN #5 returned to the unit after 10 minutes and found that the staff had assisted the resident to the wheelchair, and he/she complained of hip pain. The physical assessment, completed at that time, revealed no obvious deformity and the resident was able to bear weight on his/her leg. RN #5 reported the staff informed her that the alarms sounded when Resident #4 fell and the staff arrived to his/her room to find him/her sitting on the floor. However, the facility did not identify Resident #4's care plan was not being followed as the resident was unattended in his/her room, was not in the lobby, and had alarms in place after they had been discontinued on 03/16/12. An intervention was added to keep the resident in the hallway while up in his/her wheelchair. A review of the Plan of Care, dated 03/30/12, revealed the interventions were updated to include a pressure alarm to the resident's wheelchair even though the facility had discontinued this intervention on 03/16/12 because the Resident #4 would disconnect and hide the alarms. A review of the physician's orders [REDACTED].#4's left shoulder, left hip and left knee. A review of the nurse's note, dated 03/31/12 at 7:00 AM, revealed the x-ray results showed Resident #4 had a left hip fracture. The physician was notified and the facility transferred Resident #4 to the emergency room at 8:45 AM on 03/31/12. A review of the admission information, dated 04/06/12 at 6:00 PM, revealed Resident #4 was admitted to the facility after surgical repair of a left hip fracture which was sustained in the facility on 03/30/12. The facility continued to assess the resident at high risk for falls. Further review the Interim Plan of Care, dated 04/06/12, revealed interventions included the bed was to be in the lowest position, a verbal reminder to not ambulate alone, assistance with transfers and ambulation as needed, observe for unsteady gait, dizziness, and intervene as needed, and pressure bed alarm and chair alarm. There were no documented interventions to address Resident #4's ability to remove the alarms or the need for increased supervision due to the resident's history of falls in the facility or recent fall resulting in a hip fracture requiring surgical repair. A review of the "Fall/Change in Functional Status," dated 04/16/12, revealed Resident #4 was found sitting on the floor of room and "seemed" to be working on his/her television with a metal rod from the wheelchair brake system. The physical assessment revealed no apparent injury was sustained. An interview with CMT #3, on 04/20/12 at 10:30 AM, revealed Resident #4 was found sitting on the floor in his/her room with the wheelchair behind him/her. The resident had the television remote in his/her hand and was "fiddling with it." It "appeared" the resident sat on the floor to work on the television in an attempt to quiet the alarms which were sounding. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed she did not think the resident had fallen; however, the fall was unobserved so it must be treated as a fall. She believed Resident #4 thought the television made the alarm sound and worked on the television to make the alarm stop sounding. She stated Resident #4 was returned to the wheelchair and distracted with activities and left alone in the room. A review of the Plan of Care for falls, dated 04/16/12, revealed an intervention for the resident to be in the lobby while up in the wheelchair as the resident was non-compliant with alarms. However, there was no documented evidence the facility addressed the alarm intervention. A review of the "Fall/Change in Functional Status," dated 04/17/12, revealed Resident #4 suffered two (2) falls within one hour to one and a half (1.5) hours. Resident #4 was found sitting on the floor with one elbow on the bed and one elbow on the seat of the wheelchair. The resident was assisted back to the wheelchair and the alarms were turned off. RN #5 transferred the resident back into the wheelchair and left the room to get equipment necessary for the post falls physical assessment. Resident #4 was left alone in his/her room at that time. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed she believed the first unobserved incident on this date was a "true fall." Resident #4 was alone in his/her room when the chair and bed alarms sounded. RN #5 found the resident sitting on the floor, next to the bed, with one (1) elbow on the bed and one (1) elbow in the seat of the wheelchair. Resident #4 was returned to the wheelchair and RN #5 left the room to get assessment equipment. A review of the "Incident Accident Tracking Log," dated 04/17/12 at 2:30 PM, revealed "the resident was moving in bed and the pressure alarm went off. The resident tried to turn the alarm off and fell out of the bed." Interventions included to offer toileting, snacks or for the activities staff to spend one-to-one time with the resident. Further review of the Fall/Change in Functional Status report, dated 04/17/12 revealed Resident #4 sustained a second fall at 4:00PM. RN #5 returned to the resident's room after leaving to obtain physical assessment equipment to find Resident #4 on his/her hands and knees on the opposite side of the bed. He/she was trying to pull the bed control cord from the bed frame. A review of the post falls physical assessment revealed no injuries. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed RN #5 found Resident #4 on the opposite side of the bed, on hands and knees, trying to pull the bed control cord from the bed frame when she returned to the resident's room with the physical assessment equipment. RN #5 did not believe the second incident was a true fall because the resident was found on his/her hands and knees and pulling on the bed control cord. However, the resident was unattended and the fall was not observed which mandated the fall protocol be initiated. RN #5 stated the "alarms seem to agitate (him/her)." A review of the Incident Accident Tracking Log, dated 04/17/12 at 4:00 PM, revealed the resident was trying to go to bed unassisted and fell . Interventions included to apply geri sleeves, medications were reviewed, and the resident was started on anti-anxiety medication. There was no evidence the facility attempted to determine the root cause of the falls related to the information provided on the Incident Accident Tracking Log dated 04/17/12 compared to the information provided on the Fall/Change in Functional Status report. The Incident Accident Tracking Log listed the root cause of the incident as "Resident was moving in bed, pressure bed alarm went off. Resident tried to turn off alarm and fell out of bed." Information provided by Resident #4's charge nurse at the time of the fall was documented on the Fall/Change in Functional Status report describing the resident was found sitting on the floor with one elbow on the bed and one elbow on the seat of the wheelchair. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed Resident #4 was alone in his/her room when the chair and bed alarms sounded. RN #5 found the resident sitting on the floor, next to the bed, with one (1) elbow on the bed and one (1) elbow in the seat of the wheelchair. A review of the Plan of Care, dated 04/17/12, revealed an intervention was added to treat the resident's pain routinely. The facility did not implement any interventions related to falls prevention or resident safety, on 04/17/12, related to the falls sustained that day. On 04/18/12, an intervention was added to discontinue use of the Norvasc medication and initiate use of Lorazepam for anxiety. A review of the physician's orders [REDACTED]. However, there was no evidence that the facility considered potential side effects of the drug change as the drug Ativan acts by slowing activity in the brain and may cause side effects to include drowsiness, dizziness, weakness, and shuffling gait. An interview with CNA #7, on 04/20/12 at 12:40 PM, revealed Resident #4 did not like the alarms and wanted to try to go to the bathroom alone. CNA #7 revealed the common occurrence of the resident leaning forward in the wheelchair caused the pressure chair alarm to sound, which agitated Resident #4. On 04/17/12, CNA #7 found Resident #4 in his/her room alone after the chair alarm sounded. CNA #7 revealed Resident #4 was taken for activities but would leave the activity and return to his/her room. Supervision after the falls included taking the resident out of the room while in the wheelchair and parking the resident's wheelchair at the nurse's station; however, he/she always wanted to return to the room, and was able to self-propel back to his/her room. An interview with CMT #3, on 04/20/12 at 10:30 AM, revealed her knowledge of the falls, on 04/17/12, came as a request from the Charge Nurse for pain medication indicating pain as the possible reason for Resident #4's agitation. CMT #3 stated she gave the pain medication Lortab 5/325 milligrams (mg) as requested by the Charge Nurse. An observation, on 04/18/12 at 11:40 AM, revealed Resident #4 was in bed with his/her eyes closed and was unattended. On 04/19/12 at 8:55 AM, the resident was returned to the room from physical therapy. He/she refused to be toileted and refused to go to bed. The resident stated he/she would rather be outside in the sun. The facility staff provided Resident #4 with activities on the over bed table for easy reach and the table was on the right side of the resident's wheelchair. Afterward, the facility staff provided Resident #4 with activities and left the resident alone in the room. An observation, on 04/19/12 at 2:00 PM and at 2:30 PM, found Resident #4 lying in the bed unattended with his/her eyes closed. The personal body alarm was attached to the resident's clothing and the bed alarm activation light was blinking. An observation, on 04/20/12 at 11:55 AM, revealed Resident #4 was sitting in his/her wheelchair at the nurse's station. The resident was leaning forward, talking and gesturing with his/her hands and arms. An observation, on 04/20/12 at 1:30 PM, revealed Resident #4 was observed in the bed with a personal body alarm in place. The pressure bed alarm activation light was not blinking and the staff was notified. An observation, on 04/20/12 at 4:25 PM, revealed Resident #4 was sitting in his/her wheelchair in the doorway of his/her room in a forward drooped position with his/her eyes closed. The resident did not respond to a verbal greeting. An interview with CMT #3 revealed Resident #4 received Lortab 5/325 mg for pain at 11:00 AM, and received Ativan for anxiety at 12:00 PM. At 4:33 PM, Resident #4 remained in the wheelchair in the doorway of his/her room. His/her posture was more erect at that time. The resident responded to a verbal greeting by lifting his/her head and opening his/her "glassy" eyes. The resident's mouth fell open from a relaxed jaw, but no verbal response was given. An interview with RN #5, on 04/20/12 at 9:10 AM, revealed Resident #4 was non-compliant with being in the hallway while out of the bed. He/she self-propelled down the hallway and out of sight. Resident #4 was taken to the television room to be with other residents on another unit of the facility at times. However, the resident self-propelled around the facility as desired. RN #5 stated she checked on Resident #4 about every hour or so. Interview with CNA #6, on 04/20/12 at 10:00 AM, revealed Resident #4 got "aggravated" with alarms and threw them across the room. Resident #4 did not want "the girls," meaning the CNAs, to take him/her to the bathroom and tried to go without assistance. CNA #6 reported the staff was suppose to keep an eye on him/her and make sure the resident was not trying to get up unassisted. The staff was to watch for indications of toileting needs, such as shuffling around, or restlessness. Resident #4 was usually taken to the television area on a different unit after meals and left without supervision. An interview with CMT #3, on 04/20/12 at 10:30 AM, revealed Resident #4 moved in and out of his/her room all the time while up in the wheelchair. CMT #3 stated the resident was to be visible at all times, and recalled Resident #4 being in the television room on another unit as recently as four (4) days ago, and self-propelled back to his/her room unassisted. Interview with CNA #7, on 04/20/12 at 12:40 PM, revealed Resident #4 started going to the television room on another unit within the past week. The resident was unsupervised while in the television room. The staff assigned to Resident #4 relied on the staff from another unit when the resident traveled to the television room and called the nurses to alert them that the resident was going to the television room. CNA #7 specifically recalled the resident being in the television room unsupervised at 7:00 AM on the morning of 04/17/12. CNA #7 stated she was constantly looking for the resident as he/she was too quick and "you pretty much have to be there all the time." CNA #7 reported there was only one (1) CNA on the hallway when she worked and she could not keep the resident from going into his/her room, so she had to listen for the alarms. Interview with RN #4, on 04/20/12 at 1:45 PM, revealed the staff tried to keep Resident #4 in sight, but he/she was mobile and went to his/her room when he/she wanted to. RN #4 stated Resident #4 had no safety awareness and returned to his/her room where he/she was unsupervised. An interview with the DON, on 04/20/12 at 3:10 PM, revealed the facility had staffing to ensure adequate supervision was provided for Resident #4 to keep him/her safe. The DON stated if the nursing staff was busy, she could notify other facility departments, such as activities or the chaplain, to attend to the resident. The DON stated Resident #4 cannot be forced to stay at the nurse's station and the staff cannot keep the resident on one-to-one supervision, as the staff had to take care of other residents. The DON reported the facility ensured the safety of Resident #4 the same way as they do for all residents by moving around the facility and ensuring whereabouts of the residents. Another method of ensuring safety, reported by the DON, was "team tackling" and described this method as part of internal audits and the review of different topics each day. However, the facility continued to use interventions of alarms which staff detailed agitated the resident. Furthermore, the facility specified the resident was not to be left alone in his/her room and to be up in the lobby, but the resident was consistently found in the room unattended and found on the floor and considered to have fallen, even after the resident experienced a hip fracture requiring surigical repair. Furthermore incidents reports continued to detail the resident was attempting to go to the bathroom unassisted with no documented evidence that the facility addressed new interventions to prevent the resident from attempting to go to the bathroom unassisted. 2. A record review revealed the facility admitted Resident #1 on 10/17/07 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 02/02/12, revealed the facility assessed Resident #1 as cognitively intact and he/she required minimal assistance of one staff for ambulation. A review of the Falls assessment, dated 02/02/12, revealed the facility assessed Resident #1 at high risk for falls. A review of the Comprehensive Care Plan for falls, dated 02/06/12, revealed the facility developed interventions for Resident #1 to have a personal alarm on at all times while up in the wheelchair and a pressure alarm on while in the bed. A review of the Licensed Nurse Treatment Record, dated 04/12, revealed Resident #1 was suppose to have a personal alarm while up in the wheelchair and a pressure bed alarm on the bed at all times. A review of the CNA Treatment Record, dated 04/12 revealed Resident #1 was suppose to have a personal alarm while up in the wheelchair, and to check placement and function every shift, and for a pressure bed alarm, check placement and function every shift. Observations on 04/18/12 at 10:30 AM, 3:50 PM, 4:35 PM and 4:55 PM, and on 04/19/12 at 9:30 AM, 10:55 AM, 11:40 AM and 1:50 PM, revealed Resident #1 was up in the wheelchair with no alarm in place. Review Licensed Nurse Treatment Record revealed the licensed staff initialed the Treatment Record on 04/18/12 and 04/19/12 for both shifts (7A-7P and 7P-7A) indicating the alarm was in place and had been checked by the licensed staff. Further review CNA Treatment Record revealed CNAs indicated the alarm was in place and functioning on the Treatment Record on 04/18/12 and 04/19/12 for both shifts (7A-7P and 7P-7A). An observation and interview with LPN #1, on 04/19/12 at 10:10 AM, revealed Resident #1 was in the wheelchair with no alarm on the wheelchair and when the nurse checked the resident's bed, there was no pressure alarm under the sheet on the mattress or an alarm box in place. She stated Resident #1 was suppose to have a clip alarm on his/her wheelchair and a pressure alarm on the bed. She was unable to provide an explanation as to why the alarms were not in place. She showed the surveyor the Licensed Nurse Treatment Record and stated the Licensed Nurse checked every shift to ensure his/her alarm was in place and signed. Interviews with CNA #4 and CNA #5, on 04/20/12 at 9:15 AM and 9:25 AM, respectively, revealed Resident #1 should have had a chair alarm and bed alarm in place, but they were unable to provide an explanation as to why the alarms were not in place. They were also unable to provide an explanation as the why the CNA treatment record was initialed indicating the alarms were in place on 04/18/12 and 04/19/12. Interviews with RN #1, RN #3, and Certified Medication Technician (CMT) #2 (who initialed alarms were in place on 04/18/12 and 04/19/12), on 04/20/12 at 10:35 AM, 10:40 AM and 11:00 AM, respectively, revealed when the licensed nurse initialed the treatment record next to the alarm orders, this indicated the alarms were in place and functioning. They were unable to provide an explanation as to why the treatment record was initialed, indicating the alarms were in place on 04/18/12 and 04/19/12. Interview with the DON, on 04/20/12 at 4:00 PM, revealed licensed staff and CNAs were suppose to check and ensure alarms were in place and functioning every shift, and when care was provided for the residents. She stated the licensed treatment record and CNA treatment record was suppose to be initialed at the end of the shift to indicate the alarms were in place and functioning throughout the shift.