Every finding on record at Maefair Center for Health & Rehabilitation

Based on observation, review of the clinical record, review of facility policy and interview for 1 sampled resident (Resident #368) reviewed for Advanced Directives, the facility failed to ensure the resident signed Advance Directives were reflected correctly on the Electronic Medical Record (EMR. The findings include: Resident #368 's diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, Congestive Heart Failure (CHF) and anxiety. Review of Resident #368 paper chart indicated a code status signed on [DATE] directing Do Not Resuscitate (DNR). The care plan with a revision dated [DATE] identified the resident has an established Advanced Directive. Residents wish to receive Cardiopulmonary Resuscitation (CPR). Interventions included reviewing Advanced Directives with resident and/ or healthcare decision maker quarterly and to support residents' decision for CPR. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #368 was moderately cognitively impaired and required moderate assistance with bed mobility, transfers and personal hygiene. Observation on [DATE] at 12:00 PM of Resident's # 368 Electronic Medical Records indicated a code status of full code. Interview with the Director of Nursing Services (DNS) on [DATE] at 2:00 PM identified the nursing staff will use the code status indicated on the EMR. The DNS identified she was unsure why Resident's 368 code status from her/his chart and the EMR did not match. She also identified it is her/his expectation that the EMR is updated as soon as an Advance Directives is signed. The DNS further indicated it is the responsibility of the nursing team, including herself and physicians, to ensure this practice is done. She indicated I do audits, but I must have missed this one. After surveyors' inquiry, a physician's order dating [DATE] identified Resident # 368's Advanced Directive order and care plan were updated to reflect the signed Advanced Directives (DNR). After the surveyor inquiry, the care plan reviewed on [DATE] indicated Advanced Directive Guidelines code status: DNR/DNI/no artificial nutrition. Intervention included: to honor Advanced Directives as directed by resident/responsible party for guidance, and to provide information to resident/responsible party to complete advanced directives and assist as necessary. After surveyor to inquiry, the facility reported they conducted a mock survey on [DATE], which identified this as an issue. The facility reported believing they would have caught the missed Advanced Directive. Facility provided in service; random audits of residents related to Advanced Directives. Resident #368 was identified as resident with advanced directive concerns on [DATE], After surveyors' inquiry. Facilities Advanced Care Planning Code Status policy indicated in part; A physicians order must be written accordingly, documentation of the resident's choice to opt for Do Not Resuscitate shall be maintained in the medical records. A DNR physician's order will be placed in the EMR.

Based on clinical reviews, observations and review of facility documentation and interviews for 1 of 2 residents reviewed for the environment (Resident #82), the facility did not provide a homelike environment by not ensuring personal care equipment was stored appropriately and for 1 of 2 residents ( Resident # 68) ) reviewed for Environment, the facility failed to ensure residents room was free from odors in order to ensure a home like environment. The findings included: 1. Resident #82's diagnoses included pelvic fracture and dementia. A significant change MDS assessment dated [DATE] identified Resident #82 as severely cognitive impairment and dependent on staff for toileting. The MDS assessment also identified Resident #82 had a urinary catheter and noted continent of bowel. A care plan dated 3/10/2025 identified Resident #82 had a deficit in functional mobility and that the resident was non-ambulatory. Interventions On 4/23/2025 at 1:51 PM an interview with (Person ----) identified a concern about the smell in the resident's bathroom. People were told the facility had cleaned the room, including some rust in the bathroom, and had placed an air freshener under the sink. However, Person # indicated the dirty smell had not been resolved. Although a foul smell was not identified on 4/23/2025 at 1:51 PM, an observation of Resident #82's shared bathroom identified a grey bedpan wedged in between the right wall and the [NAME] next to the toilet. Two clear, graduated, triangular containers upside down on top of the toilet tank. Resident #82's denture cup, toothpaste, and toothbrush were also noted to be on a shelf over the sink. On 4/23/2025 at 2:02 PM, an interview with the nursing supervisor Registered Nurse (RN#1) indicated the graduated containers and bedpan were in their usual storage locations. RN#1 also indicated the resident's toiletries should have been stored in the resident's bedside dresser. On 4/23/2025 at 2:11 PM, an interview with the Nurse Aide (NA # 10) assigned to Resident #82 for the day identified she did not know who the grey bedpan belonged to or how long it had been there. NA #10 indicated the bedpan, and graduated containers should be stored in a bag and placed in the residents' nightstand. NA # 10 also indicated the graduated containers were used to empty the resident's urinary catheter bag. On 4/28/2025 at 8:42 AM, an interview with the Director of Nursing Services (DNS) indicated the facility had found out about the smell in the resident's bathroom last week and the facility had promptly gotten the room cleaned. Additionally, the DNS indicated the smell was related to an incident with the flowers that were brought in by the family and not related to the bedpan or graduated containers. On 4/29/2025 at 10:39 AM, an interview and facility record review with the Director of Maintenance identified due to a resident family concern about a urine smell in the bathroom, on 3/17/2025, maintenance performed some repairs, and housekeeping cleaned the room. A review of the facility records for Room of the Day identified a picture taken on 3/17/2025 at 10:51 AM (5 weeks before the surveyor's observation on 4/23/2025) that showed a grey bed pan wedged between a wall and the grab-bar to the right of the toilet. The picture also showed a clear graduated container on top of the toilet water tank. Although requested, the facility was unable to provide a policy for the storage and dating of bedpans and containers used to empty urinary catheter bags. 2. 2. Resident #68's diagnoses included hypertension, diabetes and Post Traumatic Stress Disorder (PTSD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 as moderately cognitively impaired and required moderate assistance with toileting hygiene and toilet transfers. The MDS further noted the resident is occasionally incontinent of urine. The care plan dated 3/25/25 identified resident continence of bladder status fluctuated and at times resident is incontinent of bladder and require assistance with: Bathing, Dressing, Hygiene. Interventions included: To gather, provide and assist with all materials, supplies, and equipment needed. To ensure materials and equipment are clean and function appropriately, to let residents know where the placement of items is located and to be consistent. On 4/23/25 at 10:47 AM Resident # 68 reported she/he sometimes urinates in her/his pull ups due to not having urinary device in the correct spot. Observation of the room identified a urine like odor. Observation on 4/24/25 at 11:04 AM of Resident #68's room identified a urine like odor. On 4/25/25 10:25 AM observation of the resident's room identified urine smell. Interview with NA #9 on 4/25/25 10:25 AM identified the odor as urine. NA#9 indicated she believes the odor might be from soiled sheets. She further indicated that if soiled sheets are the reason, then it is the responsibility of the assigned NA to remove the sheet informing the appropriate personnel to clean the room. Observation further identified beds in the room made without soil. Observation on 4/25/25 at 10:32 AM of NA#9 informing Licensed Practical Nurse (LPN#6) of the odor of room and LPN#6 informing Housekeeper#1. Interview with Housekeeper #1 on 4/25/25 at 10:34 AM identifies the smell was urine. He reported this may be due to urine seeping in the tiles over time. Housekeeper #1 also indicated the odor could be addressed by using air freshener. He further indicated if a room needed special attention, the nursing team would inform him. Housekeeper #1 indicated he was informed of this room's odor prior today. Interview with LPN#6 on 4/25/25 at 10:39 AM indicated she noticed the smell today and have informed housekeeping. LPN #6 indicated that the room might have the urine odor due to Resident #68 transitioning to independent toileting and having moments of missing the toilet. She also indicated once she notices the room has an ongoing odor, she would inform housekeeping and monitor daily.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #96) reviewed for abuse, the facility failed to ensure the resident was free from neglect and failed to ensure care was provided timely. The findings include: Resident #96 had a diagnosis of hemiparesis (weakness on one side) and vascular dementia. The Annual MDS dated [DATE] identified Resident #96 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required maximal assistance with Activities of Daily Living (ADLs) and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 4/3/2025 identified incontinence. Interventions directed two (2) staff members to provide care for left sided weakness and accusatory behaviors, and provide incontinent care. Facility incident report dated 4/11/2025 identified Resident #96 alleged on 4/11/2025 at approximately 2:45 PM he/she had the call light on for 45 minutes, and alleged that he/she did not receive ADL care from morning. Facility incident summary dated 4/15/2025 identified on 4/11/2025 at approximately 2:45 PM Resident #96 alleged no one touched him all day. The Nurse Aide (NA) and the RN unit manager went to the room immediately, NA #2 gave care immediately, and NA #2 was suspended pending an investigation. The summary indicated the facility investigation identified NA #2 checked on Resident #96 at the start of her shift, then gave incontinent care before lunch but did not provide any morning care/ADL care. NA #2 stated she told Resident #96 that she would provide a full bed bath (later). The summary indicated it was NA #2's first day on the assignment, was not familiar with the residents and she found the assignment heavy. The summary identified the facility did not substantiate the allegation of neglect. NA documentation review identified the last time Resident #96 received incontinent care was at 6:59 AM on 4/11/2025 (7 hours and 46 minutes before the complaint was made). Further record review failed to identify any documentation that Resident #96 received care from 7 AM to 3 PM on 4/11/2025. Interview with NA #2 on 4/22/2025 at 12:38 PM identified she worked from 7 AM to 3 PM on 4/11/2025 and she checked Resident #96 around 7:30 AM and 8:15 AM for incontinence, and he/she was not soiled/wet. NA #2 stated she did not check Resident #96 again until around 11:45 AM to 12 PM (approximately 3 ½ hours after she last provided care), and Resident #96 was incontinent at that time and she provided incontinent care. NA #2 stated she did not provide care again for Resident #96 until about 2:35 PM (approximately 2 hours and 35 minutes later). NA #2 stated Resident #96 required two (2) staff for care, but she provided the care for Resident #96 without a second staff member to assist her because she was experienced enough to do it herself and all other Nurse Aides (NAs) were busy. NA #2 stated she did not provide morning care/personal care for Resident #96 during the morning, and stated she gave morning care at 2:35 PM because she did not have time earlier. Interview with LPN #2 on 4/22/2025 at 1:16 PM identified she went into Resident #96's room at around 8 AM and again at around 10:30 AM for medication administration, but she did not check Resident #96 for incontinence or ADL/personal care. LPN #2 stated NA #2 did not ask her for assistance. Interview and record review with the Administrator, DNS, and ADNS on 4/22/2025 at 2:35 PM identified staff should check on residents every two (2) hours for incontinent care/repositioning, and provide ADL/personal care in the morning. Interview identified Resident #96 did not receive morning care until 2:35 after he/she requested the care. Further, rounds were not conducted every two (2) hours in accordance with facility policy. Resident #96 was checked for incontinence before breakfast and at 8:15 AM, and then again about noon (3 hours and 45 minutes after the last check). Further, morning care was not provided until directed by the supervisor about 2:35 PM. NA #2's employment was terminated due to not providing care in a timely manner. Review of NA #2 job description signed on 4/1/2025 identified their primary function includes making rounds on assigned residents at the beginning of each shift and every two (2) hours thereafter. Review of facility Resident Rights policy dated 2/2024 identified residents have the right to receive quality care and services with reasonable accommodation of their individual needs and preferences. Review of facility documentation identified staff education was initiated on 4/11/2025 and included directing staff that AM care must be provided in a timely manner, notify the nurse if unable to provide the care, and provide incontinent care. A QAPI meeting was held on 4/11/2025 and audits were initiated on 4/11/2025. Based on review of facility documentation, past non-compliance was identified.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #96) reviewed for abuse, the facility failed to ensure care was provided in accordance with the plan of care. The findings include: Resident #96 had a diagnosis of hemiparesis (weakness on one side) and vascular dementia. The Annual MDS dated [DATE] identified Resident #96 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required maximal assistance with Activities of Daily Living (ADLs) and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 4/3/2025 identified incontinence. Interventions directed two (2) staff members to provide care for left sided weakness and accusatory behaviors, and provide incontinent care. Facility incident report dated 4/11/2025 identified Resident #96 alleged on 4/11/2025 at approximately 2:45 PM he/she had the call light on for 45 minutes, and alleged that he/she did not receive ADL care from morning. Record review failed to identify documentation that another staff member was present when NA #2 provided care for Resident #96. Interview with LPN #2 on 4/22/2025 at 1:16 PM identified Resident #96 required two (2) staff members for care and NA #2 did not ask her to assist with any care for Resident #96 during the shift. Interview with NA #2 on 4/22/2025 at 12:38 PM identified she worked from 7 AM to 3 PM on 4/11/2025 and she checked Resident #96 around 7:30 AM and 8:15 AM for incontinence, and he/she was not soiled/wet. NA #2 stated she did not check Resident #96 again until around 11:45 AM to 12 PM (approximately 3 ½ hours after she last provided care), and Resident #96 was incontinent at that time and she provided incontinent care. NA #2 stated she did not provide care again for Resident #96 until about 2:35 PM (approximately 2 hours and 35 minutes later). NA #2 stated Resident #96 required two (2) staff for care, but she provided the care for Resident #96 without a second staff member to assist her because she was experienced enough to do it herself and all other Nurse Aides (NAs) were busy. NA #2 stated she should have had another staff member with her when she provided care for Resident #96. Interview and record review with the Administrator, DNS, and ADNS on 4/22/2025 at 2:35 PM identified Resident #96 required two (2) staff for care, in accordance with the resident plan of care. Interview identified NA #2 should have had another staff member to assist when providing care for Resident #96 on 4/11/2025. Interview failed to identify why NA did not have a second staff member with her to provide the care. Review of facility Comprehensive Person Centered Care Plan Policy dated 3/2023 directed in part, the care plan included information necessary to properly care for the resident. Review of facility documentation identified staff education was initiated on 4/11/2025 and included directing staff on the different types of abuse, to check on residents every two (2) to four (4) hours and provide care as needed, and to follow the plan of care, and if two (2) staff are required for care then two (2) staff must be in the room when care is provided. A QAPI meeting was held on 4/11/2025 and audits were initiated on 4/11/2025. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record, observation, facility policy and interviews for 1 of 5 residents reviewed for Unnecessary Medication, the facility failed to ensure medication was administered according to physician's orders. The findings include: Resident #14's diagnoses included Gastroesophageal Reflux Disease (GERD) without esophagitis, Type 2 diabetes mellitus and bipolar disorder. The care plan dated 1/14/25 identified resident is at risk for constipation. Interventions included administering medication as ordered, monitoring bowel movement. The resident care plan also identified Resident #14 utilization of psychotropic medications related to bipolar disorder. Interventions include orthostatic blood pressure as ordered. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #14 was cognitively intact and required supervision or touching assistance for eating. The assessment noted dependence on staff for toilet hygiene. Observation of 4/19/25 of the Medication Administration Record (MAR) identified missed medications of Pantoprazole Sodium Oral, Linaclotide and a blood sugar check. The nurse's notes dated 4/19/25 failed to indicated Resident # 14 refused the medications, or rational for why the MAR was not signed off/ and medication not given. A physician's order dated 4/22/25 directed for blood sugar check two times a day. The physician's orders dated 5/22/24 directed to give 1 tablet of Pantoprazole Sodium (for GERD) by mouth one time a day and to give 1 capsule of Linaclotide (constipation) by mouth one time a day. Interview with the Director of Nursing Services (DNS) on 4/30/25 at 10:15 AM identified all Medication Administration Records and Treatment Administration Record should be signed. The nursing team is responsible for ensuring medications are signed off when administered. Facilities Medication Pass Policy indicates in part it is the facility policy that medications are administered safely and timely per physician's order. Staff will notify the Medical Doctor (MD) if a resident refuses medication. Document the refusal in the Electronic Medical Record (EMR) the resident refused. Document the refusal also in the progress notes indication why resident refused.

Based on clinical record review, observation, facility documentation, facility policy and interviews for 4 residents (Resident #38) reviewed for accidents, the facility failed to ensure a safe transfer with a mechanical lift per manufacture specifications to prevent a potential accident. The findings include: Resident #38's diagnoses include morbid obesity, Intellectual Disabilities, and osteoarthritis. The Resident Care Plan with a revision date of 3/1/25 identified the resident had a deficit in functional mobility. Interventions included a mechanical lift for transfers. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #38 as cognitively intact and depended on staff with transferring, personal hygiene and bathing. An observation on 4/23/25 of the mechanical lift transfer at 11:05 AM identified the nurse aides (NA# 5 and NA# 6) did not open the base of the mechanical lift before getting Resident #38 out of bed. In an interview with NA #5 on 4/23/25 at 11:10 AM identified she did not open the base and never opens the base until the mechanical lift is positioned to lower the resident into the chair. Further when asked if she knew why it was important to open the base of the lift she stated no, she did not and she was not taught to do that. In an interview with NA#6 at 11:15 AM identified she was unaware the base of the lift needed to be open prior to engaging the mechanical lift. In an interview with the Director of Staff Development on 4/25/2025 at 12:15 PM she instructs the nurse aides to ensure the base is open on the mechanical lift as it provides stability. Additionally, the Director of Staff Development indicated all staff are in service on the use of the mechanical lift upon hire. NA #5 was oriented to use of the mechanical lift on 11/21/24 and NA #6 was oriented to use of the mechanical lift on 1/23/25. On 4/30/25 Mechanical lifts were assessed for maintenance and weight capacity. The Hoyer # 13 was serviced 1/25, weight capacity 500 pounds, Hoyer, (no number, but is on the resident's floor) was serviced 7/3/24, weight capacity 500 pounds and a spare Hoyer #10 had a weight capacity of 660 pounds and no date of service on it. Facility Policy, Mechanical lift, with a revision date of 1/2023 still in effect, directed in part, The base legs of the lift will be locked in the maximum open position. The base legs must be always locked for stability and resident safety when lifting and transferring a resident. As per DNS, the brand of lift is Lumex bariatric lift. Review of the Lumex manufacturers guidelines identify: Maximum weight capacity is 600 pounds evenly distributed. Patient lift may tip over if used incorrectly. Recommend that 2 care givers assist with the lift transfers. During lifting or lowering, whenever possible, always keep the patient lift legs in the maximum open position. When transferring to a patient, always keep the patient centered over the base. Do not lock the brakes or block the wheels when lifting. The casters must be free to roll to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object. During lifting or lowering, whenever possible, always keep the patient lift legs in the maximum open position.

Based on review of the clinical record, facility policy and staff interviews for 1 of 4 residents (Resident #75) reviewed for nutrition, the facility failed to ensure staff obtained weekly weights and a re-weight as ordered by the physician. The findings include: Resident #75's diagnosis included sepsis, chronic osteomyelitis, a stage 4 pressure ulcer and a urinary tract infection. A physician's order dated 12/9/2024 directed to obtain weight on admission then weekly x 4 weeks. The care plan dated 12/12/2024 indicated Resident #75 was at risk for malnutrition due to variable intake, grade 3 obesity, and a pressure wound. Interventions included: allowing sufficient time to eat, encouraging intake of fluids throughout the day, monitoring and evaluating weight and weight changes and obtaining weights as indicated. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 was cognitively intact, weighed 180 pounds and did not have a 5% weight loss or gain in the last 30 days or 10 % in the last 6 months. The MDS assessment further indicated Resident #75 had an unstageable pressure ulcer present on admission to the facility. A review of the facility documented weights in the Weights and Vitals Summary include 4 entries on admission date of 12/9/2025 of 179.6 pounds recorded at 12:55 PM, 1:05 PM, 1:07 PM and 2:03 PM. The next weight recorded was obtained on 1/03/2025 at 3:00PM recorded at 169.5 pounds (a 10.1 lb. weight loss). The Medication Administration Record (MAR) dated 12/9/2025 through 12/31/2025 directed to obtain an admission weight and weekly weight for four weeks every Saturday on 3-11 PM shift. Saturday 12/14/2024 and 12/21/2024 are signed off as completed but no weight recorded. On 12/28/2024 the MAR indicated Resident #75 was at the hospital. The facility documented weights in the Weights and Vitals Summary indicated Resident #75 weighed 169.7 pounds on 1/17/2025 and on 1/18/2025 weighed 167.2 pounds, a 5% weight loss compared to admission. The quarterly MDS assessment dated [DATE] indicated Resident #75 had mild cognitive impairment and no weight loss or gain of 5% in the last 30 days or 10% in the past 6 months. The care plan dated 3/20/2025 indicated Resident #75 was at risk for malnutrition due to variable oral intake, grade 3 obesity and a pressure wound. Interventions included: to monitor and document intake of food and beverages, monitor and evaluate weight and weight changes, notify the Registered Dietician, family and physician, and to provide a medical food supplement as ordered, obtain and record weights as indicated. A dietician note dated 3/27/2025 at 9:12 PM indicated the evaluation was a wound follow up as the healing process was slow. The note further indicated a slight weight loss x 3 months which was beneficial in terms of the coccyx wound healing. Given the stage 4 pressure ulcer and a BMI of 31.1 dietician recommendations indicated Juven, a protein supplement to restart, and the Ensure supplement to decrease from three times a day to once a day. A physician's order dated 3/27/2025 directed to discontinue Ensure 8 ounces 3 times daily and to encourage oral intake. In addition, the physician's orders also directed to restart Juven (one packet twice daily for a month and to provide a liquid protein supplement (LPS) twice daily. A health status note dated 4/1/2025 at 3:02 PM indicated the primary physician was in and was notified of Resident #75's 10 pound. weight loss in the last 3 months. A physician's order dated 4/01/2025 directed to provide Mirtazapine 7.5 Mg at bedtime for appetite stimulation. The facility documented weights in the Weights and Vitals Summary indicated Resident #75 weighed 168.4 pounds on 4/05/2025 and a weight on 4/11/2025 indicated Resident #75 weighed 153.2 pounds (a 10.2-pound weight loss in 6 days, no reweight was obtained to confirm the accuracy of the weight). A nursing note dated 4/11/2025 at 9:21 PM indicated Resident #75 took 30% of her/his meal. A weekly weight of 153.2 lbs. was documented as obtained on 4/19/2025 (8 days after the first noted 10.2 lb. weight loss on 4/11/2025). A nursing note dated 4/20/2025 at 7:47 AM indicated Resident # 75 had been taking Bactrim DS (an antibiotic) for urine infection since 4/17/2025 with drug sensitivity results received today indicated resistance to Bactrim DS. The APRN was notified and Macrobid was ordered. A physician's order dated 4/20/2025 directed to provide Macrobid (antibiotic) 100mg by mouth, twice daily for 7 days for positive urine test. Mulit-Resistant Drug Organism in the urine and to weight weekly for Wednesday for weight loss monitoring. A physician's progress note dated 4/21/2025 identified Resident #75 was evaluated due to low grade fever, weight loss, fatigue and not feeling well, having completed a 6-week course of intravenous antibiotics on 4/07/2025 to treat osteomyelitis of a pressure wound with bone involvement. A health status note dated 4/23/2025 at 11:21 AM indicated Resident #75 had a significant weight loss, the dietician, the physician and the family were notified. A physician's order dated 4/24/2025 at 2:00PM, (13 days after the initial weight loss on 4/11/2025), directed the 7-3 PM shift to reweigh Resident #75 by 4/25/2025. The resulting weight on 4/25/2025 was 153.4 pounds. An interview and record review on 4/29/2025 at 10:45 AM with Dietician #1 indicated no weights were found for 12/16, 12/23 or 12/30/2024 as ordered weekly x 4 and no weight was found for 1/10/2025. On 1/25/2025 Resident #75 went to the hospital and returned on 2/4/2025 with a weight of 166.3 pounds obtained on readmission. The resident was seen by the dietician after readmission further indicating weight loss could be expected after being in the hospital. An interview and record review on 4/29/2025 at 11:50 AM through 12:05 PM with RN #6 indicated the Director of Nursing Services (DNS) or her assistant the (ADNS) provided a list and indicated the nurse aides obtained the weights. RN#6 further indicated the DNS would also let the staff know if re-weights were needed. RN #6 indicated in addition to the list the charge nurses on the units would obtain a re- weight if they noticed a weight discrepancy. However, RN # 6 did not know why a re-weight was not obtained. An interview with the DNS at 12:00PM with RN #6 present identified she/he could not find any weights other than what was in the electronic medical record chart mentioning in January 2025 during the facility's own mock survey, not obtaining weekly weights and re-weights were identified and the facility has been working on the issue. On 4/29/2025 at 12:15 PM an interview with Dietician #2 indicated s/he had been requested by Dietician #3 to evaluate Resident #75 for a significant weight loss. Dietician #2 further indicated the DNS sent an email on 4/23/2025 at 7:36 AM requesting to look at Resident #75 weights. Dietician #2 indicated having reviewed Resident #75's weights and physician's orders she/he then responded to the DNS on 4/24/2025 (no time given) requesting a re-weight and to refer to the 3/27/2025 dietician note as the Ensure orders had been discontinued. Dietician #2 further indicated on 4/11/2025 it would have been up to nursing to have obtained a recheck of Resident #75's weight. An interview and record review on 4/29/2025 at 1:27 PM with Regional Nurse (RN #8) indicated the electronic orders on 3/27/2025 identified Dietician #3 wrote the order; the charge nurse took a telephone order from the physician and the physician signed the order to discontinue the Ensure supplement and a note indicated to encourage oral intake. An interview with Dietician #3 who evaluated Resident #75 on 3/27/2025 indicated s/he enters the recommendations in the electronic orders for the resident and the physician would review and sign the orders. Dietician #3 further indicated s/he may have changed her/his mind regarding the once daily ensure as weight loss would be beneficial due to the resident's slow to heal pressure ulcer and high body mass index (BMI). The weight loss would reduce the body weight being placed on the pressure ulcer. On 4/30/2025 at 10:00 AM the DNS provided the quality improvement plan regarding the issue of weekly weights and re-weights not obtained, was initiated on 1/17/2025 with estimated completion date of 5/31/2025. In-servicing of staff was completed by 2/18/2025 and audits of 3-5 resident's weekly were initiated on 2/24/2025 continuing for 8 weeks, then monthly for 3 months or until substantial compliance met. The facility policy labeled Weight Policy and Procedure indicated in part an initial weight will be obtained and recorded within 24 hours of a resident's admission then weighed weekly for the first 4 weeks, then monthly unless the physician orders indicate otherwise. The policy further indicated significant weight changes will have a weight measurement for accuracy and documentation purposes and once the significant weight loss is verified, the resident/responsible party, the physician and the dietician will be notified, the resident will be added to weekly weights for 4 weeks until the resident weight is stabilized as determined by the interdisciplinary team and the care plan updated.

Based on observations, the facility failed and staff interviews, the facility failed to discard expired medications in a timely manner and for 1 or 4 residents (Resident #7) reviewed for accidents, the facility failed to adequately secure medications. The findings included: 1. On 4/28/2025 at 11:41 AM, an observation of the Intravenous Therapy (IV) cart located in the third-floor medication room with the Infection Preventionist (RN #7) identified two bags of expired IV fluids. The fluids were 1-liter bags of 10% dextrose, both bags with an expiration date of March 2025. An interview with RN #7 indicated that the fluids were usually used for residents who were waiting for their total parental nutrition (TN) to arrive. RN#7 also indicated the night supervisor was responsible for checking the IV cart for expired medications. On 4/28/2025 at 11:53 AM, an observation with RN#7 and the nursing supervisor (RN#1) identified two expired tablets in the emergency stock box located in the third-floor medication room. The tablets were white circular penicillin (an antibiotic) tablets of 250 milligrams. The expiration date was 4/26/2025. An interview with RN#1 indicated the emergency stock box was usually reviewed for expired medications by the unit nurses or the supervisors and indicated she could not provide a record of the checks. On 4/28/2025 at 12:30 PM, an interview with the DNS indicated the facility has a process where the pharmacy consultant checks the emergency stock box and fluids for expired medications every month, However, the DNS was unable to indicate why the expired medications were not discarded. A review of the facility policy for medication storage indicated all medications expire on the date specified by the manufacturer on the product label and if the manufacturer only specified a month and year of expiration, the product expires on the last day of the calendar month indicated by the manufacturer. 2. Resident 7's diagnoses included dementia, heart failure, and Peripheral Vascular Disease (PVD). The Resident Care plan dated 1/15/25 identified the resident required had a self-care deficit. Interventions included allowing time to participate in tasks and using an unhurried approach. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 as cognitively intact and required maximum assistance with bathing, toileting and personal hygiene. A physician's order dated 4/22/25 directed to administer Guaifenesin Oral tablets 800 Milligrams (MG) by mouth for cough for 7 days. Observation on 4/23/25 at 10:30 AM identified a medication cup with 2 white pills in it. Resident #7 stated that the medication was his/her Mucinex (administered whole), and the staff usually leave it for him/her to take. He/she has taken the last 3 doses on his/her own as he/she takes a while to eat, so they leave pills for him/her. Resident # 7 also stated he/she has not taken the medication this AM as the nurse did not break them in half for him/her and he/she could not take them whole. Observation and interview on 4/23/25 with RN #4 at 10:45 AM identified she did not administer Resident #7's medication because the resident was taking too long this AM to take the medication. RN # 4 also identified she never leaves her medication for the resident to take later. In an interview on 4/23/25 with the Nursing Supervisor (RN #5) at 11:55 AM identified she was not sure why the medication was left for the resident to take independently this morning. Further indicated she was calling the nurses to see who left the medication for him/her to take and had not determined who left the medication. RN identified the process for self-administration of the medication is to assess the resident to determine if it is safe for self-administration, the facility will obtain a physician's order. On 4/24/25 the medication in the cup at the resident's bed side was compared to the resident's medication cards and it was identified as Guaifenesin. In an interview on 4/30/25 with Licensed Practical Nurse (LPN#5) at 1045 AM identified she administered medications to the resident on 4/23/25 in the morning. LPN # 5 also indicated she administered all her medications and did not leave any for the resident to take later. Although she saw the 2 pills in the cup, she was unaware how they got there. She also stated that she would never leave residents without seeing them swallow all their medications. A review of facility policy, Medication Pass dated 9/23/24 and still in effect, directed in part, to always observe residents until they have swallowed all medications that have been administered. Do not leave medication in the medication cup at the bedside or on the tableside.

Based on clinical reviews, observations, facility policy and interviews for 1 of 1 sampled resident, (Resident #61) reviewed for dental services, the facility failed to follow up on a recommendation made by a physician regarding dental. The findings include: Resident #61 was admitted to the facility on [DATE]. The resident's diagnoses included pulmonary embolism (blood clot in lungs), unspecified dementia with behavioral disturbance, schizophrenia, anxiety disorder, and depression. The physician's orders dated 11/30/22 directed for consult: dental care as needed. A review of the facility dental vendor visit dated 1/29/24 with Resident #61 identified a lump/lesion on lower right side of lip. A recommendation was made that the lesion on the lower lip be evaluated by an oral surgeon. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 was cognitively intact and required setup/clean up assistance with eating, maximal assistance (helper does more than half the effort) with personal hygiene, oral hygiene, putting on footwear, and dependent (helper does all the effort) with showering, toilet hygiene, and chair to bed transfers. Observation on 4/23/25 at 11:20 AM of Resident #61 who verbalized while sitting in his/her wheelchair by the nurses' station in hallway his/her tooth was hurting. A staff member went to communicate the resident concern to the nurse. The interview with Register Nurse (RN #1) on 4/28/25 at 12:01 PM identified he was very familiar with Resident #61, and noted no complaints of any pain. The resident was able to eat his/her breakfast with no issues. RN #1 further identified Resident # 61's last dental visit in the chart was from 2023. RN #1 also indicated she/he would provide documents for all of Resident #61's dental visits. An interview with the Director of Nursing Services (DNS) on 4/30/25 at 8:30 AM identified she and the Assistant Director of Nursing (ADNS) receive recommendations from the dentist by email and they print them out to review the recommendations with the Advanced Practice Registered Nurse (APRN) to ensure follow up. She identified that there was no consultation for Resident #61 to see an oral surgeon for his/her mouth legion, and she would have the APRN follow up . Review of the dental services policy dated September 2017 and revised June 2023 identified the facility is responsible for providing an outside resource, routine, and emergency dental services to meet the needs of each resident. After surveyor inquiry, an oral surgeon consultation dated for May 2025 was set up for Resident # 61.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #96) reviewed for abuse, the facility failed to ensure the record was complete and accurate to include incontinent care provided. The findings include: Resident #96 had a diagnosis of hemiparesis (weakness on one side) and vascular dementia. The Annual MDS dated [DATE] identified Resident #96 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required maximal assistance with Activities of Daily Living (ADLs) and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 4/3/2025 identified incontinence. Interventions directed two (2) staff members to provide care for left sided weakness and accusatory behaviors, and provide incontinent care. Facility incident report dated 4/11/2025 identified Resident #96 alleged on 4/11/2025 at approximately 2:45 PM he/she had the call light on for 45 minutes, and alleged that he/she did not receive ADL care from morning. Facility incident summary dated 4/15/2025 identified on 4/11/2025 at approximately 2:45 PM Resident #96 alleged no one touched him all day. The Nurse Aide (NA) and the RN unit manager went to the room immediately, NA #2 gave care immediately, and NA #2 was suspended pending an investigation. The summary indicated the facility investigation identified NA #2 checked on Resident #96 at the start of her shift, then gave incontinent care before lunch but did not provide any morning care/ADL care. NA #2 stated she told Resident #96 that she would provide a full bed bath (later). The summary indicated it was NA #2's first day on the assignment, was not familiar with the residents and she found the assignment heavy. The summary identified the facility did not substantiate the allegation of neglect. NA documentation review identified the last time Resident #96 received incontinent care was at 6:59 AM on 4/11/2025 (7 hours and 46 minutes before the complaint was made). Further record review failed to identify any documentation that Resident #96 received care from 7 AM to 3 PM on 4/11/2025. Interview with NA #2 on 4/22/2025 at 12:38 PM identified she worked from 7 AM to 3 PM on 4/11/2025. Although NA #2 stated she provided incontinent care at about 11:45 AM to 12 noon, she did not document the care in the clinical record. NA #2 stated she did not have time to document the care before her shift ended. Interview and record review with the Administrator, DNS, and ADNS on 4/22/2025 at 2:35 PM identified they were unable to provide documentation of the incontinent care provided for Resident #96 by NA #2. Interview identified NA #2 should have documented the care provided prior to the end of her shift (her shift ended at 3:15 PM). Record review of NA #2's punch detail form dated 4/11/2025 identified she punched in at 7:16 AM and punched out at 3:26 PM. Review of facility Charting and Documentation policy dated 1/2025 directed documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of wandering throughout the facility and self-propelled in a wheelchair, the facility failed to ensure the resident was accounted for after an alarmed door was triggered. The findings include: Resident #1's diagnoses included dementia, anxiety, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating short and long-term memory recall deficits, was dependent on staff for transfers and utilized a wheelchair for mobilization. The Resident Care Plan dated 12/10/24 identified Resident #1 was at risk for falls due to dementia, had a history of wandering throughout the unit while self-mobilizing in a wheelchair and at times attempted to open exit doors. Interventions directed assistance of one (1) with transfers, use of a wander guard, assist the resident to find his/her room when needed, and to keep the resident in common areas when up in the wheelchair. The nurse's note dated 2/10/25 at 6:00 PM identified the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, was alerted around 4:30 PM that Resident #1 was not on the unit. The note indicated during the search of the facility, Resident #1 was found on the floor of the 3-2 (third floor, hallway 2) stairwell with his/her wheelchair to the side, lying on the right side with his/her head near the bottom of the first flight of stairs. Resident #1 was awake and alert but unable to explain what happened, 911 was activated and Resident #1 was transferred to the hospital at 5:30 PM. The Facility Reported Incident form dated 2/10/25 at 4:30 PM identified Resident #1 was observed on the floor in the 3-2 stairwell at the bottom of the first landing. Resident #1 was lying on his/her right side with the adaptive wheelchair upside down next to him/her. Resident #1 complained of neck, left shoulder and left leg pain. The hospital discharge summary dated 2/14/25 identified Resident #1 had been admitted to the hospital on 2/10/25 for a mildly nondisplaced fracture of the sternal end of the left clavicle, a minimally displaced fracture of the left pubic ramus, and acute cystitis without hematuria. Resident #1 was admitted to the hospital and seen by orthopedics and started on an antibiotic. The resident was discharged back to the facility on [DATE]. Review of the facility's summary report dated 2/13/25 indicated at approximately 4:30 PM the staff were alerted by Resident #1's family member that Resident #1 was not in his/her room and a code yellow was called and during the search Resident #1 was found on the 3-2 stairwell. The facility's investigation indicated at approximately 3:30 PM a door alarm sounded, the 7AM-3PM Nursing Supervisor checked the three (3) doors, 3-1, 3-2, and 3-3 and no residents were found behind the fire doors, however the second door on the 3-2 leading to the stairwell was not checked. According to staff interviews, Resident #1 was last seen at approximately 3:15-3:30 PM in the hallway. The summary identified when the door alarmed at 3:30 PM, the third floor staff checked to ensure all residents were accounted but since there was a recreational activity on the first floor, the nurse aide thought Resident #1 was at the recreation activity. Interview with the Administrator on 2/28/25 at 12:35 PM identified on 2/10/25 at 3:30 PM while she was rounding on the second floor, she heard the 3-2 door alarm sound. The Administrator indicated she called the 7AM-3PM Nursing Supervisor, RN #2, and told him to check the 3-2 door, she proceeded to go to the third floor, and RN #2 reported to the Administrator that he did not see any resident on the other side of the 3-2 door. Interview and observations with the Director of Maintenance on 2/28/25 at 1:00 PM identified the only doors in the building that were activated by wander guards were on the first floor, the second and third floor hallway doors were alarmed and there were keypads at each door with codes to unlock the doors. The Director of Maintenance indicated the fire code dictates that an alarm would sound if the door was pressed for a continuous thirty (30) seconds, and the door would automatically open without entering a code into the keypad. The Director of Maintenance identified the alarm must be deactivated by staff. The Director of Maintenance explained the 3-1 and 3-3 hallways only have one door to exit through whereas the 3-2 hallway has a second door that leads to the stairwell down to the second floor and per the fire code the second door could not be locked or alarmed. The Director of Maintenance identified there were nine (9) stairs on the flight of stairs to the landing where Resident #1 was found. Interview with RN #2 on 2/28/25 at 1:25 PM identified on 2/10/25 he was in the nurse's office when the door alarm for 3-2 was activated and the Administrator called him to direct him to check all exits. RN #2 stated he checked the 3-2 exit first, did not see anyone beyond the first door but did not open the second door that led to the stairwell. RN #2 verified the two (2) other doors were checked as well, no residents were seen, and he directed the staff to check the location of all residents and report to him if any residents were not accounted for. RN #2 identified the staff did not report to him that residents were not accounted for. Interview with the Assistant Director of Nursing (ADON) on 2/28/25 at 1:40 PM identified on 2/10/25 at 4:30 PM a code yellow was called, and she went to the third floor to assist in looking for the resident. The ADON indicated while she was checking rooms on the 3-1 hallway, a nurse from the second floor called her to the 3-2 exit where the second floor staff had found Resident #1.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident # 2) who were reviewed for an allegation of abuse, the facility failed to ensure the resident was free from physical abuse by a staff member. The findings include: Resident #2's diagnoses included Alzheimer's dementia, anxiety, depression, chronic back pain, and adult failure to thrive. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decision regarding tasks of daily life and required substantial/maximum assistance with bathing, toileting, turning and repositioning, dressing, and eating. The nurse's note dated 10/23/24 at 12:36 PM identified at approximately 10:00 AM an alleged incident was reported by a visiting hospice nurse aide, a skin assessment was performed, and no injuries were noted. The Facility Reported Incident form dated 10/23/24 at 10:00 AM identified a hospice nurse aide was visiting Resident #2 and she alleged when she opened the door, she could see one (1) of the facility's nurse aide hit Resident #2 on the back and she heard Resident #1 tell the nurse aide not to hit him/her. The investigation identified the allegation of abuse was substantiated. The social service note dated 10/23/24 at 3:37 PM identified the social worker followed up with Resident #2 after the incident and although Resident #2 stated he/she had been hit in the back, Resident #2 was unable to provide any other details. The Advanced Practice Registered Nurse (APRN) note dated 10/24/24 identified Resident #2 was seen in a follow up visit after the allegation of abuse. The note identified Resident #2 had no recollection of the incident, had no active psychosis, and did not present as anxious or irritable. In an interview with the 7AM-3PM charge nurse, Licensed Practice Nurse (LPN) #1, on 11/6/24 at 12:00 PM identified the hospice nurse aide, Nurse Aide (NA) #3, reported she witnessed a facility's nurse aide, NA #2, hit Resident #2 on the back while providing care. LPN #1 stated NA #2 did not see NA #3 open the door to Resident #2's room as NA #2's back was to NA #3. LPN #1 identified she called the Director of Nursing who came to the unit, assessed Resident #2 and removed NA #2 from the unit. In an interview with the Hospice Case Manager, Registered Nurse (RN) #3, on 11/6/24 at 1:40 PM identified on 10/23/24 at 10:00AM a hospice nurse aide, NA #3, reported to her that NA #3 had knocked on Resident #2's door, when no one answered she opened the door, observed Resident #2 lying on his/her side, and observed NA #2 hit Resident #2 on the back. RN #3 stated NA #3 reported she heard Resident #2 yell don't hit me. RN #3 identified she directed NA #3 to report the incident to the charge nurse. Interview with the Director of Nursing (DON) on 11/6/24 at 2:04 PM identified LPN #1 reported to her that a hospice nurse aide, NA #3, stated she had observed NA #2 hit Resident #2 on the back and Resident #2 yell don't hit me. The DON stated she removed NA # from the unit, interviewed her, and sent her home pending an investigation. The DON identified the allegation of abuse was substantiated and NA #2 was terminated. In an interview with NA #3 on 11/9/24 at 1:23 PM identified on 10/23/24 at approximately 10:00 AM she knocked and opened Resident #2's door, observed NA #3, whose back was to her, hit Resident #2 on the back, and heard Resident #2 yell don't hit me. Although attempted, an interview with NA #2 was not obtained. Review of the abuse policy directed every facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation of his/her personal property.

Based on observation, clinical record reviews, facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for elopement, the facility failed to provide adequate supervision to prevent the resident from exiting through a door that was ajar during a recreation activity. Resident #1 was observed outside in the parking lot by another resident. The failures resulted in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. The Elopement Evaluation performed on 7/6/24 identified a score of three (3) indicating Resident #1 was at risk for wandering and elopement. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition and was independent with ambulation. The Resident Care Plan dated 7/31/24 identified Resident #1 was at risk to try and leave the nursing facility due to verbalized expressions of wanting to leave. Interventions included a wanderguard bracelet was applied to the left ankle, ensure placement of the wanderguard bracelet every shift and function every night, and to provide the resident's picture ID and description to the offices and staff located near exits. The Facility Reported Incident form and investigation dated 9/13/24 at 3:40 PM identified Receptionist #1 was alerted by Resident #2 that Resident #1 was walking outside the building unsupervised. Staff responded immediately and observed Resident #1 standing at the end of the facility's driveway. Resident #1 was calm and cooperative and walked back to the facility accompanied by facility staff. Resident #1 was assessed, and no injuries were noted. The facility investigation concluded that Resident #1 was in attendance during a group event, the program ended around 3:10 PM and Resident #1 was assisted back to his/her unit around 3:20 PM by recreation staff. The report identified at approximately 3:30-3:35 PM, Resident #1 got on the elevator (equipped with a wander guard alarm) with visitors and went back down to the first floor. The wander guard alarm did activate. Social Worker #1 deactivated the alarm and directed Resident #1 to the recreation room. At approximately 3:40 PM, facility staff became aware that Resident #1 was walking outside the building in the parking lot. The investigation identified the recreation door was observed ajar, family members were noted to have used the recreation door before the incident occurred, and no staff witnessed Resident #1 exiting the recreation room. Interview and tour of the facility with review of Resident #1's elopement on 10/3/24 with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) at 10:30 AM identified the recreation department had a party, Resident #1 was in attendance and after the party ended Resident #1 was escorted by the recreation staff back to his/her room located on the third floor. The DON explained Registered Nurse (RN) #1 saw Resident #1 at approximately 3:00-3:15 PM on the unit, at the change of shift, Resident #1 then managed to get on the elevators with visitors. The DON identified to utilize the elevator a code was required, and the code was given to visitors upon entrance to the facility by the receptionist. The elevator only needs the code from the third floor to go down to the main floor but does not need a code to go up from main floor. The DON identified when Resident #1 got off the elevator on the main floor, the wanderguard system was activated within the elevator area and SW #1 came out of her office, deactivated the alarm, and brought Resident #1 to the recreation area. Observations of the recreation area identified two (2) main double doors on the same side of the room, one (1) door was equipped with a wanderguard system, and the other door was only equipped with a keycode pad. The DON identified only staff members have the code for both doors. The DON indicated during the investigation, it was noted that the double door with only the keycode pad, was noted to be ajar and not fully latched, there was no alarm sounding, and it was believed Resident #1 managed to elope through this door into the parking lot, where he/she was found approximately 400-500 feet away from the building. Interview with Recreation Director (RD) #1 on 10/3/24 at 11:20 AM identified on 9/13/24, the recreation department had a party, with attendance of approximately thirty-two (32) residents, including Resident #1. RD #1 explained once the event was over, Resident #1 was escorted back to his/her room by the recreational staff. RD #1 identified she knew that Resident #1 was an elopement risk and would ensure supervision whenever Resident #1 or any other elopement risk resident was in the recreation area. RD #1 identified on 9/13/24 she was unaware that Resident #1 had returned to the recreation area and did not witness Resident #1 exiting the facility. Interview with Resident #2 on 10/3/24 at 11:50 AM identified he/she was sitting in the parking lot, as his/her friend had just left, when he/she noticed a person resembling Resident #1 in the distance within the parking lot. Resident #2 indicated he/she was unsure it was Resident #1, due to him/her wearing a facemask and hat and as Resident #1 got closer, Resident #2 was able to identify Resident #1. Resident #2 identified he/she asked Resident #1 what he/she was doing, and Resident #1 responded just walking, as Resident #1 continued to check car doors. Resident #2 indicated he/she ran to the front desk and reported the occurrence. Interview with SW #1 on 10/3/24 at 12:15 PM identified on 9/13/24, she was in her office, located directly across from the elevators, when she heard the wanderguard alarm sounding. SW #1 indicated Resident #1 was in the elevator area and had activated the alarm. SW #1 identified she deactivated the alarm and brought Resident #1 into the recreation area. SW #1 indicated although there were staff members in the recreation area, she did not let the staff members know she brought Resident #1 into the recreation area. Review of the Elopement Policy dated 07/2015 identified the facility strives to promote resident safety by maintaining a process to screen all residents for risk of elopement, implement preventative strategies for those identified at risk, institute measures for resident identification at the time of admission, and conduct missing resident procedures, as warranted. Elopement is defined as the ability of a resident who is not capable of protecting themselves from harm to successfully leave the facility unsupervised and unnoticed and who may enter harm's way.

Based on clinical record reviews, facility policies and interview for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to ensure two (2) staff members were present in the room as outlined in the care plan. The findings include: Resident #1's diagnoses included bipolar, dementia, anxiety, and legal blindness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was able to make decisions regarding tasks of daily life, and required substantial/ maximal assistance with toileting, personal hygiene, showering, and transfers. The resident care plan dated 7/18/24 identified Resident #1 required assistance with bathing, dressing, grooming, and hygiene and had a potential for being verbally aggressive towards staff. Interventions always directed one (1) person assistance of with activities of daily living and two (2) staff for care to ensure the resident's needs are being met. The nurse's note dated 7/21/24 at 9:00 PM identified Resident #1's family member informed the 3-11PM Nursing Supervisor of an allegation of abuse. Resident #1 reported to the family member that he/she was forced into the wheelchair in the early afternoon and forcefully given care. The note indicated Resident #1 had no complaints of pain and there were no skin impairments, and all parties were notified. The Facility Reported Incident form dated 7/21/24 identified a nurse aide assisted Resident #1 with care the morning of 7/21/24. The report indicated there were no witnesses to the incident. Interview with the nurse aide, Nurse Aide (NA) #1, on 8/15/24 at 10:18 AM identified there were no other staff member in the room when care was being given and she did not know another staff member was supposed to be present when giving care to Resident #1. Interview with Housekeeper #1 on 8/15/24 at 10:34 AM identified she went into Resident #1's room to help translate Resident #1's needs for NA #1 and then walked out of the room and she did not see care being given to Resident #1. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/15/24 at 10:57 AM identified two (2) staff members were to be present when care was being provided to Resident #1. Review of facility policy for Comprehensive Care Plans dated 11/2017 identified the care plan for each resident is to accommodate preferences, special medical, nursing and psychosocial needs.

Based on review of the clinical record and interviews for 1 of 5 sampled residents (Resident #9) reviewed for unnecessary medications, and 1 sampled resident (Resident #220) reviewed for podiatry services, the facility failed to obtain laboratory results in a timely manner and failed to ensure the resident was seen and provided necessary podiatry care in a timely manner. The findings include: 1. Resident #9 diagnoses included schizoaffective disorder, anxiety, and fracture of the right femur. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 was severely cognitively impaired, and required extensive assist for bed mobility, dressing, toileting, personal hygiene. The Resident Care Plan dated 6/14/2023 identified Resident #9 had a psychiatric disorder. Interventions directed to administer medications as ordered by the MD/APRN and to monitor for side effects/effectiveness. A physician's order dated 7/20/23 directed to administer Clozaril (an antipsychotic medication) 50 milligrams (mg) once daily. A physician's order dated 7/20/23 directed to obtain a laboratory value for a Clozaril level. Review of the clinical record failed to indicate laboratory results from 7/20/23 were available. Interview and review of Resident #9's clinical record with RN #3 on 07/26/23 at 11:34 AM failed to identify that the laboratory results, ordered by the MD on 7/20/23, were available. Subsequent to survey inquiry, RN #3 electronically obtained the Clozaril level results from the laboratory vendor. The laboratory results identified laboratory work had been drawn on 7/20/23 for Resident #9 and that the Clozaril level was noted to be high (out of range) at 874 nanograms/milliliter (ng/ml) (normal range 350-600). RN #3 indicated that the facility protocol was to follow up on pending laboratory results when results had not been received timely and report the results immediately to the MD/APRN. RN #3 identified that she would notify the provider of the results. Re-interview and review of the nurses note with RN #3, on 7/26/23 at 1:54 PM identified that she had notified the APRN of the high Clozaril level, and that the APRN directed her to hold the administration of the Clozaril due to the increased blood level of the medication. Although the facility had a Diagnostic Services policy, the policy failed to include ensuring that lab work was obtained by the facility in a timely manner. 2. Resident #220's diagnoses included dementia, type 2 diabetes, vitamin D deficiency, legally blind, cancer of the kidney and prostate, seizure disorder and hypertension. A review of Resident #220's admission documentation identified a signed consent for health drive services indicating consent for podiatry services dated 12/31/2019. The care plan dated 10/12/21 identified Resident #220 had diabetes with interventions that included podiatry consults per physician's order, and skin audits per facility's protocol. The annual MDS assessment dated [DATE] identified Resident #145 had severe cognitive impairment with no behavioral issues and required extensive assistance or was totally dependent on the assistance of others to complete activities of daily life (ADL). Monthly physician's orders effective for June/2021 directed for Resident to have diabetic foot checks at hour of sleep every evening shift, weekly body audit (skin check) on shower day every Friday on the day shift. A review of the weekly skin audits from January/2021 to August/2021 identified no new skin impairments. The audit form notes the areas of concern as skin injuries/ulcers such as bruises, abrasions, lacerations, diabetic neuropathic ulcers, pressure ulcers and abnormal skin color, moisture, temperature, integrity, and turgor as appropriate. A review of the nurse's aide (NA) flowsheets from January/2021 to August/2021 identified documentation that noted the nurse aides were putting on and taking off Resident #220's footwear each shift. Review of documentation submitted to the state survey agency identified that on 8/6/21 Resident #220 had toenails that extended four inches past the tip of the resident's toes and noted the resident's toenail was caught in the sheet and pulled off of the 4th toe on the right foot. The pictures submitted identified the resident's feet were very dry and scaly in appearance and the remaining nails appeared to be quite long and thick in appearance. Interview with the podiatry service provider on 7/27/2023 at 1:30 PM identified that the podiatrist conducted routine visits to the facility on 1/4/21, 3/8/21, 5/9/21 and 7/9/21 but Resident #220 was not seen by the podiatrist on any of the visits. Interview and record review with Social Worker #1 on 7/27/2023 at 2:00 PM identified that all residents diagnosed with diabetes mellitus were expected to be added to a list the facility created for those residents to be seen by podiatry for footcare. She further identified that Resident #220 was not listed on the podiatry list for the period of January to July of 2021. In addition, she identified that Resident #220 was not included on the list due to an oversight on the part of the nursing staff who were responsible for ensuring residents that required to be seen by the podiatrist were included on the list. Additionally, SW #1 identified that Resident #220 was seen by the podiatrist on 9/19/2021 after the resident's family complained about the state of Resident #220's feet and nails on 8/06/2021. Interview with the DNS and Administrator on 7/27/2023 at 3:30 PM identified that Resident #220's clinical record failed to reflect that the nurses were documenting on diabetic foot checks as per physician's order. The DNS further identified that the nurses are responsible for completing the weekly skin checks including the condition of the nails and for making references to podiatry services if the resident has a diagnosis of diabetes. She also identified that Resident #220 should have been seen by podiatry because of his/her diabetes diagnosis because all residents with diabetes are supposed to be seen by podiatry for management of nail and foot care. The DNS noted that when Resident #220's family complained, the resident was added to the podiatry list and seen by the podiatrist. She also identified that the facility would be revising their skin check assessment protocol and an educational in-service for all nursing staff would be conducted to prevent future occurrence. A review of the facility's ADL policy identified that ADL care is provided to maintain and restore maximum functional independence. The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or other members of the interdisciplinary team. A program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning. This process is usually reviewed at least quarterly. A podiatry policy was requested but was not provided by the facility.

Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents observed during medication administration, (Resident #30) the facility failed to notify the physician or APRN when the resident's medication was not administered as directed by the physician. The findings include: Resident #30 was admitted to the facility with a diagnosis of essential hypertension, presence of automatic (implantable) cardiac defibrillator, and congestive heart failure. The quarterly MDS assessment dated [DATE] identified Resident #30 was cognitively intact, required setup with eating, and required extensive assistance with personal hygiene. The Resident Care Plan dated 6/22/23 identified that Resident #30 had congestive heart failure and high blood pressure. Interventions directed to administer medications per physician's order. Observation of medication administration for Resident #30 on 7/25/23 at 11:21 AM with LPN #3 identified the administration of Carvedilol 6.25 milligrams and Sacubitril-Valsartan 50 milligrams. A physician's order dated 6/24/23 directed to give Carvedilol 6.25 milligrams (to treat high blood pressure), by mouth, two times daily and Sacubitril-Valsartan 50 milligrams (to treat high blood pressure), by mouth, every 12 hours. A review of the Medication Administration Record (MAR) on 7/25/23 at 11:21 AM identified that both the Carvedilol 6.25 milligrams and Sacubitril-Valsartan 50 milligrams were due at 9:00 AM. Interview with LPN #3 on 7/25/23 at 12:25 PM, identified that she was late starting medication administration on 7/25/23 due to multiple residents requiring assistance but that the facility was not short staffed. A second interview with LPN #3 on 7/27/23 at 12:12 PM identified that the nursing supervisor should be notified when a medication is administered late but that she had directly notified APRN #1 that the Carvedilol and Sacubitril-Valsartan for Resident #30 had been given beyond the physician prescribed time of administration. A subsequent review of the MAR for the administration of Carvedilol and Sacubitril-Valsartan documented that the physician ordered time of administration was 9:00 AM for both medications. On 7/25/23 the time of administration was at 11:16 AM, 1 hour and 16 minutes after the allowable administration time of 10:00 AM. A review of Resident #30's clinical record, nursing, and physician progress notes, dated 7/25/23, failed to identify that LPN #3 had notified the physician, APRN, or Nursing Supervisor of the late administration of Carvedilol and Sacubitril-Valsartan. Interview with APRN #2 on 7/27/23 at 12:28 PM identified that she denied being notified of the late administration of Carvedilol and Sacubitril-Valsartan on 7/25/23. Interview on 7/27/23 at 1:16 PM with the DNS identified that the expectation is that any medication administered beyond the allowable medication administration parameters, the APRN should be notified. Review of the facility Medication oral administration policy identified that medication would be administered at the proper time. The facility failed to notify the prescriber that the Carvedilol and Sacubitril-Valsartan failed to be administered at the right time.

Based on clinical record review, observation, facility policy review, and interviews for 1 of 3 sampled residents (Resident #113) reviewed for pressure injuries, the facility failed to ensure that the wound was initially assessed and assessed on a weekly basis by a registered nurse, failed to ensure that the wound specialist's treatment recommendation was implemented, and failed to ensure that a worsening wound was evaluated by the facility's wound specialist. The findings include. Resident #113's diagnoses included multiple fractures of ribs, cognitive communication deficit, depression, and anxiety. The Norton_Scale (used to predict risk for pressure ulcer development) dated 4/28/23 identified Resident #113 was at moderate risk for skin breakdown. A physician's order dated 4/28/23 directed to do weekly skin checks on shower day every Wednesday 7-3 shift, offload heels as tolerated every shift for skin integrity and skin prep to heels twice a day for 14 days. The skin audit assessment dated [DATE] identified Resident #113 had no suspected pressure ulcers and/or bruises. The admission MDS assessment dated [DATE] identified Resident #113 had severe cognitive impairment, required extensive assist for bed mobility, transfers, toileting and hygiene, was non-ambulatory, and was at risk for the development of pressure ulcers but did not have a pressure ulcer. The resident care plan (RCP) dated 5/9/23 identified Resident #113 had impaired circulation related to elevated cholesterol, with interventions that included: elevate legs when resting, inspect foot/ankle/calf for changes like maceration, redness, purple tinged, weeping, edema, and areas with no sensation. The revised RCP dated 5/22/23 identified Resident #113 was at risk for skin breakdown related to bowel incontinence, friction, mobility, and moisture. Care plan interventions included: inspect skin for redness, irritation or breakdown, offload heels, offer turning and positioning approximately every 2 hours and as needed, toileting/incontinent care as needed and conduct weekly skin inspections. The nurse's note dated 5/22/23 at 11:11 PM identified Resident #113 had an abrasion to the coccyx that measured 1.0 centimeter (cm) in length by 0.5 centimeter (cm) in width and 0.1 centimeter (cm) in depth. The note further identified there was superficial skin loss without bleeding and an order was obtained from the on-call APRN for Hydrogel and Optifoam dressing. A physician's order dated 5/22/23 directed to administered hydrogel to coccyx abrasion followed by Optifoam dressing every day and evening shift. The weekly non-pressure wound evaluation dated 5/22/23 identified an abrasion wound to the coccyx that measured 1.0 cm by 0.5 cm by 0.2 cm with no slough/eschar present. The nurse's note dated 5/24/23 at 10:59 AM identified Resident #113 was seen for excoriation to buttocks that measured 0.2 cm by 0.2 cm by 0 cm with small amount of redness noted. The note further identified that the skin surrounding the area was dry and intact. APRN # 1 was updated and ordered Z-guard paste with toileting and incontinent care. The weekly non-pressure wound evaluation dated 5/29/23 identified abrasion coccyx wound measure 1cm x 0.5 cm x 0.2 cm with no slough/eschar present. The weekly non-pressure wound evaluation dated 6/5/23 identified the coccyx wound measured 0.5 cm x 0.5 cm x 0.2 cm with no slough/eschar present. The weekly non-pressure wound evaluation dated 6/12/23 identified the coccyx wound was healed with skin intact and some redness. Review of the weekly non-pressure wound evaluations dated 5/22, 5/29, 6/5 and 6/12/23 identified that the assessments were completed by LPN #2 and there was no other documentation that the assessments were endorsed by a registered nurse. The wound specialist's progress note dated 6/15/23 identified Resident #113 had an unhealed unstageable wound to the coccyx (categorized as a pressure injury). The coccyx wound measurement was 1.5 cm by 1.5 cm by 0 cm. The coccyx wound bed had 76% to 100% slough. The wound specialist recommended to apply Santyl ointment then cover the coccyx wound with a bordered foam dressing and change daily. The wound specialist's progress note dated 6/22/23 identified Resident #113 had an unhealed unstageable wound to the coccyx. The coccyx wound measurement was 1.0 cm by 1.0 cm by 0.1 cm. The coccyx wound bed had 51% to 75% slough. The wound specialist recommended to apply collagen then cover the coccyx wound with a bordered foam dressing and change daily. A physician's order dated 6/23/23 directed to administered collagen followed by foam dressing on day shift every day. Review of the TAR from June 15, 2023, to June 23, 2023, failed to identify that the recommendation for Santyl was implemented. Interview and clinical record review with LPN #2 on 7/26/23 at 11:50 AM identified that she is responsible for weekly wound monitoring and rounding with the wound specialist (MD #1) every Thursday. She further identified that if the wound specialist is not available, she would ask the nursing supervisor or the DNS to assess the wound. A nurse's note dated 5/24/23 at 10:59 AM identified Resident #113's coccyx wound was evaluated by APRN #1 who determined the coccyx wound was excoriation. LPN #2 further noted that she could not identify or provide documentation to support that an RN had assessed the resident's coccyx wound on a weekly basis. LPN #2 also identified that she had not included Resident #113 on the weekly wound list to be seen by the wound specialist because the wound specialist does not follow and evaluate all residents with excoriation, and she noted that she was unaware of who placed the resident on the weekly wound list of residents for the wound specialist to assess. Interview with the DNS on 7/27/23 at 10:00 AM identified that LPN #2 was responsible for weekly wound monitoring and rounding with the wound specialist every Thursday. LPN #2 was also responsible for ensuring the updating of the wound list given to the wound specialist. She further identified that LPN #2 should have included Resident #113 on the weekly wound list for the wound specialist when Resident #113 developed a wound to the coccyx on 5/22/23. Further, the DNS could not identify that the coccyx wound had been assessed by an RN prior to 6/15/23. She also indicated that recommendations from the wound specialist should be in the physician's order and documented on the TAR. Observation of wound treatment with MD #1 and LPN #2 on 7/27/23 at 11:15 AM identified Resident #113 had an unstageable wound to the coccyx. The wound bed of the coccyx wound had 100% slough with minimal redness to the surrounding area. Interview with MD #1 on 7/27/23 at 1:20 PM identified LPN #2 was responsible for updating and maintaining the weekly list of residents for wound rounds. He identified that if the resident was not included in the wound list, he would not know that the resident had a wound. He further identified that his initial wound consult with Resident #113 was on 6/15/23 and the coccyx wound was unstageable and has remained an unstageable wound. Review of facility's Prevention and Management of Pressure Injuries policy identified that resident with pressure injuries and those at risk for skin breakdown would be identified, assessed, and provided an appropriate treatment to encourage healing and/or maintenance of skin integrity. Care plan would be developed based on resident goals and decision of treatment. The ongoing monitoring and evaluation would be provided to ensure optimal resident outcomes. The facility followed the National Pressure Ulcer Advisory Panel (NPUAP) guidelines when staging wounds. The facility failed to ensure that Resident #113's wound was initially assessed and assessed on a weekly basis by a registered nurse. The facility also failed to ensure that a recommended wound treatment was initiated with a worsening unstageable wound.

Based on clinical record review, observation, facility policy review, and interviews for 1 of 3 sampled residents (Resident #113) reviewed for pressure ulcers, the facility failed to ensure that the wound was appropriately assessed, failed to ensure that the initial treatment to the wound was appropriate, failed to ensure that appropriate ongoing assessments of the wound was provided prior to the wound worsening to the category of unstageable. The findings include: Resident #113's diagnoses included multiple fractures of ribs, cognitive communication deficit, depression, and anxiety. The Norton_Scale (used to predict risk for pressure ulcer development) dated 4/28/23 identified Resident #113 was at moderate risk for skin breakdown. A physician's order dated 4/28/23 directed to do weekly skin checks on shower day every Wednesday 7-3 shift, offload heels as tolerated every shift for skin integrity and skin prep to heels twice a day for 14 days. The skin audit assessment dated [DATE] identified Resident #113 had no suspected pressure ulcers and/or bruises. The admission MDS assessment dated [DATE] identified Resident #113 had severe cognitive impairment, required extensive assist for bed mobility, transfers, toileting and hygiene, was non-ambulatory, and was at risk for the development of pressure ulcers but did not have a pressure ulcer. The resident care plan (RCP) dated 5/9/23 identified Resident #113 had impaired circulation related to elevated cholesterol, with interventions that included: elevate legs when resting, inspect foot/ankle/calf for changes like maceration, redness, purple tinged, weeping, edema, and areas with no sensation. The revised RCP dated 5/22/23 identified Resident #113 was at risk for skin breakdown related to bowel incontinence, friction, mobility, and moisture. Care plan interventions included: inspect skin for redness, irritation or breakdown, offload heels, offer turning and positioning approximately every 2 hours and as needed, toileting/incontinent care as needed and conduct weekly skin inspections. The nurse's (RN #2) note dated 5/22/23 at 11:11 PM identified Resident #113 had an abrasion to the coccyx that measured 1.0 centimeter (cm) in length by 0.5 centimeter (cm) in width and 0.1 centimeter (cm) in depth. The note further identified there was superficial skin loss without bleeding and an order was obtained from the on-call APRN for Hydrogel and Optifoam dressing. A physician's order dated 5/22/23 directed to administered hydrogel to coccyx abrasion followed by Optifoam dressing every day and evening shift. The weekly non-pressure wound evaluation dated 5/22/23 identified an abrasion wound to the coccyx that measured 1.0 cm by 0.5 cm by 0.2 cm with no slough/eschar present. The nurse's note dated 5/24/23 at 10:59 AM identified Resident #113 was seen for excoriation to buttocks that measured 0.2 cm by 0.2 cm by 0 cm with small amount of redness noted. The note further identified that the skin surrounding the area was dry and intact. APRN # 1 was updated and ordered Z-guard paste with toileting and incontinent care. The weekly non-pressure wound evaluation dated 5/29/23 identified abrasion coccyx wound measure 1cm x 0.5 cm x 0.2 cm with no slough/eschar present. The weekly non-pressure wound evaluation dated 6/5/23 identified the coccyx wound measured 0.5 cm x 0.5 cm x 0.2 cm with no slough/eschar present. The weekly non-pressure wound evaluation dated 6/12/23 identified the coccyx wound was healed with skin intact and some redness. Review of the weekly non-pressure wound evaluations dated 5/22, 5/29, 6/5 and 6/12/23 identified that the assessments were completed by LPN #2 and there was no other documentation that the assessments were endorsed by a registered nurse. The wound specialist's progress note dated 6/15/23 identified Resident #113 had an unhealed unstageable wound to the coccyx (categorized as a pressure injury). The coccyx wound measurement was 1.5 cm by 1.5 cm by 0 cm. The coccyx wound bed had 76% to 100% slough. The wound specialist recommended to apply Santyl ointment then cover the coccyx wound with a bordered foam dressing and change daily. The wound specialist's progress note dated 6/22/23 identified Resident #113 had an unhealed unstageable wound to the coccyx. The coccyx wound measurement was 1.0 cm by 1.0 cm by 0.1 cm. The coccyx wound bed had 51% to 75% slough. The wound specialist recommended to apply collagen then cover the coccyx wound with a bordered foam dressing and change daily. A physician's order dated 6/23/23 directed to administered collagen followed by foam dressing on day shift every day. Review of the TAR from June 15, 2023, to June 23, 2023, failed to identify that the recommendation for Santyl was implemented. The wound specialist progress note dated 7/6/23 identified Resident #113's unstageable wound to the coccyx measured 1.0 cm by 0.5 cm by 0.1 cm. The coccyx wound bed had 51% to 75% epithelialization. The wound consult recommended to apply Silver Alginate then cover the coccyx wound with a bordered foam dressing to be changed daily. A physician's order dated 7/6/23 directed to administer Silver Alginate followed by foam dressing to the coccyx on the day shift. The wound specialist progress note dated 7/13/23 identified Resident #113's wound measured 2.0 cm by 2.0 cm by 0 cm. The coccyx wound had 76% to 100% slough. The wound specialist recommended that Santyl ointment be applied to the wound and covered with a bordered foam dressing, to be changed on a daily basis. A physician's order dated 7/13/23 directed to administered Santyl ointment followed by foam dressing to coccyx wound every day and change as needed if soiled and dislodged. A physician's order dated 7/17/23 directed to place a specialty air mattress and check setting and function every shift and ROHO cushion to wheelchair when in use and check for placement and inflation every day and evening shift. The wound specialist progress note dated 7/20/23 identified Resident #113's wound measured 1.0 cm by 1.0 cm by 0 cm. The coccyx wound had 76% to 100% epithelialization. Observation of wound treatment with MD #1 and LPN #2 on 7/27/23 at 11:15 AM identified that Resident #113 had an unstageable wound to the coccyx. The wound bed of the coccyx wound had 100% slough with minimal redness to the surrounding area. Interview with RN #2 on 7/25/23 at 12:10 PM identified Resident #113 had redness and an opened wound to the coccyx when he initially assessed the resident's coccyx on 5/22/23. He noted that he called the on-call APRN who ordered the treatment of Hydrogel with an Optifoam dressing. He further identified that he documented abrasion wound to the coccyx but could not identify what may have caused the abrasion. He further identified that he should have documented that the wound was a pressure ulcer because the coccyx was reddened and open. Interview with RN #1 (nursing supervisor) on 7/26/23 at 11:20 AM identified LPN #2 was responsible for weekly monitoring of the wounds and the weekly wound rounds with the wound specialist. She further identified that she had not assessed Resident #113's coccyx because LPN #2 had not asked her to assess the coccyx wound. RN #1 identified that soreness, redness, and an open wound to the coccyx would indicate a pressure ulcer wound because of its bony prominence. She further identified that Z-guard paste was used for barrier cream to protect skin from incontinence and not a treatment for a pressure ulcer wound. Interview and clinical record review with LPN #2 on 7/26/23 at 11:50 AM identified that she is responsible for weekly wound monitoring and rounding with the wound specialist (MD #1) every Thursday. She further identified that if the wound specialist is not available, she would ask the nursing supervisor or the DNS to assess the wound. A nurse's note dated 5/24/23 at 10:59 AM identified Resident #113's coccyx wound was evaluated by APRN #1 who determined the coccyx wound was excoriation. LPN #2 further noted that she could not identify or provide documentation to support that an RN had assessed the resident's coccyx wound on a weekly basis. LPN #2 also identified that she had not included Resident #113 on the weekly wound list to be seen by the wound specialist because the wound specialist does not follow and evaluate all residents with excoriation, and she noted that she was unaware of who placed the resident on the weekly wound list of residents for the wound specialist to assess. Interview with APRN #1 on 7/26/23 at 12:35 PM identified that she did not assess Resident #113's coccyx. She noted that LPN #2 verbally reported that Resident #113 had an excoriation to the buttock, and she verbally gave an order to administer Z-guard. She further identified that she comes to facility once a week and has seen Resident #113 for other medical conditions. APRN #1 identified that a reddened and open wound to the coccyx would indicate a pressure ulcer wound until otherwise evaluated by the wound specialist. Interview with DNS on 7/27/23 at 10:00 AM identified that LPN #2 was responsible for weekly wound monitoring and rounding with the wound specialist every Thursday. LPN #2 is also responsible for updating the resident wound list given to the wound specialist. The DNS further identified that RN #2 assessed Resident #113's coccyx wound but the DNS could not identify what could have caused an abrasion to the coccyx. The DNS further identified that the wound may have developed due to excoriation. She also noted that Resident #113 was being followed by the wound specialist, but she could not provide the clinical progress note that would identify that Resident #113's coccyx wound was being assessed by the wound specialist prior to 6/15/23 when the wound specialist noted that the wound was unstageable. The DNS further noted that LPN #2 should have included Resident #113 on the weekly wound rounds with the wound specialist when he/she develop an open wound to the coccyx on 5/22/23. Interview with MD #2 on 7/27/23 at 12:00PM identified that the facility utilized a wound specialist physician to monitor and evaluate resident wounds. MD #2 further noted that he would expect any newly developed wounds to be placed on the wound round list and for the wound specialist to evaluate on the next scheduled visit to the facility. In addition, he noted that a reddened and open wound to the coccyx would be classified as a pressure ulcer wound until evaluated by the wound specialist. He further noted that Z-guard paste was not typically used for a treatment of a pressure ulcer wound. Interview with MD #1 on 7/27/23 at 1:20 PM identified that Resident #113 required assistance with bed mobility, was non-ambulatory and incontinent of bowel/bladder, and an open wound to the coccyx would be a pressure ulcer wound. He further identified that his initial wound consult with Resident #113 was on 6/15/23 and the coccyx wound was unstageable and remains an unstageable wound. He also identified that the coccyx wound was caused by pressure. Review of the Prevention and Management of Pressure Injuries policy identified that residents with pressure injuries and those at risk for skin breakdown would be identified, assessed, 0and provided an appropriate treatment to encourage healing and/or maintenance of skin integrity, a care plan would be developed based on resident goals and decision of treatment.

Based on clinical record review, review of facility's documentation and interviews for 2 of 3 sampled resident (Resident #35 & #89) reviewed for accidents and who required the assistance of two staff members for bed mobility, and the facility failed to ensure that the resident received the necessary assistance resulting in a fall from the bed. The findings include: Resident #35's diagnoses included type 2 diabetes, anemia, abnormal posture, cerebral infarction due to embolism of right cerebellar artery and acquired lower extremity paralysis. The acute care hospital discharge summary dated 5/11/23 identified Resident #35 had an epidural hemorrhage which resulted in bilateral lower extremity paralysis due to cord compression. The summary further identified that Resident #35 was unable to move the lower body, was completely dependent and would require meticulous care upon discharge, such as turning every two hours, meticulous perineal care, and monitoring of nutritional status. The fall risk assessment dated [DATE] identified Resident #35 was at risk for falls. A review of the Resident #35's care card (directs the plan of care for the NA) dated 5/11/23 identified Resident #35 was alert oriented, forgetful, cooperative, and required an assistance of two persons for transfers, turning, and repositioning. The care card further identified Resident #35 required the assistance of one person for personal hygiene, bathing, and toileting. The side rail evaluation dated 5/11/23 identified Resident #35 had quarter side rails on both sides of bed located at the top of the bed. Resident #35's care plan dated 5/12/23 identified Resident #35 was a fall risk and required assistance with bathing, dressing, grooming, hygiene, and transfers. Interventions included: remind resident to call for assistance prior to transfers, place call light within reach, Hoyer lift (mechanical lift) resident using an assist of two persons and physical or occupational therapy as ordered. The admission MDS assessment dated [DATE] identified Resident #35 had moderate cognitive impairment, required supervision for eating, extensive assistance with bed mobility (2 or more persons), dressing, personal hygiene and toilet use and was totally dependent for transfers and locomotion (how Resident moves between locations in room/unit). The MDS further identified Resident #35 was totally dependent on the assistance of two or more persons for bathing and required substantial or maximal assistance to roll left and right (that is ability to roll from lying on back to left and right side and return to lying on back on the bed). A physical therapy assessment dated [DATE] identified Resident #35 was trained to perform rolling left to right or vice versa to increase level of independence. The note identified that Resident #35 performed the activity with moderate to maximum assistance. An occupational therapy assessment dated [DATE] identified Resident #35 was a fall risk and required maximum assistance with activities of daily living (ADLs). The assessment further identified Resident #35's level of assistance varied and was impacted by factors that included the resident's level of fatigue. A nurse's note dated 6/10/23 at 5:38 PM identified NA #9 reported that while providing care she asked Resident #35 to turn to his/her side and hold on to the side rail. NA #9 further identified that Resident #35 missed holding on and slipped from the bed. The note further indicated that Resident #35 was alert and oriented, denied hitting his/her head, had positive range of motion of all extremities (was able to move both hand and feet of Resident without complaints of pain or signs of discomfort) and had no visible injuries. The reportable event report dated 6/10/23 identified NA #9's statement concerning Resident #35's fall, NA #9 identified that she was providing care along with a linen change. NA #9 identified that she told Resident #35 to hold the bedrail and turn so that she could tuck the sheets under. The statement noted that she asked the resident to wait a second so she could get to the other side of the bed. NA #9's statement further identified that the resident did not wait and missed the side rail and slid out of bed. Interview with Resident #35 on 7/25/23 at 1:38 PM identified NA #9 rolled him/her over when he/she was already at the edge of the bed causing him/her to slip off the bed even while holding the side rail. Resident #35 further noted that it was not intentional it happened because NA #9 was rushing to finish and should have had someone else to help. He/she further identified that since the incident there are now two people helping and noted that most of the time the aids rush. Interview with the DNS on 7/27/23 at 3:00 PM, identified before initiating the roll of the resident, NA #9 should have checked to make sure it was safe to roll the resident. She further noted that since the incident she provided Resident #35 with a larger bed. Interview with NA #9 on 7/27/23 at 3:15 PM identified that she always provided care to Resident #35 by herself, and Resident #35 would help along the way. She further identified that she did not check to ensure it was safe for Resident to roll (not at the edge of the bed) and there were not always enough people available to ask for help even if there was a need. A review of the facility's fall policy directed that the interdisciplinary team would develop, initiate, and implement an appropriate individualized care plan based on the fall risk score.

Based on observation, review of the clinical record, review of facility policy, and interviews for 1 sampled resident, (Resident #59) reviewed for respiratory care, the facility failed to follow the physician's order for the correct oxygen flow rate. The findings include: Resident #59's diagnoses included chronic obstructive pulmonary disease (COPD), asthma, and morbid (severe) obesity. The significant change MDS assessment dated [DATE] identified Resident #59 was cognitively intact and required extensive assist of two people for bed mobility, transfers, and toileting. The care plan dated 6/27/23 identified Resident #59 had oxygen therapy with interventions that included oxygen via nasal canula at 2 liters per minute (LPM). The monthly physician's orders for July/2023 with an origination date of 6/9/2023 directed oxygen via nasal cannula at 2 LPM, and check pulse oxygen every shift. Observation on 7/20/23 at 11:46 AM identified Resident #59 had oxygen in place via nasal canula with the oxygen concentrator set to 3 LPM. Observation on 7/20/23 at 3:02 PM identified Resident #59 had oxygen in place via nasal canula with the oxygen concentrator set to 3 LPM. Interview and observation with the charge nurse (LPN #5) on 7/20/23 at 3:09 PM identified Resident #59's oxygen was set at 3 LPM when Resident #59's physician's order directed oxygen to be set at 2 LPM. LPN #5 indicated that she was told Resident #59 was on oxygen at 2 LPM and had not checked oxygen flow setting at that point. LPN #5 indicated she administered medications and treatments to Resident #59, and her shift started at 7:00 AM and she was currently still working. After surveyor's inquiry, LPN #5 adjusted Resident #59 oxygen flow rate to 2 LPM. In addition, the previous oxygen order dated 6/9/23 was discontinued, and a new physician's order dated 7/21/23 that directed oxygen via nasal cannula at 2 LPM, check pulse oxygen every shift, and may titrate oxygen to maintain oxygen saturation level of greater than 90%. Interview with the Resident #59 on 7/26/23 at 10:45 AM identified that he nurses set his/her oxygen level. The resident further noted that the nurse aids do not adjust or set the oxygen level. The resident could not identify how the oxygen level was raised to 3 LPM. Interview with NA #7 on 7/26/23 at 10:56 AM identified that Resident #59's oxygen flow rate is set at 2 LPM and the nurses are the ones who change or adjust resident's oxygen flow rate. The Oxygen Administration-Ventilation or Adjustable Concentration Mask policy/ procedure identified that oxygen tubing is connected to the oxygen source and to set the oxygen liter flow to the prescribed oxygen liters flow per minute that correspond to the prescribed oxygen percentage ordered.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #1) reviewed for pressure ulcer, the facility failed to ensure the deterioration of a pressure ulcer was noted timely and/or a new treatment was implemented timely. The findings include: Resident #1's was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] identified Resident #1 had severe impairment in cognition, required extensive assistance with bed mobility, dressing, eating and hygiene, required total assistance with transfers and toileting, was at risk for developing pressure ulcers and had no pressure ulcers. The care plan revised on 7/26/21 indicated the resident has a history of right heel wound with interventions to elevate extremities, offer to change position approximately every 2 hours and as needed, protective treatment as ordered, and skin checks per facility protocol. 1. Pressure injury evaluation dated 7/30/21 identified Resident #1 developed a 3.5 cm x 2 cm and 0 cm unstageable pressure area to the right heel with skin prep daily ordered. Review of the Wound Care Specialist progress note dated 8/5/21 identified a 3.3 cm x 3 cm x 0 cm unstageable pressure area to the right heel and the treatment was changed to [MEDICATION(S)] every other day. Wound progress notes dated 8/12/21-9/9/21 showed stable wound with continuation of [MEDICATION(S)]. Note dated 9/16/21 identified 2.5 cm x 2.5 cm x 0 cm area with treatment changed to Santyl every other day as a bridge to debridement. Notes dated 9/23/21-10/3/21 identified continuation of the Santyl. Note dated 10/14/21 identified malodorous, deteriorating wound with increased drainage and some slough with selective debridement completed and treatment changed to 1/4 strength Dakin's solution twice a day and [MEDICATION(S)] for 21 days. Progress note dated 10/21/21 identified 6 cm x 6 cm x 0 cm malodorous, infected wound with increase pain, [CONDITION(S)] and slough and resident sent to the emergency room . emergency room assessment identified temperature of 101.2, respiratory rate of 22, white blood cell count of 19.8. Resident #1 was diagnosed with right foot infection, complicated by [CONDITION(S)] and gangrene, an above the knee amputation was recommended and palliative care was discussed. The resident transitioned to hospice on 10/27/21. Review of the nursing notes from 10/14/21-10/21/21 failed to identify a description of or decline in the right heel pressure area. Review of the computerized vital signs did not identify any vital signs listed since 9/20/21. Paper vital signs sheets provided by the DNS identified Resident #1's name listed as the last name with normal vital signs on 10/14/21, 10/15/21 and 10/19/21. Review of the nursing note identified VSS (vital signs stable) on 10/17/21, 10/18/21 and 10/20/21 but no documentation of the actual vital signs was provided. The DNS indicated on 11/9/21 at 11:30 AM that vital signs would only be taken on Resident #1 with a change on condition. Interview with MD #1 on 11/9/21 at 2:10 PM indicated MD #1 met the responsible party at the resident's bedside on 10/21/21, the MD could smell an odor from the wound and the responsible party indicated the resident was in pain and confused. MD #1 indicated the dressing was taken down and he was amazed at the deterioration of the wound. MD #1 further indicated he gave the responsible party two options: culture and debride the wound at the bedside and continue antibiotics or send Resident #1 to the emergency room for debridement and intravenous antibiotics. The responsible party choose for the resident to be sent to the emergency room . MD #1 indicated the deterioration of the wound is not something that would have occurred in a day but rather something that would develop over time, develop over days. MD #1 had not been informed of the wound's deterioration over the previous week. MD #1 indicated he informs that staff not to wait until Thursday to report a worsening wound but staff can notify the APRN, DNS or call MD #1. Although attempted, an interview with LPN #1 (3-11 charge nurse on 10/19/21 and 10/20/21) was not obtained. Interview with LPN#2 (7-3 charge nurse on 10/19/21, 10/20/21, and 10/21/21) on 11/9/21 at 2:45 PM indicated she did not notice and changes in the resident's condition or the wound during the day shift dressing changes. The facility policy on prevention and management of pressure ulcers does not include deterioration of a pressure ulcer. The facility Condition: Significant Change policy includes that the physician, resident/patient and/or responsible party will not notified by the nurse in the event of a change of condition. 2. Review of the wound Care Specialists note dated 10/14/21 identified malodorous, deteriorating wound with increased drainage and new wound order for 1/4 strength Dakin's apply topically to right heel every day and evening shift. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DNS on 11/9/21 at 2:30 PM indicated the DNS noticed on 10/19/21 that the treatment order had not been changed so the new order was written and initiated on 10/19/21, (5 days later). The facility Condition: Significant Change policy indicates order changes given by the physician will be carried. out.

Based on clinical record review, facility documentation review, and interviews, for one of three residents (R #1) reviewed for accidents, the facility failed to ensure the resident was not left unsupervised while seated in a shower chair and failed to transfer the resident in accordance with physician orders. The findings include: R #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #1 was alert and oriented, required total assistance of two (2) staff for transfers, and had no falls since the prior assessment completed on 5/16/19. The Resident Care Plan (RCP) dated 8/20/19 identified the resident was at risk for falls with interventions that directed to use a Hoyer lift with assistance of two (2) staff for transfers. A physician's orders [REDACTED]. A nurse's note dated 9/3/19 at 11:32 AM identified R #1 attempted to self-transfer when NA went to get a transfer device, and while NA was transferring R #1 she hear a loud pop sound and the right leg immediately swelled up. R #1 had excruciating right leg pain and was unable to move the leg. [MEDICATION NAME] was administered and R #1 was transferred to the hospital. Review of the facility incident report and investigation, dated 9/3/19 at 10:45 AM, identified R #1 was noted to have right leg swelling and pain, right foot rotation, and was unable to move the right leg. NA #1's written signed statement dated 9/3/19 identified after completing R #1's shower, she positioned R #1 in the shower chair by R #1's bed and left the room. When NA #1 returned R #1 was standing by the bed holding onto the sheet. NA #1 then transferred R #1 into bed and called the nurse. LPN #1's written signed statement dated 9/3/19 identified NA #1 reported hearing a pop sound during the transfer, R #1's right leg started to swell, and R #1 was unable to move the leg. The physician was notified and R #1 was transferred to the hospital. The hospital discharge summary dated 9/7/19 identified R #1 was admitted to the hospital on [DATE] with a closed [MEDICAL CONDITION] distal femur and required surgery (insertion intramedullary nail). Nurse's note dated 9/7/19 at 4:45 PM identified R #1 was readmitted to the facility. Interview, clinical record review, and facility documentation review with NA #1 on 11/14/19 at 12:05 PM identified that on 9/3/19 with the assistance of NA #2, she transferred R #1 out of bed onto the shower chair using a Hoyer lift. She then left the Hoyer lift in the room, took R #1 to the shower room and gave R #1 a shower. When NA #1 left the shower room with R #1 and passed by the nurse's desk there were staff at the desk, and she did not ask the staff for assistance to transfer R #1 out of the shower chair with a Hoyer lift. When she returned to R #1's room with R #1 in the shower chair, the Hoyer lift was not in the room. NA #1 stated she positioned R #1 in the shower chair next to R #1's bed, near the middle of the bed, and left the room to search for a Hoyer lift and assistance, leaving R #1 unsupervised. She stated she was not able to locate a Hoyer lift or any staff for assistance and returned to the room within two (2) to three (3) minutes. When she entered R #1's room, she observed R #1 standing approximately one step in front of the shower chair, holding onto the bed's grab bar. She observed R #1 with his/her buttocks over the shower chair seat, starting to turn toward the right to attempt to get into bed and his/her knees were buckled. NA #1 stated she assisted R #1 to pivot into bed, rather than sit back on the shower chair in an attempt to prevent a fall. NA #1 stated R #1 complained of pain and she called the nurse immediately. NA #1 stated that she should not have transferred R #1 alone, and should not have left R #1 alone in the room while sitting in a shower chair. Interview, clinical record review, and facility documentation review with LPN #1 on 11/14/19 at 1:29 PM identified R #1 required a Hoyer lift transfer with two staff. On 9/3/19 she was notified that NA #1 pivoted R #1 into bed without assistance, and NA #1 heard a pop sound during the transfer. R #1 complained of pain and was noted to have swelling in the right leg. LPN #1 stated NA #1 should not have transferred R #1 without staff assistance and should not have left R #1 alone in the room while sitting in a shower chair. Interview, clinical record review, and facility documentation review with the DON on 11/14/19 at 1:46 PM identified R #1 required a Hoyer lift and assistance of two staff for transfers, and NA #1 should not have left R #1 alone while in the shower chair. The DON stated NA #1 should have stayed with R #1 and rang the call bell for staff assistance. Interview with the DON identified there was no facility policy regarding not to leave residents unattended when in the shower chair, however the expectation was that staff would not leave a resident that required Hoyer lift transfers unattended while in a shower chair.

Based on clinical record review, facility documentation, interviews, and observations, for one of three residents who were at risk for elopement, and exhibited exit seeking behavior, (Resident #1), the facility failed to properly assess the resident when exit seeking behavior was identified, ensure alarmed exit doors were functioning properly, and/or prevent an elopement, resulting in a finding of immediate jeopardy, which is identified as corrected as facility staff were educated on elopement policies and procedures. The finding includes: Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of court of probate paperwork dated (MONTH) 16, (YEAR) identified that the resident had a court appointed conservator of person. Review of an elopement assessment dated [DATE] identified that the resident was at risk for elopement. A physician's orders [REDACTED]. An admission Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognitive impairment, severely impaired decision making skills, severely impaired vision, highly impaired hearing, required extensive assistance with activities of daily living, supervision with ambulation on the unit, limited assistance with ambulation off of the unit, walking balance was unsteady, had 2 or more falls since admission to the facility, and wandered daily. Review of a care plan dated 4/18/18 identified that the resident wandered in the nursing home, with interventions to offer rest periods and assist the resident with locating his/her room and/or bathroom. Review of a nurse's note dated 6/14/18 at 11:23 PM identified that the resident was observed wandering in the facility parking lot, and was safely brought back into the building, the resident was assessed and noted with a skin tear to the left knee measuring 2.5 centimeters (cm) by 3.0 cm, a scratch to the left pinky measuring 0.5 cm by 0.5 cm and a lump on the right upper arm measuring 3.0 cm by 4.5 cm with minimal range of motion and pain noted. The advanced practice registered nurse (APRN) was notified and an x-ray was obtained of the right humerus, [MEDICATION NAME] was applied to the skin tear on the right knee, and close monitoring continued. Review of the accident and incident report and investigation dated 6/14/18 identified that the resident was observed in the facility back parking lot wandering, and a fall was suspected. The investigation further identified that the resident was last seen on the nursing unit at 6:30 PM, and was found in the parking lot at 6:45 PM. Review of the clinical record failed to identify an elopement care plan was in place prior to 6/18/18. Observations and interviews with the administrator and director of nurses made on 7/5/18 at 9:00 AM of the facility identified that Resident #1 resided on the third floor. Review of the exit doors on the third floor identified an elevator, although not wander guard equipped, needed a passcode to exit the unit onto the elevator. Once the elevator reached the ground floor located in the lobby area, there is a wander guard alert that will alarm if a resident with a wander guard exits the elevator area. The front door to the facility is wander guard equipped, and will lock and alarm when a resident with a wander guard approaches the door, a code must be entered to silence all the wander guard alarms. There are a total of 3 alarmed egress doors on the third floor, the alarmed egress doors all have keypad access, if the access code is punched into the keypad, the door can be opened without an alarm sounding, if the access code is not entered into the key pad, the door will alarm if pressed, and will continue to alarm for 30 seconds, when the 30 seconds has lapsed, the door will open. If the alarm sounds, the passcode must be entered to reset the alarm function. The 3-1, and 3-3 egress doors lead down 2 staircases to the lobby area, and the 3-2 door leads down 2 staircases to an exit door which is alarm free and unsecured and leads to the back parking lot. Interview with Nurse Aide (NA) #1 on 7/5/18 at 2:00 PM identified that on 6/12/18 (two days prior to the elopement) she worked the 7:00 AM to 3:00 PM shift on the third floor, she was standing in the hallway near the nurses station by the shower room, and just happened to look down the hallway and see Resident #1 pushing the 3-2 alarmed egress door, it had opened, without an alarm sounding. NA#1 stated that she ran down the hallway to stop the resident from entering the stairwell and as she got closer to the door, she was able to hear a very slight beeping. NA #1 stated she redirected the resident, then informed the assistant director of maintenance and the nurse (Licensed Practical Nurse #1) about the issue with the alarm. NA#1 further identified that the 3-2 door alarm is usually very loud and can be heard throughout the unit. Interview with NA#2 on 7/5/18 at 12:30 PM identified she works the 3:00 to 11:00 PM shift, and had been providing care for another resident with the door closed at the end of the hallway directly next to the 3-2 door, when she heard a funny sound coming from outside of the room. When she opened the door to investigate, she observed Resident #1 going through the 3-2 door, but the alarm was very hard to hear, and could not be heard unless you were standing next to the door. NA#2 stated that the door alarm is usually very loud and can be heard by the whole unit. NA#2 stated although she was not certain of the date the incident occurred, she knew it was before Resident #1's elopement on 6/14/18. NA#2 identified that she had informed the charge nurse of the issue with the alarm, but could not recall who she had told. Review of the clinical record failed to identify any documentation of the exit seeking behavior, an assessment and/or interventions were put into place to address the resident's exit seeking behavior. Interview with NA#3 on 7/5/18 at 4:00 PM identified that she had provided care for Resident #1 on 6/14/18 at 4:30 PM, and had seen the resident with her family member in the hallway at 6:00 PM. NA#3 further identified that the resident was not exhibiting any behaviors and she did not hear any alarms prior to the resident's elopement. Interview with Licensed Practical Nurse (LPN) #1 on 7/5/18 at 12:30 PM identified that on 6/14/18 she had last seen the resident sitting at the nurse's station around 6:30 PM and the resident was not exhibiting any behaviors at that time. LPN#1 further identified that she did not hear any alarms prior to Resident #1's elopement, nor had she been told about any malfunctioning door alarms. Interview with the evening receptionist on 7/5/18 at 10:00 AM identified that she had worked the 4:00 PM to 8:00 PM shift on 6/14/18, and sits at the front desk directly in front of the facility entrance. The receptionist further identified that she did not silence any wander guard alarms on her shift and at no time during her shift did she see Resident #1 in the lobby. Interview with Registered Nurse (RN) #1 on 7/5/28 at 1:00 PM identified that he was in the lobby area from approximately 6:30 PM until 6:45 PM on 6/14/18, and did not see Resident #1. RN#1 further identified that he exited the building via the front door at 6:45 PM and on the way to his car, he saw Resident #1 walking towards him from the opposite direction on the sidewalk in the side parking lot. Resident #1 had what appeared to be grass and leaves on his/her clothing from a suspected fall, he brought the resident back into the building, and noted that the wander guard sounded upon re-entry through the front door of the facility. Interview with RN#2 on 7/5/18 at 3:45 PM identified that she was the nursing supervisor on the 3:00 to 11:00 PM shift on 6/14/18 and had last seen the resident between 5:30 to 5:45 PM sitting at the nurse's station. At approximately 6:45 PM, RN#1 came to the supervisor's office with Resident #1 stating that he/she had been found in the parking lot. RN#2 identified that she had assumed the resident had fallen because he/she was noted with leaves on his/her clothing and a skin tear was noted on the right knee and scratches on his/her left 5th finger. The resident was also noted with a lump on the right upper arm, for which an X-ray was ordered and was negative. RN#2 stated that the resident was placed on every fifteen minute checks as soon as he/she re-entered the facility. Interview with the Assistant Director of Maintenance (ADM) on 7/5/18 at 2:30 PM identified that he was alerted by NA#1, (he was not sure of the exact date, but it was prior to the elopement on 6/14/18) in the hallway that the alarm on the 3-2 egress door was not alarming as loudly as it should. He then got his tools and checked the alarm, and when he pushed the door, it sounded loudly, and was functioning properly, but he did not document the issue and/or report the issue to administration. The ADM further stated that this was the only time he was notified of an issue with this door. Interview with the Director of Maintenance (DM) on 7/5/18 at 2:30 PM identified that the ADM had not informed him of the issue with the 3-2 door, nor was he aware of any issues with the door prior to Resident #1's elopement on 6/14/18. The DM further identified that the alarmed egress doors should alarm loud enough to be heard throughout the unit. The DM stated that if he had been informed about the 3-2 door not alarming correctly, he would have contacted the alarm company immediately so the door could be checked by a professional. Interview with the Director of Nurses (DON) on 7/5/18 at 3:30 PM identified that she was unaware that Resident #1 was exhibiting exit seeking behavior, and/or that there were any issues with the 3-2 alarmed egress door prior to the elopement as she obtained the information subsequent to the elopement during her investigation. The DON further identified that it would be her expectation that if a resident is exhibiting exit seeking behavior, the charge nurse and/or supervisor will be informed, an assessment would be performed to assess elopement risk, and the need to increase supervision would be based on the outcome of the assessment. The DON further identified that she would expect to be notified immediately if an alarmed door is not functioning properly, and would have contacted the DM. The DON further identified that after an extensive investigation the facility was unable to determine how the resident exited the building, as all wander guard systems and exit doors were functioning properly when checked subsequent to the elopement. Further interview with the DON on 7/6/18 at 12:00 PM identified that on 6/16/18 (2 days after the elopement) she was in the building and was testing exit doors to assess staff response. The DON stated that when the 3-2 exit door was pushed, the alarm was not audible enough to be heard by other staff, maintenance was called and the siren on the alarm was replaced. Immediately following the elopement on 6/14/18, the facility ensured every exit door was functioning properly, educated staff on response to alarms, the elopement policy, the function of egress doors, and directed staff to monitor the exit doors every fifteen minutes. Furthermore, the wander guard function check was changed from every day to every shift, and the resident was placed on every fifteen minute checks immediately upon re-entering the facility. Review of the elopement policy identified that elopement is identified as the ability of a resident who is not capable of protecting themselves from harm, to successfully leave the facility unsupervised and unnoticed and may enter into harm's way. The elopement policy further identified that the facility will implement preventive strategies for those identified to be at risk, and a care plan will be developed.

Based on review of the clinical record, review of facility policies, and interviews for one of six residents reviewed for unnecessary medications, (Resident #125), the facility failed to notify the physician of resident's elevated laboratory results in a timely manner. The findings include: 1. Resident #125 (R # 125) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that R #125's cognition was moderately impaired, and that the resident required extensive assistance with transfers and supervision with walking. Review of the care plan dated April 2015 identified a problem with [MEDICAL CONDITION] with interventions that included to administer treatment and medication as ordered and to monitor the resident's intake and output. Physician orders [REDACTED]., on 5/4/15. Nursing notes dated 5/4/15 at 2:30 PM indicated that the [MEDICATION NAME] trough level was pending. Review of the laboratory report dated 5/4/15 indicated that R #125's [MEDICATION NAME] level trough level was reported as high at 27 mg/L (Normal 10-20 mg/L). In addition, a BUN, used to assist in determining a resident's hydration status, was elevated at a level of 51 (Normal 8-21), and the resident's creatinine level, used to assist in determining kidney function, was elevated at 3.2 (Normal 0.5 -1.3). Documentation in the report indicated that the lab results were reported to the facility on [DATE] at 10:02 PM though lacked documentation to reflect that the physician was notified of the elevated [MEDICATION NAME] trough level and elevated BUN and creatinine levels. Review of a previous laboratory report dated 4/27/15 indicated that R #125's BUN was 34 (8-21) and the creatinine was 1.5 (0.5-1.3). Review of a nursing note dated 5/4/15 at 11:28 PM indicated the 5/4/15 [MEDICATION NAME] trough level was still pending. A nursing note dated 5/5/15 at 3:13 AM indicated that the IV antibiotic continued for treatment of [REDACTED]. A nursing note dated 5/5/15 at 10:05 PM indicated that R #125's IV antibiotic continued for [MEDICAL CONDITION] of bilateral heels with no adverse reaction noted. A nursing note dated 5/6/15 at 4:20 AM indicated IV [MEDICATION NAME] continued for bilateral heel infection. Review of the infusion Medication Administration Record [REDACTED]. Interview with LPN #4 on 6/30/15 at 2:34 PM identified that he/she was the charge nurse on the 3:00 PM to 11:00 PM shift on 5/4/15. LPN #4 identified that although he/she was aware that R #125 had a [MEDICATION NAME] trough level pending, he/she never checked the fax machine for the results. LPN #4 indicated that there was no established routine for checking the fax machine for pending lab results. Interview with LPN #3 on 6/30/15 at 2:38 PM identified that he/she was the charge nurse on the 11:00 PM to 7:00 AM shift on 5/4/15. LPN #3 stated that he/she noted R #125's elevated [MEDICATION NAME] trough levels and that although it was his/her responsibility to notify the physician at that time, he/she did not notify the physician nor did he/she communicate the elevated trough level to the oncoming shift nurse. LPN #3 identified that when he/she returned to work on 5/5/15 for the 11:00 PM to 7:00 AM shift, he/she realized that the elevated trough level had not been reported to the physician and instructed the oncoming 7:00 AM to 3:00 PM shift nurse to notify the physician. Interview with the DNS on 6/30/15 at 11:38 AM indicated that in May of 2015, the facility did not have a mechanism in place for ensuring antibiotic trough levels were monitored by a designated staff member and/or communicated to the physician. A nursing note dated 5/6/15 at 2:45 PM indicated MD #1 was updated on R #125's elevated [MEDICATION NAME] level of 27, two days after the elevated levels were reported to the facility. The documentation identified that MD #1 was notified that the IV [MEDICATION NAME] continued to be administered to R #125 on 5/5/15 at 6:00 AM and on 5/6/15 at 6:00 AM. Physician orders [REDACTED]. Review of the stat laboratory report results dated 5/6/15 indicated that R #125's BUN remained elevated and had risen to 68 and that the resident's creatinine remained elevated and had risen to 5.0 A subsequent physician's orders [REDACTED].#125 to the emergency room based on the resident's elevated BUN of 68 and elevated creatinine of 5.0. Interview on 6/30/15 at 4:00 PM with MD #1 indicated the facility made no attempt to notify him/her of R #125's elevated [MEDICATION NAME] trough level for two days. MD #1 stated that he/she expected to have been notified of the elevated [MEDICATION NAME] trough level as soon as the lab result was reported to the facility. MD #1 indicated that R #125 should not have received the 5/5/15 and 5/6/15 doses of [MEDICATION NAME]. MD #1 identified that the resident's elevated BUN and creatinine levels indicated there could have been kidney damage and therefore he/she sent R #125 to the hospital. MD #1 indicated that the resident is no longer on antibiotics and that his/her kidney function has improved. Review of the hospital discharge documentation dated 5/13/15 indicated R # 125 was admitted to the hospital on [DATE] with an acute kidney injury likely secondary to acute tubular necrosis in the setting of [MEDICATION NAME] toxicity. The documentation identified that R #125's [MEDICATION NAME] trough level was 46.5, up from 27 on 5/4/15, that IV fluids were started, and the [MEDICATION NAME] was discontinued. R #125's creatinine trended down from 4.1 to 4.9 on admission. Facility policy on significant change directed in part that facility staff will communicate with the physician regarding changes in condition to provide timely communication of a status change which is essential to quality care management. In addition, facility policy directed that the physician be notified with a change in status.

Based on review of the clinical record, review of facility documentation, review of facility policies /procedures, and interviews for one of three residents reviewed for accidents (Resident #181), the facility failed to provide adequate supervision to prevent an accident for the resident who had experienced multiple falls and had a history of [REDACTED]. The findings include: 1. Resident #181 (R #181) was readmitted to the facility with [DIAGNOSES REDACTED]. Review of the care plan initiated on 9/17/14 and updated on 12/25/14 included that the resident was not to be left alone in the bathroom. An admission assessment dated [DATE] identified that R #181 had a BIMs score of nine, indicative of moderate cognitive impairment, had moderately impaired decision-making skills, and required extensive assistance of two staff members for transfers and toilet use. Review of facility documentation dated 1/22/15 at 1:30 PM identified that R #181 was found holding onto his/her wheelchair while kneeling on the bathroom floor by NA #2. No injuries were reported at that time. The facility investigation identified that the resident had fallen after an unassisted transfer. Potential causative factors were documented and included that the resident was forgetful, non-compliant, and did not call for help. The care plan was updated on 1/22/15 and again identified R #181's risk for falls secondary to a history of falls. Interventions included gripper socks while in bed, to instruct the resident to ask for assistance prior to attempting to transfer and/or ambulate, and to encourage the resident to stay in common areas when out of bed. Review of facility documentation dated 1/26/15 at 6:40 PM identified that R #181 was found lying on the floor near his/her bed with complaints of pain to the bilateral knees. Review of post event progress notes date 1/27/15 identified that after hearing the resident screaming for help and finding the resident sitting on the edge of the bed, RN #1 independently transferred R #181 into his/her wheelchair and brought the resident to the bathroom. The documentation identified that after instructing the resident to remain seated, RN #1 handed the resident the call light and assured the resident that he/she would return with help. The documentation identified that RN #1 left the resident alone in the bathroom. Review of facility documentation, the clinical record, and subsequent interview with RN #1 on 6/30/15 at 11:57 AM and 12:17 PM identified that after hearing R #181 scream for help, he/she found the resident sitting on the edge of his/her bed, helped the resident into his/her wheelchair, and then into the bathroom. After standing the resident to an upright position, he/she assisted the resident to sit on the toilet. RN #1 indicated that although he/she knew that the resident wasn't to be left alone in the bathroom, he/she instructed R #181 to remain seated, provided a call light, and assured the resident that he/she would return with help. RN #1 further noted that after being out of the resident 's sight for less than two to three minutes, he/she heard the resident scream, returned to the room and found R #181 lying on the floor near his/her bed. RN #1 indicated that R #181 reported that he/she fell while reaching and turning during a self-transfer. Interview and review of facility documentation with NA #1 on 6/30/15 at 2:25 PM indicated that while helping another resident, he/she was asked by RN #1 to go to R #181's room and that the resident was in the bathroom. NA #1 identified that he/she finished with the resident he/she was caring for and went to assist R #181 but by the time he/she got to the resident's room, the resident was already on the floor near his/her bed. Interview with the DNS on 7/2/14 at 10:15 AM indicated that RN #1 identified that he/she had only spent less than a minute away from the resident trying to get help with the intention of going right back. The DNS stated that after the event, a lot of time was spent reeducating the staff to stay with the residents and utilize the call light system when attempting to get help from additional staff members. Subsequent to R #181's fall on 1/26/15, a diagnostic scan dated 1/27/15 identified that R #181 had sustained a right knee fracture involving the proximal aspect of the fibula with a possible non-displaced fracture involving the medial tibial plateau. The resident was further noted as having bone demineralization and [DIAGNOSES REDACTED], osteoarthritis and/or calcium pyrophosphate deposition disease. Review of R #181's clinical record, acute care diagnostic results dated 1/27/15, and facility documentation dated 1/22 and 1/26/15 /15 with MD #4 on 7/2/15 at 11:15 AM identified that the diagnostic report results related to R #181's right knee showed demineralized bone or osteoarthritis and [DIAGNOSES REDACTED]. MD #4 further indicated that the bone in the resident's right knee was very brittle, probably osteopenic, and that the combination of the falls and the resident's non-compliance may have contributed to the resident's fracture. Review of facility policy on Falls Management directed in part that the facility would use all available information upon admission and on an ongoing basis to determine a resident's risk for falls. The policy further directed in part that subsequent to that evaluation, the interdisciplinary team would implement an appropriate individualized plan of care based on the fall risk evaluation.

Based on review of the clinical record, review of facility policies, and interviews for one of six residents reviewed for unnecessary medications, (Resident #125), the facility failed to respond timely to an elevated serum drug level and/or failed to ensure that the medication being monitored was not administered in the presence of an elevated drug level. The findings include: 1. Resident #125 (R # 125) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that R #125's cognition was moderately impaired, required extensive assistance with transfers, and required supervision with walking. Review of the care plan dated April 2015 identified a problem with [MEDICAL CONDITION] with interventions that included to administer treatment and medication as ordered and to monitor the resident's intake and output. Physician orders [REDACTED]., on 5/4/15. Nursing notes dated 5/4/15 at 2:30 PM indicated that the [MEDICATION NAME] trough level was pending. Review of the laboratory report dated 5/4/15 indicated the [MEDICATION NAME] level trough level was reported as high at 27 mg/L (Normal 10-20 mg/L). In addition, a BUN, used to assist in determining a resident's hydration status, was elevated at a level of 51 (Normal 8-21), and the resident's creatinine level, used to assist in determining kidney function, was elevated at 3.2 (Normal 0.5 -1.3). Documentation in the report indicated that the lab results were reported to the facility on [DATE] at 10:02 PM though lacked documentation to reflect that the physician was notified of the elevated [MEDICATION NAME] trough level and elevated BUN and creatinine levels. Review of a previous laboratory report dated 4/27/15 indicated that R #125's BUN was 34 (8-21) and the creatinine was 1.5 (0.5-1.3). Review of a nursing note dated 5/4/15 at 11:28 PM indicated the [MEDICATION NAME] trough level was still pending. A nursing note dated 5/5/15 at 3:13 AM indicated that the IV antibiotic ([MEDICATION NAME]) continued for treatment of [REDACTED]. A nursing note dated 5/5/15 at 10:05 PM indicated that R #125's IV antibiotic ([MEDICATION NAME]) continued for [MEDICAL CONDITION] of bilateral heels with no adverse reaction noted. A nursing note dated 5/6/15 at 4:20 AM indicated IV [MEDICATION NAME] continued for bilateral feet. Review of the infusion Medication Administration Record [REDACTED]. Interview with the DNS on 6/30/15 at 11:38 AM indicated that in May of 2015, the facility did not have a mechanism in place for ensuring antibiotic trough levels were monitored by a designated staff member and/or communicated to the physician. A nursing note dated 5/6/15 at 2:45 PM indicated MD #1 was updated on the elevated [MEDICATION NAME] level of 27 which was completed on 5/4/15, two days after the elevated levels were reported to the facility. The documentation identified that MD #1 was also notified that [MEDICATION NAME] continued to be administered on 5/5/15 at 6:00 AM and on 5/6/15 at 6:00 AM. Physician orders [REDACTED]. Review of the stat laboratory report results dated 5/6/15 indicated that R #125's BUN remained elevated and had risen to 68 and that the resident's creatinine remained elevated and had risen to 5.0 A subsequent physician's orders [REDACTED].#125 to the emergency room based on the resident's elevated BUN of 68 and elevated creatinine of 5.0. Review of the hospital discharge documentation dated 5/13/15 indicated R # 125 was admitted to the hospital on [DATE] with an acute kidney injury likely secondary to acute tubular necrosis in the setting of [MEDICATION NAME] toxicity. The documentation identified that R #125's [MEDICATION NAME] trough level was 46.5, up from 27 on 5/4/15, that IV fluids were started, and the [MEDICATION NAME] was discontinued. R #125's creatinine trended down from 4.1 to 4.9 on admission. Interview on 6/30/15 at 4:00 PM with MD #1 indicated the facility made no attempt to notify him/her of R #125's elevated [MEDICATION NAME] trough level for two days. MD #1 stated that he/she expected to have been notified of the elevated [MEDICATION NAME] trough level as soon as the lab result was reported to the facility. MD #1 indicated that R #125 should not have received the 5/5/15 and 5/6/15 doses of [MEDICATION NAME]. MD #1 identified that the resident's elevated BUN and creatinine levels indicated there could have been kidney damage and therefore he/she sent R #125 to the hospital. MD #1 indicated that the resident is no longer on antibiotics and that his/her kidney function has improved. Facility policy on significant change directed in part that facility staff will communicate with the physician regarding changes in condition to provide timely communication of a status change which is essential to quality care management.

Based on review of the clinical record, observations, and staff interviews for one of four sampled residents (Resident #19) who were reviewed for accidents, the facility failed to ensure the necessary supervision and guidance during a mechanical lift transfer to prevent an injury. The findings include: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] identified the resident had severely impaired cognition, (BIMS 4), required extensive assistance of two staff for bed mobility and toilet use, was totally dependent on two staff for transfers, and was not ambulatory. The care plan dated 3/18/14 identified the resident had fragile skin with a risk for skin tears and bruising. Interventions included the assistance of two staff for transfers, encourage resident to wear long sleeves and long pants, inspect skin during care, lotion to dry skin, and ensure the wheelchair is locked before transfers. physician's orders [REDACTED]. A nurses note dated 4/28/14 at 22:14 identified that after a mechanical lift transfer, a 17.5 cm laceration was noted to Resident #19's left leg from below the knee to above the ankle. Subequent to notification of the Advance Practice Registered Nurse (APRN), the resident was transported to the hospital for evaluation. Hospital discharge summary dated 4/29/14 identified the resident sustained [REDACTED]. Nurses note dated 4/29/14 at 02:28 identified the resident returned to the facility at 1:40AM with a [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of the accident/incident report dated 4/28/14 identified that at 8:30PM after a transfer via hoyer lift from the chair to bed, two nursing assistants (NA) noted blood on the resident's left lower extremity pant leg. LPN #1 was notified and upon assessment identified a 17.5cm laceration to the left lower leg. A written statement by LPN #1 dated 4/28/14 identified that he/she had been in the room with the resident and visualized him/her between 7:00PM - 8:00PM that evening and there was no blood present on the left pant leg. After the hoyer transfer, at 8:30PM, LPN#1 documented that the wound on the left lower leg was fresh with wet bright red blood. Additionlly, the blood on the residents pant leg was fresh. The accident/incident report identified that a thorough investigation had been conducted by means of staff interviews, transfer re-enactments and in conclusion it had been determined that this injury likely occured during the mechanical lift transfer upon which it is believed the residents leg made contact with an edge of the custom wheelchair where the leg rests attach. Interview with the Director of Nursing Service (DNS) on 8/20/14 at 2:30PM identified that the resident had very fragile skin and although it is the facility policy to remove leg rests prior to transfers, the regular staff who know the resident very well kept the leg rests on during transfers. The DNS stated that the intervention of leaving the leg rests on by the regular nurse aides was not communicated to the nurses for inclusion on the care plan. This intevention was added to the care plan following the incident. The facility failed to ensure measures were in place to prevent an injury.

Based on review of the clinical records, staff interviews, and review of facility policy and procedure, for two of six residents reveviewed for falls (Resident # 94,145), the facility failed to follow the residents plan of care and/or position a resident in a safe manner prior to transfer resulting in an injury. The findings include: 1. Resident #94's [DIAGNOSES REDACTED]. A resident care plan dated 5/22/13 identified a risk for falls. Interventions included to utilize a mechanical lift with assist of two for transfers, and to position back to bed after lunch. A revised care plan dated 7/27/13 identified a fall from the wheel chair occurred. Intervention included to transfer to the hospital for evaluation. physician's orders [REDACTED]. A facility investigation dated 7/27/13 at 3:45 PM identified R #93 was positioned in the wheelchair and fell forward on the floor landing on his/her right side. A laceration was noted above and below the right eye. The physician was notified and directed to transfer the resident to the hospital for evaluation. The resident was admitted to the intensive care unit with a possible cervical fracture, and received 4 sutures to the right eye. Review R#94's CWC 24 hour positioning plan identified that between 10:00 AM and 11:00 AM, the resident will be out of bed, and positioned between 20 - 30 degrees for comfort. From 12:00 PM till 1:30- 2:00 PM, the CWC must be upright for lunch. From 1:30 PM - 2:00 PM, R#64 will be put back to bed for rest. Interview with NA #1 on 9/18/13 at 11:05 AM identified that at approximately 3:45 PM on 7/27/13, he/she brought R #94 into his/her room to return to bed, NA #1 positioned the resident by the side of the bed and placed the wheelchair in a straight upright position. NA #1 indicated he/she turned his/her back to the resident to prepare the bed and heard a loud noise, and when he/she turned around, the resident was lying on the floor bleeding. The NA immediately reported to the nursing supervisor. Interview and review of the clinical record with the DNS on 9/18/13 at 8:00 AM identified R #94 utilized a CWC for positioning while out of bed, and followed a 24 hour positioning plan. Additionally the resident ' s plan of care directed the staff to position the resident back to bed after lunch. The DNS identified that if the CWC 24 hour positioning plan and resident care plan directed staff to position the resident back to bed after lunch, the resident should have been positioned back to bed at that time not at 3:45 PM. The DNS indicated R #94's CWC should only be positioned in the upright position when the resident is being served lunch and dinner. 2. Resident # 145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident had severely impaired cognition, and required extensive assistance from two staff for bed mobility and transfers. A resident care plan dated 5/9/13 identified a risk for falls. Interventions included PT/OT referral as/if needed, and if you see me walking without my assistive device, please bring it to me and remind me of it's importance. Review of facility investigation dated 5/9/13 at 11:20 AM identified the resident was found on the floor in the hallway. Interventions included to keep the resident in view of nursing. A facility investigation dated 6/18/13 at 5:20 PM, identified that the resident was found on the floor in front of the wheelchair. Review of the facility documentation identified R #145 was in the hallway for close monitoring, the nurse stepped away from the resident to administer medications to another resident and when he/she returned, R#145 was on the floor. A facility investigation dated 6/21/13 at 11:45 AM identified R# 145 was found on the floor in front of the wheelchair by the elevator. Interventions included to educate the recreation staff to notify nursing upon return from activities. A facility investigation form dated 6/23/13 at 4:50 PM identified the resident was found on the floor in front of the wheelchair in R#145's room. Interventions included to apply anti-tippers to the wheelchair. A facility investigation dated 7/12/13 at 8:00 AM identified the resident was found on the floor in R#145's room. Interventions included not to leave the resident unattended in room following am care. A facility investigation dated 9/2/13 at 1:00 PM identified the resident was found on the floor in the hallway. Interventions included to place the resident by nursing station for close monitoring. Interview and review of facility investigations with the DNS on 9/23/13 at 11:00 AM indicated that although the resident's plan of care was reviewed after each fall, the intervention to keep the resident in view of the nursing staff was not consistently implemented. Subsequently the DNS indicated a facility wide review of all residents identified at risk for falls was conducted to ensure appropriate interventions were identified and implemented.

Based on clinical record reviews, interviews, review of facility documentation and facility policy for 3 of 5 residents reviewed for accidents (Residents # 29, 230 and 239) and/or for 1 of 3 residents reviewed for elopement (Resident #202), the facility failed to follow the plan of care to prevent an accident, and/or failed to protect the resident from injury and/or failed to supervise the resident to prevent an elopement. The findings include 1. Resident #29's [DIAGNOSES REDACTED]. The resident care plan dated 8/9/11 identified a risk for falls related to decreased mobility and history of falls. Interventions included a seat belt in the custom wheel chair. The physicians orders dated 9/16/11 identified the use of a motorized wheelchair with a seatbelt for positioning. The Reportable Event dated 10/11/11 identified R #29 fell out of the wheelchair while riding in an ambulance. The cause of the fall was related to in part R #29 not wearing a seat belt. R #29 sustained abrasions to the forehead and both lower extremities. Interview with Nurse Aide (NA) #2 on 10/20/11 at 1:54 PM identified the transportation van hit a bump and R #29 fell from the wheelchair. NA #2 indicated she did not check to see if the resident's seat belt was fastened. Interview with the Director of Nurses on 10/24/11 at 11:37 PM identified the NA is responsible to ensure the seatbelt is fastened while the resident per the care plan. 2. Resident #202 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The wandering elopement risk evaluation dated 7/28/11 identified the resident at risk for wandering/elopement. The resident care plan dated 7/28/11 identified wandering behavior and attempts to elope off the unit and from the building. Interventions included use of a wanderguard on the right ankle and every15 minute checks. The nurse's note dated 7/31/11 at 2:00 PM indicated R #202 was found by another resident walking up the driveway looking for Bridgeport hospital. The wanderguard was on the resident and was functional. Review of the every 15 minute check log indicated that on 7/31/11 at 1:45 PM the resident was in the hallway. This was crossed out and noted with supervisor in building. At 2:00 PM the resident was noted in the hallway and at 2:15 PM the resident was in the dining room watching TV. Interview on 10/19/11 at 10:00 AM with the Administrator indicated the wanderguard system was functioning at the time the resident exited the building on 7/31/11. The Administrator indicated the resident could access the elevator because they were not equipped with Wanderguard sensors. The Wanderguard sensor was located at the first floor elevator vestibule only. The Administrator further indicated the Wanderguard system has since been enhanced to include the front door (locks when wanderguard sensed). A subsequent interview on 10/20/11 at 10:30 AM with the Administrator indicated further investigation demonstrated the Wanderguard sensor may have been blocked by a piece of equipment as the resident walked through the door. An interview on 10/20/11 at 10:15 AM with Receptionist #1 indicated that on 7/3/11 shortly after 1:00 PM on 7/31/11, R #202 walked in the front door from outside with a visitor. Receptionist #1 stated at the time she did not know R #202 was a resident of the facility. Receptionist #1 noted the visitor stated the resident was found by the street. Receptionist #1 indicated the resident's picture was not at the front desk identified as an elopement risk. Interview on 10/20/11 at 10:40 AM with Nurse Aide (NA) #1 indicated R #202 was in the hallway on 7/31/11 at 1:45 PM and at 2:00 PM when she went to check on the resident, she was told the resident was found outside the building. NA #1 further indicated she must have crossed out the 1:45 PM observation in error. 3. Resident # 230's [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] identified the resident with moderately impaired mental status, extensive assist with transfers and toileting, and limited assist with walking in the room. A resident care plan dated 12/6/10 identified a problem with falls. Interventions included non-skid socks when not wearing shoes. A nurse's note dated 1/14/11 at 7:45 PM noted R #230 was found on the floor near the wheelchair. The resident did not have shoes on and was not wearing non-skid socks. A rehab fall screen dated 1/17/11 indicated nursing staff was re-educated on the importance of ensuring non-skid socks were on when the resident's shoes off to increase safety secondary to noncompliance with calling for assistance. The nurse's note dated 2/1/11 at 9:15 PM noted R #230 was found sitting on the floor in the bathroom with his/her shoes at the bedside and without the benefit of non-skid socks. A 4 centimeter (cm) gash was noted on the left side of head and the resident was transferred to emergency room for an evaluation. The Rehabilitation Fall Screen dated 2/2/11 indicated Nurse Aide (NA) #14 was counseled secondary to failure to apply the non-skid socks. Interview on 10/19/11 at 3:13 PM with NA #14 indicated she would sometimes put on the non-skid socks, however, the resident had been in the bed prior to the fall on 2/1/11. NA #14 noted she did not put the non-skid socks on the resident when he was in bed. 4. Resident #239's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] identified the resident with severe impaired cognition a BIMS score of 3, no behaviors were identified, and required extensive assist with activities of living. The care plan dated 1/5/11 identified a risk for falls with interventions that included to utilize a chair and bed alarm, a low bed, and to encourage the resident to rest when tired. The nurse's note dated 2/20/11 at 6:10 AM identified R #239 refused to get out of bed and complained of left groin pain. The Physician was notified and directed to obtain an x-ray of the left hip. An x -ray report dated 2/20/11 identified an acute left hip fracture with modest displacement, new since 1/10/11 and osteoporosis present. Upon notification, the Physician directed to transfer the resident to the hospital. Review of the clinical record did not identify the resident sustained [REDACTED]. The Reportable Event dated 2/21/11 at 6:00 AM identified R #239 complained of left hip pain and the x-ray report identified a left hip fracture. The Director of Nurses (DNS) indicated she did not interview other staff on duty prior to 2/21/11 to ascertain a possible cause of the fracture because she felt the injury was related to the resident's [DIAGNOSES REDACTED]. Interview with Physician #1 on 10/25/11 at 12:15 PM identified that a subcapital fracture was the result of trauma and not pathological and/or spontaneous in nature.