Every finding on record at Louisville East Post Acute

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained free of accident hazards and provide adequate supervision for one (Resident (R) 9) of five sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, eloped from the facility on 07/27/2025. Facility safety processes and systems used for supervision failed when the resident left the facility by removing the bedroom window and climbing through it without staff knowledge/supervision. The resident walked approximately 1.3 miles, in the dark. The failure to prevent R9's elopement during 81-degree heat with 90-degree heat index created Immediate Jeopardy with the likelihood for serious harm or death.Immediate Jeopardy (IJ) was identified on 08/13/2025 and was determined to exist on 07/27/2025 in the areas of 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices and 42 CFR S 483.21, F656 Develop/Implement Comprehensive Care Plan. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices. The facility was notified of the IJs on 08/13/2025.On 08/13/2025 at 4:00PM, the Director of Nursing, Administrator and the Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) and provided a copy of the Center for Medicare & Medicaid Services (CMS) IJ Template and was notified that R9's elopement from the facility on 07/27/2025 constituted an IJ.The facility provided an acceptable plan for removal of the IJ on 08/15/2025, alleging removal on 08/04/2025.The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025, prior to the SSA entrance on 08/07/2025, according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The findings include:Review of facility policy titled, Emergency Response (Emergency Preparedness Planning and Resource Manual, pages 18-21, undated), revealed the facility defined elopement as, a situation where a resident with impaired decision making ability who was oblivious to his/her own safety needs and therefore at risk for injury outside the confines of the facility had left the facility without the knowledge of staff. Further review revealed the Resident plan of care would identify interventions to reduce the risk of elopement through use of alarms, exit avoidance, visual cues, engagement, distraction, and increased supervision. Closed Record review of R9's Face Sheet, revealed the facility admitted R9 to the secure memory loss unit on 07/24/2025 with diagnoses including moderate dementia, cataracts and unilateral hearing loss. Review of R9's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/28/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. Per this MDS, R9 required supervision and/or touch prompts, throughout or intermittently, for indoor ambulation and he displayed wandering behaviors for 1-3 days during the assessment period. These factors indicated R9 was at a significant risk of potential danger, if outside the facility unsupervised. Review of R9's admission summary, dated [DATE] revealed R9 was a falls risk and would be evaluated by therapy. Additionally, an admission elopement and wandering risk observation/assessment completed the same day, triggered a risk score of 10, moderate risk of elopement., based on R9's risk factors, as follows; independent ambulation, disorientation/confusion, both his hearing and his vision were impaired, psychotropic medication which may cause irritability and/or restlessness.Review of R9's baseline care plan initiated on 07/24/2025 revealed the Resident was at risk for elopement. Multiple interventions were assigned; admission to secure memory loss unit, medications as ordered, document/notify physician if behavior interferes with daily function, monitor for environmental hazards - which may increase supervision requirements, check exit/stairwell/door alarms on a routine schedule for operability, monitor whereabouts frequently, redirect as needed, wander alarm (a device, usually placed on resident's ankle which triggers an alarm if exiting doors with companion equipment) checking placement and functionality every shift. Additionally, explain all care before providing to reduce resident tension and promote a comfortable experience, observe for behavior/cognitive status change and notify physician if they occur.Review of R9's initial skilled nursing assessment dated [DATE] entered by Advanced Practice Nurse Practitioner (APRN) revealed R9 was found wandering the streets, unable to identify where he lived on 07/14/2025. He was hospitalized on a Geriatric Psychiatric unit, where he was treated for aggression, depression and dementia. Resident 9 was admitted to the facility on [DATE] directly from the Geriatric Psychiatric unit. Review of R9's progress notes in the Electronic Medical Record (EMR) revealed a steady increase in exit seeking behavior and irritability, following his admission up to his elopement: Review of a Nursing Note dated 07/24/2025 and entered at 4:15 PM by Licensed Practical Nurse (LPN)5, revealed R9 was pleasant but confused. [R9] started looking for his keys saying it was time to go. A wander alarm was placed on the resident's left ankle at that time. Review of a Nursing Note dated 07/24/2025 entered by LPN4 at 10:12 PM, revealed R9 stated he was ready to go home and wanted his keys. Review of a Nursing Note entered by LPN4 dated 07/26/2025 entered at 5:00 AM described R9 as increasingly anxious the prior evening 07/25/2025. R9 stated he was leaving the facility, packed up his personnel belongings in paper bags and approached the exit. Further review of the Nursing Note revealed the Resident stayed near the exit door of the unit waiting to leave. Review of a Nursing Note dated 07/27/2025 at 4:50 AM revealed LPN4 entered R9 eloped, and his Power of Attorney (POA) was notified. Review of the facility's Initial Report, dated 07/27/2025 and signed by the Administrator, revealed R9 exited the facility without staff's knowledge or supervision on 07/27/2025, sometime after 2:40 AM. Staff noted R9's absence at approximately 4:00AM, when staff entered his room and discovered the window was removed, placed by the bathroom door and the screen was on the ground outside the facility. Notifications were completed appropriately. At 6:40 AM R9 was found by the police at a nearby park sitting at a picnic table and he returned to the facility with the Administrator and R9's sister, arriving at 7:15 AM. Resident 9 had no injuries; his wander alarm was intact and functional, and he was placed on one-to-one supervision. Review of the form, Division of Health Care, Long-term Care Facility - Self-Reported Incident Form, Final Reports/5 Day Follow-Up, (5-Day FU report), dated 08/01/2025 and signed by the Administrator, revealed that all staff members working on the secure memory loss unit were interviewed following the incident. The form indicated no one saw R9 exit the building. Further review of the 5-Day FU Report revealed staff discovered R9's absence during their 4:00 AM rounds. The last round was done between 2:30 AM and 2:40 AM, during which R9 was in bed with his eyes closed. Further review revealed R9 expressed he had wanted to go for a walk, clear his head and get some peace and quiet. Resident 9 also told the Administrator he was upset and frustrated with his sister. Review of the map attached to the 5-Day FU report revealed R9 had walked 1.3 miles to a nearby church. Observation on 08/11/2025, at 1:00 PM traveled by car on the path R9 followed to the church, revealed a heavily wooded primarily residential area, with scattered sidewalks. The streetlights were present, but the tree canopy would limit their effectiveness and there was no active crosswalk. According to the National Weather Service, National Oceanic and Atmospheric Administration, NOWData revealed the low temperature for July 27, 2025, occurred in the early morning when R9 was walking, was 81 degrees with a heat index of 90. An interview on 08/11/2025 at 3:11 PM with R9's family member, revealed R9 did not want to stay [at the facility] and voiced he wanted to go home. She stated the Resident slept in his room most of the time; and R9 would communicate with the staff but never with other residents, unless they came in his room. Per the interview, she stated the day the resident eloped from the facility, LPN4 called her at 4:00 AM, on 07/27/2025 and reported the resident was gone. R9's family member stated she went to the facility and noticed the resident's window, in his room, did not appear to be broken. She said she assumed it must have been easy to open, adding, the resident did not normally mess with things like that. R9's family member stated she spoke to the police and the Administrator, then she went to look for R9. Later in the morning, the police called and stated the resident was found at a local church. She went to the church immediately. Per the interview, she stated R9 refused to get in the car with her but willingly returned to the facility with the Administrator in his car, arriving at 7:15 AM.Interview with Licensed Practical Nurse (LPN)1 on 08/08/2025 at 3:40 PM revealed she had worked for the facility for over 15 years, and the secured memory care unit had been her home unit for seven years. She stated she remembered admitting R9 and stated as soon as she saw him, she was concerned how the unit would handle him. She described him as agile for his age, jumping down from the transport stretcher. She also stated he did not fit in with the other residents on the unit, they had advanced dementia. She also stated the report from the transferring hospital indicated he had recently wandered from his home and was picked up by the Crisis Intervention Team (a specialized police team trained to work with individuals with mental illness). She stated she had learned R9's sister was trying to get him somewhere safe and had motioned for emergency guardianship. LPN1 stated R9 initially presented he ‘had it all together' but when she spent some time with him his memory loss started to show. During a telephone interview with Certified Nursing Assistant (CNA)5 on 08/12/2025 at 8:25 AM, she stated she had worked 6:00PM to 6:00 AM 'nightshift' on 07/26/2025, the day of R9's elopement. She further stated R9 was 'her resident' that night. CNA5 stated she 'rounded on him' between 12:30 AM and 1:00 AM and he had struggled to get to sleep. Resident 9 wanted to know when his sister would be coming in to pick him up and ‘I told him I didn't know'. I got him a snack and a cold drink. We talked awhile and R9 settled down. She reported, upon returning to his room between 2:20 AM and 2:30 AM, her two-hour rounds, R9 appeared to be asleep. She remembered his blue jeans folded on his bedside table and his shoes next to the bed. She further explained CNAs did not document patient (resident) rounds. She stated when it was about time for her next round, she heard a code called overhead. She stated she did a headcount on the front half of her hallway and then searched all the rooms and bathrooms for R9. A phone interview with LPN4 on 08/09/2025 at 6:56 PM, revealed he was the nurse caring for R9 on 07/27/2025 when he eloped. LPN4 had cared for R9 frequently including the day of his admission, 07/24/2025. Per the interview, LPN4 stated he thought R9 was ‘sundowning' and described R9 as more anxious in the evening than in the day. LPN4 relayed on his next shift 07/25/2025 R9 packed up his stuff in paper bags and said he was ready to go. He stated R9 then went to the exit doors and waited there to leave. LPN4 stated R9 finally went to bed around 9:00 PM. He further stated, after the other Residents went to bed, R9 was still wandering around the unit. LPN4 stated ‘I asked him to go to his room, and he ignored me'. LPN4 stated nurses rounded once a shift and he thought the aids rounded more but not sure how frequently. LPN4 said he knew R9 was gone when he saw the windowpane in the frame next to the restroom and the screen outside. LPN4 stated he did not know how the resident got the window apart. Further, he stated he alerted the CNAs, called the police, R9's sister and the Administrator. An interview with the Director of Maintenance on 08/11/2025 at 3:11 PM, he stated he was called on 07/27/2025 at 7:00 AM, the morning of the elopement, and he came straight in. The Director of Maintenance stated that when he entered R9's room, he noted a staff person stationed at the window to ensure resident safety. The staff monitor remained until the window was repaired and secure. The Director of Maintenance said R9 had broken the window stop, which had been secured with a [NAME] head screw. Further, he stated this allowed the Resident to move the lower sash enough to engage the tilt latch and remove the lower sash from the window frame entirely. He stated he was not sure how R9 removed the screws, stating they were not in super tight, or the tension would have split the vinyl, but they were too tight to loosen by hand. He stated R9 had later apologized for breaking the window frame but did not elaborate on how he had dismantled the hardware.An interview with the Director of Nursing (DON) and the Administrator, on 08/12/2025 at 2:35 PM, revealed the DON stated she learned about R9's elopement while on vacation. She stated secure memory loss unit staff were trained on hire and annually on the care of residents with Dementia and the staff who cared for R9 the day he eloped were 'well-seasoned,' long term employees. During the initial interview with the Administrator, on 08/07/2025 at 1:30 PM, he stated the elopement was a 'one off', R9 was an inappropriate admission for the secured memory care unit. He stated, R9 represented 0.0001% the residents on the secure memory care unit, and no other resident could have dissembled the window or crawled through it. He further stated the facility's Director of Maintenance came in immediately following the elopement and assessed all facility windows for similar issues and found none. Per the interview, he stated that following a team discussion, the Director of Maintenance sealed all the windows shut with adhesive silicone to ensure resident safety. The Administrator relayed in continued interview, on 08/12/2025 at 2:35 PM, the facility's newly created memory care unit admission's process, staff education, coupled with the daily elopement risk review was in place to prevent any future elopement. The facility provided an acceptable plan for the removal of the Immediate Jeopardy on 08/14/2025. The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025 at 2:15 PM according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:On 07/27/2025 the Facility initiated Emergency Preparedness Plan, and the Administrator, Emergency Contact, and Police were notified. On 07/27/2025 upon return to the facility Resident 9 received a head-to-toe physical and psychosocial assessment with no injury or emotional distress noted. Resident placed one on one supervision. His wander guard placement and functionality were validated. On 07/27/2025 R9's Wandering/Elopement Risk Observation/Assessment, Brief Mental Status Exam (BIMS), Elopement/Wandering Risk Care Plan interventions were all updated. On 07/27/2025 all windows were checked for proper functionality.On 07/28/2025 all exit door armed with the wander guard system was functioning properly.On 07/27/2025 and 07/28/2025 staff assigned to R9 at time of incident received one on one education including but not limited to increased behaviors, exit seeking, notification of supervisor and physician of change of condition, resident care plan and following care plan interventions, and potential need to increase supervision.On 07/28/2025 an audit of all facility resident Elopement and Wandering safety risk was conducted by completion of: Wandering Risk/Observation Assessments, Identification of any additional potentially at-risk residents, Care Plan updates, Verification of Interventions and Inclusion in the Elopement Binders.On 07/28/2025 an Ad Hoc Quality Assurance Performance Improvement Committee (QAPI) met and performed an incident root cause analysis. An updated procedure for all new referrals was established, to ensure Resident functional status, mobility level, goals, and desire for placement are reviewed by the Interdisciplinary Team (IDT). Additionally, the secure unit began to conduct hourly rounding for all new admissions for 72 hours, this supervision will increase to every 15 minutes if residents actively exit seek, express the desire to leave, or has a noted change of condition. The QAPI committee will meet monthly and as needed. On 07/28/2025 the IDT began a daily review of the Elopement Binders and Care Plans will be reviewed for accuracy for individuals at risk for elopement. On 07/27/2025 all windows were sealed shut with adhesive caulk. Daily door checks and weekly window checks conducted for four (4) weeks, then every other week for four (4) weeks and monthly thereafter until compliance is maintained for at least three consecutive months and the QAPI Committee reviews for potential safety concerns for accidents or hazards.From 07/27/2025 through 07/28/2025 staff on the secured unit were educated on recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention, resident change in condition, notification of supervisor, person-centered care plan, and implementation of appropriate interventions to promote resident safety, identify potential elopement risks, and the process changes for screening, referrals and supervising new admissions. From 07/28/2025 through 08/04/2025 all facility staff were educated recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention. The facility elopement/wandering policy, and emergency protocol. Facility elopement/wandering policy, and emergency protocol, change of condition, care plan updates, increase behaviors, and supervision were also reviewed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' baseline care plan which provided instructions needed to provide effective and person-centered care for each resident was implemented for 1 of 5 (Resident (R) 9) sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, was care planned to be monitored frequently for his whereabouts, however, on 07/27/2025, the Resident left the facility by removing his bedroom window and climbing through it without staff knowledge/supervision. The Resident walked approximately 1.3 miles, in the dark. The failure to implement R9's baseline care plan to prevent R9's elopement during 81-degree heat with 90-degree heat index created Immediate Jeopardy with the likelihood for serious harm or death.Immediate Jeopardy (IJ) was identified on 08/13/2025 and was determined to exist on 07/27/2025 in the areas of 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices and 42 CFR S 483.21, F656 Develop/Implement Comprehensive Care Plan. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25, F689 Free of Accident/Hazards/Supervision/Devices. The facility was notified of the IJs on 08/13/2025.On 08/13/2025 at 4:00PM, the Director of Nursing, Administrator and the Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) and provided a copy of the Center for Medicare & Medicaid Services (CMS) IJ Template and was notified that R9's elopement from the facility on 07/27/2025 constituted an IJ.The facility provided an acceptable plan for removal of the IJ on 08/15/2025, alleging removal on 08/04/2025. The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025, prior to the SSA entrance on 08/07/2025, according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The findings include:Review of the facility's policy, Safety and Supervision of Residents ((C) 2001 MED-PASS, Inc.) revealed the facility used a facility and resident oriented approach to environmental safety. Per review, their systems approach considered hazard identified and individual resident risk factors and adjusted interventions accordingly. Per review, the facility mitigated safety and accident hazards with an individualized, resident-centered approach which included: identifying specific hazards by analyzing assessments and observations, provide targeted interventions, which may include adequate supervision.Review of the facility's policy Wandering and Elopements ((C) 2001 MED-PASS, Inc.) revealed the facility would identify residents at risk for unsafe wandering and elopement and strive to prevent harm while maintaining the lease restrictive environment. Per review, those identified at risk would have identified strategies and interventions included in their plan of care to maintain resident safety. Closed Record review of R9's Face Sheet, revealed the facility admitted R9 into its secure memory loss unit on 07/24/2025 with diagnoses including moderate dementia, cataracts and unilateral hearing loss.Review of R9's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/28/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. Per this MDS, R9 required supervision and/or touch prompts, throughout or intermittently, for indoor ambulation and he displayed wandering behaviors for 1-3 days during the assessment period. Review of R9's baseline care plan initiated on 07/24/2025 revealed the Resident was at risk for elopement. Multiple interventions were assigned; admission to secure memory loss unit, medications as ordered, document/notify physician if behavior interferes with daily function, monitor for environmental hazards - which may increase supervision requirements, check exit/stairwell/door alarms on a routine schedule for operability, monitor whereabouts frequently, redirect as needed, wander alarm (a device, usually placed on resident's ankle which triggers an alarm if exiting doors with companion equipment) checking placement and functionality every shift. Additionally, explain all care before providing to reduce resident tension and promote a comfortable experience, observe for behavior/cognitive status change and notify physician if they occur.Review of a Nursing note dated 07/24/2025 at 4:15 PM revealed R9 was pleasant but confused. Continued review revealed the resident started looking for his keys saying it was time to go. Per review of the note, the resident was placed on a wander alarm to his left ankle.Review of a Nursing note dated 07/24/2025 at 10:12 PM, revealed R9 stated he was ready to go home and wanted his keys. Review of a Nursing note dated 07/26/2025 at 5:00 AM described R9 as increasingly anxious the prior evening, 07/25/2025. R9 stated he was leaving the facility, packed up his personnel belongings in paper bags and approached the exit. Per review of the note, the Resident stayed near the exit door of the unit waiting to leave. However, there was no documentation to support the Resident's care plan was implemented to monitor his whereabouts frequently.Review of a Nursing note dated 07/27/2025 at 4:50 AM revealed R9 eloped and his Power of Attorney (POA) was notified.Review of a Nursing note dated 07/30/2025 at 7:20 PM revealed R9 had become increasingly agitated with staff and was verbally threatening to fight staff if they prevented him from leaving. R9 was transferred to the Veterans Administration hospital for evaluation and treatment. The Resident did not return to the facility. Observation on 08/11/2025, at 1:00 PM traveled by car on the path R9 followed to the church, revealed a heavily wooded primarily residential area, with scattered sidewalks. The streetlights were present, but the tree canopy would limit their effectiveness and there was no active crosswalk. An interview on 08/11/2025 at 3:11 PM with R9's family member revealed she recalled R9 asking for his suitcases one day when she was at the facility. Per the interview, she stated that on the day the resident eloped from the facility, Police Officer (PO) called her when R9 was found, and she drove straight to the location provided. The resident was found at a local church, sitting at a picnic table with all his earthly belongings packed into a couple brown paper bags. She stated the Resident was confused and had told the PO he had driven himself there in his mother's car. During a telephone interview with Certified Nursing Assistant (CNA)5 on 08/12/2025 at 8:25AM, she stated R9 got frustrated sometimes because staff could not give him enough attention, adding, he was a talker. She stated sometimes she could redirect him, but his anxiety increased during the part of the evening when CNAs were typically busy putting other residents to bed. CNA5 stated she wished she had had more things to offer R9 so that he could stay independently busy. She went on to say, I offered to get him some cards, but he said he didn't play.Further, CNA5 stated on 08/12/2025 at 8:25 AM, the evening of the elopement, R9 was aggravated on and off. She stated she recalled R9 followed the nurse down the hall talking to him as he passed medications but then R9 refused to take his own medications. CNA5 stated she did not think to talk with her nurse or her supervisor about his behavior. A phone interview with LPN4 on 08/09/2025 at 6:56 PM, revealed he was the nurse caring for R9 on 07/27/2025 when R9 eloped. LPN4 said R9 was courteous but began asking for his keys on his first day and told him, it was time to go home. LPN4 stated he thought the Resident was ‘sundowning' and described R9 as more anxious in the evening than in the day. LPN4 stated ‘I asked him to go to his room, and he ignored me'. LPN4 stated the aids were checking him regularly; however, stated he never contacted Administration to ensure increased supervision for the Resident was provided, as per the Resident's care plan. He stated he would have been dayshift to have made that call. An interview with the Director of Maintenance on 08/11/2025 at 3:11 PM, he stated he was called on 07/27/2025 at 7:00 AM, the morning of the elopement, and he went to the facility. The Director of Maintenance said R9 had broken the window stop, which had been secured with a [NAME] head screw. Further, he stated this allowed R9 to move the lower sash enough to engage the tilt latch and remove the lower sash from the window frame entirely. He stated he was not sure how R9 removed the screws, stating they were not in super tight, or the tension would have split the vinyl, but they were too tight to loosen by hand. He stated R9 had later apologized for breaking the window frame but did not elaborate on how he had dismantled the hardware.An interview with the Director of Nursing (DON) on 08/12/2025 at 2:35 PM, she stated it was her expectation for nursing staff to utilize the interventions on the resident's plan of care. She further stated safety was first; and staff should increase the resident's supervision without permission or an order, according to their judgement. Further, she stated staff should also inform their supervisor and/or the provider before the end of their shift, so ongoing staffing arrangements could be made. An interview with the Administrator on 08/12/2025 at 2:35 PM revealed it was his expectation that the facility would always have increased resident supervision and one-to-ones (1:1) covered. Per interview, he stated that staffing was not an issue and a supervisor present at all times to pitch in when needed. The facility provided an acceptable plan for the removal of the Immediate Jeopardy on 08/14/2025. The State Survey Agency (SSA) survey team validated the IJ was removed on 08/04/2025 at 2:15 PM according to the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice was determined to be past non-compliance. The Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:On 07/27/2025 the Facility initiated Emergency Preparedness Plan, and the Administrator, Emergency Contact, and Police were notified. On 07/27/2025 upon return to the facility Resident 9 received a head-to-toe physical and psychosocial assessment with no injury or emotional distress noted. Resident placed one on one supervision. His wander guard placement and functionality were validated. On 07/27/2025 R9's Wandering/Elopement Risk Observation/Assessment, Brief Mental Status Exam (BIMS), Elopement/Wandering Risk Care Plan interventions were all updated. On 07/27/2025 all windows were checked for proper functionality.On 07/28/2025 all exit door armed with the wander guard system was functioning properly.On 07/27/2025 and 07/28/2025 staff assigned to R9 at time of incident received one on one education including but not limited to increased behaviors, exit seeking, notification of supervisor and physician of change of condition, resident care plan and following care plan interventions, and potential need to increase supervision.On 07/28/2025 an audit of all facility resident Elopement and Wandering safety risk was conducted by completion of: Wandering Risk/Observation Assessments, Identification of any additional potentially at-risk residents, Care Plan updates, Verification of Interventions and Inclusion in the Elopement Binders.On 07/28/2025 an Ad Hoc Quality Assurance Performance Improvement Committee (QAPI) met and performed an incident root cause analysis. An updated procedure for all new referrals was established, to ensure Resident functional status, mobility level, goals, and desire for placement are reviewed by the Interdisciplinary Team (IDT). Additionally, the secure unit began to conduct hourly rounding for all new admissions for 72 hours, this supervision will increase to every 15 minutes if residents actively exit seek, express the desire to leave, or has a noted change of condition. The QAPI committee will meet monthly and as needed. On 07/28/2025 the IDT began a daily review of the Elopement Binders and Care Plans will be reviewed for accuracy for individuals at risk for elopement. On 07/27/2025 all windows were sealed shut with adhesive caulk. Daily door checks and weekly window checks conducted for four (4) weeks, then every other week for four (4) weeks and monthly thereafter until compliance is maintained for at least three consecutive months and the QAPI Committee reviews for potential safety concerns for accidents or hazards.From 07/27/2025 through 07/28/2025 staff on the secured unit were educated on recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention, resident change in condition, notification of supervisor, person-centered care plan, and implementation of appropriate interventions to promote resident safety, identify potential elopement risks, and the process changes for screening, referrals and supervising new admissions. From 07/28/2025 through 08/04/2025 all facility staff were educated recognizing exit seeking behaviors in residents with dementia, appropriate verbal redirection and other non-pharmacological intervention. The facility elopement/wandering policy, and emergency protocol. Facility elopement/wandering policy, and emergency protocol, change of condition, care plan updates, increase behaviors, and supervision were also reviewed.

Based on observation, interview, and review of facility policy, the facility failed to ensure garbage was stored in containers and off the ground to prevent potential spread of insect or rodent activity. This failure affected all 172 facility residents. Findings include: Review of the facility policy titled, Food-Related Garbage and Refuse Disposal, dated October 2017, and provided by the facility, revealed, All food waste shall be kept in containers . All garbage and refuse containers are provided when stored or not in continuous use. and must be kept covered . Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During an observation, on 07/17/2024 at 8:00 AM, in the outdoor dumpster area in a corner of the facility parking lot, a trash compactor was observed with a large pile of dirty and decaying trash underneath it on the ground. During an observation and concurrent interview with the Dietary Manager (DM), on 07/18/2024 at 12:11 PM, the trash compactor was again observed with a large pile of dirty trash on the ground underneath it. The DM stated trash was piled on the ground under the compactor and needed to be cleaned up. The DM further stated the compactor was no longer used and she did not often go out to the dumpster area. In continued interview, the DM stated the trash pile on the ground created a potential to attract bugs and rodents.

Based on observation, interview, and review of facility policy, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. During tours of the facility, on 07/16/2024 and 07/17/2024, live roaches were observed in resident room [ROOM NUMBER] and in the the dry storage area of the kitchen. Additionally, interviews with residents and staff revealed they had seen roaches in the building. All 172 residents had the potential to be affected. The findings include: Review of facility's policy titled, Pest Control with a revision date of May 2008, revealed the facility shall maintain an effective pest control program and the facility will maintain an ongoing pest control program to ensure the building is kept free of insects and rodents. Review of the Pest Activity Log, revealed resident rooms 124, 309, 402, 416; 300/400 area; resident rooms 422 through 428; kitchen; and nurses' station were treated on 05/08/2024 for non-stated pests. Review of the Pest Activity Log, revealed the kitchen; biohazard room; and resident rooms 102, 112, 408, and 416, were treated on 05/23/2024 for gnats, oriental roaches, and ants. Review of the Pest Activity Log, revealed resident rooms and offices were treated for oriental roaches on 06/19/2024 and 06/12/2024. The Log did not state which specific rooms or offices were treated. Review of the Pest Activity Log, revealed the kitchen dish room; and resident rooms 216, 309, 416, 424, were treated for oriental roaches on 07/16/2024. An interview was conducted, on 07/16/2024 at 10:55 AM, with Resident (R)26, who was assessed per the quarterly Minimum Data Set, with an Assessment Reference Date (ARD) of 06/05/2024, as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R26 stated there were roaches in his room and he watched a roach crawl around yesterday. He further stated the facility did routine spraying which seemed to help; however, they were still present. Observation on 07/16/2024 at 10:57 AM, revealed a roach crawling out from under the bed of room [ROOM NUMBER]. R26 ran over the roach with his bedside table and killed it. He stated he killed the roaches so they wouldn't crawl all over his room. An interview was conducted, on 07/16/24 2:15 PM, with Resident (R)13, who was assessed per the quarterly MDS, with an ARD date of 05/03/2024, as having a BIMS score of 13 out of 15, indicating intact cognition. R13 stated she had seen big roach-like bugs in her room about every night. During an interview with Licensed Practical Nurse (LPN) 4 and CNA1 on 07/17/2024 at 8:20 AM, they stated they had not seen roaches, but had heard other staff discuss seeing roaches within the facility. LPN4 stated the insect problem seemed to be more significant in the 300/400 hall area according to discussions. Interview with Certified Nurse Aide (CNA) 2, on 07/17/2024 at 8:50 AM, revealed she had witnessed roaches in the facility. Observation during tour of the kitchen, on 07/17/2024 at 9:35 AM, revealed a roach was crawling in the dry storage area from underneath food storage shelves. A roach trap was under the storage shelves and a separate trap was in an area beside the baking pan storage area; both contained dead bugs. Interview with the Assistant Dietary Manager, on 07/17/2024 at 9:35 AM, revealed she had worked in the facility for three (3) years. She stated the Pest Control Services sprayed the kitchen once a month and more if requested by the facility. She further stated the insect problem seemed to have worsened in the last three to four (3-4) months in the building. The Assistant Dietary Manager stated roach traps were changed every four to five (4-5) months or as needed, but she could not recall the last time the traps were changed. Interview with Resident (R)171's family member (F5), on 07/17/2024 at 6:40 PM, revealed she had witnessed roaches in R171's room while he was a resident at the facility. She further stated she had made complaints regarding the roaches to facility staff while R171 was in the facility; however, the problem continued. F5 further stated the Administrator refused to return her calls after R171 was discharged . Closed record review revealed Resident 171 resided in the facility from [DATE] until 07/29/2022. Interview with the Director of Environmental Services, on 07/18/2024 at 8:40 AM, and 3:15 PM, revealed he had been employed with the facility for [AGE] years. He stated roaches had been an issue in the past, but the problem got worse in the last six to seven (6-7) months, mostly affecting resident rooms 401-416. In further interview, he stated he and other staff checked the affected rooms and made sure any food was in sealed containers. He further stated he had staff check room [ROOM NUMBER] regularly after each mealtime to clean food up food the resident dropped on the floor during mealtime. The Director of Environmental Services stated there had been discussions in the Morning Meeting which included department heads, regarding roaches and what could be done to stop the problem or slow the spreading. Interview with the Pest Control Company Representative, on 07/18/2024 at 9:00 AM, revealed the facility had contracted with this company since 1992. He stated the facility was treated twice monthly, but did request additional treatments outside of the regular treatment schedule due to sightings/issues. The Representative stated the method of treatment utilized within the facility depended on the area of the facility being treated. He further stated the standard of treatment being used for this facility was generally effective, but there were other options if this method was not working for the facility. The Representative could not provide additional information as to what was causing the infestation of roaches. Interview with the Director of Nursing (DON), on 07/19/2024 at 8:10 AM, revealed she has been employed as the DON since February 2023. The DON stated she did recall a resident complaint in a Resident Council meeting awhile back regarding pests, but she did not recall consistent complaints. She stated she was not involved in meetings specific to pest control issues. She further stated roach issues had probably been discussed in Morning Meetings. The DON stated no formal education had been provided to nursing staff as to how to report or prevent roaches in the facility. However, the DON stated it was her expectation the facility be kept as clean as possible, and free of pests. Interview with the Administrator, on 07/19/2024 at 8:20 AM, revealed he had been employed as administrator of the facility since April 2020. The Administrator stated he did not feel roaches were a problem in the facility. He further stated he felt the facility provided a homelike environment, and homes sometimes had pests. Per interview, he had been told the State Agency Surveyors located six (6) dead roaches in a trap in the kitchen area, and further stated, then we are doing our job. During continued interview with the Administrator on 07/19/2024 at 8:20 AM, he stated roaches had been discussed in the Morning Meetings with the interdisciplinary team and solutions included continued pest control, cleanliness, and open food placed in containers. He further stated the Director of Environmental Services was immediately called when a roach was discovered in the facility. Per interview, he was sure he had probably had recent discussions with the Director of Environmental Services regarding pest control, but he couldn't recall any recently. In further interview, the Administrator stated he felt it was his job to put the right people in place to take care of things such as the Director of Environmental Services and limit his involvement to an as needed basis. He stated he could not recall having any complaints from families regarding roaches.

Based on observation, interview, and review of facility policy, the facility failed to serve meals that were palatable and attractive. Interviews with Residents (R)13, R26, R74, R81, R86, revealed concerns related to the foods not being palatable, or attractive with foods running together on the plate, causing the food to be watery and sloppy. Additionally, during the Group Interview, conducted by the State Survey Agency, R22, R12, and R46 all stated the food was not appetizing and did not taste good, partly because the foods were overcooked and watery and plated in a manner in which fluids from one food would run into the others. Furthermore, during an observation of tray line during lunch meal service in the kitchen, on 07/18/2024 beginning at 11:06 AM, Cook1 served a chicken leg and thigh, a scoop of macaroni and cheese, and a scoop of green beans all on the same plate for all diet types. Visible liquid spread over the plates when the green beans were added. Moreover, during an observation of tray line during the dinner meal service in the kitchen, on 07/18/2024 at 5:18 PM, Cook2 served red beans and sausage in gravy and boiled greens both on the same plate without using bowls. Visible liquids from the foods were observed running on the plates. In addition, observation of a test tray with the Dietary Manager (DM), on 07/18/2024 at 5:45 PM, in the 300/400 Hall, revealed the plate of greens and red beans and sausage had visible liquid running on the plate. The food on the plate appeared soupy and the juices from the foods were running together, making the meal appear unappetizing. Findings include: Review of the facility policy titled, Enhancing the Dining Experience through Garnishing, dated 2018, revealed, It is important to remember that a guest eats with their eyes first . Elements of Good Table and Plate Presentation . Complimentary food combinations with attractive arrangements on the plate . [and] using separate dishes to hold food with liquid. 1. An interview was conducted, on 07/16/2024 at 10:16 AM, with R74, who was assessed per the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/08/2024, as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. R74 stated the food was terrible and bland and all the foods ran together on the plate. R74 further stated this had always been a problem and though it has been addressed with staff, nothing had changed. 2. An interview was conducted on 07/16/2024 at 10:46 AM with R81, who was assessed per the quarterly MDS assessment, with an ARD of 04/26/2024, as having a BIMS score of four (4) out of 15, indicating severe cognitive impairment. R81 stated she received ground foods, and they all ran together on the plate and tasted the same. 3. An interview was conducted on 07/16/2024 at 10:55 AM, with R26, who was assessed per the quarterly MDS assessment with an ARD of 06/05/24, as having a BIMS score of 15 out of 15 intact cognition. R26 stated the food was not plated well and juice from vegetables often ran into other foods on the plate. R26 stated this happened recently when he was served pizza with boiled greens on the side, and the juice from the greens turned his pizza crust soggy. Per interview, this happened often with other foods and was unappetizing. R26 further stated this concern had been brought to the attention of staff many times, but had not yet been addressed. 4. An interview was conducted with R86 on 07/16/2024 at 12:00 PM, who was assessed per the quarterly MDS assessment, with an ARD of 04/22/24, as having a BIMS score of 15 out of 15, indicating intact cognition. R86 stated the food was not good and did not appear appetizing. 5. An interview was conducted with R13 on 07/16/2024 at 2:15 PM, who was assessed per the quarterly MDS assessment, with an ARD of 05/03/24, and as having a BIMS score of 13 out of 15 indicating intact cognition. R13 stated the food was not good and described the food as watery and sloppy. R13 stated all the foods ran together on the plate because they were so watery. 6. The State Survey Agency conducted a Group Interview, on 07/18/2024 beginning at 9:58 AM. R22, R12, and R46 all stated the food was not appetizing and did not taste good, partly because the foods were overcooked and watery and plated in a manner in which fluids from one food would run into the others. The residents stated this had been a concern for a while and they had already brought it to staff's attention without any follow-up. R22's annual MDS assessment, with an ARD of 05/30/24, revealed a BIMS score of 13 out of 15, indicating intact cognition. R12's quarterly MDS assessment, with an ARD of 06/24/24 revealed a BIMS score of 13 out of 15, indicating intact cognition. R46's quarterly MDS assessment, with an ARD of 05/09/24, revealed a BIMS, score of 15 out of 15, indicating intact cognition. 7. During an observation of tray line during lunch meal service in the kitchen, on 07/18/2024 beginning at 11:06 AM, Cook1 served a chicken leg and thigh, a scoop of macaroni and cheese, and a scoop of green beans all on the same plate for all diet types. The green beans on the steam table were in liquid, and the liquid was drained for approximately two (2) seconds prior to plating. Visible liquid spread over the plates when the green beans were added. 8. During an observation of tray line during the dinner meal service in the kitchen, on 07/18/2024 at 5:18 PM, Cook2 served red beans and sausage in gravy and boiled greens both on the same plate without using bowls. The beans and sausage dish appeared soupy, and the greens were stored in liquid on the steam table. [NAME] 2 drained the greens for approximately two (2) seconds before plating, and visible liquid from the foods was observed running on the plates. 9. Observation of a test tray with the Dietary Manager (DM), on 07/18/2024 at 5:45 PM, in the 300/400 Hall, revealed the plate of greens and red beans and sausage was had visible liquid from both dishes running on the plate. The food on the plate appeared soupy and the juices from the food were running together, making the meal appear unappetizing. The DM stated the foods had a lot of liquid and she would expect the soupy beans and sausage dish to be served in a bowl rather than directly on the plate. The DM further stated the facility did not have enough bowls to use, and she had already placed an order for more bowls for this purpose, but had not yet received them. She further stated the facility did have Styrofoam bowls available for use. During continued interview with the DM on 07/18/2024 at 5:45 PM, she stated she needed to direct the staff to drain out more of the liquid from foods before placing it on the steam table. The DM stated she had not provided any education to dietary staff regarding draining foods or plating foods with liquids to avoid draining on the plate. The DM further stated the residents had recently brought up this concern to her during a cook out, when the baked beans liquid ran into the hamburger buns on the plate. The facility provided an order receipt for 48 large bowls. Per the receipt, the order was placed on 06/06/2024 and received on 06/12/2024. No additional information was provided regarding a plan of action to address residents' concerns related to food palatability.

Based on interview, and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) that included all required appeal contact information for three (3) of three (3) residents reviewed for beneficiary notices out of a total sample of 39 residents, Resident (R)13, R58, and R219. Additionally, the facility failed to correctly complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for R13 and R58, informing residents or their responsible party of information related to a Medicare A; and the facility failed to follow the appropriate instructions for the SNFABN form. This failure could lead to residents or their responsible party not understanding their options when skilled care was ending. Findings include: Review of the Form Instructions Advanced Beneficiary Notice of Non-coverage (ABN), provided by the facility when the SNFABN instructions were requested, revealed .The ABN is a notice given to beneficiaries in original Medicare to convey that Medicare is not likely to provide coverage in a specific case. Notifiers include: Physicians, providers (including institutional providers like outpatient hospitals), . Medicare inpatient hospitals and skilled nursing facilities (SNFs) use other approved notices for Part A items and services when notice is required in order to shift potential financial liability to the beneficiary. 1. Review of the facility completed SNF Beneficiary Protection Notification Review form, revealed R13 began a Medicare A skilled stay on 02/05/2024 and received skilled therapy and skilled nursing. Her last covered day (LCD) was 02/16/2024. The facility issued her a Notice of Medicare Non-Coverage (NOMNC). She was also issued a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN). Both notices were issued on 02/14/2024. R13 signed both notices for herself. During an interview with R13, on 07/19/2024 at 1:30 PM, it was confirmed she signed the forms and was remaining in the building for long-term care. Review of R13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/2024, located in the resident's Electronic Medical Record (EMR) under the MDS tab, revealed the facility assessed R13 as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of the NOMNC, provided by the facility, revealed it did not include the teletypewriters (TTY), a phone system that allows deaf and hard of hearing to use the phone as directed, in the appeal information. Review of the SNFABN, revealed the form did not include R13's name and patient identification number at the top of the form. On the form under, Items or Services: Room and Board, the facility entered the semi-private cost for room board and indicated the amount was $250 per day, Therapy- PT OT [physical therapy and occupation therapy] $75 per unit, & ST [speech therapy] $150 per unit. The Because information was not completed. In the options, the facility had two (2) boxes for choices. The first option stated, Yes, I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes its decision. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare's decision. The second option stated, No. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won't pay. I understand that, in the case of any physician-ordered items or services, should notify my doctor who ordered them and that I did not receive them. R13 marked option two (2), indicating she did not want to receive any skilled nursing or therapy. The facility used instructions for completing an ABN form instead of the SNFABN form and failed to address why services would not be covered. 2. Review of the facility completed SNF Beneficiary Protection Notification Review form, revealed R58's Medicare A skilled stay started on 02/05/2024. R58 received skilled therapy and skilled nursing. Her LCD was 04/05/2024. The facility issued her a NOMNC and SNFABN. Review of the facility provided NOMNC, revealed it did not include the TTY (teletypewriters), a phone system that allows deaf and hard of hearing individuals to use the phone. Review of the facility provided SNFABN form, revealed it did not include R58's name and patient identification number at the top of the form. On the form under Items or Services: Room and Board, the facility entered the semi-private cost for room board and indicated the amount was $250 per day, Therapy PT OT (physical therapy and occupation therapy) $75 per unit & ST (speech therapy) $150 per unit. The Because information was not completed. In the options the facility had two (2) boxes for choices. The first option stated, Yes, I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes its decision. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare's decision. The second option stated, No. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won't pay. I understand that, in the case of any physician-ordered items or services, should notify my doctor who ordered them and that I did not receive them. R58 marked option two (2), indicating she did not want to receive any skilled nursing or therapy. The facility used instructions for completing an ABN form instead of the SNFABN form and failed to address why services would not be covered. Review of R58's Part A Discharge MDS with an ARD of 05/05/2024, located in the resident's EMR under the MDS tab, revealed a BIMS score of seven (7) out of 15, indicating she was severely cognitively impaired. Review of the EMR contained a Face Sheet located in the Profile tab which indicated R58 had a power of attorney (POA.) On 07/19/2024, two (2) attempts were made to reach the resident's niece, but were unsuccessful. 3. Review of R219's EMR Admission Note, revealed the facility originally admitted the resident on 03/01/2024 for therapy. Her LCD for Medicare was 03/29/2024. R219 planned to return home with one of her children. Review of R19's NOMNC did not include the TTY number. During an interview, on 07/19/2024 at 1:57 PM, the Business Office Manager (BOM) revealed she created the form for the social workers to issue to residents. The BOM was not aware the TTY number was required to be on the NOMNC and the SNFABN was to indicate why the facility did not believe Medicare would continue to pay. The BOM was not aware the ABN instructions they followed were not the same as the SNFABN instructions. During an interview, on 07/19/2024 at 3:00 PM, the Administrator revealed the facility followed the instructions for the NOMNC and SNFABN located on Center for Medicare and Medicaid Services (CMS.). NOMNC instructions were requested, but not received prior to survey exit.

Based on interview, record review, and review of the facility's policy, the facility failed to issue the resident or their representative a written notification of transfer when the resident was transferred to the hospital for three (3) of five (5) sampled residents reviewed for emergency transfers out of a total sample of 39 residents, Resident (R)73, R124, and R150. The facility failed to have a system in place for sending written notifications to residents and/or their representatives. This failure created the potential for the resident and/or the representative to lack the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Transfer or Discharge, Emergency, revised August 2018, revealed Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) . 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: . d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; . 1. Review of the undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted R124 on 09/10/2022 with diagnoses to include dementia and a subdural hemorrhage. Review of R124's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/12/2023, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of 15 indicating severe cognitive impairment. Review of R124's Progress Notes, located in the EMR under the Progress Notes tab, revealed the resident fell on [DATE] and was sent to the emergency room (ER) for evaluation and treatment. R124 returned to the facility on [DATE]. R124's responsible party could not be reached for interview. Further review of R124's medical record, revealed there was no documented evidence of a transfer notice sent to the resident/resident representative regarding the hospital transfer. 40847 2. Review of R73's undated Admission Record, located in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 08/25/2023 with diagnoses including Alzheimer's disease, gout, vascular dementia, and type 2 diabetes. Review of the care plan, dated 06/17/2024, located under the EMR Care Plan tab, revealed R73 was at risk for complications with urinary system related to obstructive uropathy; which requires indwelling catheter (suprapubic catheter). Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/29/2024, revealed the facility assessed R73 as having a Brief Interview for Mental Status (BIMS) score of four (4) out of 15, indicating severe cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as having an indwelling catheter. Review of the EMR Progress Note, dated 10/22/2023, located under the EMR Progress Notes tab, revealed R73 had a change in condition and was sent out to the hospital for further evaluation. Review of the [Hospital] document, provided by the facility and dated 10/22/2023, revealed R73 was discharged to the facility in stable condition and had a diagnosis of Urinary Tract Infection (UTI). Further review of R73's medical record, revealed there was no documented evidence of a transfer notice sent to the resident/resident representative regarding the hospital transfer. 36898 3. Review of R150's undated Admission Record, located in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 04/19/2024 with diagnoses including acute respiratory failure with hypoxia. Further review revealed the resident was readmitted on [DATE]. Review of R150's quarterly MDS with an ARD of 06/25/2024, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident as having a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of R150's nurse's Progress Note, dated 06/09/2024 and located in the resident's EMR under the Progress Notes tab, revealed, . Resident c/o [complained of] SOB [shortness of breath], weakness, nausea . 2L [liters] of oxygen, resident O2 [oxygen] continued to decrease, resident also stated she was not feeling any better. NP [Nurse Practitioner] notified and recommended to send resident to hospital. EMS [Emergency Medical Service] was called and resident was transferred . Further review of the Progress Notes. revealed R150 returned to the facility on [DATE]. During an interview, on 07/16/2024 at 12:32 PM, R150 stated she was admitted to the hospital approximately two (2) or three (3) weeks ago. R150 stated she did not receive anything in writing about her hospital transfer or any information regarding her right to return to the facility. During an interview on 07/19/2024 at 1:40 PM, the Business Office Manager (BOM) stated the facility did not send written transfer notices to residents nor their representatives. The BOM stated she was not aware of the requirement to send written notification; however, she stated she was responsible for transfer notices when residents were emergently transferred to the hospital. During an interview, on 07/19/2024 at 5:29 PM, the Administrator stated he was not aware of the regulatory requirement to send written notice after a resident's emergent transfer to the hospital.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a comprehensive person-centered care plan was developed related to falls for one (1) of 39 sampled residents, Resident (R)110. The facility assessed R110 to be at high risk for falls; however, there was no documented evidence a Care Plan was developed in an attempt to prevent falls. This placed the resident at risk for unmet care needs and at an increased risk of sustaining a fall. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . Review of R110's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, arthritis, morbid obesity, and osteoarthritis of left knee. Review of R110's Nursing Fall Risk Observation/Assessment, dated 03/20/2024 and located in the resident's EMR under the Assessment tab, revealed the facility assessed the resident as at high risk for falls. Review of R110's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/2024, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident as having a fall prior to admission to the facility. The facility further assessed the resident as dependent on staff for transfers. His walking ability was not assessed due to a medical condition or safety concerns. Continued review of the MDS, specifically the Care Area Assessment (CAA) section, revealed the assessment triggered the care area of Falls and indicated it would be addressed in the resident's care plan. Review of R110's comprehensive Care Plan, located in the resident's EMR under the Care Plan tab, revealed a care plan was not developed to include the problem area of risk for falls with goals and interventions. During an interview, on 07/19/2024 at 12:01 PM, the Director of Nursing (DON) reviewed R110's care plan and confirmed the care plan did not address the resident's risk of falls. The DON stated it was her expectation the resident's care plan would have been developed to address and mitigate the resident's risk for falls. During an interview, on 07/19/2024 at 12:06 PM, the MDS Coordinator (MDSC) stated she was responsible for the development of R110's comprehensive care plan. The MDSC confirmed the care plan did not address the resident's risk of falls. The MDSC stated R110's care plan should have addressed the resident's risk for falls and she was not sure how she omitted this. During an interview, on 07/19/2024 at 5:29 PM, the Administrator stated it was his expectation R110 would have had a care plan developed to address the resident's risk for falls.

Based on observation, interview, record review, and facility policy review, the facility failed to provide appropriate services to prevent and or treat pressure ulcers for two (2) of four (4) sampled residents reviewed for pressure ulcers out of a total sample of 39 residents, Resident (R)9 and R267. The facility failed to implement pressure ulcer prevention measures and accurately assess a pressure ulcer for R9. This failure had the potential to contribute to development of new pressure ulcers and/or a lack of wound healing or wound deterioration for R9. Additionally, the facility failed to provide pressure ulcer treatments as ordered for R267. This failure had the potential to contribute to a lack of wound healing or wound deterioration for R267. Findings include: 1. Review of R9's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including morbid obesity, type 2 diabetes with diabetic neuropathy, and muscle weakness. Review of R9's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/26/2024, located under the MDS tab of the EMR, revealed a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Per the MDS, R9 did not exhibit behavioral symptoms. R9 required partial to moderate assistance with bed mobility and was at risk for development of pressure ulcers. Per the MDS, R9 did not have an unhealed pressure ulcer. R9 received pressure-reducing devices for his chair and bed and application of ointments/topical medications. A. Heel Lift Boot Review of R9's EMR under the Orders tab, revealed a Physician's order, dated 01/11/2024, for Heel-lift boots to bilateral feet while in bed. Review of R9's Care Plan, revised 07/11/2024 and located in the Care Plan tab of the EMR revealed, Resident is at risk for impaired skin integrity related to diabetes, pain, morbid obesity, and recurring yeast to body folds. History of pressure injury left lateral ankle, stage III - resolved 03/18/2024. Stage III left lateral ankle- 07/08/2024. The approaches included, Heel lift boots bilateral, initiated 01/12/2024. Further review of the Care Plan, revealed Resident has a pressure ulcer to Left lateral ankle and is at risk for further breakdown and/or slow, delayed healing related to cardiovascular disease, decreased mobility, diabetes. During an interview with R9, on 07/16/2024 at 11:29 AM, in his room, the resident stated he had a boot on his left foot, but nothing on his right foot. R9 was observed lying in bed on his back with a large pressure-relieving boot to the left foot and his bare right foot was resting on the mattress. During an observation of R9, on 07/17/2024 at 1:20 PM, he was lying in bed in his room. R9 had a large boot on his left foot and his right foot was bare and resting on the mattress. During an observation, on 07/18/2024 at 1:41 PM, in R9's room, Licensed Practical Nurse (LPN)12 prepared to complete wound care on R9's left foot while he was lying in bed. LPN12 verified R9 wore a pressure-relieving boot on his left foot and did not have a boot on the right foot. During an interview, on 07/18/2024 at 2:55 PM, LPN12 stated R9 only wore a boot on the left and did not have a boot for the right foot. LPN12 stated she was unaware the order specified boots to be worn on both feet, and stated she would clarify with the Nurse Practitioner (NP) whether he was supposed to wear only the left boot or left and right boots. During an interview, on 07/18/2024 at 3:17 PM, Certified Nurse Aide (CNA) 4 stated R9 only had a boot for the left foot and did not wear any boot on the right foot. CNA4 stated R9 did not ever refuse to wear the the boot on the left foot and was compliant with care. During an interview, on 07/18/2024 at 5:45 PM, LPN12 stated she had verified with the NP, R9 was to wear boots on both feet, not just the left foot, for pressure ulcer prevention. LPN12 stated she spoke with R9 and he was agreeable to wearing the right boot in addition to the left. B. Wound Assessment Review of the facility Prevention of Pressure Injuries policy, dated October 2023, revealed, Conduct a comprehensive skin assessment upon admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge During the skin. assessment, inspect: . a. Presence of erythema; b. Temperature of skin and soft tissue; and c. Edema . The physician will help identify medical interventions related to wound [prevention and] management. Review of R9's Nursing - Comprehensive Skin Evaluation/Assessment, dated 07/08/2024 and located under the Evaluations tab of the EMR, revealed a pressure ulcer, stage III, to R9's left outer ankle and old pressure area reopened. Review of R9's Skin/Wound Note, dated 07/09/2024 and located in the Progress Notes tab of the EMR, revealed, Resident with area to left lateral ankle (this was a previously opened area). Treatment in place; encouraged to wear heel boots and not to rub on the mattress. Will continue to observe. Review of R9's Nursing - Comprehensive Skin Evaluation/Assessment, dated 07/11/2024 and located in the Evaluations tab of the EMR, revealed R9 did not have any wounds present. Review of R9's Nursing - Comprehensive Skin Evaluation/Assessment, dated 07/15/2024 and located under the Evaluations tab of the EMR, revealed a left outer ankle pressure ulcer, stage III, was present. During an observation of wound care for R9 in his room, on 07/18/2024 at 1:41 PM with LPN12, a small, round wound was observed on the bony part of the outside of the resident's left ankle that appeared scabbed and dry. During an interview, on 07/18/2024 at 2:55 PM, LPN12 stated R9 developed a pressure sore on 07/08/2024 and it was healing well. During a telephone interview, on 07/19/2024 at 1:48 PM, LPN9 stated she had completed the 07/11/2024 skin assessment. LPN9 stated, I must have missed the pressure ulcer on the skin assessment. She further stated the wound most likely was present at that time as, typically, it would not close up and then re-open that quickly. LPN9 stated, I bounce around a lot on different units and depend on the aides to let me know of new issues . I try to do an observation of the skin, but since it's on night shift, they don't want to be bothered . so I can't see their skin . It must have been a mistake on my part. It is hard to know the residents when I'm all over the place . It must not have been told to me in report. During an interview, on 07/19/2024 at 2:31 PM, Unit Manager (UM) 1 stated it was not acceptable for a nurse to conduct a skin assessment without visualizing the resident's skin. UM1 stated R9's pressure ulcer should have been reflected on his 07/11/2024 skin assessment. UM1 stated the assessments could be done at the beginning of the shift or during rounding to ensure the nurse was able to view the resident's skin. UM1 stated if a resident refused a skin assessment, it should be documented as a refusal rather than documented that there were no wounds present. 2. Review of R267's Admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE], readmitted on [DATE], and discharged from the facility on 08/04/2021. R267's diagnoses included chronic osteomyelitis (bone infection), deep vein thrombosis (blot clot) in the lower extremity, paraplegia, morbid obesity, multiple stage IV pressure ulcers (left heel, sacrum, and left hip), and noncompliance with other medical treatment and regimen. Review of R267's Admit/Re-Admit Screener, dated 06/08/2016 and located in the Evaluations tab of the EMR, revealed he was admitted to the facility with nine (9) pressure ulcers which were located in the following areas: left heel, right heel, scrotum, left hip, left buttock, right hip/buttock, right buttock/coccyx, coccyx bridge, and right coccyx/hip/buttock. Review of R267's Nursing - Admission/Re-Admission Assessment, dated 05/18/2021 and located in the Evaluations tab of the EMR, revealed chronic wounds to both feet, both heels, the left hip, and the coccyx present upon re-admission from the hospital. Review of R267's quarterly MDS assessment with an ARD of 05/23/2021, located in the MDS tab of the EMR, revealed a score of 15 out of 15 on the BIMS, indicating intact cognition. Per the MDS, R267 did not exhibit any mood or behavioral symptoms. R 267 was totally dependent on two (2) or more staff for bed mobility and had not transferred out of bed. He required extensive assistance with personal hygiene. Further review of the MDS, revealed R267 had two (2) stage IV pressure ulcers present on admission and surgical wounds. R267 used a pressure-reducing mattress and received pressure ulcer care and surgical wound care including application of dressings and ointments. Review of R267's Care Plan, located in the Care Plan tab of the EMR and last updated 06/18/2021, revealed R267 had wounds to the left heel, left hip, right hip, right ankle, left dorsal foot, left plantar foot, left calf, and left shin. The Care Plan documented R267 was resistant to turn and reposition and refused wound care and treatment at times. The interventions included provision of a pressure-reducing mattress, wound care specialist evaluation and treatment, encourage repositioning every two (2) to three (3) hours, monitor for infection, and provide wound treatments as ordered. Review of R267's Treatment Administration Record [TAR], dated July 2021 and located under the Orders tab of the EMR, revealed the following wound treatments were not documented as completed: A. Left Heel Pressure Ulcer Physician's Orders dated 06/26/2021 through 07/19/2021 revealed: Apply Santyl ointment (used to remove damaged tissue from chronic skin ulcers) and calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven calcium alginate fibers), cover with abdominal (ABD) gauze pad and wrap with kerlix (crinkle weave gauze roll) daily. However, there was no documented evidence this treatment was provided on 07/04/2021 and 07/11/2021. B. Right Buttock Wound Physician's Orders dated 05/18/2021 through 07/25/2021 revealed: Apply foam dressing to right buttock daily. However, there was no documented evidence this treatment was provided on 07/04/2021, 07/11/2021, 07/21/2021, and 07/24/2021. C. Right Hip Physician's Orders dated 07/09/2021 revealed: Apply Skin Prep (wipes that form a protective barrier between the skin and adhesives to help preserve skin integrity) daily. However, there was no documented evidence this treatment was provided on 07/11/2021, 07/21/2021, and 07/24/2021. Physician's Orders dated 06/25/21 through 07/08/2021 revealed: Apply calcium alginate and bordered gauze daily. However, there was no documented evidence this treatment was provided on 07/04/2021. D. Left Dorsal Foot Physician's Orders dated 07/09/2021 through 07/25/2021 revealed: Apply skin prep and cover with Hydrocolloid (a waterproof dressing that provides a moist and insulating environment to promote wound healing) every Monday, Wednesday, and Friday However, there was no documented evidence this treatment was provided on 07/21/2021. Physician's Orders dated 07/03/2021 through 07/08/2021 revealed: Apply a collagen sheet and ABD pad and wrap with kerlix every day. However, there was no documented evidence this treatment was provided on 07/04/2021. E. Left Hip Physician's Orders dated 06/25/2021 through 07/25/2021 revealed: Apply and pack with calcium alginate and cover with a border dressing daily. However, there was no documented evidence this treatment was provided on 07/04/2021, 07/11/2021, 07/21/2021, and 07/24/2021. F. Right Ankle Physician's Orders dated 06/25/2021 through 07/08/2021 revealed: Apply calcium alginate and cover with border gauze daily. However, there was no documented evidence this treatment was provided on 07/04/2021. G. Left Calf Physician's Orders dated 07/16/2021 through 07/25/2021 revealed: Apply calcium alginate and cover with dry dressing daily. However, there was no documented evidence this treatment was provided on 07/21/2021 and 07/24/2021. H. Left Plantar Foot Physician's Orders dated 07/09/2021 through 07/25/2021 revealed: Apply calcium alginate and ABD pad, wrap with kerlix every day. However, there was no documented evidence this treatment was provided on 07/11/2021, 07/21/2021, and 07/24/2021. I. Right Buttock Physician's Orders dated 05/18/2021 through 07/25/2021 revealed: Apply foam dressing every day. However, there was no documented evidence this treatment was provided on 07/04/2021, 07/11/2021, 07/21/2021, and 07/24/2021. Review of R267's Progress Notes revealed no documentation on 07/04/2021, 07/11/2021, 07/21/2021, or 07/24/2021 to indicate a reason why the treatments were not provided nor was there documentation to indicate the physician had been notified. During an interview, on 07/19/2024 at 2:57 PM, LPN10 stated R267 frequently refused care, including turning and repositioning, showers, and wound care. LPN10 stated his wounds would briefly heal, then would deteriorate again due to the resident's noncompliance. LPN10 stated when a resident refused a treatment, the refusal should be documented on the TAR and in a corresponding Progress Note to describe the situation. LPN10 stated the physician should be notified of any refusal of medications or treatments and the notification was typically documented in the Progress Notes. LPN10 stated when the TAR was left blank, it was most likely a refusal from the resident, but there was no way of knowing. During an interview, on 07/19/2024 at 4:54 PM, the Director of Nursing (DON) stated any refusal should be documented on the TAR using the corresponding numeric code. The DON stated she did not know why the TAR would be left blank, and stated without any documentation, there was no way to know whether the treatments had been done as ordered or refused.

Based on interview, record review, and facility policy review, the facility failed to ensure medications were available for administration per Physician's orders for two (2) of 39 sample residents (R74 and R717). These failures placed the residents at risk of harm or discomfort related to missed medication doses. R74 was ordered Eliquis (apixaban, an anticoagulant medication) five (5) milligrams (mg) twice daily for stroke prevention on 03/23/2023. However, there was no documented evidence the resident received the scheduled doses of medication on 05/21/2024 at 8:00 AM, 06/05/2024 at 8:00 PM and 06/19/2024 at 8:00 AM. The Progress Notes on these dates revealed the medication was re-ordered or the medication was unavailable. R717 was admitted to the facility on [DATE] at approximately 3:50 PM, and Physician's Orders on admission included Oxycodone-acetaminophen (narcotic pain medication) oral tablet 7.5-325 mg., give one (1) to two (2) Tablets by mouth every four (4) hours as needed for pain. Per the resident's Control Drug Use Record, and staff interview, R717 did not receive the Oxycodone-acetaminophen medication until 07/10/2024 at 12:30 PM, when staff obtained a one-time order from the Nurse Practitioner (NP) to administer R717 a dose of her pain medication she brought with her from the discharging facility. Findings include: 1. Review of R74's undated Admission Record, located under the Profile tab in the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including congestive heart failure and history of stroke. Review of R74's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/08/2024, located under the MDS tab of the EMR, revealed she scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Per the MDS, R74 did not exhibit any mood or behavioral symptoms. R74 used an anticoagulant medication daily. During an interview, on 07/16/2024 at 10:16 AM, R74 stated she had missed her dose of Eliquis (apixaban, an anticoagulant medication) three (3) times recently. R74 stated she was concerned about missed doses of this important medication negatively affecting her health. Review of R74's Care Plan, dated 05/23/2024, revealed Resident is at risk for bleeding and bruising related to anticoagulant use and documented the approach, Medication as ordered. Review of R74's Medication Administration Record (MAR), dated May 2024 and located under the Orders tab of the EMR, revealed a Physician's order, which originated on 03/23/2023, for apixaban, five (5) milligrams (mg) twice daily for stroke prevention. Per the MAR, the drug was not given with the code of Other/See Nurses' Notes, on 05/21/2024 at 8:00 AM. Review of R74's eMar - Medication Administration Note, dated 05/21/2024 and located under the Progress Notes tab of the EMR, revealed, Apixaban Oral Tablet 5 MG . reordered. There was no documentation to indicate the physician was notified or the medication was obtained from the emergency kit. Review of R74's MAR, dated June 2024 and located under the Orders tab of the EMR, revealed the 03/23/2023 order for apixaban, 5 mg, twice daily. Per the MAR, the drug was not given with the code of Other/See Nurses' Notes on 06/05/2024 at 8:00 PM and on 06/19/2024 at 8:00 AM. Review of R74's eMar - Medication Administration Note, dated 06/05/2024 and located under the Progress Notes tab of the EMR, revealed, Apixaban Oral Tablet 5 MG . medication not available. There was no documentation to indicate the physician was notified or the medication was obtained from the emergency kit. Review of R74's eMar - Medication Administration Note, dated 06/19/2024, written by Licensed Practical Nurse (LPN) 6, and located under the Progress Notes tab of the EMR, revealed, Apixaban Oral Tablet 5 mg . Medication unavailable. Pharmacy notified. There was no documentation to indicate the physician was notified or the medication was obtained from the emergency kit. During an interview, on 07/19/2024 at 12:48 PM with LPN6, she stated, on 06/19/2024, she was unable to locate the apixaban for R74 in the medication cart. LPN6 stated typically the nurse would fax a reorder request to the pharmacy when there was a medication supply to last six (6) or seven (7) days. However, she was unable to find evidence the medication had been reordered prior to the medication running out on 06/19/2024. LPN6 stated she did not give R74 the apixaban dose on 06/19/2024, but could not remember if she had notified the resident's physician of the missed dose. LPN6 stated the physician should be notified any time a dose was missed, and this was typically documented in the Progress Notes. LPN6 confirmed there was no Progress Note to indicate she had notified the physician. During an interview, on 07/19/2024 at 2:15 PM, Unit Manager (UM) 1 stated when a medication could not be found on the medication cart, the nurse should use the medication from the emergency kit, if available. The UM stated apixaban was available in the facility's emergency kit. UM1 stated a medication should be reordered ahead of time so a dose was not missed. UM1 stated she expected the physician to be notified of any missed doses of medications. During a subsequent interview, on 07/19/2024 at 2:53 PM, LPN6 stated she had not obtained the apixaban from the emergency kit on 06/19/2024 for R74, as she did not know what was in the kit at the time. LPN6 stated she first found out about and used the emergency kit yesterday. During an interview, on 07/19/2024 at 5:10 PM, the Nurse Practitioner (NP) stated she would expect a missed dose of apixaban to be reported to her, and she was not aware that R74 had recently missed three (3) doses of the medication. The NP stated the facility should not run out of the medication because of automatic refills through the pharmacy and availability in the emergency kit. The NP further stated one (1) missed dose of the medication may not be too detrimental to the resident's health, but more than one (1) missed dose could be dangerous. During an interview on 07/19/2024 at 4:54 PM, the Director of Nursing (DON) stated she was surprised to hear the staff documented the Eliquis medication was unavailable as it was available in the emergency kit. 36898 2. Review of the facility's policy titled, Medication Orders and Receipt Record, revised April 2007, revealed The facility shall document all medications that it orders and receives . 2. The medication order/receipt record shall contain: a. The prescription number . Review of R717's undated Admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included open wound to right foot and mononeuropathy of right lower limb. Review of R717's nurse's Progress Note, dated 07/09/2024 at 3:50 PM, and located in the resident's EMR under the Progress Notes tab, revealed, Patient arrived via facility transport . Patient currently in room resting . During an interview, on 07/16/2024 at 2:19 PM, R717 stated it took one and a half days to receive her narcotic pain medication after she arrived at the facility. R717 stated at one point her pain level was a 10, on a scale from one (1) to 10, with 10 being the highest pain level. During further interview, on 07/19/2024 at 2:55 PM, R717 stated she did not really start experiencing the pain level of 10 until the day after she was admitted to the facility. R717 stated after she was admitted to the facility and while awaiting her medication to arrive from the pharmacy, she received one (1) tablet of her narcotic pain medication from her supply from the previous facility and a Tylenol. When asked how long she was in pain at level 10, R717 stated, maybe two hours. Review of R717's Physician's Orders, located in the resident's EMR under the Orders tab, revealed an order dated 07/09/2024 for Acetaminophen Tablet 325 milligrams (mg), give two (2) tablets by mouth every four (4) hours as needed. The Physician's Orders also included an order dated 07/09/2024 for Oxycodone-acetaminophen oral tablet 7.5-325 mg., give one (1) to two (2) Tablets by mouth every four (4) hours as needed for pain. Review of R717's Medication Administration Record (MAR), dated July 2024 and located in the resident's EMR under the Orders tab, revealed the resident was administered two (2) 325 mg acetaminophen tablets on 07/09/2024 at 10:38 PM. Review of R717's nurse's Progress Note, dated 07/09/2024 at at 10:38 PM, revealed R717 was administered two (2) 325 mg acetaminophen tablets for mild pain. R717 rated her pain at a six (6), on a scale of zero (0) to ten with ten being the highest. Review of R717's nursing Progress Note, dated 07/10/2024 at 12:44 AM, revealed the follow-up pain assessment for the administration of the acetaminophen on 07/09/24 at 10:38 PM was documented as Ineffective. Review of R717's nurse's Progress Note, dated 07/10/2024, at 12:35 PM, revealed . received new order from NP [Nurse Practitioner]-okay to give pain medication from other facility until meds [medication] arrive from pharmacy. Oxycodone 10/325 tablet administered at this time. Review of R717's untitled fax confirmation, revealed the prescription for oxycodone-acetaminophen 10 mg-325 mg tablet was received by the pharmacy on 07/10/2024 at 6:37 PM, more than 26 hours after admission. An interview and review of R717's Control Drug Use Record for oxycodone 10-325 mg, was conducted with the Director of Nursing (DON), on 07/19/2024 at 4:25 PM. The Control Drug Use Record revealed one (1) tablet of oxycodone-acetaminophen 10-325 mg was signed out on 07/10/2024 at 12:30 PM by Certified Medication Technician (CMT)1. The DON stated the CMT obtained a one-time order from the Nurse Practitioner (NP) to administer R717 a dose of her pain medication she brought with her from the discharging facility. The DON stated this was the first dose of narcotic pain medication R717 received after admission to the facility. During further interview, on 07/19/2024 at 4:25 PM, the DON stated the nurse who admitted R717 put the order in the EMR for oxycodone-acetaminophen on 07/09/2024 at approximately 8:00 PM. The DON stated the pharmacy delivered the medication on 07/10/2024 at 9:13 PM, more than 25 hours later. The DON further stated the reason the medication took so long to be delivered was because the admitting nurse was using the resident's discharge summary from the discharging facility to enter the orders for the medications. The DON explained that even though the order was put in the system, there was no prescription for the pharmacy to use to fill it. The DON further stated when the medication had not arrived on the 07/10/2024 midnight delivery, the nurse called the pharmacy and was told a prescription was needed, so the nurse notified the on-call NP to get a prescription. In continued interview, the DON stated the facility emergency medication system had the oxycodone-acetaminophen medication available and she would have expected the nurse to call the NP or physician to get an order for the medication to be dispensed and administered as ordered. During an interview, on 07/19/2024 at 5:00 PM, the NP stated the nurse called the on-call nurse practitioner (who was no longer employed by the facility) to obtain a prescription for R717's narcotic pain medication. However, the on-call nurse practitioner failed to follow through and send a prescription into the pharmacy for the medication. The NP stated this failure was on the facility and R717 should not have been without her pain medication. During an interview, on 07/19/2024 at 5:29 PM, the Administrator stated it was his expectation R717's pain medication would have been obtained timely from the pharmacy.

Based on observation, interview, record review, and review of facility policy, the facility failed to remove expired hydrogen peroxide and accu-check glucose control solutions from one (1) of two (2) medication storage rooms. This failure could result in the potential of residents being subject to unsafe or ineffective treatment. Findings include: Review of the facility's policy titled, Medication Labeling and Storage, revised 02/2023, revealed .2) The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3) If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation of the medication room at the nurses' station was conducted on 07/17/24 at 1:47 PM, accompanied by Licensed Practical Nurse (LPN)1. There were two (2) bottles of hydrogen peroxide with an expiration date of 02/2023 found on a shelf within a cabinet. In addition, three (3) boxes of accu-check glucose control solutions with an expiration date of 07/05/2024 were found in a drawer. LPN1 confirmed these items were expired and removed them from the medication room. During an interview, on 07/18/2024 at 1:48 PM, LPN1 stated, the supply person checked the medication rooms daily for expiration dates and stock for reordering. During an interview, on 07/19/2024 at 11:00 AM, the Assistant Director of Nursing (ADON) stated the unit manager and pharmacy performed medication cart audits. The ADON stated she would have to check to see how often the audits were performed. The ADON further stated it was also the nurse's responsibility to remove expired medications and biologicals. During an interview, on 07/19/2024 at 11:38 AM, the Director of Nursing (DON) stated, pharmacy checked the medication rooms once a month. Typically, the nursing staff checked the medication carts for expired medications and biologicals. We don't have a designated supply person that does it.

Based on observation, interview, medical record review, review of facility policy and review of the Centers for Disease Control and Prevention guidance, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The following failures could promote the spread of multi drug resistant organisms (MDROs) throughout the facility: The facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) for one (1) of three (3) residents reviewed for enhanced barrier precautions (EBP) when providing care, Resident (R) 129. Additionally, he facility failed to ensure staff cleaned and disinfected patient equipment after use for one (1) of eight (8) residents reviewed for infection control, R139. Furthermore, the facility failed to ensure staff followed hand hygiene practices during wound care for one (1) of five (5) residents reviewed for pressure ulcers, R9. Findings include: Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, revised 09/2022, revealed the three types of transmission-based precautions are contact, droplet and airborne. The facility did not submit any policies related specifically to EBP. Review of the Centers for Disease Control and Prevention (CDC) website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug resistant Organisms (MDROs), updated: 04/02/2024 revealed, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: -Dressing -Bathing/showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator -Wound care: any skin opening requiring a dressing . Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1. Review of R129's Admission Record under the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE]. The Admission Record included a diagnosis of anoxic brain damage. Review of R129's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/2024, located under the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Observation of R129's room, on 07/17/2024 at 2:15 PM, revealed signage on the door frame stating, STOP Enhanced Barrier Precautions (EBP); however, there was no isolation cart outside the doorway. Observation of Licensed Practical Nurse (LPN) 4 providing a wound care treatment to R129's left foot on 07/17/2024 at 2:20 PM, revealed LPN4 wore gloves, but no gown during patient care. During an interview on 07/17/2024 at 2:25 PM, R129 stated, All the staff use hand sanitizer and wash their hands. They always wear gloves, but no they don't wear a gown. During an interview on 07/18/2024 at 10:25 AM, LPN4 stated, I don't know what I did wrong with R129's treatment . I have had EBP training. I should have worn a gown maybe. My last training on EBP was this past February. I'm not sure what type of resident I would need to wear a gown with, except for the contact precaution residents. But I will find out and let you know. During an interview, on 07/19/2024 at 11:02 AM, the Assistant Director of Nursing (ADON) stated, I'm also the Infection Control Preventionist for the facility. Well, I do training often and every day at this point. I have a running list of all the residents that are on precautions. The ADON further stated she updated the list daily during morning meeting and went through the list with every unit manager, MDS nurse, ADON, Director of Nursing (DON) and the dietician. Per interview, they went through every new order and checked for whatever was urgent or whoever needed to be on precautions. She stated those rooms had a magnetic sign placed on the door and a PPE cart was to be placed outside of the doorway. In further interview, she stated EBP was still new, and the facility had to learn about it quickly, but the goal to get into the habit of using EBP precautions. The ADON further stated, My expectation is staff use EBP for residents with wounds, foley catheters, central line, G-tubes [gastronomy tubes] and any recent history of MDRO. During an interview, on 07/19/2024 at 11:39 AM, the DON stated, It's so new. We're still learning. At first, we thought it was just ostomies, but now we've learned the staff need to gown up with direct contact with residents that also have open wounds, foley catheter, G-tubes, an IV [intravenous line], and with a history of an MRDO. We've already began educating our staff on EBP, since this has been brought to our attention this week. 2. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, revealed resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Non-critical items are those that come in contact with intact skin, but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores . Low-level disinfection is generally appropriate for most non-critical equipment. Review of the CDC Disinfection and Sterilization Guideline. on page 3 of 45, under 3.c. revealed: Perform low-level disinfection (noncritical items; will come in contact with intact skin) for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin. 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). Review of R139's Admission Record in the Profile tab of the EMR, revealed an admitted [DATE]. The Admission Record stated diagnoses including chronic systolic (congestive) heart failure and chronic kidney disease, stage 3. Review of R139's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2024 and located under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During observation on 07/19/2024 at 10:20 AM, R139 was sitting in a wheelchair outside of his doorway. LPN5 was observed using a blood pressure wrist cuff to take the resident's blood pressure. LPN5 then removed wrist cuff, wrote down the blood pressure reading on a sheet of white paper, and then placed the wrist cuff down on the same sheet of white paper on top of the medication cart. LPN5 then administered R139 his medications, locked the medication cart, and walked away. LPN5 returned to her medication cart at 10:41 AM and opened her laptop. During an interview on 07/19/2024 at 10:42 AM, LPN5 stated, I like to bring my own equipment. Once I'm done, I get it sanitized. I have my own special alcohol because this is my cuff. The last time I used the wipe here, it made the sensor not read. So this is a new cuff. I clean it after each use, but R139 was my last one because he doesn't like to take medicine. I won't use this one again until I clean it again. During an interview, on 07/19/2024 at 11:22 AM, the ADON/Infection Control Preventionist stated, If staff use their own equipment, I still expect staff to clean all the equipment. Staff are still expected to clean before and after they use them. The ADON/Infection Control Preventionist further stated staff should use the micro-kill disinfectant wipes in their medication carts to disinfect equipment. During an interview, on 07/19/24 at 11:47 AM, the DON stated, Staff are expected to disinfect patient equipment after using and in between. If they bring their own equipment, I still expect them to disinfect after each use. She further stated staff should use the disinfectant wipes to disinfect equipment. 26006 3. Review of the facility's Handwashing/Hand Hygiene policy, dated October 2023 and provided by the facility, revealed, Hand hygiene is indicated . immediately after glove removal. Review of R9's Admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including morbid obesity, type 2 diabetes with diabetic neuropathy, and muscle weakness. Review of R9's annual MDS assessment with an ARD of 06/26/2024, under the MDS tab of the EMR, revealed he scored 15 out of 15 on the BIMS, indicating intact cognition. R9 was assessed as not exhibiting behavioral symptoms. Per the MDS, R9 required partial to moderate assistance with bed mobility and was at risk for development of pressure ulcers. R9 currently did not have an unhealed pressure ulcer; and he received pressure-reducing devices for his chair and bed and application of ointments/topical medications. Review of R9's Nursing - Comprehensive Skin Evaluation/Assessment, dated 07/08/2024 and located under the Evaluations tab of the EMR, revealed a pressure ulcer, stage III, to R9's left outer ankle which was documented as, old pressure area reopened. Review of R9's EMR under the Orders tab, revealed a Physician's order, which originated on 07/16/2024, to cleanse the left, lateral ankle wound with wound cleanser, pat dry, and wipe with Skin Prep (wipes that form a protective barrier on the skin to help preserve skin integrity). During an observation, on 07/18/2024 at 1:41 PM, in R9's room, LPN12 completed wound care on R9's left foot while he was lying in bed. She donned (put on) a gown and washed her hands, then donned gloves. LPN12 then cleaned the wound with wound cleanser, removed her gloves, and without performing hand hygiene, donned new gloves and applied the Skin Prep to the wound. LPN12 then discarded her gown and gloves and washed her hands. During an interview, on 07/18/2024 at 2:55 PM, LPN12 stated she had not sanitized or washed her hands after removing her dirty gloves and before donning a clean pair of gloves to apply the Skin Prep. LPN12 stated she typically would use hand sanitizer before donning a clean pair of gloves; however, the sanitizer was in her pocket, and she could not reach it because of the gown she was wearing. During an interview, on 07/19/2024 at 2:31 PM, Unit Manager (UM) 1 stated the nurse should have performed hand hygiene after removing the dirty gloves, and before donning the clean pair of gloves to apply the Skin Prep to R9's wound. During an interview on 07/19/2024 at 4:54 PM, the Director of Nursing (DON) verified her expectation was for staff to perform hand hygiene using hand sanitizer after doffing gloves, before donning a new pair of gloves.

Based on interview, record review, and the facility's policy review it was determined the facility failed to revise and individualize the care plan to prevent elopement for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 as exit seeking and applied a Secure Guard bracelet. The facility care planned the resident as at risk for elopement with a goal the resident would not wander out of the facility unattended. On 09/07/2020, staff noted the window in the resident's room was opened and the resident attempted to climb out the window. However, the facility failed to revise the resident's comprehensive care plan after the incident. Interviews revealed Resident #1 exited the facility unattended, without staff knowledge on 10/09/2020. Resident #1 was discovered, by a citizen in the community, crawling on the ground near a heavily traveled roadway. The facility failed to make revisions to the resident's comprehensive care plan after the resident attempted to climb out of the window and after the resident eloped from the facility. The facility's failure to revise and individualize the resident's care plan has caused or is likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 11/19/2020, and was determined to exist on 09/07/2020. The facility was notified of the Immediate Jeopardy on 11/19/2020. The facility provided an acceptable Credible Allegation of Compliance on 11/30/2020, alleging the removal of Immediate Jeopardy on 11/23/2020. The State Survey Agency verified Immediate Jeopardy was removed 11/23/2020 as alleged, prior to exit on 12/05/2020. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The policy stated the comprehensive, person-centered care plan would include measurable objectives and timeframes; describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and describe services that would otherwise be provided for the above. Further review of the policy revealed the IDT would review and update the care plan when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident was readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Review of the clinical record revealed the facility admitted Resident #1 on 08/07/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the resident exhibited behavior(s) of wandering. Review of Resident #1's Wandering Risk Observation/Assessment, dated 08/07/2020, revealed the facility assessed the resident as High Risk to Wander. Review of the Care Plan, initiated 08/07/2020, revealed Resident #1 was at risk for elopement with a goal the resident would not wander out of the facility unattended. Interventions included allowing the resident to wander in safe paths in the facility; checking door alarms promptly to ensure safety; keeping his/her picture in the elopement risk book; Secure Guard prevention bracelet at all times; checking the bracelet for placement every shift and function at bedtime; and taking the resident on supervised walks outside when weather allowed. Review of the Nursing Progress Notes, dated 08/27/2020, revealed Resident #1 wandered in other residents' rooms, had packed a bag, and walked the halls through the night. The Note further revealed the facility would continue to follow the current plan of care. Review of the resident's care plan revealed the facility failed to revise the care plan with new interventions to manage the resident's exit seeking behavior on 08/27/2020. Review of Nursing Progress Notes, dated 09/07/2020, revealed Resident #1 continued to exit seek, wandered in residents' rooms, unlocked and opened windows, and tried to climb out of open windows. The Nursing Note stated the facility would continue to follow the plan of care. Review of the facility's investigation, dated 10/09/2020, revealed review of surveillance video determined a Maintenance Assistant entered the Arcadia Unit through the courtyard door and reset the alarm at 11:18 AM. At 11:22 AM, Resident #1 exited through the door and a Housekeeping Aide walked to the door and reset the alarm. The facility last observed Resident #1 on video at 11:28 AM walking in the driveway past a side entrance (the resident was found, off facility property, without staff knowledge, by a citizen in the community, near a heavily traveled highway.) However, review of the resident's care plan revealed the facility failed to revise the resident's care plan with new interventions, after the elopement on 10/09/2020. Interview with CNA #4, on 11/13/2020 at 9:58 AM, revealed Resident #1 walked around a lot, wandered in to other resident's rooms, would exit seek, and would said he/she wanted to go home. Further interview with the CNA, on 11/17/2020 at 12:23 PM, revealed Resident #1 tried to get other residents to open a window(s) and escape. The CNA stated she redirected the resident by having him/her color, watch a movie, or do busy work. Interview with Registered Nurse (RN) #1, on 11/13/2020 at 12:25 PM, revealed Resident #1 wandered and was exit seeking. The nurse stated she supervised the resident by keeping a close eye on him/her. RN #1 stated an intervention for exit seeking would include a Secure Guard bracelet. She stated she did not know of any other interventions, but she knew where to get the information. According to RN #1, the Unit Manager (UM) was responsible for revising the resident's care plan. Interview with Licensed Practical Nurse (LPN) #3, on 11/16/2020 at 11:57 AM, revealed Resident #1 wandered, asked to unlock doors, and was exit seeking. The nurse stated Resident #1 would put on a hat, grab his/her belongings, say he/she was headed home, and walk down the hall. The LPN stated interventions for exit seeking would include redirection or activities. She stated nurses revised the care plans as needed, but the UM revised them if they got busy. LPN #3 stated the facility monitored the courtyard door after the elopement; however, she was not aware of increased supervision for Resident #1. Interview with Registered Nurse (RN) #2, on 11/17/2020 at 2:12 PM, revealed the care plan was a communication tool for staff. She stated the purpose of revising the care plan was to identify effective interventions to address a behavior or problem. The RN stated Resident #1 was exit seeking and if the resident could go he/she would go. RN #2 stated Resident #1 kept opening the bedroom window on 09/07/2020; however, she could not recall if she revised the care plan. According to RN #2, the UM usually updated care plans. Interview with the Unit Manager (UM) for the Arcadia Unit, on 11/18/2020 at 9:36 AM, revealed the interdisciplinary team (IDT) reviewed progress notes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated interventions for exit seeking would include applying a Secure Guard bracelet, monitoring the resident, and redirection with crafts, television, or another activity. She further stated the facility talked with residents' families to identify interests and individualize the care plan. The UM stated the facility reviewed Resident #1's care plan when he/she exhibited the exit seeking behavior; however, there was nothing to change because the window would not open enough for him/her to get out. Interview with the Social Services Director (SSD), on 11/17/2020 at 4:00 PM, revealed revision of the care plan would include adding an intervention or goal. She stated interventions for exit seeking might include sitting with the resident, trying to find out what the resident was looking for, offering a snack or nap, or diversional activities like a movie, music, or dancing. The SSD stated she revised Resident #1's care plan for at risk for wandering after the elopement to include an intervention to assess for falls and that the resident's safety would be maintained. However, per interview she stated she did not revise the interventions to manage Resident #1's exit seeking behavior(s) and ensure the resident's safety. Interview with the Director of Nursing (DON), on 11/16/2020 at 3:51 PM, revealed the care plan identified a resident's diagnoses/problems and included interventions to provide the appropriate care to meet their needs. The DON stated the IDT reviewed for behaviors or exacerbation of behaviors, psych consults, or social service interventions in the daily IPOC meeting and updated the care plans if indicated. She stated she was not aware of any issues with care plans. Post-survey interview with Director of Nursing #2, on 12/18/2020 at 3:49 PM, revealed she was new to the facility and from her understanding of Resident #1, the resident's attempts to open windows was not a behavior that warranted a change to care plans. DON #2 stated the facility revised care plans to insure staff were aware of changes in a resident's status. Interview with the Administrator, on 11/16/2020 at 5:20 PM, revealed he was not aware of any issues with care plans. Further interview with the Administrator, on 11/18/2020 at 10:45 AM revealed the facility deemed Resident #1 a wandering risk but he did not think the resident was exit seeking through a window. According to the Administrator, it was a normal thing for residents on a memory care unit to try to open windows. He stated interventions were already in place to ensure Resident #1 could not elope through the window. Post-survey interview with the Administrator, on 12/18/2020 at 4:12 PM, revealed the resident's care plans communicated to facility staff the needs of a resident and established goals and defined the interventions to reach the goals. The Administrator stated the facility revised care plans based on changes in a resident's status from normal or baseline. He stated failing to revise a resident care plan could result in risks to the health or safety of a resident. The Administrator stated as the resident was non-interviewable it was not practical to attempt to determine the reasons for Resident #1's attempts to open windows and the facility did not assess the resident's actions as behaviors that warranted a care plan revision. Furthermore, the facility already had interventions in place that prohibited windows from opening fully. The Administrator stated the facility determined the interventions in place to prohibit windows from opening were adequate and no care plan revisions were necessary. The Administrator stated the facility did not revise Resident #1's care plan after the elopement; however, the facility implemented environmental/physical changes to the facility in an effort to keep residents safe. Additionally, the Administrator stated the facility probably should have revised Resident #1's care plan. Interview with the Behavioral Health Advanced Practice Registered Nurse (APRN), on 11/18/2020 at 10:53 AM, revealed Resident #1 exhibited behaviors of wandering. The APRN stated staff reported the resident tried to go out a window and that was something residents with dementia did if they were trying to leave. She stated she would expect new interventions implemented for exit seeking behaviors to include diversional activities and reorientation. The facility alleged it implemented the following actions to remove the Immediate Jeopardy: 1. A licensed nurse completed Resident #1's full body, pain, and wander risk assessments upon return to the facility. 2. An Ad Hoc QA committee met on 10/09/2020 with the Administrator, Director of Nursing (DON), Medical Director, Nurse Practitioner (NP), Quality Assurance (QA) Nurse, and Social Services regarding the elopement and action items for the Allegation of Compliance (AOC). 3. The Administrator reviewed and revised the facility's elopement policy, on 10/15/2020, to correlate with the regulation. 4. On 10/09/2020, the Maintenance Director checked and documented an audit of all doors for fifteen (15) second egress. 5. The Maintenance Director, on 10/09/2020, checked and documented audits of all doors for properly functioning wander guard system. 6. The QA Nurse checked each resident's wander guard bracelet to ensure it worked properly on 10/09/2020. 7. Treatment Administration Records (TAR) for residents with wander guard bracelets were checked by the Nursing Administrative Team, on 10/09/2020, to check for placement and functioning and was listed on the TAR and signed by the nurse. 8. On 10/09/2020, the Maintenance Director applied a self-closing latch to the courtyard gate. 9. All staff, including agency staff, began training on 10/09/2020 through 11/22/2020. In-services included abuse and neglect, behavior management, injury prevention, wandering risk/elopement, dementia, care plan, accidents and supervision, not to prop any doors open, elopement risk and procedures, and not to disarm alarms without looking outside. Staff that did not receive the training, will be in-serviced upon return to work, and weekend staff will be trained by the weekend House Supervisor. On-going in-services will be conducted bi-weekly for the next sixty (60) days and staff will be asked questions by the Administrator, DON, and QA Nurse as they round the facility. 10. All keypad codes were changed, on 10/09/2020, by maintenance and will be changed monthly. 11. An elopement drill was conducted and documented on each shift, including weekend staff, on 10/13/2020, 10/18/2020, 10/22/2020 by the QA nurse. Elopement drills will be conducted quarterly on each shift, with the next drill due in January by the Nursing Administrative Team. 12. From 10/09/2020 through 10/11/2020, continuous door watch was implemented and documented on the fifteen (15) minute check signature sheet on the Memory Care Unit exit door until the Maintenance Director installed a fifteen (15) second egress magnet lock. 13. The Maintenance Director, on 10/14/2020, applied a wander guard system to the courtyard exit door. 14. The Nursing Administrative Team (DON, QA Nurse, Unit Managers (UM), and Staffing Coordinator) compared physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility identified two (2) care plans required initiation, and another two (2) were added to the Kardex. The Secure Care Guards were physically in place. 15. All elopement risk assessments were checked by the QA Nurse and SS on 10/09/2020 to verify they were up to date. All residents identified at risk for elopement were audited for wander guard physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Elopement Risk Books were in place on the units and at the front desk. Social Services Director (SSD) will review the book weekly for updates. 16. On 10/09/2020, the facility completed new elopement risk assessments on all one hundred fifty-five (155) residents. These assessments were completed by the UMs, DON, and QA Nurse. 17. The DON, QA Nurse, SS, and Minimum Data Set (MDS) staff reviewed clinical records for all residents identified as wandering or elopement risk, from 10/09/2020 through 10/16/2020, and updated care plans as needed. Review included Nurses' Notes, Progress Notes, electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plans were reviewed for appropriate interventions for supervision, with two (2) care plans initiated, and two (2) more added to the Kardex by the QA Nurse on 10/09/2020. 18. The DON reviewed the Interdisciplinary Plan of Care (IPOC) process, on 10/09/2020 and 11/20/2020. IPOC meetings, Monday through Friday will review reports, including twenty-four (24) hour summary, incident reports- elopements, elopement attempts, progress notes behaviors, eMAR notes behaviors, completed UDA assessments behaviors, order recap report, alert listing report, and assessment report to audit weekly nurse summaries and other assessments and UDA list. Care plans will be reviewed and revised by the IPOC team as needed for behavior and supervision interventions. The DON will report results to the Quality Assurance (QA) Committee. 19. On 10/09/2020, the DON, QA Nurse, UM, and Staffing Coordinator audited TARs for wander guard placement and function and they will be reviewed weekly for documentation compliance. The audit will continue for three (3) months and re-evaluated for frequency thereafter. 20. The Maintenance Director will check the wander guard door system weekly. 21. The Human Resources (HR) Coordinator created, on 10/09/2020, Code Black in the new hire and agency orientation and post-test to validate understanding. 22. The IPOC team, beginning 11/23/2020, will review the AOC plan daily for completion and compliance and submit monthly to the regular QA Committee for additional oversight. 23. The Administrator, DON, Medical Director, NP, QA Nurse, and SS held an Ad Hoc QA meeting, on 11/20/2020, to review the Immediate Jeopardy (IJ) and establish the AOC. 24. On 11/20/2020, the Maintenance Director checked each facility window to ensure no windows opened more than two (2) inches. 25. The Maintenance Director will check all facility windows monthly to validate no window opens more than two (2) inches and will submit results to the monthly QA Committee for review. 26. On 11/20/2020, the QA Nurse reviewed the MAR for residents with documented behaviors and verified behaviors were addressed on care plans. 27. The DON, QA Nurse, SS, and MDS staff, from 11/20/2020 through 11/22/2020, reviewed all twenty-six (26) residents identified as wanderer or elopement risk clinical records to identify any unknown behaviors. The DON, Assistant DON (ADON), QA Nurse, NP, SS, and MDS staff reviewed residents' care plans and updated them as needed. 28. From 11/20/2020 through 11/22/2020, all resident clinical records were reviewed from 08/01/2020 through 11/22/2020 to identify any unknown behaviors and care plans reviewed for appropriate interventions for supervision. The DON, QA Nurse, UM, Staffing Coordinator, SS, and MDS staff updated resident care plans as needed. The SSA validated the facility implemented the following actions to remove the Immediate Jeopardy: 1. Interview, on 12/05/2020 at 3:29 PM, with the Unit Manager (UM) revealed she assessed Resident #1 upon return to the facility, completing a full body, pain, and wander risk assessments. Additionally, she stated she conducted elopement assessments for all residents on her unit. Interview with the Director of Nursing (DON), on 12/05/2020 at 12:49 PM, revealed the UM completed Resident #1's full body, pain, and wander risk assessments when the resident returned to the facility. Record review revealed an assessment of Resident #1 was completed, as alleged. Review of the wander risk assessments, dated 10/09/2020, revealed the facility assessed twenty-two (22) residents residing on the Arcadia Unit. Record review for Residents #2 and #6 on 12/02/2020 revealed the facility assessed their wander risk on 10/09/2020. 2. Interview with Nurse Practitioner (NP) #2, on 12/05/2020 at 11:59 AM, the QA Nurse, DON, and Administrator, on 12/05/2020 at 12:49 PM, revealed they participated in the ad hoc Quality Assurance (QA) meeting the day of the elopement and developed an Allegation of Compliance (AOC) action plan. Review of the facility sign-in sheet, dated 10/09/2020, revealed the facility held the QA meeting with attendance as indicated. 3. On 12/05/2020 at 12:49 PM, interview with the Administrator revealed he reviewed and revised the facility elopement policy in compliance with federal regulations. Review of the facility's policy Elopements, revealed a revision date of 10/15/2020, after the elopement. 4. Interview, on 12/05/2020 at 12:49 PM, with the Administrator revealed the Maintenance Director checked the doors for fifteen (15) second egress on 10/09/2020. Observation, on 12/01/2020 at 4:05 PM, revealed a fifteen (15) second egress on the courtyard door of Arcadia Unit. The Maintenance Director tested the function of the door with no concerns noted. 5. Interview with the Administrator, on 12/05/2020 at 12:49 PM, revealed the Maintenance Director checked the doors for wanderguard functioning on 10/09/2020. Observation, on 12/01/2020 at 4:05 PM, revealed a wanderguard alarm in place at the courtyard door of Arcadia Unit. The Maintenance Director tested the function of the alarm which revealed no concern. 6. On 12/05/2020 at 12:49 PM, interview with the QA Nurse revealed, on 10/09/2020, she checked to ensure residents' wanderguard bracelets were in place for residents utilizing them. Review of the audit form, dated 10/09/2020, revealed the QA Nurse checked the placement and function of wanderguard bracelets for twenty-six (26) residents. Observation of Resident #1 on 12/01/2020 at 4:25 PM, Resident #2 on 12/01/2020 at 4:31 PM, and Resident #6, on 12/01/2020 at 4:15 PM, revealed the prescribed wanderguard bracelets were in place. 7. Interviews with the UM, on 12/04/2020 at 3:29 PM, the DON and QA Nurse, on 12/05/2020 at 12:49 PM, revealed on 10/09/2020 they checked the wanderguards and ensured they were listed on the resident's TARs for placement and functioning and,were signed by the nurse. Record reviews of Residents #1, #2, and #6's TAR, on 12/02/2020, revealed the facility checked placement and function of the wanderguard. 8. Interview, on 12/05/2020 at 12:49 PM, with the Administrator revealed maintenance applied a self-closing latch, on 10/09/20, to the courtyard gate. Observation of the courtyard gate, on 12/01/2020 at 4:05 PM, revealed a self-closing spring door closer. Interview with the Maintenance Director, during the observation revealed the facility installed the new self-closing spring on 10/09/2020. 9. Interview with Certified Nursing Assistant (CNA) #8, on 12/03/2020 at 1:55 PM, revealed she had been trained by the facility on elopement risk, dementia, behavior management and knew she should not prop open doors or disarm the alarm without looking outside for a resident. Interview, on 12/03/2020 at 2:11 PM, with CNA #9 revealed the facility trained her on elopement procedures, who to report to, and she was quizzed after training. On 12/03/2020 at 2:23 PM and 12/04/2020 at 3:21 PM, interview with CNA #10 revealed she was trained by the facility the day of the elopement. She stated she had also received additional training's for elopement, behavior management, and resident injuries. Interview, on 12/03/2020 at 2:47 PM and 12/04/2020 at 2:45 PM, with CNA #3 revealed she was trained on elopement, dementia, behavior management, and what to do, whom to report to, and what to do if she could not account/locate a resident. On 12/03/2020 at 2:54 PM, interview with CNA #11 revealed the facility trained her what to do if there was an elopement. Interview with CNA #12, on 12/03/2020 at 3:16 PM, revealed he was trained what to do if a resident eloped from the facility, and who to notify. He stated training included behavior management, elopement, dementia, and injury prevention. He stated there had been multiple staff trainings. Further interview revealed he recalled doors should not be propped open and if an alarm was sounding staff should look around and complete a head count of residents in the facility. Interview with Housekeeper #1, on 12/03/2020 at 4:09 PM, revealed she had been trained by the facility on abuse and neglect, behavior management, injury prevention, wandering risk and elopement, dementia, care plans, accidents and supervision, elopement risks and procedures, not to prop open doors, and not to disarm alarms without looking for residents outside. Interview, on 12/04/2020 at 11:12 AM, with the Minimum Data Set (MDS) Coordinator revealed she was trained on abuse and neglect, elopement procedures, dementia care, and safety and injury prevention. Further interview revealed the Coordinator was knowledgeable regarding the procedure for a missing resident and location of the wandering/elopement books. On 12/04/2020, at 2:48 PM, interview with the Occupational Therapist Rehab Director revealed he had been trained on elopement procedures, dementia and behavior management, accident and injury prevention. Interview, on 12/04/2020 at 2:59 PM, with the Director of Environmental Services revealed she was trained on elopement procedures and if there was an alarm staff should check outside for any residents. On 12/04/2020 at 3:08 PM, interview with the Maintenance Assistant revealed he was trained on elopement, dementia and behaviors, accidents and supervision, not to prop doors open, and to check outside if an alarm was sounding. Interview with Licensed Practical Nurse (LPN) #5, on 12/04/2020 at 3:16 PM, revealed the facility trained her on dementia, behaviors, accidents, and elopement procedures. Interview, on 12/04/2020 at 3:25 PM, with Housekeeper #3 revealed she was trained in new employee orientation on behaviors, dementia, elopement, injury prevention, and what to do if there was an alarm sounding. Interview with CNA #14, on 12/04/2020 at 3:40 PM, revealed she was trained by the facility on elopement procedures, dementia and behaviors, care plans, abuse and neglect, accidents and supervision, injury prevention, not to prop doors open, and to look outside if there was a door alarm. On 12/04/2020 at 3:45 PM, interview with LPN #7 revealed she was trained on elopement, dementia, abuse and neglect, behaviors, care plans, accidents and supervision. On 12/04/2020 at 3:49 PM, interview with LPN #8 revealed she was trained on abuse and neglect, elopement procedures, dementia, behaviors, injury prevention, accidents, and to search for residents if there was an alarm. Interview, on 12/04/2020 at 3:52 PM, with LPN #9 revealed the facility trained her on abuse, injury prevention, care plans, dementia, behaviors, accidents, supervision, and what to do if there was an elopement. Interview with the House Supervisor, on 12/05/2020 at 12:10 PM, revealed she conducted employee training for weekend staff who were not trained during the week. She stated she trained facility and agency staff on elopement procedures, abuse and neglect, behaviors, dementia, injury prevention. On 12/05/2020 at 12:21 PM, interview with the RN Staff Coordinator revealed she conducted trainings for staff on abuse, elopement procedures, injury prevention, behavior management, and care plans. She stated she stayed late to train night shift staff, and the weekend supervisor usually trained staff on the weekends. Interview, on 12/05/2020 at 12:49 PM, with the Quality Assurance (QA) Nurse revealed she also conducted staff and agency staff trainings and the evening and weekend supervisors conducted trainings for those shifts. The QA Nurse stated the trainings included behavior management, elopement risk and procedures, not to prop open doors, care plans, injury prevention, abuse and neglect. She stated she questions staff as she encountered them to validate their understanding of the trainings. Interviews with the Administrator and DON, on 12/05/2020 at 12:49 PM, revealed one or two staff had not been trained as they were on leave. They stated, in the last sixty (60) days, they had made rounds and asked staff questions informally. Review of the facility sign in sheets and training materials revealed the facility trained staff on abuse and neglect, behavior management, dementia, wandering and elopement, and care plans beginning 10/09/2020 through 11/22/2020. 10. Interview with the Maintenance Director, on 12/01/2020 at 4:42 PM, revealed he changed all keypad codes on 10/09/2020 and monthly thereafter. 11. Interviews with CNA #10, on 12/03/2020 at 2:23 PM, CNA #3, on 12/03/2020 at 2:47 PM, CNA #3, on 12/04/2020 at 2:45 PM, Occupation Therapist Rehab Director, on 12/04/2020 at 2:48 PM, Director of Environmental Services, on 12/04/2020 at 2:59 PM, LPN #5, on 12/04/2020 at 3:16 PM, LPN #7, on 12/04/2020 at 3:45 PM, LPN #9, on 12/04/2020 at 3:52 PM, and House Supervisor, on 12/05/2020 at 12:10 PM, revealed they participated in elopement drills at the facility in the last few weeks. Interview with the Maintenance Assistant, on 12/04/2020 at 3:08 PM, revealed he conducted an elopement drill on 12/05/20 and everyone participated. Interviews with the Administrator, DON, and QA Nurse, on 12/05/2020 at 12:49 PM, revealed elopement drills were being conducted with the next drill scheduled in January. Review of the Code Black Disaster Drill Reports revealed the facility conducted elopement drills on 10/13/2020, 10/18/2020, and 10/22/2020. 12. On, 12/05/2020 at 12:49 PM, interview with the Administrator revealed a continuous door watch was implemented, beginning 10/09/2020, until a fifteen (15) second magnetic lock was installed on the door. Review of the fifteen (15) minute check signature sheet revealed the facility initiated checks on 10/09/2020 and concluded the checks on 10/11/2020. 13. Interview with the Administrator, on 12/05/2020 at 12:49 PM, revealed on 10/14/2020 a wanderguard system was applied by the Maintenance Director to the courtyard exit door. Observation, on 12/01/2020 at 4:05 PM, revealed a wanderguard alarm in place at the courtyard door of the Arcadia Unit. The Maintenance Director tested the function of the alarm which revealed no concern. 14. Interviews, on 12/04/2020 at 3:29 PM, with the UM, with the QA Nurse and DON, on 12/05/2020 at 12:49 PM revealed on 10/09/2020 they compared physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review for Residents #1, #2, and #6 on 12/02/2020 revealed wanderguards were included in their elopement care plan and the residents were listed in the elopement books. 15. On, 12/05/2020 at 12:49 PM, interview with the QA Nurse and DON revealed on 10/09/2020 they reviewed all resident elopement risk assessments. Residents at risk of elopement had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Social Services Director (SSD), on 12/05/2020 at 10:16 AM, revealed she reviewed and updated the elopement risk book weekly and as needed. Record review on 12/02/2020 revealed the facility assessed Residents #1, #2, and #6 at risk for elopement on 10/09/2020. Further review revealed there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents #1, #2, and #6 were listed in the elopement books. Observation, on 12/05/2020 at 3:00 PM, revealed Elopement books located at six (6) nurse stations and the front desk were current with twenty-nine (29) residents listed as at risk for elopement. 16. Interview with the UM, on 12/04/2020 at 3:29 PM, with the QA Nurse and DON, on 12/05/2020 at 12:49 PM, revealed they completed new elopement risk assessments on all one hundred fifty-five (155) residents in the facility on 10/09/2020. Record review on 12/02/2020 revealed the facility assessed elopement risk for Resident #1, #2, and #6 on 10/09/2020. 17. Interview, on 12/05/2020 at 12: [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of three (3) sampled residents' (Resident #1) environment remained as free of accident hazards as possible and that each resident received adequate supervision and monitoring. On 08/07/2020, the facility assessed Resident #1 as a wanderer and a risk for elopement. At that time, the facility placed a Secure Guard bracelet (a system designed for residents with dementia diagnosis to have freedom within the facility while alerting staff when they enter an unsafe area of the building) to the resident's ankle. Review of the Nursing Progress Notes revealed, on 08/27/2020, the resident wandered into another resident's room, with a packed bag stating he/she wanted to go home. Further review of the Progress Note revealed the resident had to be redirected multiple times from wandering; however, the resident was not provided increased monitoring and/or supervision. Continued review of the Nursing Progress Notes revealed the resident's wandering behavior increased. The resident was observed by staff attempting to climb out of his/her window on 09/07/2020 and 10/09/2020. Interviews with staff revealed the resident's supervision/monitoring increased; however, there was no documented evidence to support the resident's increase in supervision. On 10/09/2020, while staff were passing lunch trays, staff discovered the resident was missing. Review of the facility's surveillance video footage revealed the resident exited the facility around 11:22 AM by walking through an opened door through the adjacent courtyard gate, which was unsecured. After a search of the facility and surrounding community, staff located the resident riding as a passenger in a citizen's truck. Per interview with the citizen, the resident was found crawling on the ground on the side of the road, near a busy highway. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 11/19/2020, and was determined to exist on 09/07/2020. The facility was notified of the Immediate Jeopardy on 11/19/2020. The facility provided an acceptable Credible Allegation of Compliance on 11/30/2020, alleging the removal of Immediate Jeopardy on 11/23/2020. The State Survey Agency verified Immediate Jeopardy was removed 11/23/2020 as alleged, prior to exit on 12/05/2020. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy,Safety and Supervision of Residents, revised July 2017, revealed resident safety and supervision and assistance to prevent accidents were facility wide priorities. The policy revealed the interdisciplinary care team analyzed information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Further review of the policy revealed the care team would target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility's policy, Wandering and Elopements, revised 05/17/2020, revealed the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy stated the facility utilized a standard Wandering Risk Observation Assessment and the assessment scored the resident Low Risk, At Risk, or High Risk. Based on the scoring of the assessment, the resident would be determined at risk or not, for elopement and appropriate interventions would be initiated. Further review of the policy, 'Wandering and Elopements revealed if an employee observed or was alerted that a resident was attempting to leave the premises, he/she should: attempt to prevent the resident from leaving in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the Charge Nurse or Director of Nursing that a resident was attempting to leave or has left the premises. Review of the facility's Emergency Preparedness (EPS) Plan for Elopement Protocol, undated, revealed it was the protocol of the facility to protect residents from wandering away from the facility and to begin an immediate search if a resident was found missing. The protocol stated elopement was defined as a situation where a resident with impaired decision-making ability, who was oblivious to his/her own safety and, therefore at risk outside the confines of the facility, had left the facility without the knowledge of staff and was not recovered within 30 minutes of exiting the facility. Further review of the EPS Plan revealed wandering was defined as locomotion with no discernible, rationale purpose, either walking or in a wheelchair. The protocol revealed the resident would be assessed for risk of elopement upon admission. Residents on the secured unit would be deemed at risk for elopement if physical mobility indicated risk. Residents identified as At Risk would be reassessed quarterly, and as needed, through the Resident Assessment Instrument (RAI) process with behavior monitoring documentation, as indicated. Review of the clinical record revealed the facility admitted Resident #1 on 08/07/2020 with diagnoses that included Alzheimer's Disease, Alcohol Dependence with Alcohol-Induced Persisting Dementia, and Anxiety Disorder. Review of the facility's investigation, dated 10/09/2020, revealed review of the facility's surveillance video determined a Maintenance Assistant entered the Arcadia Unit (unit where Resident #1 resided) through the courtyard door and reset the alarm at 11:18 AM. At 11:22 AM, Resident #1 exited through the courtyard door and a Housekeeping Aide walked to the door and reset the alarm, and did not check outside to ensure a resident had not exited the building. The facility last observed Resident #1 on the video at 11:28 AM walking in the driveway past a side entrance. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of one (1), which indicated cognitive impairment. Further review of the MDS revealed the resident exhibited wandering behavior(s). Review of Resident #1's Wandering Risk Observation/Assessment, dated 08/07/2020, revealed the facility assessed the resident as High Risk to Wander. Further review of the clinical record revealed a Physician's Order, dated 08/07/2020, to check for placement of the resident's Secure Guard bracelet (SCB) every shift. Observation of Resident #1 on the Arcadia Unit, on 11/10/2020 at 2:37 PM, revealed the resident seated in his/her room with a Secure Guard bracelet to the right ankle. Interview during observation revealed the resident was Killing time right now. Observation, on 11/10/2020 at 3:10 PM, revealed Resident #1 ambulating in the hallway. Review of the Care Plan, initiated on 08/07/2020, revealed Resident #1 was at risk for elopement with a goal the resident would not wander out of the facility unattended. Interventions included allowing the resident to wander in safe paths in the facility; checking door alarms promptly to ensure safety; keeping his/her picture in the elopement risk book; Secure Guard prevention bracelet at all times; checking the bracelet for placement every shift and function at bedtime; and taking the resident on supervised walks outside when weather allowed. Review of the Nursing Progress Notes, dated 08/27/2020, revealed Resident #1 entered another resident's room and staff assisted him/her out of the room multiple times. The Note revealed the resident had packed a bag and walked up and down the halls throughout the night. The Note further revealed the facility would continue to follow the current plan of care. Further review of Nursing Progress Notes, dated 09/07/2020, revealed Resident #1 continued to exit seek, wandered in and out of other residents' rooms, unlocked and opened windows, and tried to climb out of open windows. The Nursing Note stated the facility would continue to follow the plan of care. Review of the Psychiatric Evaluation, dated 09/09/2020, revealed Resident #1 was exit seeking and tried to climb out of the window. Review of the Psychiatric Evaluation, dated 09/23/2020, revealed the resident continued to exhibit behavioral issues and exit seeking behaviors, per staff reports. Interview with Certified Nursing Assistant (CNA) #5, on 11/13/2020 at 9:37 AM, revealed she was the assigned staff who worked with the resident the day he/she eloped. CNA #5 stated Resident #1 loved to walk around, go door to door, and wore a Secure Guard bracelet. The CNA stated she last saw the resident sitting in the hallway around 11:30 AM, on the day the resident went missing. CNA #5 stated she noticed the resident was missing when she took the resident's lunch tray to his/her room at approximately 12:00 PM. CNA #5 revealed she did not hear an alarm go off and reported that the resident was missing to Registered Nurse (RN #1). CNA #5 stated it was at that time staff initiated a search for the resident. Interview with CNA #4, on 11/13/2020 at 9:58 AM, revealed she and CNA #5 were passing lunch trays when they discovered Resident #1 missing. She stated she notified RN #1 and staff started searching rooms on the Arcadia Unit, the unit in which the resident resided. CNA #4 stated she went outside to the secure courtyard; however, the gate to the parking lot was wide open. She stated she searched the perimeter of the facility, including an adjacent restaurant and apartment complex, then got in her car and searched the surrounding community, including a nearby gas station. The CNA stated citizens standing at a nearby intersection reported they had assisted Resident #1 to cross the street so he/she would not get hit by a car. CNA #4 stated as she returned to her car, a citizen in a truck flagged her down, and she observed Resident #1 in the citizen's passenger seat. She further stated the Citizen reported to her that he had discovered the resident sitting on a stoop by a gas station near the highway. According to the CNA, the resident was a mile from the facility and had to cross a million streets. CNA #4 stated she got in the truck with the resident and they returned to the facility. Continued interview with CNA #4 revealed Resident #1 conveyed to her that The door was left open and (he/she) was trying to go home. Interview with the Citizen, on 11/17/2020 at 4:33 PM, revealed he was driving when he observed Resident #1 crawling on the ground near the side of the road. He stated he pulled over and asked the resident if he/she needed help or an ambulance. Further interview revealed Resident #1 was wearing a white bracelet on his/her ankle and yellow emergency room socks. According to the Citizen, the resident stated he/she was getting to the car to go home. He revealed his fiancé, who worked at the facility, called at about the same time and gave him a description of a missing resident. He stated the description matched the person he was assisting and he took the resident back to the facility. Continued interview with CNA #4 on 11/17/2020 at 4:33 PM, revealed Resident #1's behaviors included walking around the facility, wandering into other resident's rooms, and exhibiting exit seeking behaviors. She stated the resident would state, (He/She) wanted to go home. CNA #4 stated she last saw Resident #1 around 11:00 AM, seated in the hallway, when she came back from her fifteen (15) minute break. CNA #4 stated the door to the courtyard would sometimes not latch and the gate stood open if pushed back far enough. Further interview with CNA #4, on 11/17/2020 at 12:23 PM, revealed Resident #1 tried to get other residents to open a window(s) and escape with him/her. The CNA stated she redirected the resident by having him/her color, watch a movie, or do busy work. She further stated the windows on the Arcadia Unit had a lock and only opened an inch or so; however, if she saw an open window she would close it. The CNA stated she made the nurse aware of the resident's exit seeking behaviors. According to CNA #4, they usually kept wanderers seated together in the hallway to supervise them. Interview with the Activities Assistant, on 11/10/2020 at 2:42 PM, revealed she heard an overhead page for Code Black and assisted with the search for Resident #1. According to the Activities Assistant, the facility discovered Resident #1 missing around noon or a little after. The Activities Assistant stated Resident #1 was an elopement risk and wore a Secure Guard bracelet on the ankle; however, she was not aware if the resident was in the facility's elopement binder, which would have identified the resident as an elopement risk. Further interview with the Activities Assistant revealed laundry and housekeeping staff used the courtyard door to remove trash and laundry. She stated staff had to pull the doors shut at times because the door would not latch and the alarm would keep going off. Per interview, the Activities Assistant revealed, there had been an issue with the door latch for a few years and the facility was installing a new door (after the elopement). Interview with the Housekeeping Aide, on 11/16/2020 at 9:29 AM, revealed she left the Arcadia Unit for lunch around 12:00 PM when she heard a page for Code Black and went to search for the missing resident. According to the Aide, the facility searched for approximately one-and-a half (1 ½ ) to two (2) hours before they found the resident. Further interview with the Housekeeping Aide revealed housekeeping staff used the courtyard door to take out trash and take their smoke breaks. The Aide stated there was a problem with the door latch and staff had to make sure it slammed hard enough to latch. She revealed the door would alarm and it was annoying because staff had to stop what they were doing to reset it. She stated staff filled out a work order or called Maintenance for any repair issues; however, she did not report the problem with the courtyard door because the alarm had been going off quite a bit and Maintenance already knew about it. Per interview, the Housekeeping Aide stated that on the day of the incident, she heard the alarm go off and reset the alarm. She further revealed she did not check outside to see if anyone left the building. Interview with Registered Nurse (RN) #1, on 11/13/2020 at 12:25 PM, revealed she discovered Resident #1 missing while administering afternoon medications. She stated once she reached the end of the hall she checked the empty rooms and activity room; then began rechecking resident rooms. She stated when she was unable to locate Resident #1 she notified the Unit Manager (UM) who announced a Code Black. She stated she assessed Resident #1 when he/she returned to the facility and there were no apparent injuries. RN #1 stated Resident #1 wandered and was exit seeking. Further interview with RN #1 revealed, the resident never stayed in his/her room and was known to go in the activity/dining room alone. RN #1 stated she supervised the resident by keeping a close eye on him/her. Interview with Licensed Practical Nurse (LPN) #3, on 11/16/2020 at 11:57 AM, revealed Resident #1 wandered and was exit seeking. LPN #3 stated Resident #1 would ask to unlock doors. The nurse stated Resident #1 would put on his/her hat, grab his/her belongings, and say, (he/she) was headed home as he/she walked down the hall. The LPN stated she supervised residents during rounds and viewed the camera monitor while she was at the nurses station. Further interview with LPN #3 revealed dietary and housekeeping staff went in and out of the courtyard door and staff went out to smoke. She stated staff started using the door because of changes due to COVID-19. Interview with the Unit Manager (UM), on 11/16/2020 at 12:30 PM, revealed a CNA (she did not specify which CNA), notified her after noticing Resident #1 was missing during lunch tray pass. The UM stated she called a Code Black and staff searched the interior and exterior perimeter for the resident. She revealed staff tried to watch and/or monitor the residents on the Arcadia Unit by assigning an activity person to the hall. She stated Resident #1 wandered up and down the hall but never attempted to exit seek. Further interview with the UM revealed staff used the courtyard door to take out garbage, deliver meal trays, and take breaks. She stated she was not aware of any issues with the courtyard door or gate. Interview with the Maintenance Assistant, on 11/13/2020 at 3:57 PM, revealed he came in the courtyard door on the day of the elopement and reset the alarm. He stated he was not aware of any issues with the courtyard door or the gate. However, the facility updated the gate to ensure it closed completely and installed a magnetic lock on the door for security measures. Interview with the Maintenance Director, on 11/17/2020 at 3:31 PM, revealed he was not aware of any issues with the courtyard door on the Arcadia Unit. He stated the facility was in the process of replacing the door before Resident #1's elopement. The Director stated staff filled out a paper work order for maintenance issues and he picked up the orders daily. However, he did not retain work orders once they were completed. He stated something major, like a door issue, should be addressed immediately because of the potential elopement risk. Interview with the Quality Assurance and Performance Improvement (QAPI) Coordinator, on 11/18/2020 at 9:36 AM, revealed she reviewed video surveillance and created a timeline related to the elopement. Per interview, the QAPI Coordinator revealed the Administrator notified her Resident #1 was brought back to the facility by 11:45 AM. She further stated she performed a root cause analysis and determined increased traffic on the unit was the root cause of the elopement. Interview with the Director of Nursing (DON), on 11/16/2020 at 3:51 PM, revealed she responded to the Arcadia Unit for the Code Black and stated RN #1 reported Resident #1 missing. She stated she searched the perimeter of the facility, the restaurant behind the facility, and looked up and down the road. The DON stated by the time she returned to the facility the resident had been located. Further interview revealed the spouse of a staff member found Resident #1 at a gas station. She stated the UM was responsible for the incident report and the Administrator was responsible for the investigation. Further interview with the DON revealed the facility was in the process of moving personal belongings and equipment through the courtyard door when the elopement occurred. She stated it appeared a Housekeeping Aide reset the door alarm thinking it was maintenance staff who set off the alarm. She further stated it was her expectation that the Housekeeping Aide would have looked outside the door, prior to resetting the alarm, as per the resident's Care Plan. The DON stated she was not aware of any issues with the function of the courtyard door; however, the facility installed a Secure Guard alarm to the door after the incident. She further stated the root cause of the elopement was the resident's wandering and the Housekeeping Aide resetting the alarm without checking to see if anyone went out the door. Interview with the Administrator, on 11/16/2020 at 5:20 PM, revealed he was in his office when he heard the Code Black announcement. He stated he went outside to search, and learned during the search that the resident had been located. The Administrator stated a citizen discovered Resident #1 in the area of a gas station near the facility. He stated the citizen returned Resident #1 to the facility and a nurse assessed the resident for injuries. Review of the Nursing Body Assessment, dated 10/09/2020 at 1:12 PM, revealed Resident #1 had no apparent injuries. Further interview with the Administrator, on 11/16/2020 at 5:20 PM, revealed at the time of the elopement the facility was expanding their COVID unit and staff used the courtyard door pretty frequently. He stated staff were responsible for supervision of the residents. However, the facility had not identified an issue with supervision of Resident #1. The Administrator stated following the resident's elopement, the facility implemented fifteen (15)-minute checks and staff manned the courtyard door until a Secure Guard system was installed. He further stated the facility identified an issue with the latch mechanism on the courtyard gate. Continued interview revealed he was not aware of any issues with the courtyard door or gate prior to the elopement. He stated the facility determined the root cause of the elopement was increased traffic on the Arcadia Unit; and, staffs' failure to check outside before resetting the alarm. Post-survey interview with the Administrator, on 12/18/2020 at 4:12 PM, revealed the facility revised care plans based on changes in a resident's status from normal or baseline. He stated failing to revise a resident care plan could result in risks to the health or safety of a resident. The Administrator stated the facility did not revise Resident #1's care plan after the elopement; however, the facility implemented environmental/physical changes to the facility in an effort to keep residents safe. Additionally, the Administrator stated the facility probably should have revised Resident #1's care plan. The facility alleged it implemented the following actions to remove the Immediate Jeopardy: 1. A licensed nurse completed Resident #1's full body, pain, and wander risk assessments upon return to the facility. 2. An Ad Hoc QA committee met on 10/09/2020 with the Administrator, Director of Nursing (DON), Medical Director, Nurse Practitioner (NP), Quality Assurance (QA) Nurse, and Social Services regarding the elopement and action items for the Allegation of Compliance (AOC). 3. The Administrator reviewed and revised the facility's elopement policy, on 10/15/2020, to correlate with the regulation. 4. On 10/09/2020, the Maintenance Director checked and documented an audit of all doors for fifteen (15) second egress. 5. The Maintenance Director, on 10/09/2020, checked and documented audits of all doors for properly functioning wander guard system. 6. The QA Nurse checked each resident's wander guard bracelet to ensure it worked properly on 10/09/2020. 7. Treatment Administration Records (TAR) for residents with wander guard bracelets were checked by the Nursing Administrative Team, on 10/09/2020, to check for placement and functioning and was listed on the TAR and signed by the nurse. 8. On 10/09/2020, the Maintenance Director applied a self-closing latch to the courtyard gate. 9. All staff, including agency staff, began training on 10/09/2020 through 11/22/2020. In-services included abuse and neglect, behavior management, injury prevention, wandering risk/elopement, dementia, care plan, accidents and supervision, not to prop any doors open, elopement risk and procedures, and not to disarm alarms without looking outside. Staff that did not receive the training, will be in-serviced upon return to work, and weekend staff will be trained by the weekend House Supervisor. On-going in-services will be conducted bi-weekly for the next sixty (60) days and staff will be asked questions by the Administrator, DON, and QA Nurse as they round the facility. 10. All keypad codes were changed, on 10/09/2020, by maintenance and will be changed monthly. 11. An elopement drill was conducted and documented on each shift, including weekend staff, on 10/13/2020, 10/18/2020, 10/22/2020 by the QA nurse. Elopement drills will be conducted quarterly on each shift, with the next drill due in January by the Nursing Administrative Team. 12. From 10/09/2020 through 10/11/2020, continuous door watch was implemented and documented on the fifteen (15) minute check signature sheet on the Memory Care Unit exit door until the Maintenance Director installed a fifteen (15) second egress magnet lock. 13. The Maintenance Director, on 10/14/2020, applied a wander guard system to the courtyard exit door. 14. The Nursing Administrative Team (DON, QA Nurse, Unit Managers (UM), and Staffing Coordinator) compared Physician's Orders for wander guards to resident care plans and elopement books, on 10/09/2020. The facility identified two (2) care plans required initiation, and another two (2) were added to the Kardex. The Secure Care Guards were physically in place. 15. All elopement risk assessments were checked by the QA Nurse and SS on 10/09/2020 to verify they were up to date. All residents identified at risk for elopement were audited for wander guard Physician's Orders, care planned, and in the elopement books. The Elopement Risk Books were in place on the units and at the front desk. Social Services Director (SSD) will review the book weekly for updates. 16. On 10/09/2020, the facility completed new elopement risk assessments on all one hundred fifty-five (155) residents. These assessments were completed by the UMs, DON, and QA Nurse. 17. The DON, QA Nurse, SS, and Minimum Data Set (MDS) staff reviewed clinical records for all residents identified as wandering or elopement risk, from 10/09/2020 through 10/16/2020, and updated care plans as needed. Review included Nurses' Notes, Progress Notes, electronic Medication Administration Record (eMAR) notes, Behavior Monitoring Notes, and Social Services Notes to identify any unknown behaviors. Care plans were reviewed for appropriate interventions for supervision, with two (2) care plans initiated, and two (2) more added to the Kardex by the QA Nurse on 10/09/2020. 18. The DON reviewed the Interdisciplinary Plan of Care (IPOC) process, on 10/09/2020 and 11/20/2020. IPOC meetings, Monday through Friday will review reports, including twenty-four (24) hour summary, incident reports- elopements, elopement attempts, progress notes behaviors, eMAR notes behaviors, completed UDA assessments behaviors, order recap report, alert listing report, and assessment report to audit weekly nurse summaries and other assessments and UDA list. Care plans will be reviewed and revised by the IPOC team as needed for behavior and supervision interventions. The DON will report results to the Quality Assurance (QA) Committee. 19. On 10/09/2020, the DON, QA Nurse, UM, and Staffing Coordinator audited TARs for wander guard placement and function and they will be reviewed weekly for documentation compliance. The audit will continue for three (3) months and re-evaluated for frequency thereafter. 20. The Maintenance Director will check the wander guard door system weekly. 21. The Human Resources (HR) Coordinator created, on 10/09/2020, Code Black in the new hire and agency orientation and post-test to validate understanding. 22. The IPOC team, beginning 11/23/2020, will review the AOC plan daily for completion and compliance and submit monthly to the regular QA Committee for additional oversight. 23. The Administrator, DON, Medical Director, NP, QA Nurse, and SS held an Ad Hoc QA meeting, on 11/20/2020, to review the Immediate Jeopardy (IJ) and establish the AOC. 24. On 11/20/2020, the Maintenance Director checked each facility window to ensure no windows opened more than two (2) inches. 25. The Maintenance Director will check all facility windows monthly to validate no window opens more than two (2) inches and will submit results to the monthly QA Committee for review. 26. On 11/20/2020, the QA Nurse reviewed the MAR for residents with documented behaviors and verified behaviors were addressed on care plans. 27. The DON, QA Nurse, SS, and MDS staff, from 11/20/2020 through 11/22/2020, reviewed all twenty-six (26) residents identified as wanderer or elopement risk clinical records to identify any unknown behaviors. The DON, Assistant DON (ADON), QA Nurse, NP, SS, and MDS staff reviewed residents' care plans and updated them as needed. 28. From 11/20/2020 through 11/22/2020, all resident clinical records were reviewed from 08/01/2020 through 11/22/2020 to identify any unknown behaviors and care plans reviewed for appropriate interventions for supervision. The DON, QA Nurse, UM, Staffing Coordinator, SS, and MDS staff updated resident care plans as needed. The SSA validated the facility implemented the following actions to remove the Immediate Jeopardy: 1. Interview, on 12/05/2020 at 3:29 PM, with the Unit Manager (UM) revealed she assessed Resident #1 upon return to the facility, completing a full body, pain, and wander risk assessments. Additionally, she stated she conducted elopement assessments for all residents on her unit. Interview with the Director of Nursing (DON), on 12/05/2020 at 12:49 PM, revealed the UM completed Resident #1's full body, pain, and wander risk assessments when the resident returned to the facility. Record review revealed an assessment of Resident #1 was completed, as alleged. Review of the wander risk assessments, dated 10/09/2020, revealed the facility assessed twenty-two (22) residents residing on the Arcadia Unit. Record review for Residents #2 and #6 on 12/02/2020 revealed the facility assessed their wander risk on 10/09/2020. 2. Interview with Nurse Practitioner (NP) #2, on 12/05/2020 at 11:59 AM, the QA Nurse, DON, and Administrator, on 12/05/2020 at 12:49 PM, revealed they participated in the ad hoc Quality Assurance (QA) meeting the day of the elopement and developed an Allegation of Compliance (AOC) action plan. Review of the facility sign-in sheet, dated 10/09/2020, revealed the facility held the QA meeting with attendance as indicated. 3. On 12/05/2020 at 12:49 PM, interview with the Administrator revealed he reviewed and revised the facility elopement policy in compliance with federal regulations. Review of the facility's policy Elopements, revealed a revision date of 10/15/2020, after the elopement. 4. Interview, on 12/05/2020 at 12:49 PM, with the Administrator revealed the Maintenance Director checked the doors for fifteen (15) second egress on 10/09/2020. Observation, on 12/01/2020 at 4:05 PM, revealed a fifteen (15) second egress on the courtyard door of Arcadia Unit. The Maintenance Director tested the function of the door with no concerns noted. 5. Interview with the Administrator, on 12/05/2020 at 12:49 PM, revealed the Maintenance Director checked the doors for wanderguard functioning on 10/09/2020. Observation, on 12/01/2020 at 4:05 PM, revealed a wanderguard alarm in place at the courtyard door of Arcadia Unit. The Maintenance Director tested the function of the alarm which revealed no concern. 6. On 12/05/2020 at 12:49 PM, interview with the QA Nurse revealed, on 10/09/2020, she checked to ensure residents' wanderguard bracelets were in place for residents utilizing them. Review of the audit form, dated 10/09/2020, revealed the QA Nurse checked the placement and function of wanderguard bracelets for twenty-six (26) residents. Observation of Resident #1 on 12/01/2020 at 4:25 PM, Resident #2 on 12/01/2020 at 4:31 PM, and Resident #6, on 12/01/2020 at 4:15 PM, revealed the prescribed wanderguard bracelets were in place. 7. Interviews with the UM, on 12/04/2020 at 3:29 PM, the DON and QA Nurse, on 12/05/2020 at 12:49 PM, revealed on 10/09/2020 they checked the wanderguards and ensured they were listed on the resident's TARs for placement and functioning and,were signed by the nurse. Record reviews of Residents #1, #2, and #6's TAR, on 12/02/2020, [TRUNCATED]

Based on interview, record review, and facility policy review it was determined the facility failed to ensure an allegation of neglect was reported to the State Survey Agency (SSA) for one (1) of three (3) sampled residents (Resident #1). On 10/09/2020, staff discovered Resident #1 missing and the adjacent courtyard gate unsecured. Interviews revealed the resident exited the facility unattended, without staff knowledge and was discovered crawling on the ground near a heavily traveled roadway. The findings include: Review of the facility's policy Abuse Investigation and Reporting, revised July 2017, revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property would be reported by the facility's Administrator, or his/her designee, to the following persons or agencies: the State licensing/certification agency responsible for surveying/licensing the facility; the local/State Ombudsman; the Resident's Representative (Sponsor) of Record; Adult Protective Services (where state law provides jurisdiction in long-term care); law enforcement officials; the resident's Attending Physician; and the facility's Medical Director. The policy revealed an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) would be reported immediately, but not later than two (2) hours if the alleged violation involved abuse or resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Further review of the policy revealed the Administrator, or his/her designee, would provide the appropriate agencies or individuals listed with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Review of the facility's Emergency Preparedness (EP) Plan for Elopement Protocol, undated, revealed it was the protocol of the facility to protect residents from wandering away from the facility and to begin an immediate search if a resident was found missing. The protocol revealed elopement was defined as that situation where a resident with impaired decision-making ability, who was oblivious to his/her own safety needs and, therefore at risk outside the confines of the facility, had left the facility without the knowledge of staff and was not recovered within 30 minutes of exiting the facility. Review of the clinical record revealed the facility admitted Resident #1 on 08/07/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Certified Nursing Assistant (CNA) #5, on 11/13/2020 at 9:37 AM, revealed Resident #1 wandered and wore a Secure Guard bracelet. The CNA stated she noticed Resident #1 missing when she took the resident's lunch tray to his/her room. Further interview with the CNA revealed she had not heard a door alarm. The CNA stated dietary staff delivered lunch trays around 12:00 PM. Interview with CNA #4, on 11/13/2020 at 9:58 AM, revealed she and CNA #5 discovered Resident #1 missing during lunch tray pass. She stated she notified the nurse and searched rooms on the Arcadia Unit. The CNA stated she searched the perimeter of the facility, and then searched the surrounding community. CNA #5 stated a citizen in the community, in a truck flagged her down during the search. The CNA stated she observed Resident #1 in the passenger seat (the resident had left the facility without staff knowledge) in the citizen's vehicle. She stated the resident was returned to the facility. Interview with the Administrator, on 11/16/2020 at 5:20 PM, revealed a citizen discovered Resident #1 in the area of a gas station near the facility. He stated the citizen returned Resident #1 to the facility and a nurse assessed the resident for injuries, with no injuries noted. Further interview with the Administrator, on 11/10/2020 at 5:40 PM, revealed the facility followed their policy for reporting Resident #1's elopement. He stated the facility found the resident within thirty (30) minutes, which the policy defined as an attempted elopement. However the resident had exited the facility, without staff knowledge and was found by a citizen at a gas station located near a heavily traveled highway. The Administrator stated the facility did not notify State agencies.

Based on interview, record review, and facility policy review it was determined the facility failed to thoroughly investigate an allegation of neglect for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 as an elopement risk and applied a Secure Guard bracelet. Interviews revealed staff discovered Resident #1 missing on 10/09/2020. After a search of the facility and surrounding community, a citizen in the community discovered the resident crawling on the ground near a heavily traveled road. However, the facility failed to interview witnesses and staff to ensure they conducted a thorough investigation. The findings include: Review of the facility's policy Abuse Investigation and Reporting, revised July 2017, revealed if an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source was reported, the Administrator would assign the investigation to an appropriate individual. The individual conducting the investigation would, at a minimum: review the completed documentation forms; review the resident's medical record to determine events leading up to the incident; interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (as medically appropriate); interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to whom the accused employee provides care and services; and review all events leading up to the alleged incident. Review of the facility's policy, Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises would be investigated and reported to the Administrator. The policy revealed the following data, as applicable, would be included on the Report of Incident/Accident form: the date and time the accident or incident took place; the nature of the injury/illness (e.g., bruise, fall, nausea, etc.); the circumstances surrounding the accident or incident; where the accident or incident took place; the name(s) of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; the date/time the injured person's family was notified and by whom; the condition of the injured person, including his/her vital signs; the disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); any corrective action taken; follow-up information; other pertinent data as necessary or required; and the signature and title of the person completing the report. Further review of the policy revealed the Nurse Supervisor/Charge Nurse and/or the department director or supervisor would complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the policy revealed the Director of Nursing would ensure that the Administrator received a copy of the Report of Incident/Accident form for each occurrence. The policy revealed Incident/Accident reports would be reviewed by the QAPI Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident's vulnerabilities. Review of the clinical record revealed the facility admitted Resident #1 on 08/07/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Incident Report, dated 10/09/2020, for Resident #1's elopement revealed the facility followed policy/procedure and there were no predisposing environmental or physiological factors that contributed to the elopement. Further review revealed the Director of Nursing (DON) and Administrator reviewed and signed the report on 10/09/2020. Review of the facility's investigation, dated 10/09/2020, revealed review of surveillance video determined a Maintenance Assistant entered the Arcadia Unit through the courtyard door and reset the alarm at 11:18 AM. At 11:22 AM, Resident #1 exited through the courtyard door and a Housekeeping Aide walked to the door and reset the alarm. The facility last observed Resident #1 on video at 11:28 AM walking in the driveway past a side entrance. Further review of the investigation revealed the facility determined the auto closing mechanism on the courtyard door malfunctioned and the door did not latch properly. However, the investigation failed to provide detailed circumstances leading up to the incident to include Resident #1's history of exit seeking behavior(s), maintenance issues with the latch on the exterior gate, and staff's failure to follow procedure when resetting the door alarm. According to an interview with the Director of Nursing on 11/26/2020 at 3:51 PM, before resetting the alarm, staff should check outside to ensure that a resident had not exited the facility, which the staff did not do. In addition, the investigation did not include the name of the person who discovered Resident #1 in the community, the location where the resident was found, the resident's dress/appearance, or details regarding his/her return to the facility. Interview, on 11/16/2020 at 12:30 PM, with the Arcadia Unit Manager (UM), who was responsible for completing the incident report, revealed she had completed the incident report for Resident #1. She stated she just documented the facts and noted the resident was missing, the facility conducted a search and the resident was recovered. The UM stated it would be important to identify the person(s) who found the resident, the location where the resident was found, and the resident's appearance/clothing; however, those details were not necessarily included in the incident report. The UM stated maintenance had identified issues with the courtyard door and exterior gate, but she was not aware of the findings. Interview with the Director of Nursing (DON), on 11/16/2020 at 3:51 PM, revealed the UM was responsible for the incident report for Resident #1 and the Administrator was responsible for the investigation. She stated the facility reviewed the incident during an Ad hoc Quality Assurance (QA) meeting and determined the resident's wandering and, staff's failure to look outside when resetting the door alarm was the root cause of the elopement. She stated she was not aware of any issues with the courtyard door; however, the facility installed a wander guard alarm to the door. Interview with the Administrator, on 11/16/2020 at 5:20 PM, revealed he interviewed the three (3) direct care staff assigned to the Arcadia Unit on 10/09/2020. He stated he did not interview the Housekeeping Aide or staff on other shifts that were assigned to care for Resident #1 prior to the elopement. The Administrator stated he interviewed the Maintenance Assistant and the Citizen who found the resident. However, he did not document the interviews because he was trying to put things together for the incident and dealing with COVID-19 in the building. He stated the priority was to ensure Resident #1 was safe in the facility and interventions were in place to prevent it from happening again. During further interview, he stated it was a judgement call on his part and he focused on what was top priority. According to the Administrator, the investigation of Resident #1's elopement was as thorough as it could be considering the circumstances.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 05/14/19, revealed food stored in the walk-in refrigerator was not dated and food items were not covered. Review of the facility Census and Condition, dated 05/14/19, revealed one-hundred and forty-three (143) of one-hundred and fifty-five (155) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Food Storage: Cold Foods, last revised (MONTH) (YEAR), revealed all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy titled, Food Storage: Dry Goods, last revised (MONTH) (YEAR), revealed all dry goods will be appropriately stored in accordance with the Food and Drug Administration (FDA) Food Code. Further review of the policy revealed all packaged food items will be kept clean, dry, and properly sealed. Observation of the walk-in refrigerator during initial tour, on 05/14/19 at 8:25 AM, revealed a pan of pork loins and gravy not dated. Further observation of the kitchen revealed a bin of sugar was open to air and not covered. Interview with Dietary Aide #1, on 05/15/19 at 2:55 PM, revealed all items stored in the refrigerator should be dated and labeled. Dietary Aide #1 stated staff should replace the bin lids on the sugar when not in use to avoid contamination. Interview with the Dietary Manager, on 05/14/19 at 9:16 AM, revealed she expected all food items in the refrigerator be dated by the staff member who placed the item in the refrigerator. She stated the lid on the sugar bin should have been in place to avoid contamination.

Based on interview, record review, facility policy review, and Hospital Medical Record review, it was determined the facility failed to ensure one (1) of three (3) sampled residents received adequate supervision and assistance devices to prevent accidents related to the use of a Hoyer lift (Resident #20). Resident #20 was assessed and care planned for a two (2) person transfer with mechanical lift; however, on 09/29/18 the Certified Nurse Aide (CNA) transferred the resident from bed to wheelchair by himself without assistance of another staff and the use of the lift. The resident sustained [REDACTED]. The findings include: Review of the facility policy titled, Safe Lifting and Movement of Residents, last revised (MONTH) (YEAR), revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Staff will be observed for competency in using mechanical lifts. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Record review revealed the facility admitted Resident #20 on 01/09/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #20's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Further review revealed the resident was totally dependent on two (2) staff members for transfers. Review of Resident #20's Comprehensive Care Plan for Self-Care Performance Deficit dated 03/14/17 revealed a goal for the resident's Activities of Daily Living (ADL's) needs to be met daily and resident will maintain a neat, well-groomed appearance. Further review revealed an intervention for two staff members to transfer the resident with a mechanical lift due to weakness, poor activity tolerance, and left sided weakness. Review of the Lift Screen for Resident #20, dated 09/05/18 revealed the resident was non-weight bearing, unable to bend hips/knees/ankles independently; however can use both upper extremities. The facility determined the Total Body Lift was to be utilized with resident. Review of the Nursing Notes revealed Resident #20 complained of new pain on 09/30/18 to left leg during the PM shift. The resident was given Tylenol and leg was repositioned. There was no swelling, bruising or heat to touch. Tylenol was effective. On 10/01/18, the day shift nurse revealed the resident did not want to get out of bed related to pain in the left leg from the knee down. LPN #5 assessed the leg and there was no swelling, redness, bruising and was not warm to touch. LPN #5 did non pharmacological interventions related to resident stating that he/she was in pain but that he/she was fine. Review of a Incident Report dated 10/03/18 revealed Licensed Practical Nurse (LPN) #4 revealed Resident #20 complained of left lower extremity pain on 10/03/18. LPN #4 did a head to toe assessment and called the Nurse Practitioner and DON to further assess resident. Orders were received and she called the resident's power of attorney. An x-ray was completed at the facility and after the reading, the physician sent the resident to the Emergency Department for Evaluation and Treatment. Review of the Hospital Medical Record Emergency Department Provider Notes, dated 10/03/18 revealed Resident #20 presented with left lower leg pain that began one (1) week ago after he/she was transferred at nursing home without a lift. Review of the Radiology Report from Emergency Department visit dated 10/03/18 revealed Resident #20 had a fracture involving the proximal tibia and fibula with no displacement. Review of the Discharge Plan revealed to apply a splint, take Tylenol as needed for pain, and follow up with an orthopedist for further evaluation and management. Review of the Resident #20's Progress Notes, revealed the resident went to a follow up appointment with an Orthopedist on 10/08/18 and the resident was to continue with wearing the splint and non-weightbearing. Interview with Resident #20 on 05/15/19 at 8:20 AM revealed his/her left ankle was injured when Certified Nurse Aide (CNA) #1 transferred him/her without the assistance of another staff and without the use of a lift. Resident #20 stated when the CNA pivoted him/her from the bed to the wheelchair, his/her ankle did not move and he/she had instant pain in his/her left ankle. He/she stated the CNA was not trying to hurt him/her, he knew he/she wanted to get to bingo. Attempted interviews with CNA #1 (transferred resident), on 05/14/19 at 12:48 PM, 05/14/19 at 4:45 PM, and 05/15/19 9:22 AM, were unsuccessful. Review of the facility investigation revealed on 10/08/18, the Administrator interviewed CNA #1 and he revealed he had seen other people transfer the resident without using the lift; however, he was unable to recall any names or description of the staff who had transferred the resident without the mechanical lift. Interview on 05/15/19 at 9:00 AM with Licensed Practical Nurse (LPN) #1, Unit Manager revealed CNA #1 knew the resident was a mechanical lift for transfers and required two (2) staff. She stated she makes sure her staff know their residents regarding transfers and he was oriented to the residents when he started to work at the facility. Interview with the Director of Nursing (DON) on 05/15/19 at 4:48 PM revealed she expected all staff to transfer the resident per their Comprehensive Care Plan/Physician Orders. **The facility implemented the following actions to correct the deficient practice: 1. All staff were inserviced on 10/03/18 by administrative staff on identifying and reporting abuse, detecting change in residents' condition, preventing injuries with topics included: body mechanics in transfers, lifting safely, using equipment safely, keeping patients safe in facility and watching for hazards/accidents; new facility process for Kardex paper access/kiosk, accessing care plans and Kardex in Point Click Care, assisting with positioning and transferring including safe lifting and movement of residents, Safety precautions and mechanics for lifting, falls management and prevention, understanding legal and ethical aspects of healthcare, and how to properly operate Battery Powered Patient Lifts 2. Immediate skin assessments were conducted on 10/03/18 to 10/05/18 for every resident to identify skin issues, and any injuries not previously known. 3. An audit was conducted facility wide repeatedly from 10/03/18 to 12/04/18 on the Use of Lift and Transfer Audit to observe and verify CNA proper lifting techniques and that plan of care was followed for transfers. 4. A facility wide Kardex and Care Plan audit was completed 10/03/18 to 10/07/18 to ensure correct mobility and transfer interventions were in place and clearly identified. 5. Interviews were conducted with each resident by administrative staff 10/03/18 to 10/04/18 to identify if there were any concerns with care or transfers. 6. Interviews were conducted with each staff member 10/03/18 to 10/07/18 by administrative staff to ensure that no staff members had any concerns with their co-workers regarding care issues, transfers. 7. New Hire Orientation and Agency Orientation reviewed in QA Committee (Administrator, Director of Nursing, Social Services Director, Unit Managers, Dietary Manager, MDS Coordinators) to include agency orientation to Kardex. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of education logs revealed all staff were educated by 10/07/18 on identifying and reporting Abuse, body mechanic in transfers, lifting safely, using equipment safely, keeping patients safe in facility, watching for hazards/accidents, and new facility process for Kardex paper access/kiosk. In addition, Nursing staff were inserviced on accessing care plans and Kardex in Point Click Care, detecting change in resident status, Falls management and prevention, Understanding Legal and Ethical aspects of healthcare, and how to properly operate Battery Powered Patient Lifts. Interviews on 05/15/19 with LPN #1 at 9:00 AM, LPN #2 at 10:43 AM, LPN #3 at 10:50 AM, and LPN #7 at 4:30 PM revealed they were educated on abuse reporting, transferring residents with Hoyer lift, following care plans, kardex use and reporting injuries. Interviews on 05/15/19 with CNA #2 at 10:30 AM, CNA #4 at 10:52 AM, revealed they were educated on transfers, activities of daily living, care plans, proper use of Hoyer lift, Kardex use, and how to find the CNA care plan for each resident. Interview CNA #3 at 10:40 AM, with revealed she is an Agency staff and when she started working at the facility, she was educated on Fall Risk education, Abuse, Use of Hoyer lift with two people, Kardex use, and Care Plan Binder to find residents needs. 2. Review of facility skin assessments revealed they were completed on 10/03/18 through 10/05/18 for all residents with no concerns identified 3. Review of facility audits revealed they were completed throughout the facility facility from 10/03/18 to 12/04/18 to verify all CNA's were using proper lifting techniques and plan of care was followed for transfers. 4. Review of facility audits dated 10/03/18 through 10/07/18 revealed all staff were audited to ensure proper used of Kardex and Care Plans and that correct mobility and transfer interventions were in place and clearly identified. 5. Review of documentation of interviews revealed each resident with a BIMS score of eight (8) or above were interviewed by administrative staff on 10/03/18 to 10/04/18 to identify if there were any concerns with care or transfers. 6. Review of documentation of interviews conducted with each staff member by administrative staff on 10/03/18 to 10/07/18 revealed they were interviewed to identify if they had any concerns with their co-workers regarding care issues, and transfers. Further review revealed all staff was interviewed. 7. Review of the QA Committee Minutes revealed the New Hire Orientation and Agency Orientation packets, which also included agency orientation to Kardex, were reviewed by QA members (Administrator, Director of Nursing, Social Services Director, Unit Managers, Dietary Manager, MDS Coordinators)

Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations of a medication pass on 05/15/19, revealed a staff touched medications with their bare hand. The findings include: Review of the facility's policy titled, Administering Medications, last revised (MONTH) 2012, revealed staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Observation of a medication administration pass on 05/15/19 at 8:23 AM, revealed Registered Nurse (RN) #1, removed a capsule from a medication card with his bare hand, prior to administering the medication to the resident. Interview with RN #1 on 05/15/19 at 8:50 AM, revealed he should not have removed the medication from the pack with his bare hand because it was unsanitary. RN #1 stated the capsule was difficult to remove from the package, as normally with applied pressure, the medication would just pop out. Interview with the Director of Nursing (DON) on 05/16/19 at 3:37 PM, revealed RN #1 should not have removed the medication from the blister pack with his bare hand. She stated he could have used a pair of gloves to remove the pill. The DON further stated the facility did not have a policy specifically regarding handling medications with bare hands; however, the facility follows state and federal regulations related to infection control during medication administration.

Based on interview, record review, review of Hospital Records, and facility policy review, it was determined the facility failed to implement a comprehensive care plan for one (1) of five (5) sampled residents related to transfers. Resident #20 was care planned for two (2) staff to transfer resident with the use of a mechanical lift, however; on 09/29/18, Certified Nurse Aide (CNA) #1 transferred the resident without the assistance of another staff and without the use of a lift which resulted in the resident sustaining a fractured ankle. The findings include: Record review revealed the facility admitted Resident #20 on 01/09/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #20's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for Self-Care Performance Deficit dated 03/14/17 revealed an intervention for two (2) staff to transfer Resident #20 with the use of a mechanical lift. However, review of Incident report dated 10/03/18 and interview with Resident #20 on 05/15/19 at 8:20 AM revealed CNA #1 transferred the resident by himself from bed to wheelchair without the mechanical lift by standing the resident up and pivoting the resident. Review of the Discharge Plan and Radiology Report dated 10/03/18 revealed Resident #20 had a fracture involving the proximal tibia and fibula (ankle area) with no displacement. A splint was applied and the resident was advised to take Tylenol as needed for pain. Attempted interviews with CNA #1 (transferred resident), on 05/14/19 at 12:48 PM and 4:45 PM, and on 05/15/19 at 9:22 AM, were unsuccessful. Interview on 05/15/19 at 9:00 AM with Licensed Practical Nurse (LPN) #1, Unit Manager revealed each CNA has the opportunity to use the CNA Kardex and the computerized Kiosk located on the walls on the unit to find out what each resident requires for transfers. Interview with the Director of Nursing (DON) on 05/15/19 at 4:48 PM revealed she expected all staff to transfer the resident per their Comprehensive Care Plan/Physician Orders. **The facility implemented the following actions to correct the deficient practice: 1. All staff were inserviced on 10/03/18 by administrative staff on identifying and reporting abuse, detecting change in residents' condition, preventing injuries with topics included: body mechanics in transfers, lifting safely, using equipment safely, keeping patients safe in facility and watching for hazards/accidents; new facility process for Kardex paper access/kiosk, accessing care plans and Kardex in Point Click Care, assisting with positioning and transferring including safe lifting and movement of residents, Safety precautions and mechanics for lifting, falls management and prevention, understanding legal and ethical aspects of healthcare, and how to properly operate Battery Powered Patient Lifts 2. Immediate skin assessments were conducted on 10/03/18 to 10/05/18 for every resident to identify skin issues, and any injuries not previously known. 3. An audit was conducted facility wide repeatedly from 10/03/18 to 12/04/18 on the Use of Lift and Transfer Audit to observe and verify CNA proper lifting techniques and that plan of care was followed for transfers. 4. A facility wide Kardex and Care Plan audit was completed 10/03/18 to 10/07/18 to ensure correct mobility and transfer interventions were in place and clearly identified. 5. Interviews were conducted with each resident by administrative staff 10/03/18 to 10/04/18 to identify if there were any concerns with care or transfers. 6. Interviews were conducted with each staff member 10/03/18 to 10/07/18 by administrative staff to ensure that no staff members had any concerns with their co-workers regarding care issues, transfers. 7. New Hire Orientation and Agency Orientation reviewed in QA Committee (Administrator, Director of Nursing, Social Services Director, Unit Managers, Dietary Manager, MDS Coordinators) to include agency orientation to Kardex. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of education logs revealed all staff were educated by 10/07/18 on identifying and reporting Abuse, body mechanic in transfers, lifting safely, using equipment safely, keeping patients safe in facility, watching for hazards/accidents, and new facility process for Kardex paper access/kiosk. In addition, Nursing staff were inserviced on accessing care plans and Kardex in Point Click Care, detecting change in resident status, Falls management and prevention, Understanding Legal and Ethical aspects of healthcare, and how to properly operate Battery Powered Patient Lifts. Interviews on 05/15/19 with LPN #1 at 9:00 AM, LPN #2 at 10:43 AM, LPN #3 at 10:50 AM, and LPN #7 at 4:30 PM revealed they were educated on abuse reporting, transferring residents with Hoyer lift, following care plans, kardex use and reporting injuries. Interviews on 05/15/19 with CNA #2 at 10:30 AM, CNA #4 at 10:52 AM, revealed they were educated on transfers, activities of daily living, care plans, proper use of Hoyer lift, Kardex use, and how to find the CNA care plan for each resident. Interview CNA #3 at 10:40 AM, with revealed she is an Agency staff and when she started working at the facility, she was educated on Fall Risk education, Abuse, Use of Hoyer lift with two people, Kardex use, and Care Plan Binder to find residents needs. 2. Review of facility skin assessments revealed they were completed on 10/03/18 through 10/05/18 for all residents with no concerns identified 3. Review of facility audits revealed they were completed throughout the facility facility from 10/03/18 to 12/04/18 to verify all CNA's were using proper lifting techniques and plan of care was followed for transfers. 4. Review of facility audits dated 10/03/18 through 10/07/18 revealed all staff were audited to ensure proper used of Kardex and Care Plans and that correct mobility and transfer interventions were in place and clearly identified. 5. Review of documentation of interviews revealed each resident with a BIMS score of eight (8) or above were interviewed by administrative staff on 10/03/18 to 10/04/18 to identify if there were any concerns with care or transfers. 6. Review of documentation of interviews conducted with each staff member by administrative staff on 10/03/18 to 10/07/18 revealed they were interviewed to identify if they had any concerns with their co-workers regarding care issues, and transfers. Further review revealed all staff was interviewed. 7. Review of the QA Committee Minutes revealed the New Hire Orientation and Agency Orientation packets, which also included agency orientation to Kardex, were reviewed by QA members (Administrator, Director of Nursing, Social Services Director, Unit Managers, Dietary Manager, MDS Coordinators)

Based on interview, record review, review of the facility's policy and Eagle Room Process, and review of the facility's videotape surveillance recording, it was determined the facility failed to have an effective system to ensure a care plan was revised for supervision of behaviors for one (1) of six (6) sampled residents, Resident #1. On 06/20/12, Resident #1 was observed by staff attempting to exit the exterior emergency door the Pathways Unit for Brain Injuries and was redirected by staff. Later, on 06/20/12, the facility placed a Secure Guard Alarm transmitter on the right ankle of Resident #1. On 06/23/12, Resident #1 was transferred to the Life Skills Unit (LSU) due to increased exit seeking behaviors. On 07/06/12, the staff Neuropsychologist developed a Behavior Plan for Resident #1 due to the resident's exit seeking behavior. However, the facility failed to revise Resident #1's comprehensive plan of care to include the Behavior Plan and staff was not aware of interventions to de-escalate the exit seeking behaviors demonstrated by Resident #1. On 08/08/12, Resident #1 successfully eloped from the Life Skills Unit without knowledge or supervision of staff. (Refer to F323) The facility's failure to revise the comprehensive plan of care to include Behavior Plan interventions to ensure a safe and secure environment for cognitively impaired individuals with known elopement risk placed the residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/15/12 of the Immediate Jeopardy at 42 CFR 483.20 Resident Assessment (F280). An acceptable Allegation of Compliance (AOC) was received on 08/16/12 and the Immediate Jeopardy was determined to be removed on 08/17/12 prior to exit, which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment (F280), while the facility monitors the plan of correction to achieve substantial compliance with the regulation, and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility's policy titled Care Plans, dated 08/2009, revealed a comprehensive care plan was developed after the completion of the comprehensive assessment. The policy stated the Interdisciplinary team (IDT) was responsible to initiate a care conference to develop the care plan based on the resident's needs. The care plan was to include measurable objectives and realistic target dates. Review of the Eagle Room Process revealed the unit or designated management nurses discussed resident issues from the 24 hour report. The unit or designated management staff obtained a report from the off-going shift to include the shift to shift report and any follow-up from the previous day. Rounds were completed on residents identified on the 24 hour report or during the shift to shift report. Lab results, clinical records, and new physician orders [REDACTED]. The goal of the the Eagle Room Process was to prioritize resident needs by identifying resident risks, determine priorities and needs, assign staff responsibility ensure task completion, and evaluate interventions. Review of Resident #1's Nursing Progress Notes revealed the resident demonstrated exit-seeking behaviors of packing clothes, standing by the door in anticipation of someone opening the door, and slipping out behind the person coming through the door into the Pathways Unit for Brain Injuries. In addition, the resident would ask staff to open the door so he/she could go home and would ask for the keys to his/her truck. Review of the Behavior Notes revealed documentation that Resident #1 demonstrated exit-seeking behaviors on fifteen (15) days during the month of July 2012, and two (2) days during the month of August 2012, which preceded the successful elopement of the resident from the facility on 08/08/12. On 08/08/12, Resident #1 exited the secure (locked) unit via the exterior emergency exit door, which was not equipped with the Secure Guard Alarm system, and without staff supervision or knowledge. Staff on the LSU reported no alarm was heard when the resident exited the facility on 08/08/12. The facility's videotape surveillance recording showed Resident #1 walked around the outside of the building to the Main Entrance to the facility at 20:03:08 (8:03:08 PM). The House Manager found Resident #1, after the resident rang the doorbell at the Main Entrance at 20:06:04 (8:06:04 PM). Review of the clinical record for Resident #1 revealed the facility admitted the resident to the Pathways Unit for [MEDICAL CONDITION] on 05/07/12. The resident was transferred to the facility from a local hospital after intercranial surgery for [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/21/12, revealed the facility assessed the resident as moderately impaired in cognition and unable to participate in the (BIMS) Brief Interview for Mental Status testing. Behavioral symptoms were triggered and the facility implemented a care plan to address the behaviors of exit seeking/elopement risk. Review of the Care Plan for Resident #1, dated 06/20/12, revealed a focus on the risk of elopement due to cognitive impairment, closed head injury, and poor safety awareness. The elopement focus included a goal that the resident would not leave the center unattended, it was initiated on 06/20/12 and revised on 06/26/12. In addition, the care plan focus revealed the resistance with treatment/care, combativeness, and wandering in/out of others rooms related to [MEDICAL CONDITION]/cognitive impairment with revision on 07/09/12. However, the elopement focus did not include the staff intervention protocols from the Behavior Plan dated 07/06/12, and did not include an intervention to direct staff to reference the Behavior Plan. Review of the Behavior Plan for Resident #1 located in the Behavior Technician documentation book, compiled by the staff Neuropsychologist on 07/06/12, revealed three (3) targeted behaviors which included exit seeking behavior, reduced orientation, and diminished safety awareness. The Behavior Plan included staff interventions for exit seeking behaviors and staff was provided a protocol that included: 1) staff was to provide verbal cues to discontinue the behavior and provide a second verbal warning; 2) If resident did not discontinue wandering behavior, the resident was to be offered a quiet room time out; 3) If resident did not de-escalate the behavior, the resident was to be offered quiet room time out as a de-escalation procedure; and, 4) Staff were to make all efforts to positively reinforce the resident for adaptive goal directed non-perseverative behavior. Review of the Nursing Progress Notes for Resident #1 dated 07/12/12, 07/21/12, and 08/08/12, revealed the resident demonstrated exit-seeking behaviors of packing clothes and standing by the door in anticipation of someone opening the door and the resident would slip out behind the person coming through the door onto the Pathways Unit. In addition, the resident would ask staff to open the door so he/she could go home, and the resident would ask for the keys to his/her truck. Review of the Behavior Notes revealed documentation that Resident #1 demonstrated these exit-seeking behaviors on fifteen (15) days during the month of July 2012, (July 4 through July 12, July 11 through July 25, July 27, and July 29) and two (2) days during the month of August 2012 (August 1, and August 8). Review of Nursing Notes and Behavior Notes found no reference of staff interventions, or use of the Behavior Plan and protocols dated 07/06/12, or attempts to de-escalate the exit seeking behaviors demonstrated by Resident #1. Interview, on 08/14/12 at 11:15 AM, with Behavior Tech (BT) #1 revealed Resident #1 watched the exit door to the Pathways Unit which was accessed by use of a pin pad code, and was able to get through the door if staff was not careful to close the door behind them. Interview, on 08/19/12 at 10:50 AM, with Certified Nursing Assistant (CNA) #6 revealed she observed Resident #1 at the doors when she worked on the Life Skills Unit (LSU). CNA #6 was not surprised that Resident #1 left the facility, because the resident believed he/she was an employee and as the day came to a close, the resident would say it was time for him/her to go home and begin looking for his/her keys. Interview, on 08/19/12 at 10:15 AM, with Licensed Practical Nurse (LPN) #3 revealed staff was responsible to advise the Charge Nurse of wandering or exit-seeking behaviors. LPN #3 stated the nurse who witnessed the behavior was responsible to document the behavior in the Nurse's Notes, perform a Behavioral RAP (Resident Assessment Protocol) if the behavior was new, and to document the behavior in the 24 hour report, which goes to the Eagle Room for discussion. LPN #3 was not sure how the Behavior Plan was incorporated into the plan of care for a resident. Interview, on 08/19/12 at 11:05 AM, with LPN #4 revealed she could recognize wandering and exit-seeking behavior. LPN #4 said residents were assessed for elopement risk upon admission to the facility, and stated when wandering or exit-seeking behavior was identified, the nurse was responsible to complete a Behavioral RAP, and document the behavior on the 24 hour report, which would be discussed at the Eagle Room meeting. LPN #4 was not aware how the Behavior Plan with protocols was included in the care plan, but thought it would be discussed in the weekly Care Plan Meetings. Interview, on 08/14/12 at 12:55 PM, with the Pathways/Life Skills Unit (LSU) Charge Registered Nurse (RN), revealed the Behavior Tech on the LSU was responsible to provide care for the residents on the unit, document behaviors, follow the Behavior Plan for each resident, and report behaviors to the nurse. Interview, on 08/14/12 at 11:15 AM, with BT #1 revealed the responsibilities of the BT were to provide care and activities of daily living for residents on the Life Skills Unit, document behaviors, and report behaviors to the nurse. BT #1 stated each resident on the LSU had a specific Behavior Plan developed with interventions for the BT to follow. Review of the acceptable Allegation of Compliance (AOC), dated 08/16/12, revealed the facility took the following immediate actions: 1. All residents in the facility were assessed for indicators of elopement risk, wandering, and unsafe wandering, and by the Unit Managers and was completed on 08/16/12. 2. All Resident Care Plans were updated to include staff interventions to manage unsafe wandering and exit seeking behaviors. Tasks and Patient Information Worksheets were updated to indicate residents who demonstrated unsafe wandering and exit seeking behaviors. These updates were completed by the Unit Managers on 08/16/12. 3. Elopement binders on the nursing stations were updated, by the Unit Managers on 08/16/12, with resident photographs and included descriptions of specific negative behaviors for staff to monitor. Specific demographic information was included for each resident who demonstrated unsafe wandering and exit seeking behaviors. 4. A mandatory Power Point presentation for the nursing staff was provided on 08/16/12 by Administrative staff to ensure staff was competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors as well as revision of care plans. The State Agency validated the AOC on 08/17/12 prior to exit as follows: 1. The State Agency validated through review of the Elopement book, used by the facility to document and identify residents at risk for elopement, that although on 08/13/12 the facility had identified five (5) residents to be at risk for elopement, the facility identified a total of twenty-six (26) residents at risk for elopement on 08/16/12. Interview, on 08/20/12 at 3:20 PM, with the Administrative Director of Nursing Services (ADNS) revealed the facility reviewed all residents for elopement risk and placed Secure Guard Alarm bands on each resident who demonstrated at least one behavior of wandering/elopement with reassessment in 30 days. 2. The State Agency validated through record review of the residents identified to be at risk for elopement that the care plans were updated and patient information worksheets (used by ancillary staff to provide resident care) were updated. 3. The State Agency validated through record review of Elopement binders, on the nursing stations, that all residents identified by the facility to be at risk of elopement were documented by photograph, and included documentation of specific behaviors and demographic information. 4. The State Agency validated through record review of the Power Point presentation for mandatory staff in-services that the appropriate content was provided to ensure staff were competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors as well as revision of care plans. Interview, on 08/19/12 at 11:35 AM, with the Weekend Charge Nurse, revealed all staff including herself had attended an all staff mandatory inservice that focused on elopement procedures, identification of elopement risks, and revision of care plans. Interview, on 08/19/12 at 10:15 AM, with LPN #2 revealed she attended an in-services on 08/16/12 regarding the facility's protocol for elopement that included documentation, and maintaining the code to exit doors in the facility. LPN #2 provided a description of the 'Code Black' process the facility used in the event of an elopement. LPN #2 stated the education included the process of documentation to include the Behavior RAP and care plans.

Based on observation, interview, record review, review of the facility's policies Wandering Patient Practice Guide and the Secure Guard Alarm System, and review of the facility's videotape surveillance recording, it was determined the facility failed to have an effective system to ensure adequate supervision of cognitively impaired residents with known elopement risk, for one (1) of six (6) sampled residents, Resident #1. The facility failed to provide a safe and secure environment for Resident #1, who was assessed by the facility to be at high risk for elopement. On 06/20/12, Resident #1 was observed by staff attempting to exit the exterior emergency door of the Pathways Unit for Brain Injuries and was redirected by staff. Later, on 06/20/12, the facility placed a Secure Guard Alarm transmitter on the right ankle of Resident #1. On 06/23/12, Resident #1 was transferred to the secure (locked) unit, the Life Skills Unit (LSU) because of increased exit seeking behaviors. A Behavior Plan was developed by the staff Neuropsychologist, dated 07/06/12, to address the resident's increased exit seeking behavior. However, the facility failed to revise the resident's comprehensive plan of care to include the Behavior Plan and staff was not aware of the plan nor the interventions. (Refer to F280). On 08/08/12, the facility's videotape surveillance recording on the LSU showed Resident #1 walking towards the LSU's emergency door exit at 19:53:21 (7:53:21 PM). Resident #1 exited the secure (locked) unit, without staff supervision or knowledge, via the exterior emergency exit door, which was not equipped with the Secure Guard Alarm system. Staff on the LSU reported no alarm was heard when the resident exited the facility on 08/08/12. The facility's videotape surveillance recording showed Resident #1 walked around the outside of the facility, which was located on a two-lane street, near a large commercial area, to the Main Entrance to the facility at 20:03:08 (8:03:08 PM). The House Manager found Resident #1, after the resident rang the doorbell at the Main Entrance at 20:06:04 (8:06:04 PM). The facility's failure to provide adequate supervision of cognitively impaired individuals with known elopement risk placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/15/12 of the Immediate Jeopardy and Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). An acceptable Allegation of Compliance (AOC) was received on 08/16/12 and the Immediate Jeopardy was determined to be removed on 08/17/12 prior to exit, which lowered the scope and severity to a "D" at 42 CFR 483.25 Quality of Care (F323), while the facility develops and implements a plan of correction to achieve substantial compliance with the regulation, and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility's policy regarding Wandering Patient Practice Guide, dated 04/2008, revealed staff was to assess each resident for indicators of unsafe wandering behaviors upon admission to the facility. The policy stated the Interdisciplinary Team (IDT) would review residents with unsafe wandering to plan effective prevention strategies, which could include the use of a Secure Guard Alarm bracelet to alert the resident of safe boundary limits, and to alert the staff that an exit seeking event was in progress. The policy stated proper functioning of the sensor in the bracelet was checked daily, and verification of placement of the device on the resident was performed each shift. Phase I of the policy stated exit doors and stairwell doors were alarmed, and included a note: some centers had specialty units with secure doors that may require testing and function validation. Phase III included interventions for residents with increased frequency of behaviors to include: one-on-one supervision, and supervised walking. Review of the facility's policy regarding Secure Guard Alarm System, undated, revealed residents who demonstrated confusion, restlessness, wandering and exit seeking, and residents who disregarded facility/unit rules which put the resident in an unsafe situation would meet the criteria for utilization of the Secure Guard Alarm System. The procedure of the Secure Guard Alarm System stated residents who resided on the locked behavior unit were not required to wear a transmitter unless the resident exhibited wandering and exit seeking behaviors. Observation, on 08/15/12 at 9:12 AM, of the facility's videotape surveillance recorded on the LSU, from 08/08/12 at 19:53:21 (07:53:21 PM), revealed Resident #1 ambulated on the LSU in the direction of room number 308. The review of the video surveillance recording did not capture an image of Resident #1 entering the room. The camera was positioned on the ceiling in front of the exterior emergency exit door which was adjacent to room 308, which created a blind spot. Licensed Practical Nurse (LPN) #1 was seen on the LSU videotape surveillance at 20:01:20 (08:01:20 PM); entered room 306 at 20:01:30 (08:01:30 PM); and entered the Day Room at 20:01:55 (08:01:55 PM). Videotape surveillance from a view of the exterior door which led to the staff parking area, showed Resident #1 walked toward the Main Entrance at 20:03:08 (08:03:08 PM). The video surveillance showed at 20:04:12 (08:04:12 PM) both LPN #1 and Behavior Tech (BT) #2 went in and out of all four (4) resident rooms and the Day Room. The Main Entrance view from the videotaped surveillance showed Resident #1 at the Main Entrance door with the House Manager at 20:06:04 (08:06:04 PM). Interview, on 08/13/12 at 2:20 PM, with the Administrative Director of Nursing Services (ADNS) revealed the exterior emergency exit door on the LSU was not equipped with the Secure Guard System Alarm on 08/08/12 when Resident #1 eloped from the facility. However, the emergency door was equipped with an alarm related to the 15 second emergency release. It was surmised the resident entered a code and released the door as the resident stated he/she just put in the bank card number. The ADNS stated the Secure Guard System was installed on the emergency exit door on 08/10/12. Review of the clinical record for Resident #1 revealed the resident was transferred to the facility from a local hospital after intracranial surgery for [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/21/12, revealed the facility assessed the resident as moderately impaired in cognition and triggered a care plan to address the behaviors of exit seeking/elopement risk. Review of the Care Plan for Resident #1, dated 06/20/12, revealed the resident was an elopement risk and the resident would not leave the center unattended. In addition, the care plan focused on the resident's behaviors of resistance with treatment/care, combativeness, and wandering in/out of others rooms. Record review revealed a Behavior Plan was developed on 07/06/12, by the staff Neuropsychologist, which included staff interventions for the resident's exit seeking behaviors and a protocol for staff to implement. However, the resident's comprehensive plan of care had not been revised to include the Behavior Plan. Review of the Nursing Progress Notes, dated 06/19/12 at 00:37 AM, revealed Resident #1 was confused, ambulated independently, entered other resident's rooms, and came behind the nurse's station. The note documented that staff was not able to redirect or divert Resident #1, who became agitated easily, and required constant observation. Review of the Nursing Progress Notes, dated 06/20/12 at 5:56 AM, revealed Resident #1 was confused and went into other resident's rooms. The 06/20/12 note further documented that Resident #1 left the Pathways Unit and went onto the LSU, where staff intervened to stop the resident from exiting the exterior emergency exit door. The note also stated Resident #1 required one-on-one supervision by staff to prevent the resident from exiting the facility. Review of the Nursing Progress Notes, dated 06/20/12 at 5:21 PM, revealed the IDT recommended the use of a Secure Guard Alarm (SGA) for Resident #1, which was applied to the right ankle of the resident. Review of the Nursing Progress Notes, dated 06/23/12 at 10:56 AM, revealed the SGA was in place when Resident #1 wandered into other resident's rooms. The resident applied gloves stating to "clean and take care of these old people." Review of the Nursing Progress Notes, dated 06/26/12 at 1:24 PM, documented that Resident #1 was transferred to the LSU on 06/23/12 due to increased maladaptive behaviors. Review of the Nursing Progress Notes, dated 07/09/12 at 5:21 PM, revealed Resident #1 was confused and occasionally wandered into other resident rooms, during the shift had tried to unlock the doors to the Pathways Unit, and requested the code to the pin pad. On 07/10/12 at 1:20 AM, the resident asked for the pass key to the door so the resident could go home. The Nursing Progress Notes, dated 07/12/12 at 6:10 PM, revealed Resident #1 packed personal belongings several times each shift and requested keys to the resident's truck to go home. The resident would request the pass code or for keys to leave the unit on a daily basis. Review of the Nursing Progress Notes, dated 08/01/12, for the shift of 6P-6A revealed the resident tried to unlock the keypad, and wanted to leave. Review of Nursing Progress Notes, dated 08/08/12 at 8:00 PM revealed the resident was packing and unpacking clothes, and exit seeking prior to the elopement at 8:01 PM. Licensed Practical Nurse #1 (LPN #1) was unable to locate Resident #1 on the LSU unit, and BT #2 was notified. LPN #1 documented that Resident #1 could not be located on the LSU, and the House Supervisor (HS) was notified at 8:05 PM, and the HS returned Resident #1 from the front entrance, to the LSU at 8:06 PM, where the resident was assessed and found to be without injury. Interview with LPN #1, on 08/15/12 at 10:20 PM, revealed that on 08/08/12 near 8:00 PM, she came onto the LSU to administer medications to Resident #1, when she found the resident missing. LPN #1 notified BT #2, and together the staff members were unable to find Resident #1 on the LSU. LPN #1 said she was not aware how Resident #1 could have left the unit, and did not hear an alarm sound to alert staff of the elopement. LPN #1 said she called a 'Code Black' to alert all staff in the facility of the elopement, when the House Manager retrieved Resident #1 from outside the front Main Entrance. Interview, on 08/14/12 at 3:20 PM, with BT #2 revealed on 08/08/12 the Behavior Technician (BT) was in a resident room for thirty (30) minutes cleaning and changing a resident's brief before she was told by LPN #1 that Resident #1 could not be located, an alarm was not sounding and she did not hear an alarm while in the room with the resident. BT #2 said Resident #1 would often attempt to leave the unit if the BT on the unit was involved in resident care with the door closed. BT #2 stated it was difficult to keep residents in view at all times with only one (1) BT on the unit. BT #2 said she was concerned about the safety of Resident #1 when the resident eloped, because the resident was at risk to wander onto the road or be hit by a passing automobile. Interview, on 08/14/12 at 11:15 AM, with BT #1 revealed it was difficult to maintain more than four (4) residents safely on the LSU because it was not possible for one (1) staff member to visualize all of the residents at all times. BT #1 said the LSU was staffed with one (1) Behavior Tech, and one (1) nurse who was also assigned to resident care on the Pathways Unit. BT #1 said the BT assigned to the LSU worked alone on the unit, except when the nurse came from the Pathways Unit to administer medications to the residents on the LSU. BT #1 said the BT could not visualize all residents when care was provided to residents in rooms when the door must be closed to maintain privacy. BT #1 was unsure how Resident #1 was able to elope via the exterior emergency exit door on 08/08/12. BT #1 said the significant other (SO) who visited Resident #1 knew the code to the exterior emergency exit door, as the SO took Resident #1 through the exterior emergency exit door to go outside and smoke during visits. Interview, on 08/14/12 at 2:45 PM, with the Recreational Therapist (RT) revealed the RT had observed that Resident #1 began exit-seeking behaviors every afternoon. The RT stated the assigned BT assigned to the LSU could not visualize all of the residents on the unit simultaneously, because there were many blind spots in the LSU, even with the videotape cameras utilized on the unit. The RT said the Significant Other (SO) for Resident #1 had the code to the pin pad on the exterior emergency exit door, and often took Resident #1 outside of the exterior emergency exit door to smoke. The RT was not certain how Resident #1 managed to leave through the door without staff knowledge or supervision. The RT said the road in front of the facility was quite busy and said if Resident #1 tried to cross the road, who knows what would have happened. Interview, on 08/14/12 at 12:55 PM, with the Charge RN for the Pathways and Life Skills Units, revealed residents who required more acute monitoring were placed on the LSU. The Charge RN said one (1) Behavior Tech could provide adequate supervision to the residents on the LSU and said the BT could obtain assistance from the Pathways Unit when needed. The Charge RN estimated the nurse assigned to the LSU would spend about ten (10) percent of their time on the LSU. The Charge RN said residents were not always in visual range of the BT, and did not believe it increased the risk for elopement on the LSU because there was always a window of opportunity, for an elopement and said this had not been a problem in the past. Interview, on 08/14/12 at 2:55 PM, with the Pathways Program Director (PPD) revealed the exterior emergency exit door was not to be used by staff or residents without prior approval. The PPD said she thought Administration considered the addition of the Secure Guard Alarm system to the exterior emergency door, but was not sure why the alarm was not installed. Interview, on 08/15/12 at 10:45 AM, with the Pathways Unit Manager (UM) revealed that a video surveillance monitor with both camera views of the LSU was positioned behind the Pathways Nursing Station. The UM said there was no designated staff member assigned to monitor the video of the LSU, as all nursing staff shared the responsibility of viewing the monitor when they were at the Nursing Station. The UM said there was usually a staff member at the Nursing Station. Observation, on 08/13/12 at 2:20 PM, found the LSU was on continuous video surveillance with two (2) views of the unit. One view of the Life Skills Unit was from the exterior emergency exit door to the double doors that lead to the Pathways Unit, and the other view was from the door/hallway to the Day Room where four (4) residents were provided a snack by the BT. Resident #1 was walking in the hallway; however, not in visual range of the BT. There was no nurse's station on the LSU, the nurse's station in charge of the LSU was on the other side of locked doors on the Pathways Unit. Observation, on 08/14/12 at 8:25 AM, revealed two (2) residents were sitting in the Day Room not in visual range of staff, while three (3) residents were outside smoking with supervision of the BT. Further observation, on 08/14/12 at 8:35 AM, revealed Resident #1 was at the double doors looking through the window, which lead to the Pathways Unit. Observation, on 08/14/12 at 11:10 AM, found Resident #1 standing at the door to the courtyard, looking outside, then paced to and from room 308. There was no nurse's station on the LSU, the nurse's station in charge of the LSU was on the other side of locked doors on the Pathways Unit. Interview, on 08/15/12 at 8:05 AM, with the ADNS revealed she did not think Resident #1 eloped on 08/08/12 when the resident left the LSU without staff supervision. The ADNS stated that Resident #1 never requested to leave the Life Skills Unit. The ADNS said although Resident #1 left the facility through the exterior emergency exit door, the resident was not at risk because the resident was fully dressed, and ambulated without assistance. The ADNS said Resident #1 would not walk into the street because the resident was currently at a higher level of function since being admitted . Review of the acceptable Allegation of Compliance (AOC), dated 08/16/12, revealed the facility took the following immediate actions: 1. Resident #1 was returned to the Life Skills Unit and was assessed on 08/08/12 by LPN #1 and found no injury was sustained. Resident #1 was placed on one to one supervision. 2. All exit doors in the facility were checked for function on 08/08/12 and found to be in working order by the Director of Maintenance. 3. All residents in the facility with Secure Guard Alarm bands were checked for placement and function on 08/08/12 by LPN #1 and were found to function properly. 4. The exterior emergency exit door on the Life Skills Unit was monitored by staff continually on 08/09/12 until the Secure Guard Alarm System was installed on the exit door on 08/10/12. 5. All residents in the facility were assessed for indicators of elopement risk, wandering, and unsafe wandering, by the Unit Managers and was completed on 08/16/12. 6. Resident Care Plans, Tasks and Patient Information Worksheets were updated as needed related to elopement risk by the Unit Managers and was completed on 08/16/12. 7. A QA meeting was held with the Medical Director in attendance on 08/09/12 and on 08/15/12 to discuss the elopement and the facility's plan of action. 8. The Secure Guard Alarm System was installed on the four (4) exit doors and the door exiting the Life Skills unit on 08/10/12 by a contracted security systems company. 9. Daily checks were done to ensure the Life Skills Door was operating properly by the Maintenance Director (Monday through Friday) and the Weekend Charge Nurse (Saturday and Sunday). 10. The Secure Guard Alarm System was installed to six (6) exterior emergency exit doors, by a contracted security systems company, which was accomplished on 08/16/12. The staff were positioned at the four exit doors accessible to the residents. 11. All staff was in-serviced on 08/16/12 by the Assistant Administrator with the Administrator in attendance and the Corporate Regional as an oversight, regarding the protocol for maintenance of the pin pad numbers and on the Wandering Patient Practice Guide. Staff was not allowed to work in the facility until the training had been completed. 12. Elopement Binders were updated on 08/16/12 by the Unit Managers, to reflect elopement risk, wandering, and unsafe wandering behaviors. The State Agency validated the AOC on 08/17/12 prior to exit as follows: 1. The State Agency validated through record review of the facility's record for Resident #1 and found the resident was assessed on 08/08/12, was found to be without injury, and was placed on one-to-one supervision. 2. The State Agency validated through review of the Maintenance Log that the exterior exit doors were checked to ensure proper function on 08/08/12. 3. The State Agency validated through record review that the residents with Secure Guard Alarm bands were checked for placement and function on 08/08/12. 4. The State Agency validated through record review, and interview with the Administrator and Administrative Director of Nursing Services, on 08/13/12 at 2:00 PM, that the exterior emergency exit door on the Life Skills Unit was monitored by staff continuously on 08/09/12 until the Secure Guard Alarm system was installed on the exit door on 08/10/12. Interviews with CNA #2 and CNA #3, on 08/16/12 at 2:15 PM and 2:30 PM, confirmed the staff was assigned to remain at the exit door until the new alarm system was installed. 5. The State Agency validated, through review of the Elopement book, the facility had originally identified only five (5) residents on 08/13/12 as at risk for elopement, then a second assessment, on 08/16/12 of all residents, identified a total of twenty-six (26) residents at risk for elopement. Interview, on 08/20/12 at 3:20 PM, with the ADNS revealed the facility completed the second assessment of all residents and placed Secure Guard Alarm bands on each resident who demonstrated at least one behavior of wandering/elopement to be reassessed in thirty (30) days. 6. The State Agency validated through record review of residents identified to be at risk for elopement that care plans were updated and patient information worksheets (used by ancillary staff to provide resident care) were updated. 7. The State Agency validated through interview with the Administrator and Administrative Director of Nursing Services (ADNS) the Quality Assurance Committee met on 08/09/12 and on 08/15/12, and that the facility's Medical Director was present to discuss the elopement on 08/08/12 and the facility's plan of action. 8. The State Agency validated, on 08/19/12 at 11:55 AM, through observation, the four (4) exterior doors and the exit door to the LSU, with pin pad access to cancel emergency alarm the doors, were equipped with the Secure Guard Alarm System. Further observation on 08/20/12 at 3:30 PM, verified the function and audible alarm as demonstrated by the Director of Maintenance. 9. The State Agency validated through record review of the maintenance logs that the exterior emergency exit doors function was checked daily. Interview the the ADNS, on 08/15/12 at 3:45 PM, and the Weekend House Supervisor, on 08/19/12 at 11:35 AM, verified the function of the exterior doors was checked by the Weekend House Supervisor on weekend days. 10. The State Agency validated through observation and interview with the Administrator and ADNS, on 08/16/12 at 2:55 PM, that staff was positioned at the four (4) exterior doors without the alarm system to maintain resident safety during the installation of the Secure Guard Alarm System. Interviews with CNA #2 and CNA #3, on 08/16/12 at 2:15 PM and 2:30 PM, confirmed the staff was assigned to remain at the exit door until the new alarm system was installed. Observations of the exit doors during this time revealed CNA #2 and CNA #3 was sitting at emergency exit doors while the alarm system was being installed. 11. The State Agency validated through record review of the Power Point presentation for mandatory staff in-services that the appropriate content was provided to ensure staff were competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors. Interview, on 08/20/12 at 3:00 PM, with the Director of Maintenance, ADNS, and the Life Skills Unit Manager, revealed that the codes on all doors were changed and the codes to the emergency exit doors were maintained by limited Management Staff. Interviews, on 08/19/12 at 11:24 AM and 11:35 AM, with CNA #8 and the Weekend Charge Nurse, revealed they had attended a mandatory inservice for all staff, that focused on elopement procedures, identification of elopement risks, codes to the exterior doors and who was allowed access to these codes. In addition, the doors were not to be used by anyone unless it was an emergency. Interview, on 08/19/12 at 10:15 AM, with LPN #2 revealed she attended an inservice on 08/16/12 regarding the facilty protocol for elopement that included documentation, and maintaining the code to exit doors in the facility. LPN #2 provided a description of the 'Code Black' process the facility used in the event an elopement occurred. LPN #2 stated the education included the process of documentation to include the Behavior RAP and care plans. Interview, on 08/19/12 at 10:50 AM, with CNA #6 revealed she attended an in-service on 08/16/12 regarding the facilty protocol for resident elopements. CNA #6 stated the teaching included recognition of signs of resident elopement, and review of the 'Code Black' procedure. CNA #6 stated the teaching also included instructions regarding staff interventions with residents who were issued the Secure Alert Alarm band. 12. The State Agency validated through review of the Elopement binders on the nursing stations that all residents identified by the facility to be at risk of elopement were documented by photograph, and included documentation of specific behaviors and demographic information. Interview, on 08/20/12 at 2:55 PM, with the Unit Manager of the Pathways and LSU stated that all residents in the facility were evaluated for the risk of elopement on 08/16/12, and stated there were residents who had been identified to be at risk for elopement and those were issued a Secure Guard Alert band. The UM stated each resident's care plan was updated, and all residents with the Secure Guard Alert band were included in the Elopement Binders on each unit. Interview, on 08/20/12 at 3:00 PM, with the Director of Nursing revealed all residents in the facility were reviewed for elopement risk, and it was determined there were twenty-six (26) residents who demonstrated at least one risk for elopement. The DON stated the Unit Managers assisted to perform a Behavior RAP for each resident, and said the Elopement binders on each units were updated to include al residents who were issued a Secure Guard Alarm band.

Based on observation, interview, record review, review of the facility's policies Wandering Patient Practice Guide and the Secure Guard Alarm System, and review of the facility's videotape surveillance recording, it was determined the facility failed to be administered in a manner to use it's resources effectively and efficiently. The facility's Administration failed to have an effective system in place to ensure policy and procedures were implemented related to supervision of cognitively impaired residents with known elopement risk, and failed to provide a safe environment for one (1) of six (6) sampled residents, Resident #1. Resident #1 was assessed by the facility to be at high risk for elopement; the facility placed a Secure Guard Alarm band on the right ankle of Resident #1 on 06/20/12; transferred the resident from the Pathways Unit for [MEDICAL CONDITION] to the Life Skills Unit (LSU), (a secure locked unit) on 06/23/12; and had a Behavior Plan developed on 07/06/12. However, the LSU was not equipped with the Secure Guard Alarm system, and the resident's comprehensive plan of care was not revised to incorporate the Behavior Plan. On 08/08/12 at an undetermined time, Resident #1 eloped from the Life Skills Unit (LSU), without supervision or staff knowledge. Resident #1 was seen on the facility's videotape surveillance on the unit at 7:53:21 PM; recorded to walk around the outside of the facility, which was located on a two-lane street, near a large commercial area at 8:03:08 PM, and then appeared at the front Main Entrance to the facility at 8:06:04 PM. (Refer to F280 and F323) The facility's failure to utilize it's resources effectively; to provide adequate supervision of cognitively impaired individuals with known elopement risk, placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/15/12 of the Immediate Jeopardy at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) and (F520) with Substandard Quality of Care in the area of 42 CFR 483.25 Quality of Care (F323). An acceptable Allegation of Compliance (AOC) was received on 08/16/12, and the Immediate Jeopardy was determined to be removed on 08/17/12 prior to exit which lowered the scope and severity to a "D" for 42 CFR 483.75 Administration (F490) while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality Assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. The findings include: 1. Review of the facility's policy regarding Wandering Patient Practice Guide, dated 04/2008, detailed that staff was responsible to assess each resident for elopement risk upon admission to the facility. The Interdisciplinary Team (IDT) was responsible to review residents with unsafe wandering/elopement risk to determine appropriate interventions, that could include the use of the Secure Guard Alarm to provide notice of safe boundaries for the resident, and to alert staff when an elopement was in progress. Phase I of the policy stated the exit doors and stairwell doors were alarmed, and included a note: some centers had specialty units with secure doors that may require testing and validation of function. Phase III included possible facility interventions for residents with more frequent behaviors that included one-on-one supervision and supervised walking. Review of the facility's policy regarding Secure Guard Alarm System, undated, detailed residents that would benefit from the use of the Secure Guard Alarm were those with confusion, restlessness, wandering and exit seeking behaviors, and residents that disregarded facility rules and policies which placed them at risk for harm. Observation, on 08/15/12 at 9:12 AM, of the facility's videotape surveillance recorded on the LSU, from 08/08/12 at 19:53:21 (07:53:21 PM), revealed Resident #1 ambulated on the LSU in the direction of room [ROOM NUMBER] and the unit's emergency exit door. Videotape surveillance from a view of the exterior door which led to the staff parking area, showed Resident #1 walked toward the Main Entrance at 20:03:08 (08:03:08 PM). The Main Entrance view from the videotaped surveillance showed Resident #1 at the Main Entrance door with the House Manager at 20:06:04 (08:06:04 PM). Interview and record review revealed Resident #1 exhibited exit seeking behaviors, wandered in and out of resident rooms, and expressed a desire to go home. The facility assessed the resident as a high elopement risk, applied a Secure Guard Alarm band to the resident's right ankle, and transferred the resident to a secured (locked) unit. However, the emergency exit door to the secured unit was not equipped with the Secure Guard Alarm System. Interview, on 08/15/12 at 10:20 AM, with the Assistant Administrator (AA), employed by the facility for twenty-five (25) years, revealed that he was aware the exterior emergency exit door was not equipped with the Secure Guard Alarm system and said there was never a need for it. The AA said he thought the odds were too great that a resident could enter the correct code to silence the emergency alarm. The AA stated he thought the exterior emergency exit door was secure with the pin pad device. Interview with the Life Skills Unit Manager, on 08/15/12 at 10:45 AM, revealed she was aware the LSU was not equipped with the Secure Guard Alarm System. The LSU Manager stated residents with the Secure Guard Alarm bands had been placed on the LSU unit prior to the admission of Resident #1, and said she did not know why the exterior emergency exit door was not equipped with the Secure Guard Alarm System. The LSU Manager said several years ago a resident applied great pressure to the exterior emergency exit door an forced it open and the emergency alarm sounded to alert staff. The Manager said prior to Resident #1, no resident had been able to enter the correct code into the pin pad and exit without staff knowledge. Interview, on 08/20/12 at 2:55 PM, with the Pathway/LSU Unit Manager revealed that she was aware there was no Secure Guard Alarm system on the exterior emergency exit door prior to 08/08/12 when Resident #1 eloped, and said she did not think it was needed because the door was never used. However, interview with CNA #6, on 08/19/12 at 10:50 PM, revealed she knew the code to the exterior emergency exit door, and would use the code to silence the alarm to discharge a wheelchair bound resident to an automobile parked just outside the door. CNA #6 also stated the door was used to bring yard sale items into the facility because it was convenient to park the automobile just outside the exit door to unload. Interview, on 08/20/12 at 3:00 PM, with the ADNS revealed she was not aware that staff and visitors used the LSU exterior emergency exit door for any purpose. Interview, on 08/13/12 at 2:00 PM, with the Administrator and Administrative Director of Nursing (ADNS) revealed the facility installed the Secure Guard Alarm to the exterior emergency exit door of the Life Skills Unit on 08/10/12 in response to the elopement of Resident #1 on 08/08/12. The Administrator said the exterior emergency exit door would alarm if the door was exited on an emergent basis, and said the door was equipped with a pin pad to cancel the alarm when the appropriate code was entered. The Administrator stated the staff on the Life Skills Unit did not report hearing any alarm when Resident #1 exited the door. The Administrator said Resident #1 was understood to have entered the appropriate code to silence the alarm, and was not aware how the resident could have obtained the code to exit the door. The Administrator stated that staff was not supposed to use the exterior emergency exit door and stated no one ever used that door. Observation, on 08/15/12 at 3:00 PM, with the Director of Maintenance (DOM) and the Administrative Director of Nursing Services (ADNS) revealed the facility had fourteen (14) exterior doors. Five (5) of the exterior doors shared the same access code, and four (4) of the five (5) exterior doors could be exited without alarm by entry of the code, and were not equipped with the Secure Guard Alarm system. Further interview, on 08/15/12 at 3:45 PM, with the ADNS revealed the ADNS was aware of many confused residents on the 200 Unit, but did not believe any of those were at risk for elopement since none were observed to wander on the unit. The ADNS stated if a resident was observed to attempt to use pin pads or demonstrate wandering behavior, staff would redirect the resident and identify the resident to be at risk for elopement. The ADNS said it was a one in a million chance that Resident #1 could get out of the facility without staff knowledge or supervision. 2. Review of the Eagle Room Process revealed the unit or designated management nurses discussed resident issues from the 24 hour report. The unit or designated management staff obtained a report from the off-going shift to include the shift to shift report and any follow-up from the previous day. Rounds were completed on residents identified on the 24 hour report or during the shift to shift report. Lab results, clinical records, and new physician orders [REDACTED]. The goal of the Eagle Room Process was to prioritize resident needs by identifying resident risks, determine priorities and needs, assign staff responsibility, ensure task completion, and evaluate interventions. Review of the Care Plan for Resident #1, dated 06/20/12, revealed a focus on the risk of elopement due to cognitive impairment, closed head injury, and poor safety awareness. The elopement focus included a goal that the resident would not leave the center unattended. Record review revealed a Behavior Plan was developed on 07/06/12; however, Resident #1's comprehensive plan of care was not revised to include the staff intervention protocols from the Behavior Plan, and did not include an intervention to direct staff to reference the Behavior Plan. Review of the Behavior Notes revealed documentation that Resident #1 demonstrated exit-seeking behaviors on fifteen (15) days during the month of July 2012, and two (2) days during the month of August 2012, which preceded the successful elopement of the resident from the facility on 08/08/12. Interviews with staff revealed staff was not aware of interventions to de-escalate the exit seeking behaviors demonstrated by Resident #1 as outlined in the resident's Behavior Plan. Interview with the ADNS, on 08/15/12 at 11:30 AM, revealed the respective Unit Managers were responsible to ensure the completeness and accuracy of staff documentation, and to ensure care plans were updated as necessary. Further interview, on 08/15/12 at 3:45 PM, with the ADNS revealed the facility did not utilize a formal tool to determine if a resident was at risk for elopement. The ADNS stated the facility's practice was to continuously monitor all residents for exit seeking behavior, and only when this behavior was identified were the risks of elopement evaluated. Further interview, on 08/20/12 at 3:40 PM, with the facility Administrator revealed he had worked at the facility for 90 (ninety) days and had not been advised the Life Skills Unit was not equipped with the Secure Guard Alarm on the exterior emergency exit door. AT 3:50 PM, the Administrator revealed he was not aware of other exit doors in the facility that residents could access by use of the pin pad code to disable the alarm, which were not equipped with the Secure Guard Alarm; however, did not believe this posed a risk for resident elopement. Review of the acceptable Allegation of Compliance (AOC) dated 08/16/12, revealed the facility took the following immediate actions: 1. Resident #1 was returned to the Life Skills Unit and was assessed on 08/08/12 by LPN #1 and found no injury was sustained. Resident #1 was placed on one to one supervision. 2. All exit doors in the facility were checked for function on 08/08/12 and found to be in working order by the Director of Maintenance. 3. All residents in the facility with Secure Guard Alarm bands were checked for placement and function on 08/08/12 by LPN #1 and were found to function properly. 4. The exterior emergency exit door on the Life Skills Unit was monitored by staff continually on 08/09/12 until the Secure Guard Alarm System was installed on the exit door on 08/10/12. 5. All residents in the facility were assessed for indicators of elopement risk, wandering, and unsafe wandering, by the Unit Managers and was completed on 08/16/12. 6. Resident Care Plans, Tasks and Patient Information Worksheets were updated as needed related to elopement risk by the Unit Managers and was completed on 08/16/12. 7. A QA meeting was held with the Medical Director in attendance on 08/09/12 and on 08/15/12 to discuss the elopement and the facility's plan of action. 8. The Secure Guard Alarm System was installed on the four (4) exit doors including the door exiting the Life Skills unit on 08/10/12 by a contracted security systems company. 9. Daily checks were done to ensure the Life Skills Door was operating properly by the Maintenance Director (Monday through Friday) and the Weekend Charge Nurse (Saturday and Sunday). 10. The Secure Guard Alarm System was installed to six (6) exterior emergency exit doors, by a contracted security systems company, which was accomplished on 08/16/12. Staff were positioned at the four (4) doors accessible to residents. 11. All staff was in-serviced on 08/16/12 by the Assistant Administrator with the Administrator in attendance and the Corporate Regional as an oversight, regarding the protocol for maintenance of the pin pad numbers and on the Wandering Patient Practice Guide. Staff was not allowed to work in the facility until the training had been completed. 12. Elopement Binders were updated on 08/16/12 by the Unit Managers, to reflect elopement risk, wandering, and unsafe wandering behaviors. The State Agency validated the AOC on 08/17/12 prior to exit as follows: 1. The State Agency validated through record review of the facility's record for Resident #1 and found the resident was assessed on 08/08/12, was found to be without injury, and was placed on one-to-one supervision. 2. The State Agency validated through review of the Maintenance Log that the exterior exit doors were checked to ensure proper function on 08/08/12. 3. The State Agency validated through record review that the residents with Secure Guard Alarm bands were checked for placement and function on 08/08/12. 4. The State Agency validated through record review, and interview with the Administrator and Administrative Director of Nursing Services, on 08/13/12 at 2:00 PM, that the exterior emergency exit door on the Life Skills Unit was monitored by staff continuously on 08/09/12 until the Secure Guard Alarm system was installed on the exit door on 08/10/12. Interviews with CNA #2 and CNA #3, on 08/16/12 at 2:15 PM and 2:30 PM, confirmed the staff was assigned to remain at the exit door until the new alarm system was installed. 5. The State Agency validated, through review of the Elopement book, the facility had originally identified only five (5) residents on 08/13/12 as at risk for elopement, then a second assessment, on 08/16/12 of all residents, identified a total of twenty-six (26) residents at risk for elopement. Interview, on 08/20/12 at 3:20 PM, with the ADNS revealed the facility completed the second assessment of all residents and placed Secure Guard Alarm bands on each resident who demonstrated at least one behavior of wandering/elopement to be reassessed in thirty (30) days. 6. The State Agency validated through record review of residents identified to be at risk for elopement that care plans were updated and patient information worksheets (used by ancillary staff to provide resident care) were updated. 7. The State Agency validated through interview with the Administrator and Administrative Director of Nursing Services (ADNS) the Quality Assurance Committee met on 08/09/12 and on 08/15/12, and that the facility's Medical Director was present to discuss the elopement on 08/08/12 and the facility's plan of action. 8. The State Agency validated, on 08/19/12 at 11:55 AM, through observation, the four (4) exterior doors including the exit door to the LSU, with pin pad access to cancel emergency alarm the doors, were equipped with the Secure Guard Alarm System. Further observation on 08/20/12 at 3:30 PM, verified the function and audible alarm as demonstrated by the Director of Maintenance. 9. The State Agency validated through record review of the maintenance logs that the exterior emergency exit doors function was checked daily. Interview the the ADNS, on 08/15/12 at 3:45 PM, and the Weekend House Supervisor, on 08/19/12 at 11:35 AM, verified the function of the exterior doors was checked by the Weekend House Supervisor on weekend days. 10. The State Agency validated through observation and interview with the Administrator and ADNS, on 08/16/12 at 2:55 PM, that staff was positioned at the four (4) exterior doors without the alarm system to maintain resident safety during the installation of the Secure Guard Alarm System. Interviews with CNA #2 and CNA #3, on 08/16/12 at 2:15 PM and 2:30 PM, confirmed the staff was assigned to remain at the exit door until the new alarm system was installed. Observations of the exit doors during this time revealed CNA #2 and CNA #3 was sitting at emergency exit doors while the alarm system was being installed. 11. The State Agency validated through record review of the Power Point presentation for mandatory staff in-services that the appropriate content was provided to ensure staff were competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors. Interview, on 08/20/12 at 3:00 PM, with the Director of Maintenance, ADNS, and the Life Skills Unit Manager, revealed that the codes on all doors were changed and the codes to the emergency exit doors were maintained by limited Management Staff. Interviews, on 08/19/12 at 11:24 AM and 11:35 AM, with CNA #8 and the Weekend Charge Nurse, revealed they had attended a mandatory inservice for all staff, that focused on elopement procedures, identification of elopement risks, codes to the exterior doors and who was allowed access to these codes. In addition, the doors were not to be used by anyone unless it was an emergency. Interview, on 08/19/12 at 10:15 AM, with LPN #2 revealed she attended an inservice on 08/16/12 regarding the facility protocol for elopement that included documentation, and maintaining the code to exit doors in the facility. LPN #2 provided a description of the 'Code Black' process the facility used in the event an elopement occurred. LPN #2 stated the education included the process of documentation to include the Behavior RAP and care plans. Interview, on 08/19/12 at 10:50 AM, with CNA #6 revealed she attended an in-service on 08/16/12 regarding the facility protocol for resident elopements. CNA #6 stated the teaching included recognition of signs of resident elopement, and review of the 'Code Black' procedure. CNA #6 stated the teaching also included instructions regarding staff interventions with residents who were issued the Secure Alert Alarm band. 12. The State Agency validated through review of the Elopement binders on the nursing stations that all residents identified by the facility to be at risk of elopement were documented by photograph, and included documentation of specific behaviors and demographic information. Interview, on 08/20/12 at 2:55 PM, with the Unit Manager of the Pathways and LSU stated that all residents in the facility were evaluated for the risk of elopement on 08/16/12, and stated there were residents who had been identified to be at risk for elopement and those were issued a Secure Guard Alert band. The UM stated each resident's care plan was updated, and all residents with the Secure Guard Alert band were included in the Elopement Binders on each unit. Interview, on 08/20/12 at 3:00 PM, with the Director of Nursing revealed all residents in the facility were reviewed for elopement risk, and it was determined there were twenty-six (26) residents who demonstrated at least one risk for elopement. The DON stated the Unit Managers assisted to perform a Behavior RAP for each resident, and said the Elopement binders on each units were updated to include al residents who were issued a Secure Guard Alarm band.

Based on observation, interview, record review, and review of the facility's policy Wandering Patient Practice Guide, it was determined the facility failed to have an effective system to identify and correct quality deficiencies. The facility failed to ensure implementation of polices; failed to evaluate the effectiveness of the management of residents with exit seeking behavior to ensure a secure environment; and, failed to develop and implement appropriate plans of action for one (1) of six (6) sampled residents, Resident #1. Members of the QA committee were not aware the facility's system to maintain the safe and secure environment for residents at risk for elopement was not efficient. (Refer to F280, F323, F490) The facility assessed Resident #1 as high risk for elopement on 06/20/12, and placed a Secure Guard Alarm band on the resident's right ankle. Resident #1 was transferred from the Pathways Unit for [MEDICAL CONDITION] to the secure (locked) Life Skills Unit (LSU) on 06/23/12 because of the resident's increased exit seeking behaviors. The facility failed to revise the resident's comprehensive plan of care to include the Behavior Plan, developed by the staff Neuropsychologist, dated 07/06/12. On 08/08/12, Resident #1 successfully eloped from the LSU via the exterior emergency exit door without staff knowledge or supervision. Staff on the LSU reported no alarm was heard when Resident #1 exited the facility. The secure unit (LSU) was not equipped with the Secure Guard Alarm system. The facility had fourteen (14) exterior doors, five (5) of the doors were accessed with the same code to disable the emergency alarm, and four (4) of the five (5) doors were accessible to residents and were not equipped with the Secure Guard Alarm system. The facility's failure to identify the need to revise the comprehensive plan of care to include the Behavior Plan protocols and the Quality Assurance's failure to review and assess the security system utilized to protect at risk residents and develop plans of actions placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death. The facility was notified on 08/15/12 of the Immediate Jeopardy at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) and (F520) with Substandard Quality of Care in the area of 42 CFR 483.25 Quality of Care (F323). An acceptable Allegation of Compliance (AOC) was received on 08/16/12 and the Immediate Jeopardy was determined to be removed on 08/17/12 prior to exit which lowered the scope and severity to a "D" for 42 CFR 483.75 administration (F520) while the facility develops and implements a plan of correction to achieve substantial compliance with regulation and while the facility's Quality assurance continues to monitor the effectiveness of staff education, utilization of tools developed, and revisions to policies and procedures. The findings include: Review of the facility's policy regarding the Eagle Room Process and the Wandering Patient Practice Guide, dated 04/2008, revealed Phase IV detailed the need for the facility to evaluate the effectiveness of the management of exit seeking and unsafe wandering behavior by means of Quality Assessment and Assurance (QAA) audit tools, and discussions within the Eagle Room Process. Review of the facility's investigation of the elopement of Resident #1, dated 08/08/12, revealed the facility determined the root cause of the elopement to be the lack of the Secure Guard Alarm on the exterior emergency exit door in the Life Skills Unit. The facility's investigation was based on the assumption that Resident #1 entered the correct code into the pin pad to disengage the emergency door alarm, as staff reported they did not hear an alarm when Resident #1 eloped from the facility on 08/08/12. The facility's investigation stated the facility intervened to conduct a resident head count, and alarms and doors were checked for proper function. Resident #1 was placed on one-to-one observation on 08/08/12, and the one-to-one observation was to include continuous observation of the exterior emergency exit door of the Life Skills Unit on 08/09/12 until the alarm system was added. The facility placed a call to the security contractor on 08/09/12 to request the Secure Guard Alarm be installed to the exit door on the Life Skills Unit. Interview, on 08/13/12 at 2:00 PM, with the Administrator and Administrative Director of Nursing (ADNS) revealed the facility installed the Secure Guard Alarm to the exterior emergency exit door of the Life Skills Unit on 08/10/12 in response to the elopement of Resident #1 on 08/08/12. The Administrator said the exterior emergency exit door would alarm if the door was exited on an emergent basis, and said the door was equipped with a pin pad to cancel the alarm when the appropriate code was entered. The Administrator stated the staff on the Life Skills Unit did not report hearing any alarm when Resident #1 exited the door. The Administrator said Resident #1 was understood to have entered the appropriate code to silence the alarm, and was not aware how the resident could have obtained the code to exit the door. The Administrator stated that staff were not supposed to use the exterior emergency exit door and stated no one ever used that door. Interview, on 08/15/12 at 3:45 PM, with the ADNS revealed the facility did not utilize a formal tool to determine if a resident was at risk for elopement. There were many confused residents on the 200 unit; however, since the staff had not observed these residents with wandering and/or exit seeking behaviors these residents were not assessed for elopement risk. The ADNS stated the facility's practice was to continuously monitor all residents for exit seeking behavior, only when exit seeking behavior was identified were the risks of elopement evaluated. Further interview, on 08/20/12 at 3:00 PM, with the ADNS revealed the elopement attempts and wandering behaviors of Resident #1 were not reviewed by QA until after the successful elopement from the facility on 08/08/12. However, per interview, Resident #1's wandering and exit seeking behaviors were discussed in the Eagle Room many times. Interview, on 08/20/12 at 3:40 PM, with the facility's Administrator revealed he had worked at the facility for 90 (ninety) days and had not been advised the Life Skills Unit was not equipped with the Secure Guard Alarm on the exterior emergency exit door. At 3:45 PM, the Administrator stated he was not aware of other exit doors in the facility that residents could access by use of the pin pad code to disable the alarm, which were not equipped with the Secure Guard Alarm, but did not believe this posed a risk for resident elopement. Review of the acceptable Allegation of Compliance (AOC), dated 08/16/12, revealed the facility took the following immediate actions: 1. Resident #1 was returned to the Life Skills Unit and was assessed on 08/08/12 by LPN #1 and found no injury was sustained. Resident #1 was placed on one to one supervision. 2. All exit doors in the facility were checked for function on 08/08/12 and found to be in working order by the Director of Maintenance. 3. All residents in the facility with Secure Guard Alarm bands were checked for placement and function on 08/08/12 by LPN #1 and were found to function properly. 4. The exterior emergency exit door on the Life Skills Unit was monitored by staff continually on 08/09/12 until the Secure Guard Alarm System was installed on the exit door on 08/10/12. 5. All residents in the facility were assessed for indicators of elopement risk, wandering, and unsafe wandering, by the Unit Managers and was completed on 08/16/12. 6. Resident Care Plans, Tasks and Patient Information Worksheets were updated as needed related to elopement risk by the Unit Managers and was completed on 08/16/12. 7. A QA meeting was held with the Medical Director in attendance on 08/09/12 and on 08/15/12 to discuss the elopement and the facility's plan of action. The facility determined the need to install the Secure Guard Alarm to the Life Skills Unit exterior exit door. 8. The Secure Guard Alarm System was installed on the four (4) exit doors including the door exiting the Life Skills unit on 08/10/12 by a contracted security systems company. 9. Daily checks were done to ensure the Life Skills Door was operating properly by the Maintenance Director (Monday through Friday) and the Weekend Charge Nurse (Saturday and Sunday). 10. The Secure Guard Alarm System was installed to six (6) exterior emergency exit doors, by a contracted security systems company, which was accomplished on 08/16/12. Staff was positioned at the four (4) doors accessible to the residents. 11. All staff was in-serviced on 08/16/12 by the Assistant Administrator with the Administrator in attendance and the Corporate Regional as an oversight, regarding the protocol for maintenance of the pin pad numbers and on the Wandering Patient Practice Guide. Staff was not allowed to work in the facility until the training had been completed. 12. Elopement Binders were updated on 08/16/12 by the Unit Managers, to reflect elopement risk, wandering, and unsafe wandering behaviors. The State Agency validated the AOC on 08/17/12 prior to exit as follows: 1. The State Agency validated through record review of the facility's record for Resident #1 and found the resident was assessed on 08/08/12, was found to be without injury, and was placed on one-to-one supervision. 2. The State Agency validated through review of the Maintenance Log that the exterior exit doors were checked to ensure proper function on 08/08/12. 3. The State Agency validated through record review that the residents with Secure Guard Alarm bands were checked for placement and function on 08/08/12. 4. The State Agency validated through record review, and interview with the Administrator and Administrative Director of Nursing Services, on 08/13/12 at 2:00 PM, that the exterior emergency exit door on the Life Skills Unit was monitored by staff continuously on 08/09/12 until the Secure Guard Alarm system was installed on the exit door on 08/10/12. Interviews with CNA #2 and CNA #3, on 08/16/12 at 2:15 PM and 2:30 PM, confirmed the staff was assigned to remain at the exit door until the new alarm system was installed. 5. The State Agency validated, through review of the Elopement book, the facility had originally identified only five (5) residents on 08/13/12 as at risk for elopement, then a second assessment, on 08/16/12 of all residents, identified a total of twenty-six (26) residents at risk for elopement. Interview, on 08/20/12 at 3:20 PM, with the ADNS revealed the facility completed the second assessment of all residents and placed Secure Guard Alarm bands on each resident who demonstrated at least one behavior of wandering/elopement to be reassessed in thirty (30) days. 6. The State Agency validated through record review of residents identified to be at risk for elopement that care plans were updated and patient information worksheets (used by ancillary staff to provide resident care) were updated. 7. The State Agency validated through interview with the Administrator and Administrative Director of Nursing Services (ADNS) the Quality Assurance Committee met on 08/09/12 and on 08/15/12, and that the facility's Medical Director was present to discuss the elopement on 08/08/12 and the facility's plan of action. 8. The State Agency validated, on 08/19/12 at 11:55 AM, through observation, the four (4) exterior doors including the LSU, with pin pad access to cancel emergency alarm the doors, were equipped with the Secure Guard Alarm System. Further observation on 08/20/12 at 3:30 PM, verified the function and audible alarm as demonstrated by the Director of Maintenance. 9. The State Agency validated through record review of the maintenance logs that the exterior emergency exit doors function was checked daily. Interview the the ADNS, on 08/15/12 at 3:45 PM, and the Weekend House Supervisor, on 08/19/12 at 11:35 AM, verified the function of the exterior doors was checked by the Weekend House Supervisor on weekend days. 10. The State Agency validated through observation and interview with the Administrator and ADNS, on 08/16/12 at 2:55 PM, that staff was positioned at the four (4) exterior doors without the alarm system to maintain resident safety during the installation of the Secure Guard Alarm System. Interviews with CNA#2 and CNA#3, on 08/16/12 at 2:15 PM and 2:30 PM, confirmed the staff was assigned to remain at the exit door until the new alarm system was installed. Observations of the exit doors during this time revealed CNA #2 and CNA #3 was sitting at emergency exit doors while the alarm system was being installed. 11. The State Agency validated through record review of the Power Point presentation for mandatory staff in-services that the appropriate content was provided to ensure staff were competent to identify, report, react effectively to elopements, and document wandering and exit seeking behaviors. Interview, on 08/20/12 at 3:00 PM, with the Director of Maintenance, ADNS, and the Life Skills Unit Manager, revealed that the codes on all doors were changed and the codes to the emergency exit doors were maintained by limited Management Staff. Interviews, on 08/19/12 at 11:24 AM and 11:35 AM, with CNA #8 and the Weekend Charge Nurse, revealed they had attended a mandatory inservice for all staff, that focused on elopement procedures, identification of elopement risks, codes to the exterior doors and who was allowed access to these codes. In addition, the doors were not to be used by anyone unless it was an emergency. Interview, on 08/19/12 at 10:15 AM, with LPN #2 revealed she attended an inservice on 08/16/12 regarding the facility protocol for elopement that included documentation, and maintaining the code to exit doors in the facility. LPN #2 provided a description of the 'Code Black' process the facility used in the event an elopement occurred. LPN #2 stated the education included the process of documentation to include the Behavior RAP and care plans. Interview, on 08/19/12 at 10:50 AM, with CNA #6 revealed she attended an in-service on 08/16/12 regarding the facility protocol for resident elopements. CNA #6 stated the teaching included recognition of signs of resident elopement, and review of the 'Code Black' procedure. CNA #6 stated the teaching also included instructions regarding staff interventions with residents who were issued the Secure Alert Alarm band. 12. The State Agency validated through review of the Elopement binders on the nursing stations that all residents identified by the facility to be at risk of elopement were documented by photograph, and included documentation of specific behaviors and demographic information. Interview, on 08/20/12 at 2:55 PM, with the Unit Manager of the Pathways and LSU stated that all residents in the facility were evaluated for the risk of elopement on 08/16/12, and stated there were residents who had been identified to be at risk for elopement and those were issued a Secure Guard Alert band. The UM stated each resident's care plan was updated, and all residents with the Secure Guard Alert band were included in the Elopement Binders on each unit. Interview, on 08/20/12 at 3:00 PM, with the Director of Nursing revealed all residents in the facility were reviewed for elopement risk, and it was determined there were twenty-six (26) residents who demonstrated at least one risk for elopement. The DON stated the Unit Managers assisted to perform a Behavior RAP for each resident, and said the Elopement binders on each units were updated to include al residents who were issued a Secure Guard Alarm band.

Based on interview, closed record review, and Pain Process Flowsheet review, it was determined the facility's administer failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental psychosocial well-being for residents regarding pain management for five residents (#1, 4, 5, 7, and 9) of nineteen (19) sampled residents. The facility administration failed to ensure policies and procedures were developed regarding pain management. The facility administration failed to ensure staff effectively implemented the facility's Pain Process Flowchart in order to effectively manage residents pain. On 10/08/10, the facility admitted Resident #1 and assessed the resident as having left hip pain. The facility nursing and therapy departments were aware of Resident #1's consistent complaints of pain through out the resident's fourteen day stay at the facility. The facility failed to take action to address the resident's pain through nursing and therapy assessment, care plan intervention, and physician notification to determine if an alteration in treatment was necessary. On 10/21/10, the facility transferred the resident to the hospital for surgical intervention related to the left [MEDICAL CONDITION]. Furthermore, the facility admitted Resident's #4, 5, 7, and 9 in March 2011; however, failed to ensure nursing staff assessed and evaluated the characteristics of intensity, location, and precipitating/relieving factors of pain in order to determine effective pain management or the need to inform the physician for a change in treatment. Administration was knowledgeable of reporting process errors; however, had not implemented measures to ensure accuracy. Based on the above findings, it was determined the facility failed to ensure policies and procedures were developed and implemented related to pain management and physician notification to ensure each residents' pain was effectively managed and notification of the physician occurred to determine the need to alter treatment as necessary which was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 10/08/10 and is ongoing at F157 "J", F281 "J", F309 "J", F490 "J" and F520 "J". The findings include: Refer to F309 S/S J: Based on observation, interview, record review, policy review, and Pain Process Flowchart review it was determined the facility failed to effectively maintain the highest practicable physical well-being for five (5) of nineteen (19) sampled residents (Residents #1, #4, #5, #7 and #9). The facility failed to assess and manage the pain for Resident #1. The facility failed to notify the physician with changes in Resident #1's condition as it related to pain. Nursing staff failed to read the results of an x-ray immediately which revealed a [MEDICAL CONDITION] for one (1) of nineteen (19) sampled residents thus delaying the resident from receiving emergent care for more than twenty-four (24) hours. In addition, the facility failed to evaluated the characteristics of intensity, location, and precipitating/relieving factors of pain for Residents #4, #5, #7 and #9. Interview with the Administrative Director of Nursing Services (ADNS) on 03/31/11 at 10:40am revealed the facility utilized the Pain Process Flowchart and did not have a formal pain management policy and procedure. Review of the Pain Process Flowchart revealed it detailed the need for nursing staff to conduct assessments regarding pain, development of care planning, implementation and evaluation of pain for the resident. While the facility utilized the Pain Process Flowchart, observation of LPN # 4, on 04/01/11 at 9:40am, and Unit Manager (UM), Registered Nurse (RN) #4, on 04/01/11 at 11:00am, revealed they were unable to locate the Pain Process Flowchart on the nursing units and it wasn't necessary to have Flowchart accessible to staff. She further revealed staff use the zero (0) to ten (10) pain scale or the Wong-Baker scale to assess pain. Continued interview with the ADNS revealed while there was no written policy for Therapy communication, she would prefer for Physical Therapy and Occupational Therapy to document concerns of hip pain on the twenty-four (24) hour report. Interview with the Director of Rehabilitation, on 04/01/11 at 1:00pm, revealed the old system was to document on the twenty-four (24) hour report and communicate to the nursing department any concerns. If a resident has significant pain, this pain will be charted on the twenty-four hour report, but it is not to replace reporting the pain to the nursing department. Continued interview with RN #4 revealed the twenty-four hour report was used by staff to communicate concerns during Eagle Room (Quality Assurance Process) and follow up was often required. Review of the facility's Eagle Room Process detailed the process was an ongoing, interdisciplinary care and service management system. Its purpose is to triage patient needs by implementing the following: Identify patient risks, Determine priorities and needs, Evaluate action steps required, Assign staff responsibility and Substantiate task completion. Patient issues are: new admissions, changes in condition, status of unstable patients, abnormal lab values, new and discontinued physician orders, accidents and incidents, pain scale greater than or equal to 4, unexpected hospital readmission, concerns, other issues not noted and unfinished items from the previous day. Interview with the Administrator, on 04/01/11 at 1:20pm, revealed the facility did not have a pain management policy and procedure, they only had the Pain Process Flowchart and did not have a policy that addressed completing pain assessments. While the facility utilized the twenty-four hour report process, the Administrator revealed she was aware that the reporting process had errors; however, did not have any staff designated to audit the reports to ensure accuracy. She further revealed that there was no policy related to the twenty-four hour report process and had no policy related to communication between departments outside of the Eagle Room Process. The Administrator further stated the potential for harm is present as it is related to the lack of communication and documentation by nurses. 1. Closed record review revealed on 10/08/10, the facility admitted Resident #1, conducted a pain assessment which identified Resident #1's left hip pain was an orthopedic condition, with an onset in the last five (5) days, which was described as aching. Resident #1 reported that the hip pain impaired the ability to sit or stand comfortably. Physical Therapy (PT) and Occupational Therapy (OT) evaluation documentation revealed, on 10/09/10, both PT and OT were aware of the resident's left hip pain; however, did not notify the nursing department of the resident's complaints of pain and continued to provide treatments despite the resident's pain. Record review revealed the nursing staff did not consistently document and complete the steps of the Pain Process Flowchart or the Pre and Post Pain Score Assessments for administration of pain medications. There was no documented evidence that the facility had notified the physician of resident #1's pain to the left hip and leg despite the evaluations and treatments conducted by PT and OT and Nursing administration of pain medication to Resident #1. Record Review of the twenty-four (24) hour book revealed from the dates of 10/08/10 through 10/21/10 there was no documentation from Physical Therapy or Nursing Department about Resident #1 having increased pain or hip issues. Interview with the physician, on 03/31/11 at 9:47am, revealed he was informed of the resident's pain through the family and could not recall the facility notifying him of the resident's pain. The facility transferred Resident #1 to the hospital for surgical intervention related to the [DIAGNOSES REDACTED]. (Refer to F309, F157) 2. The facility did not consistently implement the Pain Process Flowchart and/or the Pre and Post Pain Score Assessments for Residents #4, 5, 7, and 9. (Refer to F309 for detailed record review) Review of Resident #4's care plan revealed nursing should assess for the resident's pain intensity, location, precipitating/relieving factors of pain; however, review of the nurses' notes for this resident and the pain medication administration revealed there were no entries that details nursing staff had assessed the resident's pain sixty-one (61) times from 03/02/11 through 03/31/11. Interview, on 04/11/11 at 10:35am, with the ADNS confirmed that the pain assessment for Resident #4 was not completed. Record review for Resident #5 Medication Administration Record (MAR) from March 20 through March 30, 2011, revealed thirty-five (35) opportunities for a pain score assessment to be completed; however, the pain assessment score was not utilized by the facility twenty-eight (28) times out of those thirty-five (35) opportunities. Review of Resident #7's care plan revealed nursing staff was to assess the resident's pain intensity, location, precipitating/relieving factors of pain; however, review of the nursing notes and MAR revealed no documented entries of such assessments despite having administered pain medication twenty (20) times since admission on 03/04/11. Record review of the MAR for Resident #9 revealed PRN pain medication had been administered without noting the effectiveness, fifteen (15) out of fifteen (15) times. The current MAR and nurses notes for April 1 to April 6, 2011, revealed the pain score was not utilized eleven (11) times out of fifteen (15) opportunities for pain assessment.

Based on interview, closed record review, Pain Process Flowchart, the twenty-four hour reports, and literature review of the American Nurses Association (ANA) website it was determined the facility failed to ensure nursing staff developed an admission pain care plan for one (1) of nineteen (19) sampled residents, to include measurable objectives and timetables to meet Resident #1's pain needs which were identified in the facility's initial assessment. On 10/08/10, the facility admitted and assessed Resident #1 as having aching pain to the resident's left hip with pain medications ordered on an as needed (PRN) basis; however, the facility failed to develop a pain care plan to address and manage Resident #1's pain. The facility nursing staff and therapy staff had assessed Resident #1's pain levels during a fourteen day stay at the facility as ranging from zero (0) to twelve (12) on a ten point pain scale where a ten (10) is greatest pain. The continued failure by the facility to develop and initiate a pain care plan prevented the facility from addressing and managing Resident #1's pain effectively. On 10/21/11, the facility transferred Resident #1 to the hospital for surgical repair of the Left hip related to an acute left [MEDICAL CONDITION]. The facility's failure to ensure staff developed a pain care plan after identifying through assessment the resident was experiencing hip pain, prevented the facility from ensuring the resident was accurately monitored and assessed for pain management. This failures and the facility's non-compliance has caused or is likely to cause Resident #1 and other residents with identified pain, serious injury, harm, impairment,or death to a resident.. Immediate Jeopardy was identified on 04/06/11 at F157 "J", F281 "J", F309 "J", F490 "J" and F520 "J". The findings include: Refer to F309, S/S J Based on observation, interview, record review, policy review and Pain Process Flowchart review, it was determined the facility failed to effectively maintain the highest practicable physical well-being for Resident #1 as evidenced the failure of the facility to assess and manage pain for Resident #1. The facility failed to implement the plan of care for four (4) of nine (9) sampled residents, Residents #4, #5, #7 and #9. The facility failed to notify the physician with changes in Resident #1's condition as it relates to pain. Nursing staff failed to read the results of an x-ray immediately which revealed a [MEDICAL CONDITION] for one (1) of nine (9) sampled residents thus delaying the resident from receiving emergent care for more than twenty-four (24) hours. Interview with the Administrative Director of Nursing Services (ADNS), on 03/31/11 at 10:40 am, revealed the facility followed a Pain Process Flowchart. Review of the Pain Process Flowchart revealed upon assessment it must be determined if the resident has pain or a condition that is likely to cause pain. Once this assessment is completed and it is determined that the resident has concerns with pain, the physician is contacted for orders and a plan of care is initiated. If the assessment reveals that the resident has no issues with pain, the patient is screened for pain daily and a care plan is initiated. The Pain Process Flowchart also revealed that once an assessment is completed an Minimum Data Set (MDS) Assessment should be completed, a plan for the resident must be formulated and the comprehensive care plan will be developed and revised. Interview with the Minimum Data Set (MDS) Coordinator, on 03/31/11 at 8:45 am revealed she MDS Coordinator was responsible to ensure that care plans have been initiated and they are placed on the chart. She explained that the care plan is the plan of care for residents. The care plan was to be reviewed by day fourteen after admission. The MDS Coordinator further revealed that during the Eagle Room meeting, they review the twenty-four (24) reporting to make sure care plans are in place and revised daily. 1. Closed record review revealed on 10/07/10 Resident #1 sustained a fall landing on the left hip while residing at another facility. The other facility obtained an x-ray which revealed no fracture. Christopher East Health Care Center admitted Resident #1 on 10/08/10 with a history of partial ileus of the small bowel, acute kidney injury, [MEDICAL CONDITION], constipation, [MEDICAL CONDITION] and hypertension. Review of the physician admission orders [REDACTED]. Pre and Post pain scores were ordered to be documented on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The assessment detailed the resident's pain was located at the left hip, was contributed to bending and described as aching. The assessment revealed that relieving factors were medications and repositioning. The facility also completed an initial assessment on 10/08/10 which identified that a pain care plan should be initiated. Record Review revealed no documented evidence that the facility had completed a pain care plan on 10/08/10. Record review of the MAR indicated [REDACTED]. The facility assessed Resident #1 post-pain score as a two (2). On 10/09/10, Physical Therapy (PT) completed a Physical Therapy Evaluation Tool which detailed PT was unable to test Resident #1's left lower extremity (left leg) related to severe pain with active movement and noted that Resident #1 didn't like to move the left leg related to hip pain from a fall. The summary and assessment of the document revealed PT assessed Resident #1's pain level of the left hip as an eight (8) or nine (9) on a pain scale of one (1) to ten (10), one (1) meaning the least pain, and ten (10) meaning the greatest pain. The PT Evaluation further revealed testing was not performed for Resident #1 in the left lower extremity related to severe pain with active movement. On 10/09/10 an Occupational Therapy (OT) Evaluation documented Resident #1 complained of left hip pain related to a fall and demonstrated decreased strength, decreased activity tolerance and functional level, and also the impaired ability to perform activities of daily living and diminished home management skills. The document revealed OT assessed resident #1's pain level at an eight (8) and nine (9) out of ten on 10/09/10 during the evaluation. There was no evidence that either Therapy staff notified the nursing staff of the pain Resident #1 experienced during either evaluations. Further review of the record revealed a pain care plan had not been developed on 10/09/10. Record review of the MAR indicated [REDACTED]. The facility administered Tylenol 650 mg during the day and assessed the resident's post-pain score as a three (3). Record review revealed no documented evidence the facility had developed a pain care plan as of 10/11/10 to address Resident #1's pain. On 10/12/10, the MAR indicated [REDACTED]'s pain levels before or after the medication administration. Review of the Physician order [REDACTED]. Care plan review revealed no documented evidence that the facility had developed a care plan for pain as of 10/12/10, even though Resident #1 had experienced complaints of pain assessed as high as a ten (10) since admission, and the physician had ordered routine pain medication in addition to the PRN pain medication. Review of the MAR indicated [REDACTED]. Review of the facility's Quality Assessment Auditing Tool revealed the facility assessed Resident #1's highest pain score level at a five (5) for the whole day. Record review revealed the facility had no documented evidence that a pain care plan had been developed as of 10/13/10. Review of the nursing notes, dated 10/14/10 at 8:15 pm, revealed Resident #1 complained of right hip pain. The facility completed a pre pain score assessment and determined the resident's pain level was at an eight (8). The facility administered the routine medication, [MEDICATION NAME], and completed a post pain score assessment and determined the resident's pain level had improved to a two (2). Record review revealed no documented evidence that the facility developed a pain care plan to address Resident #1's pain as of 10/14/10. On 10/15/10, the Occupational Therapy weekly status notes revealed OT had assessed Resident #1's left hip pain at a twelve (12) on the ten (10) point scale. The Occupational note further stated Resident #1 frequently shifted his/her weight in the wheelchair to obtain pain relief. Interview with the Occupational Therapist (OT) #1, on 03/30/11 at 2:30 pm, revealed she could remember Resident #1 verbalizing pain frequently, but did not recall notifying nursing of the resident's pain during therapy treatment. Record review revealed as of 10/15/10, there was no documented evidence that the facility developed a pain care plan despite the Resident experiencing pain levels as high as a twelve during OT. Review of the nurses notes, dated 10/16/10 at 7:00 pm, revealed the family had been waiting on a pain pill for hours; however, the nurse documented that she had not been made aware of the resident's pain or the request for medication. Review of the MAR indicated [REDACTED]. There was no documented evidence that the facility completed a post pain score assessment on 10/16/10 after the administration of the PRN pain medication. Further review of the care plan revealed the facility had not developed a pain care plan as of 10/16/10. Review of the MAR indicated [REDACTED]. Further review revealed the facility administered PRN pain medication to Resident #1 twice; however, completed only one pre pain score assessment which detailed the resident's pain level was a seven (7). There was no documented evidence on the MAR indicated [REDACTED]. Review of the care plan revealed the facility, as of 10/17/10, had not developed a pain care plan despite the resident's complaints of pain. Review of the 10/18/10 Quality Assessment Auditing tool revealed the facility had assessed Resident #1's highest pain level for that date as a five (5); however, there was no documented evidence the facility administered the PRN pain medication to Resident #1. As of 10/18/10, there was no documented evidence that the facility had developed a care plan for pain. Review of the 10/19/10 MAR indicated [REDACTED]. There was no documented evidence that the facility had developed a pain care plan. On 10/20/10, the facility administered a PRN pain medication, per the MAR; however, there was no documented evidence of the completion of the pre and post pain score assessment. Review of the facility's Quality Assessment Auditing tool revealed the facility had assessed Resident #1's highest pain level for the entire day as a four (4). As of 10/20/10, there was no documented evidence that the facility had developed a pain care plan. Family interview, on 04/01/11 at 11:53 am, revealed the family was aware that Resident #1 experienced pain since admission. The family stated that Resident #1 "always had pain" despite the fact that the resident was being given pain medication. She stated while she never witnessed Resident #1 during therapy treatments she was aware that the resident voiced pain while being walked with physical therapy. Review of the Radiology report, dated 10/20/10 at 12:36 pm, revealed resident #1 had a [DIAGNOSES REDACTED]. Review of the nurses notes, dated 10/21/10, revealed the facility transferred Resident #1 to the hospital for surgical repair of the left hip. Continued interview with the Minimum Data Set (MDS) Coordinator revealed there was no care plan initiated for Resident #1. A part time MDS employee conducted the initial assessment on Resident #1 and failed to complete a care plan for pain. The MDS assessment triggered that Resident #1 was having pain and the care plan should have been reviewed by day 14 fourteen. The MDS Coordinator stated that "we do not do 14 day assessments on private pay" residents. The care plan is the plan of care for residents. The care plan was to be reviewed by day fourteen and the facility failed to do so. The MDS Coordinator shared that during the Eagle Room meeting, the interdisciplinary team reviews the twenty-four hour report and discuss issues regarding residents to include making sure care plans are in place and revised daily. However, review of the twenty-four hour reports revealed no documented evidence of Resident #1's left hip or need for care plan development. Further interview with the MDS Coordinator revealed the type of care given to Resident #1 was to offer pain medication and monitor for effectiveness. The MDS Coordinator further stated that "you would have thought we had a pretty care plan in place". The MDS Coordinator further stated that she was responsible to make sure care plans were completed. Interview with the ADNS, on 04/01/11 at 2:20 pm, revealed she had not comment regarding nursing staff not developing a care plan to address Resident #1's pain. However, interview with the Administrator, on 04/01/11 at 1:15 pm, revealed that Resident #1 was never discussed during the Eagle Room meetings or on the twenty-four hour reporting process as having any issues with left hip pain. She further revealed that a care plan should have been developed.

Based on interview, record review, the Pain Practice Guide and Pain Care Plans, it was determined that the facility failed to evaluate the intensity, location, description of pain for three (3) of seven (7) sampled residents Residents #3, #4 and #7. Furthermore, the facility's failure to complete pre and post pain score assessments for residents receiving PRN (as needed) medication prevented the facility from assessing the effectiveness of the medication, thus inhibited the facility from determining if the physician needed to be contacted for a change in treatment. The Findings Include: The Pain Practice Guide; Change in Condition section states if a change in patient condition occurs, the licensed nurse re-evaluates the intensity, location, type and history of pain and document findings in the progress notes of the patient's clinical record. Based upon this evaluation, the physician is notified to obtain orders if indicated. The patient's plan of care is reviewed and updated to reflect current care delivery needs. Record review of pain care plans for Residents #3, #4, and #7 revealed the facility would evaluate pain characteristics: intensity, location and descriptor of pain. Record review of Resident #3's MAR (medication administration record) for the month of April 2011 revealed since 04/21/11 through 04/25/11, there were eleven (11) opportunities for a pain evaluation to be completed by the facility, of the eleven (11) opportunities, the intensity was not utilized by the facility one (1) time (04/25/11). Review of the care plan dated 04/23/11 revealed pain medications were to be given as ordered by the physician with a note of effectiveness. Record review of Resident #4's MAR for the month of April 2011 revealed since 04/18/11 through 04/25/11, there were fifteen (15) opportunities to conduct a pre and post pain score of the fifteen (15) opportunities, the intensity was not utilized by the facility six (6) times. Review of the care plan revised date of 04/16/11 revealed the same general interventions as Resident #3's. Record review of Resident #7's MAR for the month of April 2011 revealed on two (2) occasions, it was documented the PRN medication was given; [MEDICATION NAME] 10mg for complaints of pain to left hip. On one (1) occasion it was documented the PRN medication was given; [MEDICATION NAME] 10mg for complaints of pain, eight (8) of ten (10). Review of the MAR revealed no pre or post score was ever documented, furthermore there was no evidence a pre and post scores were ordered for this medication. Review of the care plan dated 04/26/11 revealed the facility was to evaluate pain characteristics, i.e. intensity, location, and description of pain. Pain medication was to be administered per physician's orders [REDACTED]. Interview with the Administrative Director of Nursing Services (ADNS) on 04/26/11 at 5:00pm revealed staff are to evaluate pain characteristics. Staff are trained to reassess if pain spikes and investigate. The ADNS stated that the charge nurse is to ensure reassessment is completed per Pain Practice Guide and the Director of Clinical Delivery (DCD) is responsible to ensure that PRN medications are given and physicians are called. The ADNS stated the charge nurse, Director of Clinical Delivery (DCD) was responsible to make sure nurses were completing pre and post pain scores. The ADNS further stated the only audit that she completed was to ensure the pain audit tool was completed by the DCD, she does not go through and check to see that each resident's pain score was recorded in the nurses notes, MAR and twenty-four hour report are accurately documented on the pain auditing tool by the DCD. The ADNS further stated there are just to many residents to complete this task. Interview with the Director of Clinical Services on 04/26/11 at 6:10pm revealed the nurses rely on residents requesting pain medication. Nurses are to evaluate pain characteristics which is stated in the care plan and interventions are to be documented for PRN pain medications regardless if the medication is a narcotic or not. Documentation of pain assessments still need improvement, they not being consistently completed at this time. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/23/11. The state agency verified Immediately Jeopardy was removed during the onsite survey of 04/25-26, 2011, which lowered the scope and severity to a "E" at F157 while the facility's Quality Assurace monitors residetnts condition changes to identify appropriate assessment and treatment and to ensure physicians are notified of any significant changes in the patient's condition.

Based on observation, interview, closed record review, record review, policy review, and Pain Process Flowchart review, it was determined the facility failed to effectively maintain the highest practicable physical well-being for five (5) of nineteen (19) sampled residents (Residents #1, #4, #5, #7 and #9). The facility failed to assess and manage the pain for Resident #1. The facility failed to notify the physician with changes in Resident #1's condition as it related to pain. Nursing staff failed to read the results of an x-ray immediately which revealed a [MEDICAL CONDITION] for one (1) of nineteen (19) sampled residents thus delaying the resident from receiving emergent care for more than twenty-four (24) hours. Resident #1 was transferred to the hospital for surgical repair and later expired. In addition, the facility failed to develop and implement an effective system to ensure that nursing staff assessed and evaluated the characteristics of intensity, location, and precipitating/relieving factors of pain in order to determine effective pain management or the need to inform the physician for a change in treatment for [REDACTED].#9, who were admitted in [DATE]. The facility's failure to ensure staff developed a pain care plan after identifying through assessment the resident was experiencing hip pain, prevented the facility from ensuring the resident was accurately monitored and assessed for pain management. This failures and the facility's non-compliance has caused or is likely to cause Resident #1 and other residents with identified pain, serious injury, harm, impairment,or death to a resident.. Immediate Jeopardy was determined to exist on [DATE] and is ongoing at F157 "J", F281 "J", F309 "J", F490 "J" and F520 "J". The findings include: The facility was unable to provide documented evidence of a policy developed for pain management and assessment. However, interview with the Administrative Director of Nursing Services (ADNS), on [DATE] at 10:40am, revealed the facility utilized the Pain Process Flowchart. Review of the Pain Process Flowchart revealed that nursing staff would complete an assessment, then complete the pain section of the Admission Evaluation, determine the resident's pain level based on the pain scale. The Flowchart then directs questions for the nursing staff to answer regarding if the resident has pain or a condition that is likely to cause pain. If the answer is yes, the Flowchart directs the nursing staff to notify the physician for orders. After which, the nursing staff are to initiate a pain care plan. If the answer is no, they are to screen the resident daily and document. Once the care plan is developed and implemented those residents with a history of pain will be screened for pain daily and documented on. Further interview with the ADNS revealed that nursing staff are required to conduct each morning for all residents a Pain Assessment with AM Medication Pass. For residents receiving as needed medications for pain, the nursing staff are required to complete a Pre and Post (Medication) Assessment each time the medication is administered to the resident in order to assess the level of the resident's pain. Observations, on [DATE], with LPN #4 at 9:40am and RN #3 at 10:20am, revealed could not located pain policy in the policy and procedure manual and furthermore was unable to find pain flow chart in the nursing station. Interviews, on [DATE], with LPN #4 at 9:40am and RN #3 at 10:20am, revealed they could not locate the pain process flowchart as it was not readily available for staff use. Interview with Unit Manager/RN #4 on [DATE] at 11:00am, revealed she was aware of the Pain Process Flowchart but felt it was not necessary to have it accessible for staff and that staff would have to ask her for the flowchart. Additionally, the ADNS revealed that she would prefer for Physical Therapy (PT) and Occupational Therapy (OT) to document concerns of pain on the twenty-four (24) hour report. Interview with OT #1, on [DATE] at 2:30pm and on [DATE] at 8:10am, revealed she was not aware of a policy on pain specific to the Therapy Department, but in the past they notified the nursing department of the resident's complaints of pain. OT #1 verbalized if a resident was experiencing pain she would have asked the resident how she could help the resident with the pain. If the pain was unbearable, she would take the resident to the nurse for further assessment. OT #1 stated that occupational therapy utilizes the pain scale, zero (0) through ten (10), ten (10) meaning the worst pain ever. She further stated she would notify nursing if a resident was verbalizing severe pain. Review of the Laboratory Tracking Procedures (dated [DATE]) detailed the following points to be addressed to track labs/critical results: If the results are abnormal, the nurse notifies the physician and documents in the progress notes. If the result is a panic or critical value the attending physician is immediately notified. If the result is abnormal, outside the normal ranges, but not a panic or critical value, the attending physician is notified promptly during the shift. Interview with the Director of Clinical Delivery, Hall 100 Unit Manager, on [DATE] at 4:11pm, revealed when an x-ray is ordered a call is placed to the Portable X-ray Company and a confirmation number is given. The Portable Xray company arrives within two hours and usually the results are received on the same day. If a critical x-ray result is received, the results should be called to the Physician immediately. Interview with the Registered Nurse (RN) #1, on [DATE] at 4:00pm, revealed when nurses receive a lab/x-ray from the fax machine they are to initial that they have addressed it. Interview with the Unit Secretary, on [DATE] at 2:25pm, revealed when a critical lab comes in, a phone call is made to the Physician. 1. Closed record review revealed while residing at another nursing facility on [DATE], Resident #1 sustained a fall, landing on the left hip. The other nursing facility obtained an x-ray which revealed no fracture. On [DATE], Christopher East Health Care Center admitted Resident #1 and assessed the resident as having a history of falls, unsteady gait, and muscle weakness/numbness/tightening. Upon admission, [DATE], the physician ordered Tylenol 650 mg every four (4) hours as needed for mild pain Resident #1. On [DATE], the facility conducted a pain assessment and identified the cause of Resident #1's pain was an orthopedic condition, with an onset in the last five (5) days, the location of pain was the left hip, which was described as aching. The assessment further revealed pain relieving factors were medications and repositioning and bending was a contributing factor of the resident's pain. Resident #1 reported that the hip pain impaired the ability to sit or stand comfortably. The facility's initial assessment, dated [DATE] for Resident #1, identified that a care plan should be initiated; however, interview with the Minimum Data Set (MDS) Coordinator (responsible for developing the care plans), on [DATE] at 8:45am, and record review revealed there was no pain care plan initiated for Resident #1. Record review of the Medication Administration Record (MAR) dated [DATE] revealed on [DATE] the facility assessed Resident #1's pain that morning during the medication (med) pass and documented the resident's pain level was a four (4) out of ten (10). Then review of the facility's pre pain score assessment prior to medication administration revealed Resident #1's pain was at a five (5) at which time the facility administered 650 mg during the morning med pass. Review of the post pain score assessment revealed the resident's pain level was a zero (0). However, review of the Physical Therapy Evaluation Tool revealed, on [DATE], Physical Therapy was unable to test Resident #1's left lower extremity (left leg) related to severe pain with active movement and noted that Resident #1 "Doesn't like to move left lower extremity related to hip pain from fall". The summary and assessment section detailed Resident #1 reported the pain level of the left hip as an eight (8) or nine (9) on a pain scale of one (1) to ten (10) (one (1) meaning the least pain, and ten (10) meaning the greatest pain). Review of the twenty-four (24) hour book revealed there was no documentation from PT about Resident #1 having any pain or hip issues on [DATE]. Interview with Physical Therapist (PT) #2, on [DATE] at 2:05pm, revealed on [DATE] she conducted the physical therapy evaluation for Resident #1. PT #2 stated that she checks for strength in both legs and arms, tests to see how well residents can transfer out of a chair on to the mattress which helps her to determined how well the resident will ambulate. PT #2 further stated Resident #1 was having severe pain to left leg and felt testing resistance to the left leg should not occur. Interview with PT #1, on [DATE] at 9:17am, revealed after review of Residents #1's Physical Therapy Evaluation, dated [DATE], revealed Physical Therapy during the initial evaluation had Resident #1 to walk 50 feet with a rolling walker using hands on assist, despite the resident's complaints of pain from a fall. Furthermore, continued interview with PT #2 revealed she could not remember telling anyone to assess Resident #1's leg and that she looked at the chart and assumed that the other facility cleared Resident #1. Furthermore on [DATE], Occupational Therapy Evaluation revealed Resident #1 complained of left hip pain related to a fall and demonstrated decreased strength, decreased activity tolerance and functional level, and also the impaired ability to perform activities of daily living and diminished home management skills. During the evaluation Occupational therapy documented Resident #1 as having pain of an eight (8) and nine (9) out of ten (10). Interview with Occupational Therapy (OT) #3, on [DATE] at 2:30pm, revealed on [DATE] she conducted the occupational therapy evaluation for Resident #1. OT #3 stated that she tests the activities of daily living as much as she can especially when a resident is coming from the hospital. OT #3 further stated that she set a goal for Resident #1 to stand for 10 minutes at a time to perform cooking action and if Resident #1 ever complained of pain, she would have reported it to nursing; however, there was no documented evidence OT utilized the twenty-four (24) hour book or any other communication method to notify nursing staff of Resident #1's pain or hip issues on [DATE]. Review of the MAR revealed the facility administered the PRN Tylenol to Resident #1 during the afternoon of [DATE], the facility documented Resident #1 received Tylenol in the afternoon; however, there was no documented evidence that the facility conducted the pre pain score assessment or the post pain score assessment on the MAR or in the nursing notes. Review of the [DATE] Physician assessment revealed Resident #1 had bilateral knee swelling with positive range of motion (ROM); however, there was no documented evidence that the physician had been made aware of the nursing and therapy evaluations which identified Resident #1's pain with movement to the left hip and left leg. Review of the MAR revealed, on [DATE], the facility conducted the morning pain assessment and detailed Resident #1's pain level was a zero (0); however, Tylenol was given during am and evening med pass, with no documented evidence that the facility completed a pre and post score pain assessment for both medication administrations. Review of the MAR revealed, on [DATE], the facility conducted the morning pain assessment and detailed Resident #1's pain level was a zero (0). The document also detailed that the facility assessed Resident #1's pre pain score at ten (10) after which the facility administered Tylenol 650 mg during the day. The facility completed a post pain score assessment after the administration which identified the resident's pain level had decreased to a three (3). Record review revealed no documented evidence that the facility notified the physician of the resident's increase in pain. Review of the MAR revealed, on [DATE], the facility conducted the morning pain assessment and detailed Resident #1's pain level was a zero (0). The document also detailed the facility administered Tylenol 650 mg twice during the day to Resident #1; however, there was no documented evidence that the facility completed the pre or post pain score assessments for either medication administrations on the MAR or in the nurses notes. The facility documented on the Quality Assessment Auditing tool that Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score for the day was a zero (0). On [DATE], the Physician assessment revealed Resident #1 complained of pain and as a result the physician ordered pain medication, [MEDICATION NAME] ,[DATE] mg twice a day routinely and every four (4) hours as needed (PRN). Review of the MAR revealed, on [DATE], the facility did not conduct a morning pain assessment for Resident #1. Review of the MAR also revealed no PRN pain medication was administered on [DATE], thus no pre or post pain score was obtained. The facility documented on the Quality Assessment Auditing tool that Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score for the day was a zero (0). Review of the nursing notes dated [DATE] revealed that no pain scores were assessed by the nursing staff. Review of the MAR revealed, on [DATE], the facility did not conduct a morning pain assessment for Resident #1. Review of the nursing notes dated [DATE] at 8:15pm revealed Resident #1 complained of right hip pain and routine pain medication was given. A pre pain score of eight (8) and a post pain score of two (2) was assessed by the facility. Since no PRN medication was given, no pre and post pain scores were documented on the MAR. The facility documented on the Quality Assessment Auditing tool that Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score for the day was a zero (0). On [DATE] review of the MAR revealed, the facility did not conduct a morning pain assessment for Resident #1. Review of the nursing notes dated [DATE] revealed no documented pain scores were assessed by the nursing staff. On [DATE], Occupational Therapy weekly status notes revealed Resident #1 had complained of left hip pain stating the pain level was a twelve (12) on the ten (10) point scale. The OT note further revealed Resident #1 frequently shifted his/her weight in the wheelchair to obtain pain relief. Continued interview with OT #1 revealed she could remember Resident #1 verbalizing pain frequently; however, could not recall verbalizing the pain to nursing on [DATE] regarding Resident #1's severe pain level of twelve (12) out of ten (10). While she stated she would notify nursing if a resident was verbalizing severe pain and would communicate by documenting on the 24 hour book when there are resident concerns, there was no documented evidence that OT #1 notified nursing of Resident #1's complaints of pain on [DATE]. Review of the MAR for Resident #1 revealed no as needed (PRN) pain medication was given the day of [DATE]. Review of the Quality Assessment Auditing tool revealed the facility documented Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score was a zero (0). Continued interview with PT #1 revealed that Physical Therapy worked with Resident #1 on [DATE] and had Resident #1 walk 80 to 100 feet using a rolling walker with hands on assist. She also stated that looking at the Physical Therapy Evaluation sheet Resident #1 was not tested in resistance and the right leg was documented to have more strength than left leg. On [DATE] review of the MAR revealed, the facility conducted the morning pain assessment and detailed Resident #1's pain level was a zero (0); however, [MEDICATION NAME] was given once to Resident #1 who voiced a pre pain score of an eight (8) and no post pain score was documented on the MAR. Review of the Nursing notes on [DATE] at 7:00 pm revealed the family had been waiting on pain medication for "hours". The nurse explained to the family that this was the first time he/she had been notified of Resident #1's pain. There was no documented evidence that the facility had notified the physician of Resident #1's pain to the left hip or leg. Review of the Quality Assessment Auditing tool revealed the facility documented Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score was a zero (0). On [DATE] review of the MAR revealed, the facility conducted the morning pain assessment and detailed Resident #1's pain level was a three (3); however, [MEDICATION NAME] was given twice to Resident #1 who voiced one (1) pre pain score of a seven (7), no post pain scores was documented. There was no documented evidence that the facility had notified the physician of Resident #1's pain to the left hip or leg and interview with the Physician, on [DATE] at 9:47am, revealed that he could not recall being notified by the facility of the resident's pain. Review of the Quality Assessment Auditing tool revealed the facility documented Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score was a zero (0). On [DATE] review of the MAR revealed, the facility did not conduct a morning pain assessment. Review of the nursing notes and the MAR PRN medications, revealed no documented pain assessments for the day of [DATE]. Review of the Quality Assessment Auditing tool revealed the facility documented Resident #1's highest pain score for the day of [DATE] was at a five (5) and the lowest pain score was a zero (0). On [DATE] review of the MAR revealed, the facility conducted a morning pain assessment and detailed Resident #1's pain level was a two (2). Review of the MAR revealed no PRN medication was given through out day of [DATE]. Interview with family member #1, on [DATE] at 1:29pm and on [DATE] at 11:53am revealed the family was aware that Resident #1 walked and voiced pain despite not having observed Resident #1 during therapy. She stated that Resident #1 "always had pain" even though the facility administered pain medication. The family member stated that on [DATE], she discussed her concerns and the resident's pain regarding the resident's left leg with Resident #1's Physician and requested to have an x-ray completed. Continued interview with the Physician confirmed that the family of Resident #1 was present when he assessed Resident #1 the day of [DATE]. He stated the family verbalized that Resident #1 was voiced having hip pain. The physician stated that he was able to examine Resident #1's hip and found that Resident #1 had positive range of motion and no tenderness, but wanted to do an x-ray to make sure Resident #1 had no fracture. He revealed that he had no recollection of the facility notifying him of the resident's pain. Record review revealed on [DATE], the Physician ordered an X-ray. Review of the Quality Assessment Auditing tool revealed the facility documented Resident #1's highest pain score for the day of [DATE] was a two (2) and the lowest pain score was a zero (0). Continued interview with Resident #1's physician revealed he could not remember anyone notifying him of any changes in Resident #1's condition the days between [DATE]-[DATE]. If anyone would have called regarding Resident #1's complaints of pain being at a twelve (12), he would have adjusted the medication or assessed Resident #1 further. The Physician further stated that PT/OT should have informed the nursing department of Resident #1's pain and the Nursing Department should have called him concerning Resident #1's pain. On [DATE] review of the MAR revealed, the facility conducted a morning pain assessment and detailed Resident #1's pain level was a zero (0). The MAR revealed Resident #1 received an as needed pain medication once on [DATE]; however, no pre or post pain medication score was documented. On [DATE], the facility received the radiology report, dated [DATE] at 12:36pm, which detailed a [DIAGNOSES REDACTED]. Continued interview with the Unit Secretary revealed a fracture is a critical result and the Physician should be called immediately. She stated that the only way a lab could be missed is if the results were misplaced. Interview with RN #2, on [DATE] at 4:11pm, revealed when x-ray reports are received they are via facsimile and are not placed in the Lab Tracking work document. If the results of the x-ray reveal a fracture nursing would call the Physician immediately. Review of the Quality Assessment Auditing tool revealed the facility documented Resident #1's highest pain score for the day of [DATE] was a four (4) and the lowest pain score was a two (2). On [DATE] review of the MAR revealed, the facility conducted a morning pain assessment and detailed Resident #1's pain level was a zero (0). Continued interview with RN #1 revealed on the day of [DATE] the family of Resident #1 approached her to see if the results of the x-ray had come in. RN #1 acknowledged the x-ray result was found in the Doctor book with no initials of acceptance. Review of the nurses notes, dated [DATE] at 9:00pm, revealed the Physician was notified of the x-ray results and the facility transferred Resident #1 to the hospital for surgical intervention related to the [DIAGNOSES REDACTED]. Continued interview with the Physician also stated that he was aware of the delay in being notified of the resident's x-ray results detailing a left [MEDICAL CONDITION]. Record Review of the twenty-four (24) hour book revealed from the dates of [DATE] through [DATE] there was no documentation from PT about Resident #1 having any pain or hip issues. Continued interview with PT #2 further revealed that certain activities could worsen a fracture and if a fracture was split in two the resident should not be walking on it; however, record review and interview revealed that physical therapy continued to have Resident #1 walk in therapy. Interviews with the nursing staff, on [DATE] at 11:40am with LPN#3, on [DATE] at 11:50am with RN #2, on [DATE] at 3:55pm with LPN #5, on [DATE] at 9:17am with LPN #1, on [DATE] at 10:20am with RN #3, who worked while Resident #1's was at the facility revealed that did not remember the resident, even though LPN #5, RN #2, and LPN #1 had signed the MAR as having administered pain medication to resident #1. Furthermore, these nursing staff confirmed their knowledge of the facility's requirement to document the pre and post pain score assessments regarding administration of PRN medication detailing the effectiveness of the pain medication administered based on the pain scale; however, this process through closed record review and record review was not consistently implemented. Continued interview with the Director of Clinical Delivery revealed she was unable to determine which staff member would have placed an x-ray result for Resident #1 in the Doctor Book without calling in the critical lab first. Continued interview with the ADNS revealed that from a nursing stand point she does not think the nursing department is to blame and when it comes to Resident #1, she would say there is a lack of communication between Therapy and the Nursing Department. 2. Record review of Resident #4 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was documented as a fourteen (14) which identifies this resident as cognitive (interviewable). Resident #4's admitting orders revealed [MEDICATION NAME] ,[DATE] mg was to be given every 4 hours as needed for pain, including [MEDICATION NAME] pre and post pain scores. Interview with Resident #4 on [DATE] at 7:30am revealed he/she was having bladder spasms through the night of [DATE] and received PRN [MEDICATION NAME] for pain. Review of the MAR and nursing notes revealed no pain assessment was evaluated or documented. Record review of Resident #4's MAR revealed since admission on [DATE] through [DATE], there were seventy-three (73) opportunities for a pain assessment to be completed by the facility, of the seventy-three (73) opportunities, the pain assessment score was not utilized by the facility sixty-one (61) times. Review of Resident #4's care plan revealed nursing should assess for the resident's pain intensity, location, precipitating/relieving factors of pain; however, review of the nurses' notes for this resident and the pain medication administration revealed no documentation the nursing staff had assessed the resident's pain sixty-one (61) times from [DATE] through [DATE]. Interview, on [DATE] at 10:35am, with the ADNS confirmed that the pain assessment for Resident #4 was not completed. 3. Record review of Resident #7 revealed an admission date of [DATE] with multiple [DIAGNOSES REDACTED]. Resident #7's admitting orders revealed [MEDICATION NAME] mg, give one tablet by mouth twice a day. Review of the Roster Matrix revealed Resident #7 was not marked to have a cognitive impairment. Review of the morning pain assessment revealed five (5) of the twenty-seven (27) opportunities to complete the morning assessment was not completed by the nursing department. Record Review of Resident #7's MAR revealed since admission on [DATE] through [DATE], there were twenty-six (26) opportunities for a pain assessment to be completed by the facility, of the twenty-six (26) opportunities, the pain assessment score was not utilized by the facility twenty (20) times. Observation of Resident #7 on [DATE] at 8:15am revealed facial grimacing when the resident finished his/her therapy. Interview with Resident #7 on [DATE] at 8:15am revealed he/she had not received pain medication that morning. Interview with Nurse Manager RN #5 on [DATE] at 11:05am revealed the pain characteristics: intensity, location, precipitating and relieving factors were to be charted in the nursing notes. Review of Resident #7's care plan revealed nursing staff was to assess the resident's pain intensity, location, precipitating/relieving factors of pain; however, review of the nursing notes and MAR since admission on [DATE] revealed no documented entries of such assessments despite having administered pain medication twenty (20) times. 4. Record review of Resident #9 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #9 had a BIMS score of fifteen (15), which means this resident was not cognitively impaired. Resident #9's admitting orders revealed [MEDICATION NAME] 2.5 ml (5 mg) orally every 4 hours PRN, including a pre and post pain score with [MEDICATION NAME] administration. Record review of the care plan for Resident #9 stated to note the effectiveness of the PRN pain medication and to notify the physician if pain frequency/intensity was worsening or if current [MEDICATION NAME] regimen had become ineffective. Record review of the MAR on [DATE] revealed Resident #9 received [MEDICATION NAME] 2.5ml two (2) times. Review of the MAR on [DATE] revealed Resident #9 received [MEDICATION NAME] 2.5ml, five (5) times. Review of the MAR on [DATE] revealed Resident #9 received [MEDICATION NAME] 2.5ml, five (5) times. Record review of the MAR for Resident #9 revealed PRN pain medication had been administered without noting the effectiveness, fifteen (15) out of fifteen (15) times. The current MAR and nurses notes for [DATE] to [DATE], revealed fifteen (15) opportunities for pain assessment, of the fifteen (15) opportunities, the pain score was not utilized eleven (11) times. 5. Record review of Resident #5 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #5's admitting orders revealed [MEDICATION NAME] 60 mg every eight (8) hours, [MEDICATION NAME] 7XXX,[DATE] mg take one (1) tablet every 4 hours as needed for pain, including a pre and post pain score with [MEDICATION NAME] administration and Tylenol 650 mg taken rectally every 6 hours as needed for pain, including a pre and post pain score with Tylenol administration. Record Review for Resident #5 MAR from [DATE] through [DATE], revealed thirty-five (35) opportunities for a pain score assessment to be completed, of the thirty-five (35) opportunities, the pain assessment score was not utilized by the facility twenty-eight (28) times. Upon review of ,[DATE] MAR for Resident #5, LPN #4 acknowledged more entries of the pre and post scores should of been documented. Interview with LPN #4 on [DATE] at 9:40am revealed she felt the biggest problem with documentation compliance, was the fact that there was so little room to document the scale for the time the medication was given. LPN #4 also stated that the pre and post scores were important to the physician and believes the staff would be more likely to comply with documentation if room was provided on the pre and post section of the MAR. Interview on [DATE] at 11:40 am with Licensed Practical Nurse (LPN) #3 revealed nurses are to place the pain score on the pain assessment which is located on the MAR. The post medication administration scores are to be assessed with [REDACTED]. Interview on [DATE] at 2:00pm with RN #3 revealed a pain assessment was done with each resident's complaints of pain. Interview on [DATE] at 2:50pm with the Nurse Manager for the 100 Hall revealed documentation for pain characteristics "should be in the nurse's notes". It was further revealed documentation for the evaluation of pain "should be in the nurse's notes". The pain policy was not provided by the facility; however, the pain process flowchart revealed the nursing staff was to screen patients for pain daily and document, though the word "document" was not specified as to whether to document in the nursing notes or MAR. No pre or post pain assessment policy was provided by the facility. Interview with the Administrator on [DATE] at 1:20pm revealed the facility did not have a pain management policy and procedure, they only had the Pain Process Flowchart and did not have a policy that addressed completing a pain assessment, the Administrator revealed she was aware that the reporting process had errors; however, did not have any staff designated to audit the reports to ensure accuracy.

Based on interview, closed record review, record review, and review of the facility's Pain Process Flowchart it was determined the facility failed to ensure the physician was consulted for the need to alter treatment significantly for one (1) of nineteen (19) sampled residents (Resident #1). The facility failed to notify the physician with changes in Resident #1's condition as it related to pain and failed to timely notify the physician of the resident's X-ray report which disclosed an acute fracture to the left hip. Resident #1 was assessed to have pain during the resident's initial admission assessment completed on [DATE]. Record review and interview revealed Resident #1 complained of severe pain frequently during therapy sessions and during the nursing pain assessments. However, there was no documented evidence the Physician was notified of the resident's pain. On [DATE], after the family expressed concerns to the Physician about the resident's left hip pain, the Physician ordered an X-ray. On [DATE], the facility received the radiology report, dated [DATE] at 12:36 pm, which diagnosed an acute [MEDICAL CONDITION] hip. However, the facility did not notify the Physician until [DATE], delaying the resident from receiving emergent care for more than twenty-four (24) hours. Resident #1 was transferred to the hospital for surgical intervention related to the [DIAGNOSES REDACTED]. Resident #1 expired while at the hospital. Furthermore, the facility's failure to complete pre and post pain score assessments for resident's receiving PRN (as needed) medications, prevented the facility from assessing the effectiveness of pain medication for residents #4, #5, #7, and #9 who had been admitted to the facility in [DATE], to determine if the physician needed to be contacted for a change in treatment. The facility's failure to ensure the physician was consulted for the need to alter treatment significantly for Resident #1 has caused or is likely to cause Resident #1 and other residents with identified pain, serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist from [DATE] and is ongoing at F157 "J", F281 "J", F309 "J", F490 "J", and F520 "J". The findings include: Review of the Pain Process Flowchart revealed nursing staff would complete an assessment, then complete the pain section of the Admission Evaluation, to determine the resident's pain level based on the pain scale. The Flowchart then directed questions for the nursing staff to answer regarding if the resident had pain or had a condition that was likely to cause pain. If the answer was yes, the Flowchart directed the nursing staff to notify the physician for orders. 1. Closed record review revealed Resident #1 sustained a fall on [DATE], prior to admission on [DATE], at which time an x-ray was obtained at the previous facility which revealed no fracture. The facility's initial assessment, dated [DATE], assessed and identified the cause of Resident #1's pain was an orthopedic condition, with an onset in the last five (5) days, and the location of pain was the left hip, which was described as aching. The assessment further revealed pain relieving factors were medications and repositioning, with bending as a contributing factor of pain. Resident #1 reported the hip pain impaired the resident's ability to sit or stand comfortably. There was no evidence the facility had notified the physician of Resident #1's pain. Interview with the Physician, on [DATE] at 9:47am, revealed he did not recall being contacted by the nursing department regarding Resident #1's pain. Review of Therapy Evaluation Tool revealed, on [DATE], Physical Therapy was unable to test Resident #1's left lower extremity (left leg) related to severe pain with active movement and noted that Resident #1 "Doesn't like to move left lower extremity related to hip pain from fall". The documentation revealed Resident #1 reported the pain level of the left hip as an eight (8) or nine (9) on a pain scale of one (1) to ten (10), one (1) meaning the least pain, and ten (10) meaning the greatest pain. Interview with PT #2, on [DATE] at 9:25am, revealed Resident #1 "was having severe pain to left leg" and felt testing resistance to the left leg should not occur. She stated that she could not remember telling anyone to assess Resident #1's leg. Additionally on [DATE] review of the Occupational Therapy evaluation revealed Resident #1 complained of left hip pain related to a fall and demonstrated decreased strength, decreased activity tolerance and functional level, and also the impaired ability to perform activities of daily living and diminished home management skills. Interview with Occupational Therapy (OT) #3, on [DATE] at 2:30pm, revealed on [DATE] she conducted the occupational therapy evaluation for Resident #1. OT #3 stated that she set a goal for Resident #1 to stand for 10 minutes at a time to perform cooking action and if Resident #1 ever complained of pain she would have reported it to nursing; however, she could not recall who she told and furthermore there was no documented evidence OT utilized the twenty-four (24) hour book or any other written communication method to notify nursing staff of Resident #1's pain or hip issues on [DATE]. Review of the [DATE] Physician assessment revealed Resident #1 had bilateral knee swelling with positive range of motion (ROM). However, there was no documented evidence that the physician had been made aware of the nursing and therapy evaluations which identified Resident #1's pain with movement to the left hip and left leg. Continued interview with the Physician revealed he could not recall nursing informing him of the resident's complaints of pain to nursing or therapy. On [DATE] review of the MAR revealed, the facility conducted the morning pain assessment and detailed Resident #1's pain level was a zero (0). Review of the MAR revealed, on [DATE], the facility assessed Resident #1's pre pain score at ten (10) after which the facility administered Tylenol 650 mg during the day. Record review and continued Physician interview revealed no documented evidence that the facility notified the physician of the resident's increase in pain and the physician had no recollection that the facility had notified him of the resident's pain. Review of the Physician Assessment, dated [DATE], revealed Resident #1 complained of pain during the assessment. The assessment detailed new physician orders [REDACTED]. On [DATE], Occupational Therapy weekly status notes revealed Resident #1 had complained of left hip pain and frequently shifted his/her weight in the wheelchair to obtain pain relief. Occupational staff interviews revealed the resident's pain level would indicate severe pain. Documentation on the medication administration record indicated the highest pain level of an eight (8) on [DATE] and a highest pain level of a seven (7) on [DATE]. There was no documented evidence that the facility had notified the physician of Resident #1's pain to the left hip and leg despite the evaluations and treatments conducted by Physical and Occupational Therapy and Nursing administering pain medication to Resident #1. On [DATE], the Physician ordered an X-ray after Resident #1's family member discussed the resident's fall at another facility and the resident's continued complaints of pain to the left hip. On [DATE], the facility received the radiology report, dated [DATE] at 12:36pm, which detailed a [DIAGNOSES REDACTED]. However, there was no evidence that the facility notified the physician of the results until [DATE] at 9:00pm after the family requested to know the test results. The facility transferred Resident #1 to the hospital for surgical intervention related to the [DIAGNOSES REDACTED]. Continued interview with Physical Therapist (PT) #2 revealed on [DATE] she conducted the physical therapy evaluation for Resident #1. PT #2 stated that she checks for strength in both legs and arms, tests to see how well residents can transfer out of a chair on to mattress. Depending on the transfer it determines how well the resident will ambulate. PT #2 further stated Resident #1 was having "severe pain to left leg" and felt testing resistance to the left leg should not occur. She stated that she could not remember telling anyone to assess Resident #1's leg and she looked at the chart and assumed that the other facility cleared Resident #1. PT #2 revealed certain activities could worsen a fracture and if a fracture was split in two the resident should not be walking on it. PT #2 stated when a resident complains of pain, we usually notify the nursing department. Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 3:55pm, revealed Physical Therapy was to report to nursing staff any concerns about pain or call the nursing department directly. Interview with the Administrative Director of Nursing Services (ADNS) on [DATE] at 10:40 am revealed while there was no established written protocol, she would prefer for PT/OT to document concerns of hip pain on twenty-four (24) hour report. The ADNS further stated she would expect nursing to assess the level of pain and the location of the pain. The ADNS stated that from a nursing stand point she did not think the nursing department was to blame and when it came to Resident #1, she would say there was a lack of communication between PT and Nursing Departments. Interview with the Director of Rehab on [DATE] at 1:00pm revealed if a resident had significant pain, this pain would be charted on the twenty-four hour report, but the twenty-four hour report would not replace reporting the pain directly to the nursing department. Record Review of the twenty-four (24) hour book revealed from the dates of [DATE] through [DATE] there was no documentation from PT about Resident #1 having any pain or hip issues. Interview with the Physician, on [DATE] at 9:47am, revealed he could not remember anyone notifying him of any changes in Resident #1's condition the days between [DATE]-[DATE]. If anyone would have called regarding Resident #1's complaints of pain being at a twelve (12), he would have adjusted the medication or assessed Resident #1 further. The Physician further stated that PT/OT should have informed the nursing department of Resident #1's pain and the Nursing Department should have called him concerning Resident #1's pain. 2. Record review revealed the faciilty admitted Resident #4 on [DATE] with a [DIAGNOSES REDACTED]. Review of the admitting orders for Resident #4 revealed [MEDICATION NAME] ,[DATE] mg was to be given every 4 hours as needed for pain, including [MEDICATION NAME] pre and post pain scores. Interview with Resident #4, on [DATE] at 7:30am, revealed he/she was having bladder spasms through the night of [DATE] and received PRN [MEDICATION NAME] for pain. Review of the MAR and nursing notes revealed no documentation that a pain assessment was completed or documented. Review of Resident #4's care plan revealed nursing should assess for the resident's pain intensity, location, precipitating/relieving factors of pain; however, review of the nurses' notes for this resident and the pain medication administration revealed no documentation the nursing staff had assessed the resident's pain sixty-one (61) times from [DATE] through [DATE]. Interview, on [DATE] at 10:35am, with the ADNS confirmed that the pain assessment for Resident #4 was not completed. This failure to assess the effectiveness of the pain medication prevented the facility from identifying whether they should notify the physician for a change in treatment to ensure pain management for Resident #4. 3. Record review revealed the facility admitted Resident #7 on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the admitting orders revealed [MEDICATION NAME] mg, give one tablet by mouth twice a day. Review of the morning pain assessment revealed five (5) of the twenty-seven (27) opportunities to complete the morning assessment was not completed by the nursing department. Record Review of Resident #7's MAR revealed since admission on [DATE] through [DATE], there were twenty-six (26) opportunities for a pain assessment to be completed by the facility, of the twenty-six (26) opportunities, the pain assessment score was not utilized by the facility twenty (20) times. Observation of Resident #7 on [DATE] at 8:15am revealed facial grimacing when the resident finished his/her therapy. Interview with Resident #7, on [DATE] at 8:15am, revealed he/she had not received pain medication that morning. Review of Resident #7's care plan revealed nursing staff was to assess the resident's pain intensity, location, precipitating/relieving factors of pain; however, there were no documented entries of such assessment completed by nursing per the nursing notes and MAR since admission on [DATE]. Interview with Nurse Manager RN #5 on [DATE] at 11:05am revealed the pain characteristics: intensity, location, precipitating and relieving factors were to be charted in the nursing notes. This failure prevented the facility from assessing to determined the effective of the pain medication and to identify if the facility needed to notify the physician to determine of an alteration in treatment was necessary. 4. Record review revealed the facility admitted Resident #9 on [DATE] with a [DIAGNOSES REDACTED]. Review of the admitting orders revealed [MEDICATION NAME] 2.5 ml (5 mg) orally every 4 hours PRN, including a pre and post pain score with [MEDICATION NAME] administration. Care plan review revealed nursing was to note the effectiveness of the PRN pain medication and to notify the physician if pain frequency/intensity was worsening or if current [MEDICATION NAME] regimen had become ineffective. Record review of the MAR on [DATE] revealed Resident #9 received [MEDICATION NAME] 2.5ml two (2) times. Review of the MAR on [DATE] revealed Resident #9 received [MEDICATION NAME] 2.5ml, five (5) times. Review of the MAR on [DATE] revealed Resident #9 received [MEDICATION NAME] 2.5ml, five (5) times. Record review of the MAR for Resident #9 revealed PRN pain medication had been administered without documenting the effectiveness, fifteen (15) out of fifteen (15) times. The current MAR and nurses notes for [DATE] to [DATE], revealed the pain score was not utilized eleven (11) times out of fifteen (15) opportunities for pain assessment. Thus preventing the facility from assessing to determine the effectiveness of pain management for Resident #9. This prevented the facility from identifying whether the physician needed to be notified for an alteration in treatment related to pain management. 5. Record review revealed the facility admitted Resident #5 on [DATE] with a [DIAGNOSES REDACTED]. Resident #5's admitting orders revealed [MEDICATION NAME] 60 mg every eight (8) hours, [MEDICATION NAME] 7XXX,[DATE] mg take one (1) tablet every 4 hours as needed for pain, including a pre and post pain score with [MEDICATION NAME] administration and Tylenol 650 mg taken rectally every 6 hours as needed for pain, including a pre and post pain score with Tylenol administration. Record Review for Resident #5 MAR from [DATE] through [DATE], revealed the pain assessment score was not utilized by the facility twenty-eight (28) times out of thirty-five (35) opportunities for a pain score assessment to be completed. Therefore, the facility's failure to assess the effectiveness of the pain medication prevented the facility from identifying the need to notify the physician for a change in treatment.

Based on interview, record review, pain process, pain guides, and the AOC it was determined that Immediate Jeopardy (IJ), identified during the abbreviated survey (04/06/11) had been removed; however, non-compliance continued to exist related to administration regarding the pain assessment process. The facility failed to ensure staff effectively implemented the facility's pain process flowchart in order to effectively manage residents pain for three (3) of seven (7) sampled residents, Residents #3, #4 and #7. The findings include: Refer to F157, F281, F309, and F520. Review of the Pain Process Guide revealed patients were evaluated daily for evidence of pain. A pain evaluation was also completed before and after routine and PRN pain medication administration. The patients pain scale score was recorded on the Medication Administration Record (MAR). The Allegation Of Compliance (AOC) dated 04/18/11 stated patient pain scores would be monitored daily in the Eagle Room (interdisciplinary team meeting) to identify appropriate assessment and treatment for [REDACTED]. The ADNS will randomly audit compliance with the process daily and submit findings to the Quality Assessment and Assurance (QA&A) committee daily meeting (Eagle Room Process). The Administrator will complete a daily audit of pain using the established pain tracking tools. The Director of Rehab (DOR) will complete an audit of therapists' notes, communication and process compliance. She will report her findings to the daily QA&A meeting. Record review of Resident #3's Medication Administration Record (MAR) for the month of April, 2011 revealed from 04/21/11 through 04/25/11, there were eleven (11) opportunities for a pain evaluation to be completed by the facility, of the eleven (11) opportunities, the intensity was not utilized by the facility one (1) time. Record review of Resident #4's MAR for the month of April 2011 revealed from 04/18/11 through 04/25/11, there were fifteen (15) opportunities to conduct a pre and post pain score of the fifteen (15) opportunities, the intensity was not utilized by the facility six (6) times. Record review of Resident #7's MAR for the month of April 2011 revealed on two (2) occasions, it was documented the PRN medication [MEDICATION NAME] 10mg was given for complaints of pain to left hip. There was no documented evidence a pre or post pain score was conducted. Refer to F309 Interview with a Licensed Practical Nurse (LPN) #7 on 04/25/11 at 9:33am revealed the nursing staff were inserviced on charting pre and post scores on MAR's. LPN #7 further stated pre and post scores should be documented in nursing notes. Interview with LPN #8 on 04/26/11 at 3:55pm revealed that when a resident complains of pain, the pain is assessed for the intensity; one (1) to ten (10), location of the pain and the type of pain. Complaints of pain should always be assessed and documented. LPN #8 further stated pre and post pain scores should be done on all PRN medications. Interview with the Administrative Director of Nursing Services (ADNS) on 04/26/11 at 5:00pm revealed that once residents were identified as having pain issues, the patients pain will be monitored day by day. Trends of each patient are assessed to make sure there are no documented increase in pain. ADNS further stated the facility nurses have been trained when a pain score increases, the staff are to reassess the resident's pain and investigate further. The ADNS stated the charge nurse (DNS) is responsible to make sure nurses are completing daily audits. The ADNS further stated the only audits that she completes are the pain audit tool for completion. She indicated she did not go through and check to see that each resident's pain score documented in the nurses notes, MAR and twenty-four hour report are accurately recorded on the pain auditing tool by the DNS. The ADNS further stated there are just to many residents to complete this task. Interview with the Director of Clinical Services on 04/26/11 at 6:00pm revealed that it was there policy to do pre and post pain scores on PRN pain medication. Interview with the Administrator on 04/26/11 at 6:00pm revealed the only audits completed by her are the auditing tools used in QA&A. The Administrator further stated that she does not audit the ADNS or the DNS to make sure they are completing there assigned jobs. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/23/11. The state agency verified Immediately Jeopardy was removed during the onsite survey of 04/25-26, 2011, which lowered the scope and severity to a "E" at F490 while the facility's Quality Assurace monitors the effectiveness of audit tools for pain scores, pain process tools, and pain tracking to identify if appropriate assessment and treatment are in place.

Based on interview, record review, Pain Process Flowchart review, Eagle Room Process review, and twenty-four hour report review, it was determined the facility failed to identify quality deficiencies, develop, and implement appropriate plans of action related to pain management for five (5) of nineteen (19) sampled residents (Residents #1, #4, #5, #7, and #9). The facility failed to ensure policies and procedures were developed regarding pain management and failed to ensure staff effectively implemented the facility's Pain Process Flowchart in order effectively manage residents' pain. The facility failed to provide a quality assessment which depicted an accurate account of Resident #1's left hip pain on a daily basis. On 10/08/10, the facility admitted Resident #1 and assessed the resident as having left hip pain. The facility failed to take action to address the resident's pain through nursing and therapy assessment, care plan intervention, and physician notification to determine if an alteration in treatment was necessary. On 10/20/10, a radiology report detailed Resident #1 had an acute left [MEDICAL CONDITION]. On 10/21/10, the facility transferred the resident to the hospital for surgical intervention related to the left [MEDICAL CONDITION]. Record review and interview revealed the facility failed to complete a pain assessment for Resident #4 sixty-one times, 03/02-03/31/11; Resident #7 twenty times, 03/04-03/31/11; Resident #5 twenty-eight times, 03/20-03/30/11; and, Resident #9 eleven times, 04/01-04/06/11. The facility's failure to identify quality deficiencies, develop, and implement appropriate plans of action to ensure pain was accurately monitored, assessed, care planned, documented, and communicated between the Therapy Departments, Nursing Departments and the Physician, has caused or is likely to cause residents with identified pain serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on 10/08/10 at F157 "J", F281 "J", F309 "J", F490 "J" and F520 "J" and is ongoing. The findings include: Refer to F309 S/S J Review of the Eagle Room Process revealed through preparation, the unit or designated management nurses prepare to discuss patient issues on 24 hour report. The unit or designated management would obtain report from off-going shift to include and follow up from previous day. Rounds are completed on patients identified on 24 hour report or during shift-to-shift report. The lab results, clinical records and new physician orders [REDACTED]. Its purpose is to triage patient needs by implementing the following: Identify patient risks, Determine priorities and needs, Evaluate action steps required, Assign staff responsibility and Substantiate task completion. Patient issues are: new admissions, changes in condition, SBARs, status of unstable patients, abnormal lab values, new and discontinued physician orders, accidents and incidents, pain scale greater than or equal to 4, unexpected hospital readmissions, concerns, other issues not noted and unfinished items from the previous day. 1. Record review revealed prior to admission to the facility Resident #1 sustained a fall landing on the left hip on 10/07/10, at which time an x-ray was obtained which revealed no fracture. The facility admitted Resident #1 on 10/08/10 and conducted a pain assessment identifying Resident #1 had left hip pain due to an orthopedic condition that had developed the last five days and was described as aching. The assessment detailed bending was a contributing factor of pain. Resident #1 reported that the hip pain impaired the ability to sit or stand comfortably. Record review revealed the resident frequently complained of severe pain during therapy sessions; however, there was no documented evidence the resident's complaints of pain were communicated to nursing. Review of the resident's October Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s pain level was a four or higher on a scale of ten. Further review revealed the facility inaccurately documented the resident's level of pain eleven times. On 10/20/10, a radiology report was received which detailed Resident #1 had an acute fracture to the Left hip. Record review revealed the facility transferred Resident #1 to the hospital for surgical intervention to the left hip. 2. Record review revealed the facility failed to complete a pain assessment for Resident #4 from 03/02/11 through 03/31/11 sixty-one (61) times. Review of Resident #4's nursing notes revealed no documented entries noting the resident's pain intensity, location, precipitating/relieving factors of pain per the resident's plan of care. 3. Record review revealed the facility failed to complete a pain assessment for Resident #7 from 03/04/11 through 03/31/11 twenty (20) times. Review of Resident #7's nursing notes and MAR, revealed no documented entries noting the residents pain intensity, location, precipitating/relieving factors of pain per the resident's plan of care since admission on 03/04/11. 4. Record review revealed the facility failed to complete a pain assessment for Resident #5 from 03/20/11 through 03/30/11 twenty-eight (28) times. 5. Record review revealed the facility failed to complete a pain assessment for Resident #9 from 04/01/11 through 04/06/11 eleven (11) times. Interview with the Administrative Director of Nursing Services (ADNS), on 03/31/11 at 10:40am, revealed when nurses completed pain assessments she would expect nursing to assess the level of pain and the location of the pain. She revealed nursing staff were required to conduct Pain Assessments each morning for all residents with the morning Medication Pass. For residents receiving "as needed" pain medications, the nursing staff were required to complete a Pre and Post (Medication) Assessment each time the medication was administered to the resident in order to assess the level of the resident's pain. Continued interview with the ADNS revealed Therapy should document concerns of pain on the twenty-four (24) hour report. She further revealed the facility used a Quality Assurance (QA) Auditing tool for pain assessment that was to be completed by the nurse manager and they were to place the highest pain score for the day for the resident on the document. The ADNS further stated the Administrator, the Assistant Administrator, and the ADNS were responsible to ensure the nurse managers were completing documents accurately. Interview with the Administrator on 04/01/11 at 1:20pm revealed the pain assessment sheet was a part of the Eagle Room Process called "Pain Tracking Tool" (QA Auditing tool). The Administrator stated she did not know what tool Therapy was using to assess resident's pain. There was no standard tool the whole facility used for pain, each department was free to use what ever tool they preferred. She further stated the Quality Assurance process (QI) did not include pain assessments utilized by the Therapy department. The Administrator further stated that the only scores assessed and placed on the QI Pain Tracking Tool were the pre and post pain scores from the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s pain assessments on the QI pain tracking system. There was no auditing tool to verify that Therapy and the nursing department managers were completing Quality Assurance documents accurately. The Administrator further stated the potential for harm was present related to the lack of communication and documentation by the nurses.

Based on interview record review and the Pain Practice Guide, it was determined that the facility failed to ensure staff effectively implemented the facility's pain auditing tool and pain process flowchart in order to effectively manage residents pain. The facility failed to complete a quality assessment which depicted an accurate account of Resident #2, #3, #4 and #7's pain, for four (4) of seven (7) sampled residents. The findings include: The Pain Practice Guide; Quality Assessment and Assurance (QAA) section revealed the pain prevention or reduction process is routinely audited through the utilization of the QAA audit tools to identify potential or actual system issues. The results of the audits are submitted to the QAA committee for review and follow-up as clinically indicated. Change in Condition section states if a change in patient condition occurs, the licensed nurse re-evaluates the intensity, location, type and history of pain and document findings in the progress notes of the patients clinical record. Based upon this evaluation, the physician is notified to obtain orders if indicated. The patients plan of care is reviewed and updated to reflect current care delivery needs. Eagle Room Review section revealed patients with pain are reviewed in Eagle Room daily. Results are tracked on the Eagle Room Pain Tool and on the Pain Management Tool as indicated and submitted to the QAA Committee for review. Interview with the DCD #1 on 04/26/11 at 10:35am revealed she audits the PRN pain scores, therapy notes off the twenty-four (24) hour report, nurses notes, SBAR and if the MD and the family were called. DCD #1 further stated the pain score of ten (10) on the SBAR was missed because there new system indicates that they identify if the SBAR was completed, it does not indicate to evaluate if a score was given on the SBAR. DCD #1 also stated that she can see that the SBAR scores need to be incorporated into the process. Interview with the Administrative Director of Nursing Services (ADNS) on 04/26/11 at 5:00pm revealed that once residents were identified as having pain issues, the patients pain will be monitored day by day. Trends of each patient are assessed to make sure there are no documented increase in pain. ADNS further stated that they are training staff that if a pain score spikes up, the staff are to reassess pain and investigate further. The ADNS stated the charge nurse Director of Clinical Delivery (DCD) was responsible to make sure nurses were completing daily audits. The ADNS further stated the only audits that she completes are the pain audit tool for completion, she does not go through and check to see that each resident's pain score recorded in the nurses notes, MAR and twenty-four hour report are accurately documented on the pain auditing tool by the DCD. The ADNS further stated there are just to many residents to complete this task. Interview with the Director of Clinical Services on 04/26/11 at 6:00pm revealed that it was there policy to do pre and post pain scores on PRN pain medication. Interview with the Administrator on 04/26/11 at 6:00pm revealed the only audits completed by her are the auditing tools used in QA&A. The Administrator further stated that she does not audit the ADNS or the DNS to make sure they are completing there assigned jobs. The QAA pain audit tool, pain process tool and the pain management tracking tool will be evaluated by QAA committee members for all areas of non-compliance. A compliance audit will be reviewed monthly for six months.

Based on interview and record review it was determined that the facility failed to ensure the nursing staff met professional standards of quality of care for four (4) of seven (7) sampled residents. The facility failed to ensure the Director's of Clinical Delivery (DCD's) completed the Pain Management Tool and Pain Audit Tool's thoroughly to depict an accurate account of Resident #2's pain score for a twenty-four (24) hour period. The facility failed to ensure the nursing staff completed pre and post pain scores daily for Residents #3, #4 and #7. The findings include: Review of the Pain Management Tool revealed the directions were to review the twenty-four (24) report/change in condition report, medication administration record or other sources documented to identify patients with pain. Document the highest pain score observed or reported and the related post-treatment score each day. Patients with a score of four (4) to seven (7) twice in a seven day period or who had one score of eight, nine or ten are reviewed during the Eagle Room process and the findings submitted to the QAA committee for analysis of pain management interventions and updates to each patient plan of care. 1. Record review of Resident #2's Medication Administration Record (MAR) dated 04/19/11 revealed Tylenol 650mg suppository was given at 1:30am for complaints of pain; bladder spasms. No pre or post scores were documented on the MAR. Record review of the Pain Audit Tool utilized by the Director of Clinical Delivery (DCD) #1 revealed that pain scores were obtained on 04/19/11 for Resident #2. Record review of the Pain Management tool dated 04/19/11 revealed Resident #2 highest score of pain, for the day was a seven (7) and lowest score of pain was a zero (0). Record review of the SBAR dated 04/19/11 revealed Resident #2 rated pain, on a scale of zero (0) to ten (10) (zero meaning no pain and ten meaning the greatest amount of pain), as a ten (10). Interview with the DCD #1 on 04/26/11 at 10:35am revealed she audits the PRN pain scores, therapy notes off the twenty-four (24) hour report, nurses notes, SBAR and if the MD and the family were called. DCD #1 further stated the pain score of ten (10) on the SBAR was missed because there new system indicates that they identify if the SBAR was completed, it does not indicate to evaluate if a score was given on the SBAR. DCD #1 also stated that she can see that the SBAR scores need to be incorporated into the process. 2. Record review of Resident #7's PRN pain medication orders revealed [MEDICATION NAME] 10mg by mouth four times a day as needed for spasms. Review of the MAR dated 04/11 revealed Resident #7 received three (3) doses of [MEDICATION NAME] on 04/23/11 at 11:45am and 5:00pm and on 04/25/11 at 8:00am. On two (2) occasions it was documented the PRN medication was given; [MEDICATION NAME] 10mg for complaints of pain to left hip. On one (1) occasion it was documented the PRN medication was given; [MEDICATION NAME] 10mg for complaints of pain, eight (8) of ten (10). Review of the MAR revealed no pre or post scores were given as it relates to the pre and post scores not being ordered for this medication. 3. Record review of Resident #4's PRN pain medication orders revealed [MEDICATION NAME] (MS) Liquid 10mg/5ml solution to be given 2.5ml every four (4) hours PRN pain. The facility was to utilize pre and post pain scores for the MS liquid solution orders. Record review of Resident #4's MAR dated 4/11 revealed since 04/18/11 through 04/25/11, there were fifteen (15) opportunities to conduct a pre and post pain score. There was no documented evidence of intensity assessed by the facility six (6) times. 4. Record review of Resident #3's admitting orders revealed Tylenol ES (extra strength) one (1) tablet every four (4) hours as needed (PRN) mild pain and Tylenol ES two (2) tablets every four (4) hours PRN moderate pain. The facility was to utilize pre and post pain scores for Tylenol ES one tablet and Tylenol ES two tablet orders. Record review of Resident #3's MAR dated 4/11 revealed since 04/21/11 through 04/25/11, there were eleven (11) opportunities for a pain evaluation to be completed by the facility, of the eleven (11) opportunities, there was no documented evidence the intensity was assessed by the facility one (1) time. Interview with the Director of Clinical Services on 04/25/11 at 10:30am revealed pre and post scores, descriptor and location need to be added to the audit tool so the audit will produce positive results. Furthermore on 04/26/11 at 6:00pm the Director of Clinical Services revealed that it was there policy to complete pre and post pain scores on all PRN pain medication. Interview with the DCD on 04/26/11 at 2:15pm, revealed information about the intensity of pain should be documented on the MAR. Interview with the Administrative Director of Services (ADNS), on 04/26/11 at 5:00pm, revealed the DCD's are responsible to make sure nurses are completing pre and post pain assessments of residents. The ADNS further stated it is her expectation that the system is followed, we assess pain, call the Physician and call the family of the residents. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/23/11. The state agency verified Immediately Jeopardy was removed during the onsite survey of 04/25-26, 2011, which lowered the scope and severity to a "E" at F281 while the facility's Quality Assurace monitors the effectiveness of audit tools for pain scores to identify appropriate assessment and treatment are in place as well as pain care plans.

Based on observation, interview, record review, pain process guide and pain management tool, it was determined the facility failed to effectively maintain the highest practicable physical well-being for four (4) of seven (7) sampled residents (Residents #2, #3, #4 and #7). The facility failed to provide a quality assessment which depicted an accurate account of Resident #2 and #7's pain. The facility failed to develop and implement an effective system to ensure that the nursing staff assessed and evaluated the characteristics of; intensity, location, and descriptors of pain for Residents #3 and #4. The findings include: Review of the Pain Process Guide revealed patients are evaluated daily for evidence of pain. A pain evaluation is also completed before and after routine and PRN pain medication administration. The patients pain scale score is recorded on the Medication Administration Record (MAR). Review of the Pain Management Tool revealed the directions were to review the twenty-four (24) report/change in condition report, medication administration record or other sources documented to identify patients with pain. Document the highest pain score observed or reported and the related post-treatment score each day. Patients with a score of four (4) to seven (7) twice in a seven day period or who had one score of eight, nine or ten are reviewed during the Eagle Room process and the findings submitted to the QAA committee for analysis of pain management interventions and updates to each patient plan of care 1. Record review of Resident #2's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #2's as needed (PRN) medication orders (dated 03/20/11) revealed Tylenol 650mg with directions to insert two (2) suppositories rectally every six (6) hours for mild pain with the utilization of a pain score before and after giving pain medication. Record review of the Medication Administration Record (MAR) dated 04/19/11 revealed Tylenol 650mg suppository was given at 1:30am for complaints of pain; bladder spasms. No pre or post scores were documented on the MAR. Record review of the Pain Audit Tool utilized by the Director of Clinical Delivery (DCD) #1 revealed that pain scores were obtained on 04/19/11 for Resident #2. Record review of the Pain Management tool dated 04/19/11 revealed Resident #2's highest score of pain for the day was a seven (7) and lowest score of pain was a zero (0). Record review of the SBAR dated 04/19/11 revealed Resident #2 rated pain, on a scale of zero (0) to ten (10) (zero meaning no pain and ten meaning the greatest amount of pain), as a ten (10). Interview with the DCD #1, on 04/26/11 at 10:35am, revealed she audits the PRN pain scores, therapy notes off the twenty-four (24) hour report, nurses notes, SBAR ( and if the MD and the family were called. DCD #1 further stated the pain score of ten (10) on the SBAR was missed because there new system indicates that they identify if the SBAR was completed, it does not indicate to evaluate if a score was given on the SBAR. DCD #1 also stated that she can see that the SBAR scores need to be incorporated into the process. 2. Record review of Resident #7's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #7's PRN pain medication orders (dated 04/22/11) revealed [MEDICATION NAME] 10mg by mouth four times a day as needed for spasms. Review of the MAR dated 04/11 revealed Resident #7 received three (3) doses of [MEDICATION NAME] on 04/23/11 at 11:45am and 5:00pm and on 04/25/11 at 8:00am. On two (2) occasions it was documented the PRN medication was given; [MEDICATION NAME] 10mg for complaints of pain to left hip. On one (1) occasion it was documented the PRN medication was given; [MEDICATION NAME] 10mg for complaints of pain with pain score of eight (8) of ten (10). Review of the MAR revealed no pre or post pain scores were documented. 3. Record review of Resident #4's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #4's PRN pain medication orders revealed [MEDICATION NAME] (MS) Liquid 10mg/5ml solution to be given 2.5ml every four (4) hours PRN pain. The facility was to utilize pre and post pain scores for the MS liquid solution orders. Record review of Resident #4's care plan created on 03/11/11, with a focus on pain revealed pain would be evaluated for characteristics of intensity, location and descriptors. Record review of Resident #4's MAR dated 4/11 revealed since 04/18/11 through 04/25/11, there were fifteen (15) opportunities, the intensity was not utilized by the facility six (6) times, the location was not utilized by the facility five (5) times and the description of the pain was not utilized by the facility seven (7) times. 4. Record review of Resident #3's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #3's admitting orders revealed Tylenol ES (extra strength) one (1) tablet every four hours as needed (PRN) mild pain and Tylenol ES two (2) tablets every four (4) hours PRN moderate pain. The facility was to utilize pre and post pain scores for Tylenol ES one tablet and Tylenol ES two tablet orders. Record review of Resident #3's care plan created on 04/05/11 with a focus on pain revealed pain would be evaluated for characteristics of intensity, location and descriptors of pain. Record review of Resident #3's MAR dated 4/11 revealed since 04/21/11 through 04/25/11, there were eleven (11) opportunities for a pain evaluation to be completed by the facility, of the eleven (11) opportunities, the intensity was not utilized by the facility one (1) time, the location was not utilized by the facility five (5) times and the description of the pain was not utilized by the facility six (6) times. Interview with the Director of Clinical Services on 04/25/11 at 10:30am revealed pre and post pain scores, descriptor and location of pain need to be added to the audit tool so the audit will produce positive results. Furthermore, on 04/26/11 at 6:00pm, the Director of Clinical Services revealed it was facility policy to complete pre and post pain scores on all PRN pain medication. Interview with the DCD #3 on 04/26/11 at 2:15pm revealed information about the description of pain, the location of pain and the intensity of pain should be documented on the MAR. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/23/11. The state agency verified Immediately Jeopardy was removed during the onsite survey of 04/25-26, 2011, which lowered the scope and severity to a "E" at F309 while the facility's Quality Assurace monitors the effectiveness of pain score tools, pain process tools, and pain tracking audits. The resident's pain scores are to be monitored to determine if alternative interventions are indicated and the physician is to be notified of any changes.