Every finding on record at Medicalodges Goddard

The facility reported a census of 45 residents. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year. Two of the five nurse aides sampled lacked the required training topics. Two of five nurse aides sampled lacked the required 12 hours per year of in-service training. Findings included:- On 01/14/26 at 03:05 PM, review of training records for five CNAs employed by the facility for more than one year revealed two CNAs had less than 12 hours of documented in-service training for the previous 12 months. CNA HH had one hour of documented training, and CNA II had eight hours of documented training. On 01/14/26 at 03:05 PM, review of training records for five CNAs employed by the facility for more than one year revealed CNA HH and CNA II did not have the required topics for in-service training for the previous 12 months. On 01/14/26 3:05 PM, Administrative Nurse D confirmed the CNAs were required to have 12 hours of training annually and stated there were no records of additional training for those CNAs. Administrative Nurse D added that the staff members were working to complete the training. The facility did not provide a policy.

The facility reported a census of 45 residents. Five staff were reviewed for background checks. Based on interview and record review, the facility failed to implement their policy when facility failed to ensure background checks were completed for one staff. Findings included:- On 01/14/26 at 3:05 PM, Administrative Nurse D stated she was unable to locate the background check for Certified Nurse Aide (CNA) HH. She said she was aware it was a requirement for all staff to have a background check. On 01/15/26 at 10:23 AM, Administrative Staff A stated it was the expectation that all staff have background checks, per the facility's policy. The facility's policy Abuse, Neglect, and Exploitation, dated 10/02/22, documented all new employees will be investigated prior to employment for a previous history of abuse, neglect, or exploitation.

The facility had a census of 45 residents; the sample included 13 residents. Twenty-nine medications administrations were observed with three errors identified resulting in a medication error rate of 10.34 %. Based on observation, record review, and interview, the facility failed to ensure a medication error rate below five percent. Findings included:- Review of the Electronic Health Record (EHR) for Resident (R) 46 revealed the following orders: 1. Citalopram (a medication used to treat depression) 10 milligrams (mg), give one tablet by mouth one time a day. 2. Folic acid (a supplemental vitamin) one mg, give one tablet by mouth once daily. 3. Senna (a medication used to treat constipation) 8.6 mg, give two tablets by mouth two times daily. R46's EHR lacked orders for medications to be crushed and mixed. Observed on 01/15/26 at 07:12 AM, Certified Medication Aide (CMA) R, crushed together citalopram 10 mg, folic acid one mg, and senna 8.6 mg, and then gave them to R46. During an interview on 01/15/26 at 07:15 AM, CMA R stated R46's medications were always crushed together and then given to R46. During an interview on 01/15/26 at 07:49 AM, CMA R stated there should have been an order to crush medications and an order allowing the medications to be mixed together. During an interview on 01/15/26 at 07:56 AM, Licensed Nurse (LN) G stated there should have been an order to crush and mix the medications; if this happened without an order, then it was a medication error. LN G verified R46 had no order to crush medications, and she was not listed as a resident who required medications to be crushed. During an interview on 01/15/26 at 08:00 AM, Administrative Nurse D stated there should have been an order to crush medications and if there are specific warnings about medications being crushed, then there should have been an order related to the specific medication. Administrative Nurse D also said if medications were crushed and given with no crush order, it was not a medication error. The facility's policy Medication Administration General Guidelines, dated 01/24, documented the need for crushing medications was to be indicated on the resident's orders and the medication administration record (MAR) so all were aware of the need, and the consultant pharmacist could advise on safety and alternatives, if appropriate, during medication regimen reviews (MRR).

The facility reported a census of 45 residents. The sample included 13 residents with four residents reviewed for accident. Based on observation, interview and record review, the facility failed to clean reusable shared equipment between residents and failed to use proper Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for R1 who had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and wounds. Findings included:- On 01/14/26 at 07:55 AM, Certified Nurse Aide (CNA) N and CNA O entered Resident(R)1's room to transfer him with a mechanical lift. There was no visible EBP notification on the door. R1 had an indwelling catheter visible, with the tubing visible. CNA P and CNA O did not wear gowns during the care. On 01/14/26 at 10:17 AM, Certified Medication Aide (CMA) S finished a glucose check for Resident (R) 26 using a glucometer (instrument used to assess blood glucose levels) and proceeded to the cart. CMA S wrote down the number but did not clean the glucose monitor. CMA S pushed the cart to R1's room. CMA S obtained a test strip and placed it in the glucometer and obtained gloves. CMA S entered the room and uncovered R1 per his request. CMA S laid the glucometer and gloves on the overbed table, then washed her hands. CMA S applied gloves, started the monitor, cleaned R1's finger with alcohol, poked R1's finger to get a drop of blood, and checked the blood glucose level. CMA S threw trash away, then washed her hands. CMA S went to the hall and started to proceed to the next resident. Administrative Nurse E walked up to get dressing supplies out of the cart. Administrative Nurse E saw what CMA S was doing and left and returned with Sani-cloths. Administrative Nurse E cleaned the glucometer and wrapped it up, then got out another glucometer so they could have two in use, one to use while the other was sanitized. Administrative Nurse E told CMA S the glucometer should be cleaned between uses. On 01/14/26 at 10:40 AM, CMA S stated she was not aware that the glucometer was to be cleaned between residents. She has not been doing it and said she was never taught it needed to be done. On 01/15/26 at 10:58 AM, Administrative Nurse D stated she expected the CNAs to utilize EBP every time a resident with a wound or artificial opening was present. On 01/15/26 at 11:58 AM, Administrative Nurse D and Administrative Nurse E stated they expected staff to clean glucometers between each use. The facility's ML Skills Check-Blood Glucose Monitoring - Cloned 3/20/201 documented that the glucometer was to be cleaned after use, wrap the meter inside a wipe, and place a new clean field. Review of the facility provided policy Summary of Personal Protective Equipment [PPE] Use and Room Restrictions When Caring for Residents in Nursing Homes, EBP was to be used for all residents with wound or indwelling medical devices ( such as catheters) regardless of MDRO infection or colonization.

The facility reported a census of 45 residents; the sample included 13 residents. Based on interview, observation, and record review, the facility failed to protect the dignity of Resident (R) 33 when staff was argumentative and used foul language while speaking to R33. Findings included:- During an observation and interview on 01/13/26 at 12:10 PM, R33 sat in her wheelchair. R33 stated she had requested the staff to perform additional vaginal area cleaning due to itching and irritation, and one of the staff members started to argue with her and used foul language. R33 requested her to leave several times, and the staff member said R33 was not her mother and left. R33 said she has had issues with that Certified Nurse Aide (CNA) before. During an interview on 01/15/26 at 09:04 AM, Licensed Nurse (LN) G reported R33 had reported to her that an evening aide was not handling her gently during cares and was not speaking to her appropriately, and she had requested for the CNA to leave. LN G said the CNA did not leave, and R33 had to tell her several times to leave. LN G said the CNA told R33 that R33 was not her mama, and the CNA was argumentative with R33. LN G also said R33 reported the CNA was no longer allowed in her room. During an interview on 01/15/26 at 09:53 AM, Administrative Nurse D reported she had been informed about the CNA interaction with R33, and she had re-arranged the schedule so the CNA would not be part of R33's care, and then the problem had corrected itself when the CNA abruptly quit without notice before working again. The facility policy Abuse, Neglect and Exploitation, dated 10/2022, documented it was the policy of Medicalodges, Inc., to treat each resident with respect, kindness, dignity, and care, and to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged abuse and neglect.

The facility reported a census of 45 residents; the sample included 13 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 18 and/or his representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:- Review of the Electronic Health Record (EHR) for R18 included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic pain (persistent pain lasting over three months). R18's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R18's pain frequency was almost constant. The Psychotropic Drug Use Care Area assessment (CAA), dated 01/02/26, documented R18 had been administered antidepressant (a class of medications used to treat mood disorders) medications. The Pain CAA, dated 01/02/26, documented R18 had reported pain almost constantly with a pain value of 7 to 10 on a numeric rating scale of zero to 10. R18's Care Plan, dated 03/18/24, documented R18 had been taking medication to manage his chronic and acute pain. An intervention dated 12/19/25 included the administration of ordered Lyrica (an anticonvulsant and analgesic drug used for nerve pain) 50 milligrams (mg), one capsule three times a day for pain. R18's EHR revealed a psychotropic consent signed and dated 05/08/25 which listed Lyrica 50 mg to be given twice daily. R18's EHR documented a new order, dated 12/15/25, for Lyrica 50 mg, three times daily for pain related to chronic pain. R18's EHR lacked evidence R18 or his representative received education and/or informed consent regarding the Lyrica dose and frequency increase. During an interview on 01/15/26 at 10:34 AM, Licensed Nurse (LN) G stated psychotropic consent was for the purpose of informing the resident and/or legal representative of risk/benefits of medications and then to approve the medication. She then said she was unsure when those consents were done and unsure who was responsible for having them done. During an interview on 01/15/26 at 11:04 AM, Administrative Nurse D reported she and Administrative Nurse E were responsible for performing the psychotropic medication consents. She stated the consents were done on admission if the resident was admitted on a psychotropic medication, before starting a psychotropic medication, and any time there was a change in the medication. She confirmed R18's consent was not accurate. The facility policy Behavior Management & Psychotropic Medications, dated 04/2025, documented informed consent was to be completed for the use of psychotropic medications and off-label use of medication which affects brain activity for the residents prior to initial administration of the medication and with a dose increase of psychotropic medication.

The facility had a census of 45 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide a bed hold and written notification of transfer for Resident (R) 49 and failed to provide written notification of transfer for R33. The facility additionally failed to notify the Office of the Long-Term Care Ombudsman (LTCO). Findings included:1. R49's Progress Notes dated 11/04/25 at 12:36 PM, documented another facility had arrived to pick up R49 to transport her to their facility for transfer. R49 would not wake up, and efforts to arouse R49 were ineffective. Staff notified Emergency Medical Service (EMS), and EMS transported R49 to the hospital. R49's Electronic Medical Record (EMR) lacked evidence the facility provided written notification of the transfer, and a bed hold notice to R49 and/or his representative. The facility was unable to provide evidence of notification to the LTCO for R49's transfer. 2. R33's Transfer Note dated 08/24/25 at 09:12 PM, documented R33 was not able to have a sensible conversation with caregivers, was not able to voice her pain levels, and was not able to wheel herself in her wheelchair as normal. R33 was sent out to the emergency room (ER) for further checkup. The admission Progress Note, dated 08/29/25 at 09:00 PM, documented R33 was readmitted to the facility from the hospital. R33's EMR lacked evidence R33 or her legal representative was provided written notification, and lacked evidence the LTCO was notified of her transfer to the hospital on [DATE]. During an interview on 01/14/26 at 10:13 AM, Social Services X stated the nurse on duty would provide the bed hold when a resident transferred to the hospital. Social Services X also said there should have been a bed hold provided when R49 transferred to the hospital, and the nurse should have provided the written reason for transfer. Social Services X also stated the LTCO was notified monthly of transfers and discharges via email. Social Services X confirmed there was no bed hold provided, and the written notification was not provided to the R$9 or his legal representative, or to the LTCO regarding his transfer or discharge. During an interview on 01/14/26 at 10:30 AM, Licensed Nurse (LN) I stated she was unsure about who provided a bed hold and had never been informed about who provided a bed hold. LN I said she believed the business office or social services designee (SSD) provided bed holds and written notification. During an interview on 01/14/26 at 11:00 AM, Administrative Nurse G stated the bed hold notification was kept at the nurse's station, and it was sent with the resident and EMS when the resident was transferred to the hospital. Administrative Nurse G then said the business office provided follow-up within 24 hours of transfer or discharge. She further stated a progress note was also done, which documented a notification was provided and sent. During an interview on 01/14/26 at 04:02 PM, Social Services X said there was no written notification provided to R33 or her legal representative about her transfer to the hospital, and there was no evidence the LTCO was notified of R33's transfer to the hospital. The facility policy Notice of Bed Hold Policy and Returns, dated 12/14/17, documented it was the policy in all Medicalodges, Inc. facilities to provide a written notice to residents, family members, or legal representatives of the facilities bed hold policies at the time of admission and again at the time of transfer of a resident to a hospital or for therapeutic leave.

The facility identified a census of 45. The sample included 13 residents with one resident reviewed for mobility or range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement an assistive program to help maintain ROM and prevent a potential decrease in ROM/mobility for Resident (R) 22. Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness) and a paralytic gait (a walking pattern characterized by stiffness, decreased coordination, and muscle weakness). R22's Significant Change Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 99, which indicated R22 was unable to complete the interview. Per staff interview, he had short-term and long-term memory deficits. The MDS documented R22 had an impaired ability to make himself understood through verbal and non-verbal expression of ideas and/or wants because he was rarely or never understood. The MDS documented R22 had received antidepressant (a class of medications used to treat mood disorders) and antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications. R22's Care Plan, created on 01/22/21 and revised on 11/26/25, documented the nursing staff would monitor for tearful behavior. R22's Care Plan, created on 01/22/21 and revised on 04/03/24, documented R22 was dependent with all activities of daily living (ADLs) except eating, for which he required maximum assistance. R22's EMR, including under the Tasks section, lacked evidence active or passive ROM or restorative care was provided. Observation on 01/13/26 at 09:30 AM revealed R22 sat in the television room in a high-backed wheelchair. His hands were curled inwards with fingers extended and held close to his chest. Observation on 01/13/26 at 11:25 AM revealed R22 remained in the television room. His hands were in the same position as in the previous observation. The television showed only a blue screen. On 01/14/26 at 11:55 AM, observation revealed R22 sat in his wheelchair at a table in the dining room. His hands were underneath a blanket was pulled up to his elbows. His eyes were closed, and he had a facial grimace. On 01/14/226 at12:03 PM, staff fed R22 his meal while the resident's arms and hands remained under a blanket. On 01/15/26 at 07:49 AM, R22 sat in his wheelchair in the television room/. His right hand was clenched shut and rested in his lap. R22 had very limited ability to open and close his right hand, and he nodded yes when asked if it was difficult to open and close his hands. On 01/14/26 at 11:02 AM, Certified Nurse Aide (CNA) P said she felt all residents should have a restorative program. On 01/14/26 at 11:04 AM, CNA N stated she felt residents should have a restorative program which included ROM, mobility, and stretching. On 1/14/26 at 02:12 PM, CNA M revealed R22 was not able to utilize a call light due to the limited range of motion of his hands. On 01/15/26 10:09 AM, License Nurse (LN) G revealed R22 does not have any restorative or specific care areas to prevent contractures (abnormal fixation of a joint or muscle) or prevent a decline in his ROM or mobility care. LN G revealed R22 had restricted ROM in all his extremities. LN G stated staff assessed R22 every two hours for positioning. LN G confirmed a passive ROM plan would be a good idea for R22. LN G also stated due to R22's limited mobility and ROM restriction in his hands, a soft-touch call light might be more appropriate for the resident than a regular push-button call light. On 01/15/26 at 10:20 AM, LN J stated the facility no longer had a restorative program. On 01/15/26 at 11:40 AM, Administrative Nurse D revealed restorative services, or a passive ROM program, would be expected for R22. Administrative Nurse D verified there was no documentation in the resident's clinical record or tasks which indicated ROM services to prevent further decline were provided. The facility's Restorative Program policy dated 03-2014; Rev. 12-2018; 12-2022 documented restorative programs will be provided to each resident based on their individual needs to maintain their highest level of functioning in the areas of physical, mental, and psychosocial well-being.

The facility reported a census of 45 residents; the sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow an intervention to prevent further falls after a fall for Resident (R) 6. This placed the residents at risk for further falls and related injuries. Findings included:- R6's Electronic Medical Records (EMR) documented diagnoses which included anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dialysis (a procedure where impurities or wastes are removed from the blood), and hyperextension (movement at a joint to a position beyond the joint's normal maximum extension). R6's 03/25/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R6 had no falls within the last six months or while admitted . R6's Falls Care Area Assessment documented R6 was at risk for falls. R6's Care Plan documented she was at risk for falls related to confusion; initiated on 03/19/25. Staff were to place R6's wheelchair by her bed, and anti-roll back brakes were attached on 02/07/24. A bed alarm was placed on 09/01/24. Staff were to frequently check on R6, initiated on 12/10/24, and lower the bed to the lowest position, initiated on 06/04/25. R6's Care Plan directed staff to ensure her fall mat was in place, initiated on 03/25/25. R6's Fall Risk Assessment V1.0, dated 01/05/26, documented she had a high risk of falls. On 01/13/26 at 09:43 AM, R6 laid in bed with the wheelchair beside her bed. She had a large bruise on the left side of her face from her forehead to her neck. R6 was lying toward the side of the bed closest to the wheelchair. There was no fall mat on the floor beside her bed. On 01/13/26 at 03:54 PM, R6 was sleeping on the side of the bed. There was no fall mat in place. On 01/14/26 at 08:47 AM, Certified Nurse Aide (CNA) M assisted R6 to her room and assisted her to her bed. CNA M placed the wheelchair in the bathroom and did not place the fall mat on the floor beside her bed. On 01/14/26 at10:15 AM, R6 laid in bed. No floor mat was on the floor beside the bed. On 01/14/26 at 03:42 PM, CNA N stated R6 was a high risk for falls. CNA N stated staff were to put a fall mat on the floor on the side of the bed. On 01/15/26 at 11:42 AM, Administrative Nurse D stated R6's interventions for falls include a fall mat next to bed, assisting R6 to her room after meals, assisting R6 to the bathroom, placing a stop sign, leaving a bathroom light on at night, checking oxygen level at night, proper footwear, and a call light. Administrative Nurse D said she expected R6's interventions be followed. The facility's undated policy Electronic Care Plan documented the resident's person-centered plan of care was an active working document that reflects the care needs and resident voice. The facility's undated policy Falls Management documented the facility strives to minimize the risk for resident falls and to reduce injuries associated with resident falls.

The facility identified a census of 45 residents. The sample included 13 residents with three sampled for nutrition. Based on observation, interview and record review, the facility failed to promote Resident (R) 3's highest practicable nutritional status when staff failed to weigh the resident upon admission and readmission after hospitals stays in order to establish a baseline and/or identify weight loss. Findings included:- R3's Electronic Medical Record (EMR) revealed a diagnosis of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), osteomyelitis (local or generalized infection of the bone and bone marrow), right leg above-the-knee amputation (surgical removal of a body part), and left leg below-the-knee amputation. R3's 12/05/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R3 had a weight loss of five percent (%) or more in the last month or 10% or more in the last six months. R3's Care Plan, dated 08/26/25, documented R3 was at risk of weight loss or gain due to the disease process and directed staff to weigh him as the physician ordered. R3's Physician's Order documented an order for a weekly weight with a start date on 09/01/25. R3's Physician's Order documented an order for a daily weight for three days with a start date on 10/04/25. R3's Physician's Order documented an order for a daily weight with a start date on 10/10/25. R3's Physician's Order documented an order for a weekly weight with a start date on 10/15/25. R3's Physician's Order documented an order for a weekly weight for four weeks with a start date on 11/2625. R3's EMR documented an admission date of 08/25/25. R3's EMR lacked an admission weight until 09/09/25. The weight recorded for 09/09/25 was 259.6 pounds (lbs). R3 was discharged from the hospital on [DATE]. R3 was readmitted on [DATE] and discharged back to the hospital on [DATE] with no weight obtained during this time. R3 readmitted on [DATE]. R3's EMR lacked evidence of a weight assessment at that time or for the next 19 days. R3's EMR recorded a weight dated 10/29/25 prior to discharge back to the hospital that day. R3's weight on 10/29/25 was 249.4 lbs., showing a 10 lb. weight loss. R3 readmitted on 11/19//25 and discharged on 11/23/25 with no weight obtained during the stay. R3 readmitted on [DATE]. R3's EMR lacked evidence of a weight assessment at that time and did not record a weight until 12/11/25, when his weight was measured at 222.2 lbs. On 01/14/26 at 07:50 AM, R3 reclined in bed with his bedside table over him. He ate breakfast at that time. His eggs were partially eaten. R3 stated he was feeling a little better than the previous day. On 01/14/26 at 3:42 PM, Certified Nurse Aide (CNA) N stated R3 had been sick and had not been eating as much the last few days. CNA N reported R3 snacked a lot and had food delivered. CNA N stated the CNAs help get the residents' weights. On 01/14/26 at 03:58 PM, Licensed Nurse (LN) H stated staff weigh residents as ordered. The dietary manager and the CNAs weigh the residents, and Dietary BB entered the weights in the EMR. On 01/14/26 at 01:36 PM, Administrative Nurse D stated she expected staff to weigh a resident as ordered. The expectation was that when a resident was admitted or readmitted , staff would weigh the resident weekly for four weeks, then monthly unless otherwise ordered by the physician. The facility's policy Weight Assessment and Intervention documented the nursing staff will record the resident's weight the day they move in and once a week for four weeks. If no weight concerns are noted, the resident's weight will be recorded monthly.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include actual staff hours, as required. Findings included:- During an observation on 01/14/26 at 11:27 AM, the daily staffing sheet hung on the wall near the nurse's station. The daily nurse staffing form for 01/13/26 and 01/14/26 was posted and lacked the actual hours worked per shift for licensed and unlicensed staff providing resident care. Review of the daily staffing sheets from September 2025 through January 14, 2026, revealed some of September's staff sheets were filled out correctly. There were no staffing sheets for October 2025. November's staffing sheets lacked actual hours. December's staffing sheets lacked actual hours. January 1 through 6 staffing sheets lacked actual hours worked. January 7 through 12 had actual hours worked. On 01/14/26 at 11:27 AM, Administrative Nurse E stated she filled out the staff sheet and did not put actual hours on the posted sheet; the business office completed it later. On 01/14/26 at 2:48 PM, Administrative Nurse D stated she was not aware of the requirement to have actual hours posted on the daily staff sheet. The business office took care of it later. The facility's Benefits Improvement Protection Act (BIPA) Nurse Staff Posting, revised 12/2019, documented the total hours worked this shift will be completed by the charge nurse at the end of the shift. The actual hours worked will be verified by the business office.

The facility reported a census of 44 residents with three residents included in the sample. Based on observation, interview, and record review the facility failed to ensure an environment free of accident hazards on 01/14/25 when Certified Nurse Aide (CNA) M did not follow the standard of care and utilize another staff member assistance during the transfer of Resident (R) 1 from his wheelchair to his bed, using a Hoyer Lift (a mechanical device that helps people with limited mobility be transferred safely with minimal physical effort). Findings included: - The Quarterly Minimum Data Set (MDS) dated [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The Care Plan revision dated 12/31/24 revealed R1 required assistance from staff with all transfers. An observation on 01/14/25 at 12:35 PM revealed CNA M transferred R1 from his wheelchair to his bed using the Hoyer lift by herself. An interview on 01/14/25 at 12:35 PM with CNA M revealed if the resident was light, they could use the Hoyer and lift the resident by themselves. An interview on 01/14/25 at 01:25 PM with Administrative Nurse D revealed the protocol for transfers of a resident using the Hoyer lift was two staff members to always be present to assist with transfers. An interview on 01/14/25 at 02:50 PM with CNA N revealed the facility provided training on the Hoyer and Sit-to-Stand lifts and noted they were to always have two staff members while using the lifts. On 01/14/25 at 03:00 PM Administrative Nurse D stated the facility did not have a policy regarding Transfers and further stated staff were to follow known standards of care utilizing two staff to transfer residents using a Hoyer lift. The facility failed to ensure an environment free of accident hazards on 01/14/25 when CNA M transferred R1 from his wheelchair to his bed with the use of a Hoyer lift and did not have an additional staff member present for the transfer.

The facility reported a census of 43 with 3 residents selected for review. Based on observation, interview, and record review, the facility failed to implement infection control measurements by the failure to cleansing hands between glove changes during a wound dressing change on Resident (R) 2. Findings included: - The Physicians Order dated 08/29/24 revealed R2 had diagnosis that included chronic multifocal osteomyelitis of multiple sites (local or generalized infection of the bone and bone marrow), and pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence as results of pressure or pressure in combination with shear and/or friction). The Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief interview for Mental Status (BIMS) of 15, that indicated intact cognition. R2 had one stage three pressure ulcer injury over bony prominence upon admission. R2 used a pressure reducing device for chair and bed and was on a turning repositioning program. The Care Plan dated 08/16/24, revealed R2 was at risk for alteration in skin integrity related to limited mobility and pain. Staff to provide education on the need to change position with staff every two hours and as needed. Licensed staff instructed to provide wound care to the left hip, right buttocks, left buttocks, and right below knee amputation. The Wound Care Plus orders received on 09/03/24 included for the left hip/ Right stump: cleanse area with hypochlorous acid (a cleanser that acts as a preservative that inhabits microbial contamination), place gauze soaked in hypochlorous acid on the wound for 15 minutes and apply Santyl (medication used to remove dead tissue for chronic skin ulcers). Apply calcium alginate (used to treat wounds that are moderately to heavily drainage, helps to create a moist healing environment), and change dressing to areas every other day. The Electronic Medical Records dated 09/03/24, revealed R2 returned from the hospital with new wounds. R1 readmitted with wounds to the right shin, lateral buttock, to and one over the left greater trochanter (hip). Observation on 09/09/24 at 11:15 AM revealed wound care provided by Licensed Nurse (LN) G for the following areas of R2's right hip, right stump, and left hip. During the wound care observations, LN G failed to cleanse her hands after removing her soiled gloves and donning on clean gloves throughout the dressing changes. On 09/09/24 at 12:15 PM, Interview with Licensed Nurse G regarding proper hand sanitizer between the soiled gloves and clean gloves, LN G stated she was aware she needed to use hand sanitizer or wash her hands between each glove changes. On 09/09/24 at 04:30 PM, Interview with Administrative Nurse D revealed the expectations was the nurses to follow the standard procedure for wound care. The policy Wound Prevention and Management dated 12/2018 to provide a systematic approach for identifying resident at risk for skin breakdown and develop interventions to decrease the incidence of residents who develop pressure ulcers while providing guidelines for optimal care to promote healing for resident with all identified skin alterations. The facility failed to implement infection control measurements for R2 by not cleansing hands between gloves during wound care.

The facility reported a census of 38 residents. Based on observation, interview, and record review, the facility failed to store Controlled Medications (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence), permitting only authorized personnel to have access related to diversion of controlled medication for three residents. Resident (R)145 for unknown quantity of Lorazepam, 0.5 milligram(mg) tablets (anti-anxiety medication), R 146 for unknown quantity of Oxycodone ,d+[DATE] mg. tablets (a narcotic/pain medication), and R 147 for unknown quantity of Lorazepam. Additionally, the facility failed to provide a safe environment for all residents by the failure to ensure one of two medication carts, used to store resident's medications remained locked when not in direct line of vision of the licensed nurse passing medications from their carts. Findings included: - On [DATE] at 10:29 AM, Administrative Nurse B confirmed the diversion of controlled medications reported on [DATE] of two residents, (R)145 and R 146 resulting in the discovery of an additional missing controlled medication card for resident R 147. She reported the events as follows: On [DATE] at 12:23 PM, Licensed Nurse (LN) N called Administrative Nurse B and reported during the shift change medication reconciliation between LN N and LN P they identified a discrepancy. Two medication cards of controlled medications were missing. The card count (vacuum sealed cards which contained up to 31 tablets) for Lorazepam 0.5 mg Ativan for Resident (R)146 and Oxycodone ,d+[DATE] for (R) 145. There were two missing cards with unknown quantities of controlled medication. The total tablet count was not established due to the alleged perpetrator (AP Administrative Nurse O,) removed the count sheet used for reconciliation which contained the number of tablets in each medication card. LN N reported he asked LN P (no longer employed) the day shift nurse why the cards were missing, and LN P informed him Administrative Nurse O (no longer employed) had taken them out of the locked narcotic medication drawer earlier in the day to destroy them. Administrative Nurse B stated the facility protocol required both Administrative Nurse B and Administrative Nurse O to be present when removing controlled medication from the medication cart to be destroyed. Controlled medications should be destroyed when the medication order changed, or the resident is discharged from the facility. She stated the two administrative nurses have different keys to the lock box for controlled medications and the destroy cabinet. Both keys were required to enter the controlled medication cabinet where and /or the medication cart, the director of nursing (DON) and Assistive director of nursing (ADON) are to be present when medications are taken out of the Cart to the Nursing office with the corresponding narcotic sheet, to verify the medication count and then put in the destroy closet to be destroyed when the pharmacist comes to the building. The destroy medication closet is to be locked and requires the two administrative nurse's keys to be opened. Upon reconciling medications, Administrative Nurse B reported she noted the destroyed medication closet was missing an additional card of unknown quantity of Lorazepam for R 147 in addition to the two missing cards that Administrative Nurse O reportedly removed from the medication cart to place in the destroy closet. She stated when she opened the closet while conducting the investigation of the first two missing medication cards, she noted the destroyed narcotic count book with logged entries with the last line whitened out, the count revealed the third missing card of medications for R 147. Upon inquiry, Administrative Nurse B stated that at the time of the missing medication cards she had kept her keys to the destroyed closet in a purse under her desk, the AP was the assistant director of nursing at the time and had the second key required to enter the destroy closet. LN P was a new nurse and may not have been aware of the policy to only allow the removal of controlled medications from the cart with two administrative nurses present at the time of removal. Additionally, Administrative Nurse B reported she could not get into the destroy closet to investigate because Administrative Nurse O had the second key, so she had to call the policy to break into the closet to conduct the investigation. The police came and broke in the door to gain access to the closet and the reconciled closet content revealed R 147, was missing Ativan 0.5 mg card and the paper sheet. His medications were taken out of the medication cart and put in the closet on [DATE], because he was deceased . The police came out filed a report. She reported she then notified the state agency on [DATE]. On [DATE] at 12:05 PM, LN M, performed the count for the North Hall Medication Cart and the medication storage room. Reconciliation of the count sheets and the medications was completed accurately. On [DATE] at 12:25 PM, LN M stated when a physician discontinued a resident's-controlled medication, the narcotics were pulled by two administrative nurses at the same time. They count and reconcile the medications at that time and put them in the destroyed medication closet. The nurses count the medication each time when we switch cart. Medication aides do not have access to narcotics nurses only pass the controlled medications. Nurses are to count every shift change. On [DATE] at 12:58 PM, Administrative Nurse B confirmed the above findings. She stated the diversion did occur. Administrative Nurse O accessed both keys entered the cart independently, removed two controlled medication cards for two residents. She reported she should have maintained her key on her person at all times, to prevent any one person having access to both keys. Additionally, she stated the new nurse's orientation should have included not to give access to the controlled medication drawer to remove medications to be destroyed without the direct presence of two administrative nurses. She agreed the facility failed to implement the system designed to ensure secure storage of controlled medications. The facility policy, Storage of Medication, dated 2007, documentation included controlled medications should be stored separately from non-controlled medications. The access system (key, security codes) used to lock schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. The facility failed to store Controlled Medications permitting only authorized personnel to have access related to diversion of controlled medication for the residents of the facility. 46960 - On [DATE] at 08:25 AM, a Nurse treatment cart that contained wound care supplies and medicated ointments had been unlocked and unattended. At 08:30 AM, Administrative Nurse C stated that the cart was the nurse's responsibility and confirmed that the cart was unlocked and unattended. Administrative Nurse C stated that the treatment cart should be locked when unattended. The facility's Storage of Medication policy, dated ,d+[DATE] documented that the medication supply shall be accessible to licensed nursing personnel, pharmacy personnel or staff members that are lawfully authorized to administer medications. Further documented that to limit the access to prescription medications, storage areas should remain locked when not in use or attended by persons with authorized access. The facility failed to provide a safe environment for all residents by the failure to ensure a medication cart used by the facility remained locked when not in direct line of vision of the licensed nurse passing medications from their carts.

The facility reported a census of 38 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to weekend staffing data is excessively low. Findings included: - Review of the Payroll Based Journal (PBJ) Staffing Data Report submitted revealed weekend staffing data excessively low as follows: 1. The first quarter of fiscal year (FY) 2023, (10/01/22 through 12/31/22). 2. The second quarter of FY 2023, (January 01,2023 through March 31/2023). 3. The third quarter of FY 2023, (04/01/2023 through 06/30/2023). 4. The fourth quarter of FY 2023 (July 01/2023 through September 30, 2023). Review of the nursing staff schedule, agency staff, and staff postings for direct care on the weekends identified above were inaccurate and did not capture the direct care time delivered by licensed nurses, certified department heads, and agency staff. Additionally, review of the agency staff time sheets, and the certified department heads attendance revealed the available staff present which provided direct care during the identified weekends noted in the above quarters. On 02/22/24 at 10:45 AM, Administrative Nurse B reported here were some weekends the facility was short of preferred nurse staffing, but the positions were covered by the administrator, department heads, and agency staff that were licensed or certified, to ensure direct care was provided for the residents. Upon review of the documentation noted above, she confirmed the PBJ failed to accurately reflect the direct care staff available to provide care on the weekends for the above noted quarters. On 02/22/24 at 12:40 PM, Administrative Staff A confirmed the PBJ did not capture the agency staff and the department heads that worked on the weekends as CNAs time accurately for the above noted. The facility lacked a policy to address the submission of accurate PBJ staffing report to CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to weekend staffing data is excessively low.

The facility reported a census of 38 residents with 13 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms and failure to follow the standard of practice when performing a partial bed bath to Resident (R) 195's perineum (the area of skin between the anus and the genitals). This deficient practice has the potential to lead to cross contamination between residents, and to place the residents receiving bed baths at increased risk of developing infections. Findings include: - On 02/20/24 at 12:46 PM, Laundry Staff I observed with an uncovered linen cart with clean linen being transported down the hallway, and Laundry Staff I delivered linens to several resident rooms while wearing the same gloves, no hand hygiene or glove change performed between contacts with resident rooms. On 02/20/24 at 12:50 PM, Laundry Staff I reported the linen cart could be covered or uncovered, depending on the preference of whomever delivered the laundry. Further stated that she was unsure what the policy documented related to the delivery of clean linens. The act of wearing gloves were for her protection and that she had not received training to change gloves or perform hand hygiene between resident room contacts. On 02/20/24 at 04:19 PM, Maintenance Supervisor J revealed that he did not know if linen carts were to be covered or if staff should change gloves or perform hand hygiene between resident room contacts. On 02/26/24 at 01:24 PM AM, Administrative Nurse B stated that her expectation for laundry personnel to change gloves (if applicable) and perform hand hygiene between resident room contacts. Administrative Nurse B stated that at the time of the observation on 02/20/24 when Laundry Staff I transported clean linens down the hallway, she was unaware of any requirement to transport clean linens by methods that ensure cleanliness and protect from dust and soil. Additionally stated that it was an infection control concern for cross-contamination between residents if the linen cart remained uncovered. The facility's 11/2023 Infection Management Process policy failed to document instructions for staff related to delivery of clean linens. The facility's 05/2017 Hand Hygiene policy documented that hand hygiene should be completed by staff before and after resident contact and between glove changes. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards for handling and transporting linens to prevent the spread of infection. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. - R195's Electronic Health Record (EHR) revealed diagnoses that included the following: urinary tract infection (UTI-an infection in any part of the urinary system), lack of coordination, overactive bladder, encounter following surgical amputation (surgical removal of a body part), osteomyelitis (local or generalized infection of the bone and bone marrow), need for assistance with personal care and generalized weakness. R195's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R195 required total care of two persons for all cares except eating which required supervision. R195 had an indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag). R195's Quarterly MDS, dated [DATE] documented a BIMS score of 13, which indicated intact cognition. R195 was occasionally incontinent of urine and had no indwelling or external urinary catheters. R195's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R195 was incontinent of urine and at risk for recurrent UTIs with contributing factors of weakness, impaired mobility and cognitive loss. On 02/21/24 at 01:25 PM, Certified Nurse Aide (CNA) G performed peri-care (cleaning of the area between resident's anus and genitals) and a partial bed bath which included cleaning of several wounds on the resident's buttocks, perineum and coccyx (small triangular area at the base of the spine). CNA G performed hand hygiene and collected a basin full of warm soapy water that had previously been placed on an over the bed table. Staff positioned the resident on his back and spread his legs and exposed his genitals and perineum. CNA G washed area above genitals, then returned the soiled washcloth back to basin of soapy water and reused the same washcloth. CNA G then washed the resident's left inguinal crease (the area of the body where the leg joins the torso), then returned the washcloth back to the basin of soapy water and reused the washcloth. CNA G then washed the right inguinal crease, then returned the washcloth back to the basin of soapy water and reused the washcloth. CNA G then washed the resident's genitals, then returned the washcloth back to the basin of soapy water and reused the washcloth. CNA G then assisted the resident to roll to his left side and cleaned perineum and anus, then returned the washcloth back to the basin of soapy water and reused the washcloth. CNA G then washed the resident's right buttock, then returned the washcloth back to the basin of soapy water and reused the washcloth. Resident was assisted to roll to his right side. CNA G then picked up the basin of soapy water and walked around to the other side of the bed and placed the basin of soapy water onto the fall mat positioned on the floor. CNA G then assisted the resident to stay on his right side with her left hand and bent down to the floor and retrieved the same washcloth from the basin of soapy water on the floor and washed the resident's left buttock. CNA G then assisted resident to roll left to right and removed the bath blanket that was under the resident. CNA G utilized a single washcloth to perform peri care and returned the washcloth back to the basin full of soapy water throughout the entire procedure. On 02/21/24 at 01:40 PM, CNA G stated that this method of cleaning was how she was trained to perform this task. Stated that she has seen other CNAs perform this task by utilizing multiple washcloths to perform the same task. Further, CNA stated that she did not know what the policy or procedure was to perform this task. CNA G then stated that if the washcloth was visibly soiled, she would have utilized a new washcloth for additional cleaning. Additionally confirmed that the washcloth could have been soiled with contaminates that were not visible to normal human vision. On 02/21/24 at 01:45 PM, Licensed Nurse (LN) E stated the standard of care for peri-care and bed baths was that the tasks should be performed with a one-wipe-per-swipe method without regard to whether a washcloth or disposable wipe was used and that the wash basin should be set on a surface at waist height and not on the floor. On 02/21/24 at 02:00 PM, LN F stated that the standard of care for peri-care and bed baths was that the tasks should be performed with either washcloths or disposable wipes utilizing a one-wipe-per-swipe method and that wash basins should be set on a surface at waist height and not on the floor. On 02/21/24 at 02:20 PM, Administrative Nurse B stated that peri care should be done using one wipe per swipe and preferably with disposable wipes. Further stated that the wash basin or pack of disposable wipes should be set on the bedside table or some other surface, but never on the floor. Stated that all staff perform a skills check-off to perform cares and that indicated to use at least four disposable wipes for the procedure. Stated that she was unsure if there's a specific policy/procedure guide for the performance of this skill and confirmed improper cleansing technique was an infection control concern. On 02/22/24 at 08:15 AM, Administrative Nurse B stated that peri care should be performed to the professional standard of care and that the facility lacked a policy or procedure guide specific to this task. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms and failure to follow the standard of practice when performing a partial bed bath to Resident (R) 195's perineum (the area of skin between the anus and the genitals). This deficient practice has the potential to lead to cross contamination between residents, and to place the residents receiving bed baths at increased risk of developing infections.

The facility reported a census of 38 residents. Based on observation, interview, and record review the facility failed to ensure a safe sanitary environment for the residents and staff in the facility laundry. Findings included: - On 02/22/24 at 08:04 AM, the tour of the laundry with Maintenance Staff J and Laundry Staff I revealed the following concerns: 1. The linoleum floor with multiple raised, unsealed, and unsanitizable areas throughout the laundry area. 2. The ceiling with an approximate six-foot brown stain. 3. An approximate four-to-five-foot section of the sheetrock wall had missing and bubbling paint. The wall with the bubbling paint measured approximately a 4 by 5-foot section. 4. A unpainted, unsealed, irregular textured epoxy patch along the wall which was unsanitizable. 5. Approximately one to two feet of torn sheetrock behind the soiled linen barrels storage. 6. Multiple broken and missing floor tiles. On 02/22/24 at 08:24 AM, the tour of the laundry with Maintenance Staff J and Laundry Staff I confirmed and agreed with the above identified concerns . On 02/22/24 at 08:45, Administrative Staff A confirmed the above concerns related to the laundry environment and sanitation. He reported the maintenance supervisor should address the noted concerns. The facility policy Housekeeping, Laundry, and Maintenance, dated 06/03/2014, documentation included the goals of the Housekeeping, Laundry, and Maintenance are to maintain a sanitary, comfortable environment and help prevent the development and transmission of infection. The facility failed to ensure a safe sanitary environment for the residents and staff in the facility laundry.

The facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility. Findings included: - On 02/22/24 at 04:00 PM, initial walk through of the facility with Administrative Staff A, identified a broken fiberglass reinforced panel (FRP - a waterproof plasticized product that is often used on high-contact surfaces such as walls or doors to prevent damage to the structural integrity of the material underneath), with a jagged edge approximately 10-12 inches off the floor on the door to the shower room on 100 hall that was only utilized by the residents on the 100 hall. On 02/22/24 at 04:05 PM, Administrative Staff A stated that the shower room would be removed from service until the door had been repaired and notified the appropriate personnel to remove and replace the panel. On 02/26/24 at 07:30 AM, surveyor verified with Administrative Staff A that the door panel had been replaced and with visual inspection of the shower room door on the 100 hall. On 02/26/24 at 01:30 PM, environmental tour with Maintenance Supervisor J revealed and confirmed the following areas of concern: 1. Seventeen (17) areas of concern where the carpet had frayed at the seams in the dining area, main hallway, nurses station area, 100 hall carpet and 200 hall carpeting. 2. A broken transition and frayed carpeting between the hallway and the shower room on 200 hall that was only utilized by residents of the 200 hall. 3. Numerous broken tiles in shower room on 200 hall that was only utilized by residents of the 200 hall. 4. The ceiling in the nursing station area immediately inside the main entry that led to the 200 hall had a seam where the drywall panels separated, and the seam had fallen away from the ceiling but was still attached to the ceiling. 5. Multiple areas on numerous visible walls in the residents' rooms, and hallways with wallpaper peeling away from the wall. 6. An area on the ceiling and the wall of 200 hall that transitioned from the nursing station where the wallpaper was held in place with scotch tape. On 02/26/24 at 01:45 PM, Maintenance Supervisor J was unable to provide an explanation why the identified items had not been replaced and/or repaired by the facility. The facility's undated Housekeeping, Laundry and Maintenance policy documented that the maintenance person is responsible for the routine repair and maintenance of the facility and equipment and preventative maintenance must be performed as listed in the Preventative Maintenance manual. The facility failed to provide a Preventative Maintenance manual. The facility's Housekeeping, Laundry and Maintenance policy, dated 06/03/14, documented that housekeeping, laundry and maintenance were responsible to keep the interior of the building clean, safe and orderly. Further documented that maintenance would maintain the facility in good repair and free from hazards such as loose or cracked floor coverings and other similar conditions. The facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility.

The facility reported a census of 38 residents with 13 residents sampled, that included five residents selected for review related to dignity. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Residents (R)40 and R95. This deficient practice led to R40's and R95's respective urinary catheter (a tube inserted into the bladder to drain urine and into a collection bag) bags to be visible to visitors and other residents. This practice had the potential to lead to negative psychosocial effects related to dignity. Findings included: - R40's Electronic Health Record (EHR) revealed a diagnosis of benign prostatic hyperplasia (BPH, a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 13, which indicated intact cognition. R40 had an indwelling urinary catheter (a tube inserted into the bladder to drain urine and into a collection bag) and required substantial or maximal assistance with all cares except eating, which he was independent. The Quarterly MDS dated [DATE], documented a BIMS of 13, which indicated intact cognition and that R40 had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/12/23 documented that R40 required assistance with toileting needs and actual incontinent episodes. The Care Plan, dated 11/20/23, revealed R40 had an indwelling catheter related to urinary retention (lack of ability to urinate and empty the bladder) and included the following interventions: On 11/20/23, staff were to change the catheter every 30 days. On 11/20/23, staff were to change the catheter as needed. On 11/20/23, staff were to monitor catheter output every shift. On 01/20/24, staff were to change the catheter every 30 days at bedtime on the 16th of every month. The care plan lacked interventions related to maintaining or protecting the resident's privacy or dignity related to the urinary catheter. The EHR Physician Orders documented the following: 1. On 02/16/24, urinary catheter in place and to change every 30 days and as needed on the 13th of each month related to BPH with urinary obstruction. 2. On 02/14/24, flush catheter nightly with 60 milliliters (mL) of sterile water at bedtime related to BPH with urinary obstruction. On 02/20/24 at 01:23 PM, R40 observed from the hallway resting in bed with a urinary catheter drainage bag hanging from the bed frame. The drainage collection bag was approximately 1/3 full of a transparent light-straw colored liquid. On 02/22/24 at 11:25 AM, Certified Nurse Aide (CNA) G revealed that urinary catheter bags should always be covered with a dignity bag or otherwise obscured from view of visitors and other residents to protect the resident's dignity. On 02/21/24 at 01:10 PM, Licensed Nurse (LN) F revealed urinary catheter bags should be inside dignity bags when ever they are visible to other residents or visitors and explained if a resident was in their bed, the drainage bag should be placed on the other side of the bed, other than in view of the hallway door. When a resident sat in their recliner or wheelchair, the drainage bag should be in a dignity bag or other device to obscure it from public view. On 02/26/24 at 12:57 PM, Administrative Nurse B revealed that all urinary catheter drainage bags should be in a dignity bag or otherwise always obscured from the view of other residents or visitors. The facility's undated Resident Rights policy documented that each resident has the right to a dignified existence and should be treated with consideration, respect and full recognition of their dignity and individuality which included privacy in treatment and care of their personal needs. The facility failed to protect the privacy and dignity of R40. This deficient practice led to R40's urinary catheter bag to be visible to visitors and other residents. This practice had the potential to lead to negative psychosocial effects related to dignity. 31078 - Resident (R) 95's signed physician orders dated 02/09/24, revealed the diagnosis that included bladder neck obstruction (lack of ability to urinate and empty the bladder). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident required moderate assist with toileting and supervision with mobility. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 02/14/24, revealed R95 required assistance with toileting needs and actual incontinent episodes. Contributing factors included weakness, impaired mobility, and cognitive loss. The risk factors included skin breakdown, falls, and recurrent UTIs (urinary tract infections). A care plan will be initiated/reviewed to improve/maintain current toileting skills and ability to transfer to the commode, continence status, decrease fall and pressure ulcer risk, and decrease risk for UTI. The CAA lacked documentation of the resident having an indwelling urinary catheter on admission to the facility due to bladder neck obstruction. R95's Care Plan dated 02/06/24, revealed the resident had an indwelling urinary catheter. Staff were to change the catheter every eight to ten days related to bladder obstruction and to monitor the output every shift. Review of the physician's admission orders, dated 02/08/24, revealed orders for a Foley catheter (urinary catheter), 18 French, with a 10 cubic centimeter (cc) bulb. Change every eight to ten days due to bladder neck obstruction. Observation on 02/20/24 at 09:00 AM, revealed staff assisted R95 to ambulate in the hallway with a walker as a mobility device. The resident's catheter bag hung on a bar on the side of the walker with no dignity bag in place and yellow urine was visible in the tubing and the urine collection bag. Observation on 02/20/24 at 01:35 PM, revealed the resident on his bed. The resident's catheter bag hung from the footboard of the bed. The urine collection bag lacked a covering, and yellow urine was visible from the hallway outside of the resident's room. Observation on 02/20/24 at 03:43 PM, revealed the catheter bag hung from the footboard on the bed above the level of the bladder. The collection bag lacked a covering and the resident's uncovered collection bag was visible from the hallway. Observation on 02/21/24 at 09:39 AM, revealed the resident on his bed. The collection bag contained urine and lacked a dignity bag. R95's door was open, and the uncovered collection bag was visible from the hallway. On 02/21/24 at 09:48 AM, Certified Nursing Assistant (CNA) D reported staff should cover the urinary collection bag. On 02/21/24 at 09:45 AM, Licensed Nurse (LN) E reported staff should keep a dignity bag on urinary collection bags. On 02/22/23 at 11:00 AM, Administrative Nurse B reported CNA's have skills checklists and should know how to care for a resident with a urinary catheter. All catheter bags should be kept in a dignity bag. The undated facility's policy for Resident Rights revealed the resident shall be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and in the care of personal needs. The facility failed to protect the privacy and dignity of R95 by not providing a dignity bag to cover his catheter drainage bag.

The facility reported a census of 38 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one sampled resident, Resident (R)195, related to the use of indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag). This placed the resident at risk for uncommunicated care needs. Findings include: - R195's Electronic Health Record (EHR) revealed diagnoses that included the following: urinary tract infection (UTI-an infection in any part of the urinary system), lack of coordination, overactive bladder, encounter following surgical amputation (surgical removal of a body part), osteomyelitis (local or generalized infection of the bone and bone marrow), need for assistance with personal care and generalized weakness. R195's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R195 required total care of two persons for all cares except eating which required supervision. R195 had an indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag). R195's Quarterly MDS, dated [DATE] documented a BIMS score of 13, which indicated intact cognition. R195 was occasionally incontinent of urine and had no indwelling or external urinary catheters. R195's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R195 was incontinent of urine and at risk for recurrent UTIs with contributing factors of weakness, impaired mobility and cognitive loss. The Care Plan, dated 01/07/24, revealed that R195 had an indwelling urinary catheter and included the following interventions: On 09/16/24, staff were to provide assistance with pericare (care of the skin of the area of the body between the anus and genitals) and catheter care. On 01/07/24, staff were to change the catheter as needed. On 01/07/24, staff were to monitor catheter output every shift. On 01/19/24, staff were to flush the catheter every night at bedtime. On 01/20/24, staff were to change the catheter every 30 days. The EHR Physician Orders documented the following: 1. On 01/11/24, to insert indwelling urinary catheter and lacked indication for use. 2. On 02/15/24, to flush urinary catheter every night at bedtime for wound care management. 3. On 02/15/24, to change the indwelling urinary catheter every 30 days for wound care management. The Progress Notes documented the following: On 01/06/24 at 12:12 PM, that staff had spoken with resident and family about changing from a condom catheter (a tube attached to a sheath for the penis used to carry urine to a collection bag) to indwelling catheter On 01/10/24 at 03:45 PM, that staff had spoken to wound clinic who had sent the resident from the wound clinic to the Emergency Department (ED) and staff explained that they had put in an indwelling catheter (at undocumented date/time) due to condom catheter being insufficient to control urinary incontinence. Review of EHR Tasks documented 39 entries that indicated the completion of catheter care between 01/06/24 and 02/22/24. On 02/22/24 at 02:30 PM, Administrative Nurse B revealed that the resident had a condom catheter changed to indwelling catheter some time on 01/06/24. On 02/26/24 at 12:57 PM, Administrative Nurse B confirmed that R195's Quarterly MDS, dated [DATE] incorrectly documented no indwelling or external urinary catheters. Further stated that her expectation was for all assessments including MDS assessments to be accurate. The facility failed to provide a policy related to accuracy of assessments as requested on 02/26/24 at 01:00 PM. The facility failed to accurately complete the MDS for R195 related to the use of indwelling urinary catheter. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 48 residents, with four residents sampled, including three reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure staff performed a safe transfer for Resident (R) 4, when the sling (unknown age) ripped and R4 fell three feet from a mechanical lift and resulted in a laceration to the back of her head that required two staples. Findings included: - R4's diagnoses from the Electronic Health Record (EHR) documented obesity, gout (inflammation of the joints), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and respiratory failure (lack of oxygen). The 03/27/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 required extensive assistance of two staff for transfers. R4 had no falls since the prior assessment. The 03/10/23 Care Plan documented R4 was at risk for falls. R4 required the use of a mechanical lift and two staff for transfers. The Care Plan did not include interventions related to sling use until a revision on 05/21/23, after the fall, which directed staff to audit slings prior to use. Review of the Fall Investigation dated 05/21/23, documented at approximately 10:00 AM, R4 was in bed and facility staff used a full body mechanical lift to transfer the resident to her recliner. As staff moved R4 in the mechanical lift, the sling (the harness-type material that connects to the lift and is used to hold the resident during transfers) broke and R4 fell about three feet to the floor. R4 had hit her head and sustained a laceration to the back of her head. Staff applied pressure to the laceration which took approximately 20 minutes to stop the bleeding. R4 was transported to the emergency room by emergency services, where R4 received staples to close the laceration. R4 returned to the facility. All slings in use were audited after the fall. The Witness Statement for the incident on 05/21/23 for R4, by Certified Nurse Aid (CNA) E, documented CNA D asked her to assist in getting R4 up. R4 was already in the sling. CNA D lifted R4 with the mechanical lift and the top strap on the sling snapped. CNA E noted R4 was in the air and fell to the floor. CNA D stayed with R4, and CNA E went to get the LN. The Witness Statement for the incident on 05/21/23 for R4, by CNA D, documented another staff member assisted with putting R4 in the sling. CNA D started to maneuver the mechanical lift over the recliner, the sling ripped, and R4 fell and hit her head on the leg part of the mechanical lift. Review of Progress Note dated 05/21/23, documented R4 did not lose consciousness, was alert and oriented. R4 complained of head and back pain, and she had a large bump to the back of her head. The bleeding subsided and R4's head was wrapped in a pressure dressing. R4 was being transferred in a mechanical lift when the strap gave way, and R4 fell from about three feet. Two CNAs were present during this and immediately got Licensed Nurse (LN) C for help. LN J entered R4's room to help, applied pressure to R4's head for about 20 minutes, and was able to stop the bleeding. A pressure dressing was then applied around her head and staff telephoned for emergency services (EMS) to transport R4 to the hospital. Review of Progress Note dated 05/21/23, documented R4 returned to the facility around 03:30 PM. R4 received two staples to the laceration on the back of her head and was given pain medication at the emergency room . R4 had directions to follow up in seven days with her provider to remove the staples. The staff administered pain medication to R4 when she stated she had pain to her back and hips. On 05/24/23 at 10:09 AM, observed R4 laid in her bed, in the regular height position, two CNAs were present, and a sling was under R4, as they prepared to get R4 up for the day. The two CNAs transferred R4 to her recliner. On 05/24/23 at 10:39 AM, R4 reported on that morning (05/21/23) she was in the lift with CNA D and CNA E there, and then she fell . R4 stated now she is leery of the mechanical lift, but the staff are good at talking to her during the transfers. R4 stated she went to the emergency room and got two staples in her head. On 05/24/23 at 11:09 AM, Laundry Staff H reported she did launder the slings for the mechanical lifts. Laundry Staff H reported she did inspect the slings each time they were laundered. Laundry Staff H reported she would report to her supervisor if she noted any frayed or ripped areas. On 05/24/23 at 11:40 AM, Laundry Staff I reported she did inspect the slings when she washed them. Laundry Staff I reported she would tug on the straps and look for rips or tears. On 05/25/23 at 06:40 AM, Maintenance Staff G reported the labels on the slings had worn off and were unreadable. He did not know the length of time they had been in use. Maintenance Staff G reported he inspected the slings as they were laundered but had no way of tracking each specific sling. Maintenance Staff G reported when he called the manufacturer, they informed him of the suggested length of time for use of a sling, was five years. They also had informed him of things to look for, such as slick or shiny spots at stress points. On 05/25/23 at 09:45 AM, Certified Nurse Aide (CNA) E reported on the morning of 05/21/23 she was called into R4's room to assist CNA D with the transfer, CNA D already had R4 in the sling. They began the transfer and R4 fell . CNA E went to get the LN. On 05/25/23 at 10:00 AM, Administrative Staff K revealed she completed an audit on all of the slings in use and discarded six of the nine. Administrative Staff K stated she discarded them due to tearing away from stitching at the shoulder areas on the netting material, and one had the handle on the back of the sling, pulling apart. None of them were discarded due to damage to the straps. On 04/27/23 at 10:30 AM, Administrative Nurse B revealed she expected all the staff to have the knowledge to use the mechanical lifts safely. Administrative Nurse B reported that she had looked at the broken strap that led to the fall and saw no rips, tears, or fraying that could have caused it. Administrative Nurse B reported all the slings they ordered were rated for up to 600 pounds. The facilities 12/2022 Fall Management policy documented the facility strived to minimize the risk for resident falls and to reduce injuries associated with resident falls. The facility failed to provide adequate assistive devices to prevent accidents, when R4 fell from a mechanical lift when the sling ripped on 05/21/23, which resulted in two staples to the back of R4's head.

The facility census totaled 49 residents, with three residents reviewed for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review the facility failed to ensure a safe/secure environment for cognitively impaired, independently mobile Resident (R) 1, with a known history of exit seeking, to prevent him from leaving the facility on [DATE] at around 08:00 PM. The facility failed to ensure all staff working were trained in elopement procedures, failed to have an effective system in checking the wandering alarm system for functionality at the exit door, and did not provide adequate supervision for R1. The resident remained outside of the facility for 17 minutes and staff found R1 walking west on the southside a four-lane divided highway, with speeds of 60 miles per hour. These failures placed R1 and one other resident with a WanderGuard and at risk for elopement, in immediate jeopardy. Findings included: - R1's diagnoses from the [DATE] Physician's Orders in the Electronic Medical Record (EMR) revealed dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors and delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue). The [DATE] Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. The resident was independent with ambulation and the MDS indicated R1 did not wander during the seven-day look back period. The [DATE] Cognitive and Behavioral Care Area Assessment (CAA) documented that R1 demonstrated fluctuating disorganized thinking during his look back period. The [DATE] Quarterly MDS revealed a BIMS of five, indicating severe cognitive impairment. The resident was independent with ambulation and the MDS indicated R1 did not wander during the seven-day look back period. The [DATE] Elopement Risk Scale assessment documented R1 was a high risk for elopement, due to wandering, verbal threats of elopement, packing his belongings, exit seeking, and his ability to open doors independently. The assessment documented R1 wore a WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on his ankle. The [DATE] Care Plan documented R1 ambulated independently and had a history of removing his WanderGuard. Staff were to check for WanderGuard placement each shift and to follow the facility protocol if he eloped. Staff were to complete frequent visual checks if R1 was near the exit doors. The Care Plan lacked updated elopement interventions after [DATE], as of review on [DATE]. The Behaviors Notes written by staff between [DATE] and [DATE] documented R1 opened the front exit door on four occasions and walked out of the facility once. The front door alarm sounded on one of the four occasions, and the WanderGuard alarm system sounded on two of the four occasions. The [DATE] Behavior Note documented R1 walked out the front door of the facility and down the sidewalk toward the street. The note lacked documentation if any alarms triggered or sounded. The [DATE] Physician Orders documented the staff were to check for placement of the WanderGuard each shift. The [DATE] Behavior Note documented that R1 opened the front door to the facility and walked outside, set off the door alarm, but not the WanderGuard alarm system. The [DATE] Nurse's Note documented R1 exhibited exit seeking behaviors throughout the shift, with attempts to exit the facility. The [DATE] Nurse's Note documented staff heard the door alarm sound around 08:00 PM, assessed the area, and noted no one present. The note documented R1 was the highest risk for elopement and staff initiated the facility's elopement protocol. Administrative Staff A found R1 outside of the facility and returned R1 to the facility at 08:17 PM, unharmed. Review of the surveillance video of the elopement involving R1 from [DATE] (no audio available) revealed R1 walked to the front lobby, pushed the front left door open (without difficulty) and exited the facility at 08:00 PM, per the time stamp. Both Administrative Staff A and Administrative Nurse B confirmed the door alarm sounded throughout the facility. The video review revealed the staff in the area at the time were walking or standing in the halls, but did not have a reaction to the audible door alarm, with staff observed walking in the opposite direction of the lobby and the front door. At 08:03 PM, Licensed Nurse (LN) P walked to the nurse's station, checked the alarm box for the exit door, then walked to the front door. LN P shut off the alarm via the code box at the front door and walked outside. LN P went back into the facility after a few seconds and walked to the nurse's station. Both Administrative Staff A and Administrative Nurse B confirmed that LN P initiated the facility's elopement procedure. Administrative Staff A left the facility at 08:08 PM, while staff walked throughout the facility, checking rooms and opening doors. At 08:17 PM, Administrative Staff A walked up to the front door with R1. Observation on [DATE] at 10:00 AM revealed the only facility door to have the WanderGuard alarm system was the front door. Administrative Staff A checked the WanderGuard for functionality and used a hand-held (unnamed) device which scanned the tag that displayed tag ok, indicating the WanderGuard tag was functioning properly. Administrative Staff A then took the WanderGuard tag to the front lobby, which set off the alarm system and created a loud alarm sound. Administrative Staff A walked to the front door and turned off the alarm. On [DATE] at 10:10 AM, R1 ambulated throughout the halls independently and wore a WanderGuard on his right wrist. Resident was steady on his feet with a normal gait and wore appropriate clothing and shoes. On [DATE] at 03:51 PM, LN Q used the hand-held device to check R1's WanderGuard for functionality. After confirming the WanderGuard was on R1's right wrist LN Q scanned the WanderGuard tag with the device, receiving the tag ok message. Staff did not check the WanderGuard with the WanderGuard system alarm in the lobby area. On [DATE] at 02:50 PM, Certified Nurse Aide (CNA) S stated R1 went out the facility door on [DATE]. CNA S confirmed R1 wore a WanderGuard, but that it did not work, allowing R1 to walk out the front door. The evening of [DATE], the front door did not latch and R1 pushed it open easily. When R1 exited the facility, staff told CNA S to check every room and open every door to look for R1, but she could not find him. CNA S stated other staff found R1 and brought him back to the facility unharmed. The facility gave R1 a new WanderGuard tag when he returned to the facility. CNA S stated she did not have any training on elopement protocol. Interview on [DATE] at 03:52 PM with LN Q revealed staff checked the placement of the WanderGuard each shift for R1 with the hand-held device to ensure the WanderGuard tag worked properly. When the device displayed tag ok, it meant that the WanderGuard tag functioned properly and will set off the WanderGuard alarm system if R1 walked too close to the front door. LN Q did not know what the hand-held device would show if the WanderGuard tag was not functioning properly, because it had never happened before. LN Q stated staff also checked the placement of R1's WanderGuard to ensure it was still on him. She stated that the WanderGuard tag was not checked with the WanderGuard alarm system regularly, only when the WanderGuard was first put on the resident. LN Q stated R1 set off the WanderGuard alarm system almost daily when he walked into the lobby and attempted to open the front door. LN Q said Maintenance Staff R was responsible for checking the doors and would sometimes set off the alarm, but LN Q did not know how he completed the task. Interview on [DATE] at 11:27 AM with LN P revealed on [DATE] he heard the door alarm sound when he passed medications and he went to investigate. He turned off the door alarm and walked outside to see who set off the alarm, but he could not find anyone. LN P stated he did not hear the WanderGuard alarm system sound at any time. He then walked back inside to look for R1 because R1 was a high elopement risk resident, but he could not find R1. LN P initiated the search for R1 with the other staff and notified Administrative Staff A of the elopement, who left the facility to go look for R1. LN P and the other staff continued to look for R1 in all rooms, opening doors and calling R1's name. Administrative Staff A called LN P stating staff found R1. LN P stated R1 was missing for approximately 15 minutes, and the staff assessed R1 when he returned to the facility unharmed with normal vital signs R1 told LN P he left the facility because he wanted to visit his wife. LN P stated he cut off the WanderGuard tag on R1's ankle and checked it with the WanderGuard alarm system, but the alarm did not trigger. LN P put a new WanderGuard tag on R1, but it too did not trigger the alarm. LN P stated the facility notified the WanderGuard company to fix the issue. Once fixed, both the old WanderGuard tag and the new WanderGuard tag triggered the WanderGuard alarm system. LN P confirmed the WanderGuard tags were checked daily with the hand-held device that displayed tag ok when it was working, but he did not know what was displayed when the tag did not work. LN P stated he remembered hearing the WanderGuard alarm system being triggered sometime earlier in the week, but did not know when it stopped working. R1 was a high elopement risk and LN P tried to keep track of him as often as he could, to monitor for attempted elopements. LN P stated R1 frequently spoke of wanting to leave to see his wife, but R1 never eloped prior to [DATE]. LN P stated the management team was responsible for checking the WanderGuard alarm system. Interview on [DATE] at 05:07 PM with Maintenance Staff R revealed he checked the code to the front door weekly to ensure it still worked and he changed the code each month. Maintenance Staff R stated the nursing staff were responsible for checking the WanderGuard code daily, but Maintenance Staff R stated he would check that it worked each week. Maintenance Staff R stated that the front door was stuck and would not latch properly at one point, so he had the company go out to the facility to fix it. He checked the door alarm by opening the front door and holding it open until the alarm sounded. Maintenance Staff R stated that staff would sometimes respond to the door alarm, but they had a monitor at the nurse's station and could see him, so they would not always respond. Maintenance Staff R stated he did not check the WanderGuard tags against the doors and that the nursing staff would check them daily. Interview on [DATE] at 09:15 AM with Administrative Nurse B revealed all facility doors had an alarm that would sound if left open for five to eight seconds. All residents with a WanderGuard were checked each shift for placement and functionality, with the hand-held device. Interview on [DATE] at 10:00 AM with Administrative Staff A revealed a resident's family arrived at the facility at 07:45 PM and entered through the front door. Administrative Staff A reviewed the surveillance footage with Administrative Nurse B and noted R1 pushed the front door open at 08:00 PM. Administrative Staff A stated he assumed the door was not latched all the way closed or that the door was malfunctioning because R1 should not have been able to open the door. He confirmed that door alarm triggered and sounded throughout the facility, but the WanderGuard alarm system did not trigger or sound. When R1 exited the facility, the WanderGuard was on his left ankle, covered by socks and pants and Administrative Staff A thought that the layers could have interfered with the WanderGuard tag triggering the system. Because of this, staff moved R1's WanderGuard to his right wrist after the elopement. Administrative Staff A stated R1 removed the WanderGuard from his wrist in the past, so it was moved to his left ankle. When R1 was found by Administrative Staff A on [DATE], the WanderGuard was on R1's left ankle. Administrative Staff A stated he saw R1 walking at 08:10 PM, and got in his car to pick up R1. At 08:13 PM, R1 was found walking on a [major four-lane] US Highway, at mile marker 202, walking west on the south side of the highway. Administrative Staff A stated R1 got in the car and told him I know you. I am going to visit my wife. At 08:13 PM, Administrative Staff A called LN P at the facility, to notify staff they found R1 unharmed. R1 returned to the facility by car with Administrative Staff A, at approximately 08:15 PM. Administrative Staff A stated the weather was warm and in the 70s, and R1 wore appropriate clothing and shoes. He stated R1 had many elopement attempts, but was never successful until [DATE]. Interview on [DATE] at 01:15 PM with Administrative Nurse B revealed R1 was last seen walking down the south hall toward his room at 07:50 PM by LN P. R1 then turned around and walked up the hall toward LN P and the front door. Administrative Nurse B stated R1 was a known elopement risk and she continued to educate staff on monitoring R1 for exit seeking behavior. The only documentation used for monitoring R1 was the WanderGuard placement checks. On [DATE] at 04:30 PM, Administrative Staff A and Administrative Nurse B revealed the WanderGuard tags could be used until the expiration date listed on the tag, and stated changing of the batteries was not necessary. When the WanderGuard tag stopped working or met the expiration date, staff disposed of the expired WanderGuard tag and placed a new WanderGuard tag on the resident. Staff checked the WanderGuard tag against the front doors when first placed on a resident. They stated R1 would set off the WanderGuard alarm system all the time, so the WanderGuard alarm system did not need to be checked. When R1 got too close to the lobby, the WanderGuard tag would sound and would turn off when R1 backed out of the area. If R1 opened the front door, both the door alarm and the WanderGuard alarm system would be triggered and sound off. Interview on [DATE] at 09:16 AM with Administrative Nurse B revealed on the evening of [DATE], at the time of the elopement, four of the six staff working were agency staff. She stated the agency staff going to the facility to work did not have elopement training, but she expected them to use the agency book [a book for agency staff, filled with facility policies and procedures and emergency phone numbers] located at the nurse's station. Administrative Nurse B expected all staff in the facility, including agency staff, to respond immediately to any alarm, find out what the alarm was, where it was coming from, and the act accordingly. The ,d+[DATE] Resident Elopement Policy and Procedure documented interventions were to be documented in the care plan for residents at risk for elopement. The policy lacked clear directions for testing the functionality for the WanderGuard system when worn by a resident. The facility failed to ensure a safe/secure environment for cognitively impaired, independently mobile Resident (R) 1, to prevent him from leaving the facility on [DATE] at around 08:00 PM without staff knowledge. The facility staff working did not respond appropriately to the door alarm (the wandering resident alarm system did not activate) per video review and four of the six staff working, at the time of the incident, did not have facility elopement training. The resident was outside of the facility for 17 minutes and found walking west on the southside a four-lane divided highway, with speeds of 60 miles per hour. The facility staff did not have an effective system in checking the wandering alarm system for functionality at the exit door. The facility did not provide adequate supervision for R1, identified by the facility as a high risk for elopement and who exited the facility on three separate occasions prior to the [DATE] incident, to prevent the elopement. These failures placed R1 and one other resident with WanderGuard in immediate jeopardy. On [DATE] at 12:41 PM, the facility provided an acceptable plan for removal of the immediate jeopardy, when the facility implemented the following: 1. The facility checked all exit doors to ensure all alarmed doors were in proper working order on [DATE]. 2. All residents at risk for elopement were reevaluated and assessments and care plans were updated on [DATE]. 3. The facility will review elopement risk residents weekly at the risk meeting. 4. The facility identified the need for staff education on the elopement policy, drills and plan of action and completed an in-service on [DATE] with all facility and agency staff. All staff members not in attendance must complete training prior to working the floor. 5. Elopement drills were completed each shift on [DATE] and will continue monthly. 6. The elopement book was reviewed to ensure accuracy on [DATE]. 7. Weekly door checks will be completed by maintenance staff documented in tracking system, to include taking a WanderGuard bracelet to the door, for verification of alarm functionality (implemented on [DATE]). 8. A Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE] with Administrative Staff A, Administrative Nurse B and Physician O.

The facility census totaled 44 residents, with three sampled for wandering behaviors. Based on observation, interview, and record review the facility failed to provide sufficient supervision to cognitively impaired Resident (R) 1, identified by the facility as an elopement risk with known wandering/exit seeking behaviors, to prevent an elopement. On 09/04/20 R1 exited the facility via a malfunctioning door staff exited prior which failed to alarm for five to six minutes after R1 left the facility through the same door. A facility staff member silenced the alarm to the door without checking for eloped residents and no facility staff knew R1 eloped without his walker and shoes for 1 hour and 16 minutes, when the local police department called to ask if the facility if R1 was a resident. The emergency responders found the resident within a block of a busy four-lane highway with speed limits of 60 miles per hour (mph), during a high traffic time, after a neighbor reported to emergency services a man yelling for help in a backyard. These failures placed R1 in immediate jeopardy. Findings included: - Review of R1's pertinent [DIAGNOSES REDACTED]. to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), [MEDICAL CONDITION] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia with Lewy Bodies (a type of progressive [MEDICAL CONDITION] dementia closely associated with [MEDICAL CONDITION] primarily affecting older adults; the primary feature is cognitive decline, which can lead to hallucinations, as well as varied attention and alertness), pacemaker (an implanted device to regulate the beating of the heart), and artificial right knee joint. Review of the 05/21/20 Annual Minimum Data Set (MDS) revealed the staff assessment of R1's mental status indicated modified independence with some difficulty in new situations only. The MDS noted R1 with fluctuating inattention, disorganized thinking, and altered level of consciousness. R1 exhibited wandering behaviors for one to three days of the seven-day review period that indicated the resident's wandering placed him at risk of getting into a potentially dangerous place. The resident required supervision of one staff with walking/locomotion off the unit, had impairment to his bilateral (both) lower extremities, and used a walker for mobility. R1 experienced one non-injury fall since prior assessment and used a wandering/elopement alarm daily. Review of the 08/20/20 Quarterly MDS revealed a brief interview for mental status (BIMS) score of 13, indicating intact cognition. R1 exhibited no wandering behavior during the seven-day review period. The resident required supervision of one staff with walking, limited one-person assistance for locomotion off the unit, had bilateral lower extremities impairment, and used a walker for mobility. R1 experienced two or more non-injury falls and used a wander/elopement alarm daily. Review of the 05/21/20 Cognitive Loss Care Area Assessment (CAA) revealed R1scored 99 due to confusion and inability to progress with assessment. R1 displayed short-term memory loss and modified independence with daily decision-making skills. Review of the 05/21/20 Activities of Daily Living (ADL) CAA revealed R1 required staff assistance with walking and was unsteady while moving from a sitting to a standing position and walking/turning but could rebalance without staff assistance. Review of the 05/21/20 Behavioral CAA revealed the resident had multiple episodes of wandering during his look back period, which was an increase in behaviors over the last quarter. The CAA noted the wandering placed R1 at risk for elopement, and the behavior was not redirectable and could be disruptive. Review of the 05/21/20 Falls CAA revealed R1 exhibited multiple episodes of wandering during his look back period. R1 had one non-injury fall on 05/19/20, and risk factors for falls included [MEDICAL CONDITIONS] (a sudden severe confusion, disorientation and restlessness), agitated behavior, and cognitive impairment. Review of the 09/17/18 Care Plan identified R1 as an elopement risk due to door watching and intermittent confusion. A revision dated 02/12/20 revealed R1 with a Wander Guard (technology with the express purpose of keeping wanderers safe, preventing them from straying too far) on his right ankle in which the staff checked every shift for placement and effectiveness. The care plan noted if an elopement occurred, the staff followed the facility protocol. The staff were to provide frequent checks when R1 was close to the front door or any exit door and to divert him away from the door if able. Review of 09/17/18 Care Plan revealed R1 had an Activities of Daily Living (ADL) deficit related to [MEDICAL CONDITION], change in cognitive status, behavior symptoms, communication problems, mood decline, medication use, weakness and poor balance. A revision dated 08/27/20 revealed R1 required supervision of one with use of a walker and noted his tendency to often walk away from his walker. Review of 09/17/18 Care Plan revealed R1's BIMS score of 14, but due to his poor decisions, the staff needed to monitor him for safety. A revision dated 01/31/20 revealed R1 wore a Wander Guard due to poor decision-making skills. Due to these poor decisions, he would choose to go outside not dressed appropriately for the weather or at an inappropriate time of day, therefore staff may need to monitor R1 for safety. Review of 02/05/20, 05/13/20, 07/29/20, 08/12/20 and 09/04/20 Clinical Health Reviews for elopement risk identified R1 as a high risk for elopement. Review of 07/22/20 at 03:55 PM Behavior Note revealed R1 continued to wander and noted him as increasingly difficult to redirect. The staff re-directed but noted the redirection as ineffective and it held the resident's attention for just minutes before he needed additional redirection. Review of 07/24/20 at 09:31 PM Behavior Note revealed R1 exhibited increased anxiety and wandering. The resident attempted to break down the front doors and leave the facility. He also attempted to leave by other doors in the facility. When staff intervened, he became hostile, though he was redirectable. Review of 09/04/20 at 03:55 PM Nurse's Note Late Entry revealed the police department contacted the facility to inform them of R1's location as outside of the facility. The administrator brought the resident back to the facility and assigned him a 1:1 sitter (provided to ensure the safety of residents who may be suffering from cognitive impairment, exhibit challenging behavior, or may be at risk of falls or of causing harm to themselves or others). R1's vital signs were within normal limits, and his skin was diaphoretic (sweaty), pink, and intact. The note mentioned the Wander Guard as present to his left ankle and functional. The note continued and included a review of the security cameras by the administrator. The video revealed at 01:30 PM R1 walked toward the exit door on North hall. He pushed on the North hall door for approximately three minutes without the ability to open it. He then walked away from door and his four-wheeled walker, then headed toward the nurse's station. At the nurse's station, he turned the corner and approached the exit door located in front of the Director of Nursing's (DON) office. At 01:35 PM, he opened the door without difficulty and exited the building walking without an assistive device and wore lightweight sweatpants, short sleeved shirt, and non-skid socks. The temperature at 01:35 PM noted as approximately 90 degrees Fahrenheit (F) and sunny. Review of 09/15/20 Facility Investigation for the 09/04/20 elopement revealed R1 left the faciity on [DATE] at approximately 01:34 PM until 02:50 PM when the facility received a telephone call informing them police found R1 in the residential area 1-2 blocks from facility, and returned back to the facility at 03:05 PM (1 hour and 31 minutes out of facility). R1 spent 1 hour and 16 minutes alone outside the facility and walked to a residence one block away from the facility (per google maps, the residence was near highway 54, approximately 1450 feet from facility and approximately 600 to 700 feet from the residence). The high temperature noted as 90 degrees F and R1 wore a white tee shirt, sweats, and gripper socks (no shoes). Observation of R1 on 09/15/20 at 03:36 PM revealed R1 was in his room, seated in his recliner with a baby doll cradled on his shoulder. R1 had a Wander Guard noted to his left ankle, and his walker was approximately three to four feet away from the resident in his recliner. R1 made no attempts to get up from his recliner or to wander. Observation on 09/16/20 at 02:25 PM of the area outside the DON doors and into the residential area in which the police located R1 on 09/04/20 included a steep hill with a concrete drainage area near the residential area When standing in front of the residential area in which the police found R1 revealed the four-lane highway was easily visible. Interview with R1 on 09/15/20 at 03:36 PM revealed he did not know if he went somewhere on 09/04/20. He indicated that his Wander Guard ensured he did not get a speeding ticket. Pleasantly confused, he stated the month and day currently as December of 2018, and stated he was in the Army and the facility was not his home. Interview with Activity Aide M on 09/16/20 at 09:33 AM revealed when a door alarm sounded, the staff go out the alarming door and look around the perimeter for any eloped residents. She indicated the facility staff were on especially high alert because of the most recent elopement on 09/04/20. Interview with Certified Nurse Aide (CNA) D on 09/16/20 at 07:32 AM revealed she had taken the laundry downstairs and come back down the hallway toward the DON's office and the DON door alarm was going off, but the door was locked, so she turned off the alarm. She did not think any resident went out of the building because when she pushed on the door it was latched. She indicated that if staff heard a door alarm, the staff should go outside to look around the area and see if we could locate a resident. She also indicated that people had been going in and out that door that morning for COVID testing, so she thought one of them set it off. She indicated that now, if a door alarmed, staff alert other staff and do a perimeter check because that was what staff were supposed to do when that situation happens. R1 wandered and stood by the exit doors often before he eloped on 09/04/20. R1 would say things like I have to feed the cows or I have to get this lawn mower on the back of my truck because he would get confused. Interview with CNA E on 09/16/20 at 07:44 AM revealed R1 liked to get up and wander the halls, sometimes he would go without his walker and staff would retrieve it for him. Staff were pretty busy, on the go all the time caring for other residents. Staff do one-on-one time with R1, but she could not verbalize any other interventions for his wandering, other than keeping a closer eye on him. Interview with CNA F on 09/16/20 at 07:51 AM revealed he worked the day R1 eloped, but left at 01:15 PM. R1's behaviors included walking around the facility often, he had [DIAGNOSES REDACTED] and had a mindset that he worked on the farm with his cattle. R1 could be easily redirected some days and others his agitation and confusion were high. When R1 tried to get out of a door, staff asked him what he was doing, CNA F indicated he reached his arm around R1 and talked with him, explained that it was not safe to go outside because of coronavirus, and R1 laughed and talked on the way back to the resident's room. There were safety concerns with R1's cognition and unsteady gait since he fell in the facility before. CNA F indicated he had not read R1's kardex (care planned interventions) in the last couple days and was unsure about what other interventions for elopement/wandering for R1. Interview with CNA G on 09/16/20 at 08:35 AM revealed R1 sat himself in the recliner at the nurse's station on 09/04/20 at approximately 01:25 PM. He then decided to stand and walked toward the North exit door. CNA G brought his walker to him at that time because of R1's unsteady gait while walking. She then went to assist other residents and indicated that the door alarm never went off at all that day. R1 wandered, looked outside, and asked staff to open the doors, so she re-directed him by bringing R1 back to the nurse's station or to his room, the bathroom, get him a snack if he wanted, and try anything to see if she could change his mind. R1 stated he was looking for his truck or something. Interview with CNA B on 09/16/20 at 01:22 PM revealed she left the building after her shift right before R1 eloped on 09/04/20 at 01:30 PM. She indicated that the DON door clicked so she knew it was closed. R1 had been a farmer and stated often that he needed to milk the cows, get the tractor, and looked for exits, trying to leave the facility. R1 used a walker most of the time, but he stated that he did not need it. R1's Wander Guard was on his left ankle. When an elopement occurred, staff looked outside for a resident, and if no resident visualized, staff followed procedure. If a resident made it outside or was missing, staff notified the DON and charge nurse. Staff answered door alarms quickly, any resident that eloped could be found quickly. CNA B indicated that she did not know how R1 got through the locked DON doors. Interview with LN I on 09/16/20 at 08:09 AM revealed R1 wandered all the time in the facility. He ambulated to the North/South hall doors frequently and staff re-directed/reminded him to use his walker. He fell prior to his elopement because he forgot his walker, and he had an unsteady gait at times. No staff notified her about his walker being at the end of North hall or that he was missing on the 09/04/20 shift. She did not recall hearing the alarm go off that day. R1's cognition varied, some days he understood nothing, and other days he experienced lucid cognition (expressed clearly; easy to understand). Interview with LN C on 09/16/20 at 08:02 AM revealed R1 exhibited sundowners (a neurological phenomenon associated with increased confusion and restlessness in patients with [MEDICAL CONDITION] or some form of dementia) and wore a Wander Guard on his left ankle. He indicated to staff he needed to leave the facility to milk the cows or feed them, he would go to the doors and pushed on them, and also looked for hidden keys. The staff ensured his walker was near him, but he left it and walked alone. She indicated that R1's fell while in the facility. When the facility received the call R1 was found out of the facility, staff completed an elopement drill. LN C indicated she looked on North hall and found R1's walker then, no staff alerted her to his walker being in the hall prior to this. She indicated that R1 walked pretty well, but he was unstable enough to need his walker. His cognition s varied, and he could be clear sometimes and confused at other times. When R1 arrived back to the facility, she completed a full skin assessment and he had a shower. R1 had no scratches, no open areas, his vital signs were good, with no adverse consequences of his elopement. Interview with Activity Staff H on 09/16/20 at 08:22 AM revealed she opened the DON door after a family member delivered an item before R1 eloped. When she pulled the DON door shut, it latched with no alarming. R1 always tried to get out of the North hallway door like he did in the video on 09/04/20, but he then walked down the North hallway without his walker and exited the building through the DON doors. The door alarm never triggered the whole time, from when she closed the door until the facility got the call R1 was found outside of the facility. She indicated that R1's cognition at times was very good and other times very bad. He exhibited sundowners and wanted to milk the cows and get the truck/trailer every afternoon. His unsteady gait presented problems for him, and staff reminded him to use his walker. Interview with Maintenance Staff J on 09/16/20 at 08:50 AM revealed the other maintenance staff indicated to her that the pin mechanism fell out of the DON door or malfunctioned, and the door latched incorrectly when staff had last closed the door. R1 walked out of the DON doors and then approximately six minutes later, staff finally turned off the door alarm, but did not go outside and look to ensure a resident had not eloped. The staff should have taken that alarm seriously and started looking for the resident. Interview with Administrative Nurse A on 09/15/20 at 01:34 PM revealed R1 did not have any elopements in last six months. She indicated the reason the staff member did not look outside or follow elopement policy was because the DON door was not open, it appeared to be closed and she assumed the door alarming was an error. The DON door alarmed simply because the doors did not close all the way or stayed open too long. Interview with Administrative Nurse A on 09/15/20 at 04:07 PM revealed a police officer contacted the facility on 09/04/20 at 02:50 PM and asked if R1 was a resident at this facility. She then told staff and started the elopement drill. She indicated that the video revealed R1 had been exit seeking at the North hall door and then ambulated without his walker to the nurse's station, then went to the DON door next to the DON's office and walked right through the door at approximately 01:35 PM and no alarm sounded. The alarm for the door did not sound until approximately 01:40 PM when CNA D turned it off. The door alarm should signal within 30 seconds of being opened, but it did not go off for approximately five minutes. Maintenance checked the door alarms monthly, the last time door alarms were checked, the DON door worked correctly. The locking mechanism on the DON doors malfunctioned, the mechanism prevented the door from latching appropriately. She indicated that R1's had a high elopement risk and staff were aware. He exhibited exit seeking one to three times a week since January 2020 and his elopement on 09/04/20. In the elopement video on 09/04/20, R1 slept in the recliner at the nurse's station, and then got up and walked down the North hallway without his walker. A staff member brought him his walker, and when the staff walked away, R1 then left his walker in the hallway, and he walked to the DON doors and eloped. She indicated R1 was pretty steady on his feet, even without his walker, ambulatory, and moved without assistance, even though he should be assisted. His cognition varied on the time of day; some days he woke lucid, other days he knew nothing. R1 requested help when ambulating with his walker, but he forgot most of the time. The DON doors functioned correctly before 09/04/20. She indicated that the she initiated elopement training as soon as the facility knew of the elopement and was completed prior to midnight of that day. Interview with Administrative Nurse A on 09/16/20 at 07:18 AM revealed R1 eloped out of the hospitality room door in January 2020, and it appeared from the video that he punched in the code, walked out, and then came right back in when staff re-directed him. He has a Wander Guard, and his care plan indicated that he did not make good decisions. The nurses charted these behaviors frequently on the report sheets. R1 exhibited exit seeking behavior approximately five minutes before he actually eloped at the DON door near the nurse's station, a double door, on 09/04/20. One door had shut, which did not allow the other door to latch correctly, but did not set off the door alarm. A staff member opened the door to exchange items with family of a resident, and the door did not latch when it closed. R1 opened it without difficulty when he eloped. The door itself had pins at the top that come down when the door closed, but the feature malfunctioned. From the bottom of the door, it appeared closed, and when staff recreated the situation it took a few minutes for the door alarm to go off. The door alarmed that day and indicated the door had been open too long, and CNA D turned the alarm off without looking further to figure out why the DON door alarmed. Interview with police officer K on 09/16/20 at 11:52 AM revealed he dispatched for a welfare check because a residential neighbor behind the facility called 911 because he thought his neighbor yelled help, but it was R1 who stood in his backyard. When officer K arrived on the scene, R1 wore sweatpants, shirt and socks (no shoes), and the officer thought that R1 may be a silver alert (a missing senior citizen). He checked R1's name for warrants and called a family member who recognized R1 as a resident of the facility. Officer K then notified the facility, and Emergency Medical Services (EMS)/Paramedics checked R1 out for injuries with none noted. R1 gave officer K his personal address before living at the facility. Officer K indicated that R1 was very coherent at that point, with some confusion. R1 did not know who to call to come get him, but he talked to the other first responders, and offered water. Interview with Dietary staff L on 09/16/20 at 11:03 AM revealed officer K realized R1 was a resident of the facility and called saying that a homeowner over near the facility heard R1 yelling for help because he got himself in a pickle and stuck in a bush and called 911. Review of the revised 12/2019 Resident Elopement Policy and Procedure policy revealed the elopement drills were to be completed a minimum of quarterly on each shift. Staff were educated that when a resident was missing from the facility, staff are to immediately report to the charge nurse or the Director of Nursing. The charge nurses initiate a search inside the facility, on the premises, and account for other residents within the facility. On 09/16/20 at 04:50 PM, Administrative Nurse A and Administrative Staff N were provided with the IJ template and notified that the facility failed to provide appropriate supervision to cognitively impaired R1 (without shoes or his walker), identified by the facility as at risk for wandering and who exhibited exit seeking behaviors, to prevent an elopement of 1 hour and 16 minutes, when staff did not check the alarm door and silenced it without checking for eloped residents which constituted immediate jeopardy at F689. The immediate jeopardy at F689 also constituted Substandard Quality of Care at 42 CFR 483.12. The immediate jeopardy was determined to first exist on 09/04/20 at 01:35 PM, when R1 eloped out of the DON doors. The facility identified and corrected the deficient practice on 09/04/20 by 11:59 PM when the facility implemented the following: 1. 1:1 sitter initiated for R1 2. Mandatory elopement drills performed on all shifts. 3. All staff reviewed the elopement policy and procedure. 4. Maintenance verified door functioning, door company notified to repair door and door was locked and not used until fixed on 09/10/20. 5. QAPI to monitor the on-going effectiveness of the corrective action plan. Due to the facilities actions to identify and correct the deficient practice on 09/04/20, it was deemed past non-compliance at a scope and severity of J. The facility failed to provide sufficient supervision to cognitively impaired R1 who eloped from the facility for 1 hour and 16 minutes without staff knowledge within a block of a busy four-lane highway. These failures placed R1 in immediate jeopardy.

The facility census totaled 50 residents. Based on interview and record review the facility failed to ensure that resident #1 received care, consistent with professional standards of practice, to prevent an unstageable pressure ulcer to their left foot. Findings included: Resident #1 admitted to the facility on [DATE] from assisted living due to multiple falls and admitted with the following physician's admission Diagnoses: [REDACTED]. It usually begins in the hands and feet and may progress to arms and legs and sometimes to other parts of the body where it may affect the autonomic nervous system.) On [DATE] resident #1 had physician [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set, dated dated [DATE], revealed resident #1 had a brief interview for mental status (BIMS) score of 10 (moderately impaired cognition), required extensive assistance of one staff for bed mobility, dressing, toilet use, personal hygiene, supervision for eating, at risk for pressure ulcers development and no pressure ulcers on admission. Review of the Activity of Daily Living (ADL's) care area assessment (CAA), dated [DATE], revealed resident #1 had a functional deficit due to his/her needs of extensive assistance with most of his ADL's. Resident #1 was admitted from assisted living and is receiving Physical Therapy and Occupational Therapy with goal to return to the assisted living if he is able. Review of the Nutritional CAA revealed resident #1 had the potential for a nutritional problem due to being on a consistent carbohydrate diet for Diabetes Mellitus. He/she is alert and able to make his/her own food choices, feeds himself/herself, good appetite consuming ,[DATE]% of breakfast and weight stable at 165. Review of the Pressure Ulcer CAA revealed resident#1 has the potential for development of pressure ulcers due to the need for extensive assistance with bed mobility, transfers, toileting and personal hygiene. Review of resident #1's care plan, dated [DATE] for nutrition indicated the resident was on a therapeutic diet due to Diabetes Mellitus, provide meal set up and or physical help as needed with meals, provide consistent carbohydrate regular diet and weigh weekly and notify physician of any significant weight gains of losses. Review of resident #1's care plan, dated [DATE] for potential for development of pressure ulcer due to need for extensive assistance with bed mobility and repositioning. The care plan instructed staff to ensure a pressure relieving device for wheelchair, pressure relieving mattress, have licensed nurse complete a weekly head to toe skin assessment, report concerns to physician and provide extensive assistance with repositioning every 2 hours or when requested. The facility did an initial skin assessment upon admission and identified no skin issues. Progress notes on [DATE] identified the resident continues on Keflex antibiotic for [MEDICAL CONDITION] of right lower shin area, area remains reddened with scabbed areas. Skin condition note, dated [DATE] indicated warm, pale,dry scabbed areas to right front shin. Skin condition note, dated [DATE] indicated warm, pale,dry scabbed areas to right front shin. Skin condition note, dated [DATE] indicated warm, dry, pink scabbed areas to right front shin. Skin condition note, dated [DATE] indicated left lower extremity skin had peeled and was open due to washing. Right lower extremity had scabs from healing. Cleanse left lower extremity with wound cleaner (w/c), pat dry, apply Vaseline, cover with band aide and the resident was educated to notify staff when irritated and do not scratch to prevent opening. Skin/wound condition assessment on [DATE] identified left little toe, pressure ulcer measured 1.5 cm (centimeter) in length, 1.6 cm in width, no depth and unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Treatment changes associated with this assessment, see orders. Resident or responsible party notified of current skin/wound condition status and treatment, and physician notified of current skin/wound status and treatment. Skin condition note, dated [DATE] indicated warm, dry, pink, good turgor, scabbed areas to front of bilateral shins, open area to posterior aspect of fifth toe of left foot. Progress note on [DATE] at 9:52 A.M. documented cleanse wound with w/c (wound cleaner), pat dry, apply xeroform and cover with dry dressing until resolved, one time a day for skin condition, wound bed is red and black, wound has foul odor, top of left foot is red and hot to touch. There was no documentation to support that the resident's physician was notified of this finding. Progress note on [DATE] at 13:06 (1:06) P.M. revealed resident discussed at Risk Meeting this AM with pressure ulcer to left foot. Pressure ulcer resulted from old shoes that resident had. New shoes were ordered and resident is not to wear shoes at this time unless walking. Treatment to be evaluated due to sore not improving. Care plan updated at this time. The physician's APRN (Advanced Practiced Registered Nurse) was notified of the resident's wound condition and would be in to see resident on rounds later in the day. The APRN was in the facility on [DATE] at 15:00 (3:00 P.M.) and gave the following orders: 1. Dig level, hemoglobin A1C, complete metabolic profile and complete blood count on one order sheet taken by Licensed Nurse D. 2. [MEDICATION NAME] 1 mg (milligram) IM x 2 days then Keflex 500 mg po (orally) every day x 8 days on another order sheet taken by Licensed nurse D. 3. Arterial Doppler studier of both lower extremities (wound to left toe), foot cradle, leave foot undressed and open to air, and get to the wound care center ASAP. This order was never followed through on and the facility found the order on [DATE] during a mock survey. The resident should have been sent out of the facility on [DATE] after 3:00 PM. Skin/wound condition assessment on [DATE] at 12:06 P.M. identified left little toe, pressure ulcer measured 1.8 cm in length, 2.1 cm in width, no depth and unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Treatment changes associated with this assessment, see orders. Resident or responsible party notified of current skin/wound condition status and treatment, and physician notified of current skin/sound status and treatment. Skin condition progress note on [DATE] at 15:49 (3:49 P.M.) documented wound to left little toe open and draining foul/rotten smelling thick red and black drainage. Denies pain. Left foot reddened across whole top of foot and was spreading upwards toward ankle. Area swollen. Dr. Bryant's office notified of worsening of the wound. Progress notes on [DATE] at 15:57 (3:57 P.M.) indicated the staff notified the resident's physician and staff received an order to transfer the resident to a local hospital's emergency room and the resident sent out via ambulance and staff left a message with the resident's family member regarding the transfer. Review of the facility investigation dated [DATE] revealed Resident #1 entered the facility without any initial skin conditions, developed [MEDICAL CONDITION] in his legs and had been treated with antibiotics. Resident #1 was assessed on [DATE] to have an unstageable pressure ulcer with no drainage to his left little toe caused by his shoes. The facility notified the physician and obtained a treatment order for daily dressing changes. On [DATE] during the dressing change the nurse noted the wound had foul/rotten odor drainage and notified the APRN who was making rounds in the facility that day. The APRN gave the charge nurse a set of three different orders for lab, antibiotic and Doppler studies of both lower extremities, wound open to air and to get the resident into the wound care center ASAP. The final order with the Doppler study and wound care center ASAP were not followed and staff noted this on [DATE] at which time the resident was sent to a local emergency roiagnom on [DATE] and was still there. Review of the facility Medication Orders Policy dated 2007 under New orders (handwritten by prescribe of verbal orders): * Order is written by the prescriber while present in the nursing center; or may be received verbally by the nurse on duty for transcription. If verbally received, the nurse writes down the complete order and then reads the information back to the prescriber for confirmation. * Order is transcribed onto the physician's orders [REDACTED]. *Order is noted by the nurse receiving the order. * Order is recorded in the MAR indicated [REDACTED] *Send the appropriate copy of the telephone order to the prescriber for signing in a timely manner. * Written transfer orders (sent with the resident from a hospital or other health care facility). Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete of the date signed is different from the date of admission. Interview on [DATE] at 12:15 P.M. with a concerned citizen revealed Resident #1 passed away at a local hospital due to an left foot infection which contributed to organ shut down and [MEDICAL CONDITION]. The concerned citizen indicated he/she was not notified of changes, had no care plan meetings with the facility and that resident #1 was malnourished. Review of a witness statement by licensed nurse C dated [DATE] revealed he/she observed the wound on [DATE] and thought it looked worse and was not getting any better and he/she contacted the Physician's APRN and asked them to look at resident #1's wound when they were in the facility later that day. Licensed nurse C observed the wound again on [DATE] and had the Director of Nursing (DON) look at the wound at which time they called the attending physician and got the order to transfer resident #1 to a local emergency room . Licensed nurse C reviewed his/her notarized statement and verified as accurate on [DATE] at 1:45 P.M. Review of a witness statement by Licensed nurse B dated [DATE] revealed she was asked to observe resident #1's wound on his/her left foot and after looking at the wound and talking with licensed nurse C he/she called the attending physician and got the order to transfer the resident to the VA hospital for treatment of [REDACTED].M. Licensed Nurse D was given an Employee Conference Report on [DATE] for failure to complete orders on [DATE] for Resident #1 and no longer worked at this facility. Interview on [DATE] at 2:30 P.M. with Licensed nurse B and licensed nurse E revealed resident #1 was on various antibiotics for [MEDICAL CONDITION] of his legs since (MONTH) of (YEAR). A CNA identified a blister on resident#1's left little toe on [DATE]. The physician and family was notified and a treatment order was obtained from the attending physician. Resident #1's family member came in on [DATE] to pick up his/her old shoes and a care plan meeting was held with him/her at that time. Treatments were being done as ordered and the area was not improving. On [DATE] licensed nurse C notified the APRN to check resident #1's toes while he/she was in the facility later in the day. The APRN wrote new antibiotic orders, ordered lab work, and orders for arterial Doppler studies of both lower legs and to send the resident to a local wound care center. The orders for the Doppler study and getting the resident to the wound care center ASAP were not followed and was not found until [DATE] during a Mock Survey of the facility. Licensed nurse B called the VA for an update on Resident #1 and was told the resident had osteo[DIAGNOSES REDACTED] in his left foot and would be getting intravenous antibiotics for 4 to 6 weeks. The resident expired at a local hospital. A phone interview on [DATE] at 8:00 A.M. with Licensed nurse B revealed a progress note dated and signed on [DATE] at 9:52 A.M. by licensed nurse D that documented the following information: Cleanse wound with w/w, pat dry, apply xeroform and cover with dry dressing until resolved daily one time a day for skin condition. Wound bed is red and black, wound has foul odor, top of foot is red and hot to touch. Licensed nurse B indicated licensed nurse D no longer works at this facility and that there was no indication that the resident's physician was notified of the wound condition. Resident #1 entered the facility without any pressure ulcers and developed an unstageable pressure ulcer. The facility failed to inform the physician of the wounds worsening condition and also failed to obtain the Doppler study and failed to send the resident to the wound care center as physician ordered.

The facility census totaled 42 residents. The sample included 3 residents reviewed for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without staff knowledge). Based on observation, interview, and record review the facility failed to identify 1 of the 3 sampled residents as an elopement risk and implement interventions to reduce the resident's risk for elopement. This deficient practice placed resident #1 in immediate jeopardy on 10/20/17 when the resident eloped from the facility between 10:30 p.m. and 11:50 p.m. and was located 862 feet from the facility, in an open field near a busy residential area and a highly travel highway with 50-60 miles per hour (mph) speed limits, with injuries to his/her head, bilateral (both) hands and knees that required medical intervention. Findings included: - Review of resident #1's physician's orders [REDACTED]. Review of the resident's annual minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 10 (moderate cognitive impairment). The resident had minimal difficulty hearing without a hearing device and made his/her wants and needs known. The resident required supervision of one staff member for transfers, locomotion on and off the unit and was independently ambulatory in his/her room and the facility and the resident required corrective lenses for vision. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact). The resident required set-up help and supervision of staff for walking in his/her room and the corridor and locomotion on the unit and supervision of one staff member for locomotion off the unit. The MDS indicated the resident wandered. Review of the activities of daily living (ADL) CAA dated 8/3/17 revealed he/she required supervision to limited assistance with his/her ADLs and he/she ambulated independently with a walker. Review of the Fall CAA dated 8/3/17 revealed the resident had the potential for falls related to his/her cognitive deficit and required a walker for ambulation. Review of resident #1's elopement risk assessments revealed the following dates and score: 7/26/17-3, no risk 10/15/17-14, high risk 10/21/17 at 2:30 a.m. -29, high risk Review of the resident's comprehensive care plan dated 8/3/17 lacked interventions to address elopement risks prior to the resident's elopement on 10/20/17. The clinical record revealed staff assessed the resident as high risk for elopement on 10/15/17. Review of the resident's care plan for elopement risk initiated on 10/21/17 after his/her elopement identified the resident at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without staff knowledge) related to an elopement attempt on 10/20/17 and he/she had increased wandering and progression of his/her disease process. The care plan lacked interventions to prevent elopement prior to the resident's elopement attempt on 10/15/17. The care plan directed the staff to initiate one on one monitoring on 10/22/17 thru 10/24/17. The resident had a wander guard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) and directed staff to check the placement of the wander guard every shift. The facility updated the care plan on 10/23/17 to inform the staff the resident had a wander guard bracelet on his/her left ankle and to check the wander guard for placement and functioning every shift. The facility updated the care plan on 10/24/17 to inform staff the resident tended to remove the wander guard between checks. The facility updated the care plan on 10/25/17 and directed the staff to look behind themselves before they exited the door to ensure the resident had not followed them out and to ensure the doors closed completely when they left the facility. Review of the care plan last revised 10/24/17 revealed resident #1 was at risk for falls. The care plan directed the staff to ensure the resident wore appropriate footwear, ensure his/her room was well lit and uncluttered, and to monitor resident #1 for changes in his/her gait. The care plan revealed the resident required corrective lenses for vision and the elopement his/her glasses were missing. Review of the nurse's progress note on 10/14/17 at 10:30 p.m. revealed the resident wandered the halls, shook the door handle and tried to get out of the facility. Review of the nurse's progress note on 10/15/17 at 1:30 a.m. revealed the resident wandered the facility all night long. The resident pulled the fire alarm and opened the south exit door and was stepped out the door to exit the building until the staff stopped him/her and returned him/her to the building. Review of the facility's elopement investigation dated 10/20/17 revealed the resident admitted on [DATE], he/she ambulated independently but at times he/she had an unsteady gait. On 10/20/17 at 12:04 a.m. licensed nurse C identified the resident was not in his/her room. Staff C implemented a full internal search of the building, a search of the outside property, and an expanded search of the surrounding neighborhood. At approximately 12:20 a.m. direct care staff D located the resident in an open field northeast of the building near the main highway through the area with a fence separating the field and the main highway. The resident did not make it past the fence. Staff C called 911 emergency services and reported the resident missing from the facility and reported he/she was last seen at approximately 11:30 p.m. Upon resident #1's return to the facility the staff assessed the resident with an abrasion to his/her forehead, nose and both knees. The investigation revealed the resident wore a sweatshirt, a pair of sweatpants, socks and his/her glasses at the time of the elopement. The outdoor temperature was 72 degrees Fahrenheit (F). Administrative staff A performed an inspection of the doors, door locks, and the alarm system with no malfunctions identified. The facility changed the door codes and reviewed the video surveillance system. The video revealed the resident was last observed on camera at 10:31 p.m. on 10/20/17. Administrative staff A interviewed the resident and asked how he/she exited the facility and the resident said, I just pushed on the door and it opened. Review of the nurse's progress note dated 10/21/17 at 12:00 a.m. revealed at 11:50 p.m. on 10/20/17 the staff noticed the resident was not in his/her bed. The staff looked for the resident inside the facility and could not locate him/her. Staff extended the search around the building and neighborhood and called 911. Direct care staff D located the resident 1 block away from the facility and returned the resident to the facility with a bruise on his/her forehead, knees and left arm and the staff observed blood coming from the resident's mouth. The staff notified the resident's physician and received an order to send the resident to the hospital for evaluation. Review of the nurse's progress note dated 10/21/17 at 5:30 a.m. revealed the resident returned from the emergency room . The resident had a laceration to his/her forehead about 3 centimeters (cm) x 3 cm, a bruise on his/her left arm below the elbow, and a bruise on his/her nose. Review of the Wunderground.com weather application revealed the weather on 10/20/17 at 10:00 p.m measured 71 degrees F, with winds out of the south at 31 miles per hour (mph), no precipitation and at midnight the temperature measured 69 degrees F, with winds out of the south at 31 mph, and no precipitation. Observation on 10/26/17 between 7:50 to 7:58 a.m. revealed a total of 7 cars entered or exited the cul-de-sac on the northeast side of the building on the paved residential street were the resident was found with a speed limit of 20 mph. The field where staff found the resident was adjacent to a high traffic highway with a speed limit of 50 to 60 mph. Observation on 10/26/17 at 8:00 a.m. revealed administrative staff A and administrative nurse B measured the distance from the hospitality room door (the door the resident eloped from on the south side of the facility) to the approximate location the resident was located by staff in the open field northeast of the facility. Staff A and B confirmed the resident walked approximately 862 feet after he/she eloped from the facility. Interview on 10/26/17 at 8:14 a.m. with the resident revealed he/she could not remember how he/she got of the facility on 10/20/17. He/she believed a person just had to open the door to go outside but he/she could not be certain. Interview on 10/26/17 at 8:26 a.m. with resident #1's roommate, resident #4, revealed he/she knew the resident was more confused and he/she did not usually wake up when the resident entered or left the room at night. Interview on 10/26/17 at 5:01 a.m. with direct care staff D revealed he/she last observed the resident in the facility at approximately 8:00 p.m. in the hospitality/dining room area drinking coffee. Staff D revealed when licensed nurse C determined the resident was not in the building he/she got in his/her car and drove around the facility. Staff D revealed he/she found the resident at 12:30 a.m. in a field on the northeast side of the facility next to the water tower. Staff D revealed it was so dark he/she required a flashlight to see into the field where he/she located the resident. Interview on 10/26/17 at 6:22 a.m. with direct care staff E revealed the resident frequently walked up and down the halls during the night. Staff E revealed he/she last observed the resident at 10:30 p.m. as he/she ambulated into the hospitality room and he/she did not see the resident again until direct care staff D returned him/her to the facility after the elopement. Interview on 10/26/17 at 9:50 a.m. with direct care staff G revealed the resident was not identified on the care plan as an elopement risk before 10/20/17. Staff G revealed the staff assumed the resident was an elopement risk because he/she had tried to get out of the facility doors before and watched the doors when staff and family members left. Interview on 10/25/17 at 11:30 p.m. with licensed nurse C revealed the resident eloped from the facility on 10/21/17. Staff C staff revealed he/she identified the resident was not in his/her bed while passing midnight medications to his/her roommate (#4) at 12:04 a.m. Staff C revealed he/she did not know which door the resident exited from because the doors did not alarm when the resident eloped. Staff C revealed the resident did not know the code upon interview when he/she returned to the facility. Staff C revealed direct care staff D located the resident a block from the facility in an open field and returned him/her to the facility via private vehicle. Interview on 10/26/17 at 4:48 a.m. with licensed nurse C revealed the resident attempted to leave the facility on 10/15/17 by pulling the fire alarm and pushing the south hall exit door open. Staff C revealed he/she and direct care staff D intervened and staff got resident #1 back into the building. Staff C revealed the resident attempted to leave the facility because his/her roommate was in the hospital and he/she wanted to be with him/her. Staff C revealed he/she notified administrative nurse B of the incident because the police and fire department responded to the facility after the fire alarm was pulled. Staff C revealed the facility thought the resident would quit trying to leave the building once his/her roommate returned from the hospital. Interview on 10/26/17 at 12:39 a.m. with administrative nurse B revealed the facility identified resident #1 as an elopement risk prior to his/her elopement on 10/20/17. Staff B revealed the resident shared a room with his/her significant other and the significant other usually kept an eye on resident #1 when he/she left the room. Staff B confirmed the resident's roommate did not get out of bed and follow the resident around the facility when he/she wandered at night. Staff B confirmed the facility failed to implement effective interventions in an elopement care plan for the resident after his/her elopement attempt on 10/15/17 and confirmed the facility only implemented an elopement care plan for the resident after he/she eloped from the facility on 10/20/17. Interview on 10/26/17 at 8:00 a.m. administrative nurse B revealed resident #1's glasses were missing and the facility was unable to locate them outside the facility. Staff B revealed the facility was in contact with resident #1's family and made arrangement to have his/her glasses replaced by the facility. Interview on 10/26/17 at 12:32 a.m. with administrative staff A revealed the resident had a [DIAGNOSES REDACTED]. Staff A revealed the resident eloped from the facility via the hospitality room door (south side of the building). Staff revealed the door alarms did not sound when the resident exited the building and he/she check the doors and locks after the elopement and found the doors and locks functioned appropriately. Staff A revealed after he/she completed the elopement investigation the only conclusion he/she determined was the resident followed an employee out of the hospitality room door and the staff did not see him/her leave the facility. At 5:57 a.m., administrative staff A revealed the resident was last observed on the video footage at 10:30 p.m. when he/she entered the hospitality room and was not seen on video again until after the staff brought him/her back into the building after his/her elopement at 12:30 a.m. on 10/21/17. The facility elopement policy and procedure last revised on 12/2014 revealed the facility promoted a safe and secure environment to help minimize the risk of the resident leaving the premises or a safe area without the necessary supervision or authorization to do so. Elopement occurred when a resident left the premises or a safe area without the necessary supervision or authorization to do so. The risk for elopement would be identified for residents and an individualized care plan developed based on the risk. Staff would investigate and report all instances of potential elopement. The facility would have a process to monitor security of the premises on a routine basis. The resident would be assessed for elopement risk within the first 24 hours of admission, quarterly, annually, and with any significant change. Assessment would be documented in the clinical record. If identified risk was present the interventions implemented would be commented on the care plan. If it was determined the resident exited through a door, door alarm systems should be tested and confirmed in working order, as close to the time of the event as feasible. The facility failed to implement intervention on resident #1's care plan after assessing the resident as at risk for elopement on 10/15/17 which place the resident in immediate jeopardy on 10/20/17 when the resident eloped from the facility, ambulated 862 feet in the dark near a highly traveled highway and sustained injuries and lost his/her corrective lenses he/she required for vision while unsupervised by the facility staff. The deficient practice was identified as past non-compliance and was corrected 10/25/17 the facility provided staff education on the policy and procedure for elopement, completion of elopement drills on all shifts, the key pads and door locks was tested and determined to be functional, key pad codes changed, resident #1 was re-assessed for elopement and his/her care plan was updated, and the elopement book was reviewed and updated by the facility staff.

The facility census totaled 44 residents and the sample included 2 residents reviewed for nurse assessment of a change in condition. Based on observation, interview and record review the facility failed to ensure 2 of 2 sampled residents (#1 and #2) received nurse assessments following a change in condition, monitoring of health conditions, and timely and accurate response to a critical laboratory results Resident #1 had changes in his/her condition from 8/22/17 through 8/30/17 without nursing assessments or complete vital sign measurements and monitoring. On 8/27/17 the resident presented with onset of [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) in his/her bilateral (both sides) hands without evidence of a nurse assessment or vital signs. On 8/29/17 the physician examined the resident during a routine visit and ordered multiple laboratory tests and a chest X-ray. On 8/29/17 the laboratory notified the facility of critical lab values of Troponin (a cardiac enzymes indicative of heart damage), elevated brain natriuretic peptide (BNP-a blood test which measured levels of a protein {BPN} levels higher than normal indicating heart failure) and elevated white blood cell count (indicative of an infectious process) and the nurse did not perform an assessment or obtain and monitor vital signs. On 8/30/17 at 8:40 AM, at the insistence of a family member, the resident transported by emergency medical services (EMS) to the hospital and was found to have a non-ST (refers to the ST segment of the heart tracing test used to diagnose a [MEDICAL CONDITION]) elevated [MEDICAL CONDITION] infarction (MI-[MEDICAL CONDITION]). This resident's change in condition occurred over 8 days. Findings included: - Review of the physician's orders [REDACTED]. vessels). The annual minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment with no behaviors. He/she required extensive assistance of 1 staff for bed mobility, dressing and eating with 2 staff needed to transfer and use the toilet. He/she had no shortness of breath, was not terminal, and with no fever/vomiting/dehydration during the 7 day observation period. He/she had no swallowing difficulties. He/she received a diuretic (a medication to help the kidneys excrete excess fluid from the body) on 3 days of the observation period and used oxygen. The cognition care area assessment (CAAs) dated 4/3/17 identified the resident had actual cognitive deficits. This was a decline from his/her previous score of 9 (moderately impaired). He/she was alert and able to usually understand and be understood. The quarterly MDS dated [DATE] included the same for information as 3/30/17 MDS. The care plan for fluid deficit due to use of [MEDICATION NAME] (a medication to remove access fluid from the body) created and without revision since 11/19/15 stated staff should monitor the resident for signs and symptoms (s/s) of dehydration, administer the [MEDICATION NAME] as ordered, monitor for side effects, obtain and monitor lab work as ordered and report abnormal results promptly. The frequently incontinent of bowel care plan created on 3/21/11 directed staff to monitor the resident for s/s UTI, such as cloudy or foul smelling urine, pain/burning; increased need to void, increased confusion or elevated temp and notify the physician as indicated. The ADLs care plan due to weakness and poor balance created on 3/21/11 directed staff to use the sit-to-stand lift as needed with transfers, assist him/her with ADLs as needed and encourage him/her to participate to greatest extent possible. Staff revised the care plan on 7/28/15 for staff to monitor the resident for a decline in ADLs and notify the physician as indicated and provide extensive assist with bed mobility, transfers, dressing, toileting and personal hygiene. On 4/3/17 staff updated the care plan to provide the resident with extensive assistance for eating/drinking. Review of the recapitulation of the physician's orders [REDACTED]. [MEDICATION NAME] (a medication to help the kidneys excrete excess fluids from the body) 20 milligrams (mg) every other day for pleural effusion ordered on [DATE]. Review of the record lacked evidence staff monitored the resident's oxygen saturation as ordered to ensure his/her saturation remained above 90% as ordered. Staff documented an oxygen saturation on 6/28/17 at 92% on room air and the next recorded assessment on 9/3/17 of 91% on supplemental oxygen. The vital sign record had daily blood pressure and pulses without documentation of the temperature and respirations from 6/28/17 to 9/3/17. Review of the 24 hour North Hall report sheets from 8/20/17 through 8/29/17 revealed no comments about the reports made from direct care staff about changes in the resident's condition. On 8/27/17 the sheet included Add resident to the doctor's list for [MEDICAL CONDITION] - call Monday to add per family request. On 8/28/17 it read add to doctor's list '[MEDICAL CONDITION]' call to add (Monday) per family request. Review of the nursing notes revealed the following: On 8/17/27 at 5:16 AM staff assessed the resident with good skin turgor and no pain. On 8/21/17 at 12:17 PM social service noted the resident saw the dentist, needed some extractions but were not bothering him/her so it could wait. On 8/24/17 at 3:14 AM staff assessed the resident with good turgor, redness to the groin and buttocks and staff applied moisture barrier. The resident denied pain, confused, and cooperative with cares. On 8/28/17 at 7:52 PM staff recorded not administering a medication for heartburn due to the resident was sleeping. The nursing notes lacked any evidence of a nurse assessment for the changes reported by direct care staff or the [MEDICAL CONDITION] noted on 8/27/17. Review of the electronic assessment tab in the record revealed a skilled assessment dated [DATE] and the next assessment as a clinical health assessment dated [DATE]. The physician progress notes [REDACTED]. The note listed fatigue, fever with highest 99 degrees F, and reported SOA. The physical assessment listed alert with no acute distress, respirations normal with bilateral rales (crackles caused by fluid in the small airways) and no wheezing, regular heart rate and rhythm with bilateral [MEDICAL CONDITION] of the lower extremities. The physician later at 2:51 PM faxed orders to the facility for a complete blood cell count (CBC), BNP, Troponin, chest X-ray, blood cultures drawn at 2 different times and a urinalysis with culture. The chest X-ray results were noted as faxed to the physician on 8/29/17 at 5:13 PM as impression: increase in congestive changes and trace fluid in the minor fissure (divides the right middle lobe from the right upper lobe of the lung) consistent with borderline [MEDICAL CONDITION] ([MEDICAL CONDITION]- a condition with low heart output and the body becomes congested with fluid) with no change in visibility of the air spaces with the fluid in the left angle of the lung which may be recurrent or residual. The laboratory test results collected on 8/29/17 at 4:20 PM included: WBC - 15.5 was High (normal 4.8-10.8 kilo per microliter-K/ul) Troponin- 15.47 critical high (normal 0-0.1 nanograms per milliliter-ng/ml) BNP- 2510 high (normal 0-99 picograms per milliter-pg/ml) The lab report noted the lab called the results to licensed nurse H at the facility and faxed to the facility on [DATE] at 8:33 PM. Review of the nursing notes revealed no assessment of the resident or vital signs following the notification of these critical and high lab tests on 8/29/17. The notes included the following in succession: On 8/29/17 at 9:14 PM licensed nurse H received the lab results which showed a critical high (CH) troponin level of 15.47. The nurse called the on-call physician's service and received orders from physician extender J to call the lab results to the primary physician's office in the morning. During interview on 10/10/17 at 3:20 PM, Nurse H revealed he/she questioned the on-call physician extender J about the need to send the resident into the emergency room . The resident's primary physician who is also the facility Medical Director was not contacted regarding the critical lab values and high values indicating infection. On 8/30/17 at 8:44 AM licensed nurse K recorded the resident's family member requested the resident be sent into the hospital. Licensed nurse H called the on-call physician service and received orders to transfer the resident to the hospital by emergency medical services (EMS). The resident left the building by EMS at 8:40 AM. Review of the emergency room (ER) report dated 8/30/17 at 9:17 AM revealed the resident had a history of [REDACTED]. The resident's symptoms per family member included lethargy, difficulty breathing, SOA and swelling of both hands. Physical exam showed the resident was drowsy, but able to answer questions with 1 word, moderate respiratory distress, and tachypnic (breathing rapidly) with respirations staying in the 30's per minute (normal 12-20 breaths per minute), a loud heart murmur (caused when the blood flow moves through the heart in turbulence from obstruction of blood flow) and non-pitting lower extremity [MEDICAL CONDITION]. The 9/1/17 hospital history and physical indicated the resident admitted to the hospital on [DATE] with chief complaint of dyspnea (difficulty breathing) and lethargy. The resident had a past history of [MEDICAL CONDITION], HTN, and came from the facility with decreased level of consciousness and dyspnea. The family member provided the resident's history of illness as bilateral [MEDICAL CONDITION] of resident's hands on Sunday (8/27/17) and he/she was lethargic. The family member requested an evaluation by the resident's primary care physician the following day. Laboratory tests were obtained at the facility and found the resident to have largely abnormal labs with white count of 15,500, BNP of 2510 and Troponin was 15.47. Because of abnormal labs he/she transferred to the ER for further evaluation. Upon arrival the resident appeared to have labored breathing and was dyspneic with respiratory rate in the 20-30 range (12-20 breaths per minute), required 2 liters of supplemental oxygen, but still worked hard to breathe. Therefore, he/she was placed on [MEDICAL CONDITION] (a device used to provide positive airway pressure). The resident's troponin remained elevated at 4, BNP was 1514, white count of 14,900, and an electrocardiogram (EKG-records the electrical signals in the heart) which showed changes from a previous EKG done in 2/2016. Discussion with the cardiologist revealed the changes were likely a non-ST-elevated MI. The physical exam revealed decreased breath sounds bilaterally with no crackles or wheezing. The extremities had level 2 or greater bilateral upper extremity [MEDICAL CONDITION] and right lower extremity [MEDICAL CONDITION] with level 1 or greater in left lower extremity [MEDICAL CONDITION] (did not include if pitting or non-[MEDICAL CONDITION]). The treatment plan for the resident included the resident presented with:[MEDICAL CONDITION] (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases [MEDICAL CONDITION] can lead to the medical emergency, septic shock) from a urinary and [MEDICAL CONDITION] source with [MEDICAL CONDITION] (low blood pressure) and leukocytosis (an increase in number of white cells in the blood, especially during an infection) and continue with intravenous (IV) fluids and antibiotics (a medication to treat infection), acute respiratory distress with BNP of 1500 which appeared to improve on the [MEDICAL CONDITION] and planned to continue low-dose IV [MEDICATION NAME], suspect this was likely a [MEDICAL CONDITION] fluid overload versus possible aspiration pneumonia (when inhale food, stomach acid or saliva into the lungs causing inflammation or infection) , urinary tract infection to continue antibiotics and follow up after the urine culture, elevated troponin - suspect this was demand ischemia (an inadequate blood supply to an organ or part of the body, especially the heart muscle) due to the above per cardiology with continue daily aspirin suppository (administered by rectum) until patient could take by mouth. The interagency transfer form signed 9/1/17 returning the resident to the facility included [DIAGNOSES REDACTED]. Interview on 10/10/17 at 1:56 PM and on 10/11/17 at 11:50 AM with direct care staff E revealed on 8/22/17 staff E assisted the resident in the dining room and the resident was not picking up his/her silverware like he/she normal did. He/she had a faraway look in his/her eyes. Staff E reported to charge nurse K and licensed nurse H. Licensed nurse K went to the dining room and noted the resident would not hold his/her head up or try to feed him/herself. Licensed nurse K also present in the dining room agreed he/she is different. Staff E reported one of the nurses obtained vital signs and then after that he/she did not know what happened to the resident. On 8/27/17 when staff E again assisted the resident, he/she remained about the same. He/she had to ask the resident to lift up his/her head, had to actually feed the resident and then after a few bites he/she had to take the food back out of the resident's mouth because he/she would not chew. Staff E reported the change in the resident's condition to licensed nurse D and then assisted the resident back to bed. Interview on 10/11/17 at 1:10 PM with direct care staff M revealed he/she could not remember specific dates when he/she noticed a gradual decline in the resident's ability to function but knew it was before the hospitalization . The resident used to feed him/herself with occasional prompts from staff. He/she started requiring more prompts and eventually needed to be fed completely by staff. He/she reported the resident was very lethargic and got more tired over time, no matter how much sleep he/she received. The notarized statement by direct care staff M dated 10/11/17 indicated he/she reported to licensed nurse K about the resident being tired, not standing on the sit-to-stand lift, not eating and needing extra help. The nurse told him/her to lay the resident down. Interview on 10/11/17 at 3:16 PM with direct care staff N revealed in late August 2017 he/she noted changes in the resident. He/she did not remember the specific day, but it occurred in the dining room. He/she sat at the same table across from the resident assisting another resident when another direct care staff assisted the resident. The resident was just not acting right, he/she would not hold up his/her head or attempt to eat, even when the aide put the silverware in his/her hand. This was not normal for the resident. Prior to that day on several occasions he/she and other direct care staff reported to the nurses about the resident not acting right and the resident had bad smelling urine. On one occasion licensed nurse C responded the resident's urine always smelled bad. The resident was one day talking and smiling with him/her and the next day he/she sat slumped over in the wheelchair and could not propel him/herself which he/she normally preformed independently. Interview on 10/10/17 at 12:55 PM with licensed nurse C revealed he/she did not work 8/27/17, but worked 8/28/17 from 10:00 AM until 4:00 PM. He/she said the resident was different, but not in distress. His/her breathing was normal for him/her. He/she was not as talkative, seemed to be moping around and he/she usually smiled, but did not on that day. He/she and other nurses began monitoring the resident's condition and put him/her on the list for the doctor to see when he/she visited on 8/29/17. Interview on 10/10/17 at 1:42 PM with licensed nurse D revealed he/she worked Sunday 8/27/17 when family reported about the hand swelling and he/she noted the resident's hands had some swelling which was unusual. The resident would normally have swelling in his/her feet. He/she visited with the family member about the resident's condition and put on the report sheet to add to the physician's visit list. He/she confirmed the 24 hour report sheet was the only place he/she recorded about the resident's [MEDICAL CONDITION]. He/she did not indicate he/she completed a nurse assessment, obtain vital signs, listen to lung sounds or obtain an oxygen saturation related to the unusual swelling of the hands. Interview on 10/10/17 at 3:20 PM with licensed nurse H revealed on 8/29/17 he/she filled in for a nurse who was sick. In report he/she heard the resident was seen by the physician and he/she ordered labs. Later that evening he/she received a call from the lab about the critical Troponin. He/she called the on-call physician services and spoke with physician extender J who said he/she did not know the resident and directed nurse H to call the primary physician in the morning. He/she reported the resident rested in bed sleeping, vital signs were taken and in normal range with supplemental oxygen on at 2 liters. The record lacked evidence of any recorded vital signs for 8/29/17 including oxygen saturations and no physical nurse assessment after learning of the abnormal labs. Interview on 10/11/17 at 1:36 PM with licensed nurse H in regards to him/her being notified of the resident's change in condition on 8/22/17 in the dining room revealed he/she was not notified. He/she reported direct care staff should go to the charge nurse of the resident. He/she reported facility policy (none provided) included charting only when assessments or vital signs were out of normal. Interview on 10/11/17 at 3:27 PM with licensed nurse K revealed the resident required assistance from staff for activities of daily livings and he/she could propel him/herself in the wheelchair and did not talk much, but would smile. He/she was not aware of any changes in the resident. On 8/30/17 he/she received report at the start of the shift and learned about the resident's hands and arms being swollen. He/she did not respond when asked if he/she assessed the resident's condition. He/she reported at about 8:30 AM the family came and asked to have the resident sent to the hospital. Interview on 10/10/17 at 4:20 PM with administrative nurse B revealed an expectation for nurses to identify sudden changes in a resident's condition such as [MEDICAL CONDITION], record the information in the record, perform an assessment then based on the results notify the physician as indicated. He/she expected any changes be recorded on the report sheet for the following shifts to monitor the condition and in the resident's record. He/she expected the physician be notified of general changes in condition which presented as emergent during physician office hours. On 10/11/17 at 7:30 AM he/she said the nurse assessments regarding a change in condition would be documented under the assessment tab as a situation, background, assessment and recommendation (SBAR). He/she said the facility no longer faxed lab to doctors because the lab already faxed the results to the physician. The lab would call the facility for critical values and the facility had the responsibility to call the physician. He/she expected staff to notify him/her of critical labs especially if the response from the on-call physician did not seem appropriate and the nurse should notify the Medical Director. Interview on 10/11/17 at 10:58 AM with physician extender J revealed he/she did not remember getting a call regarding the resident. He/she said if he/she was told about a critical Troponin, elevated WBC and BNP he/she would have ordered to send the resident to the emergency room for evaluation. The facility failed to provide a policy regarding change of condition, nurse assessment or monitoring for [MEDICAL CONDITION] or response to lab results as requested on 10/10/17. The facility failed to ensure resident #1 received nurse assessments following a change in condition, monitoring of health conditions, timely and accurate response to critical laboratory results. The resident had changes in his/her condition from 8/22/17 through 8/30/17 without any nursing assessment or complete vital sign measurements and monitoring. On 8/27/17 the resident had swelling in both hands without a nurse assessment or vital signs. The resident had critical lab values on 8/29/17 and no nurse assessment or vital signs were obtained. On 8/30/17 at 8:40 AM at the insistence of a family member the resident was transported by emergency medical services to the hospital and found to have a non-ST elevated [MEDICAL CONDITION] infarction. - Review of physician's orders [REDACTED]. enough insulin made or the body cannot respond to the insulin), essential hypertension (persistent high blood pressure of no known cause), dependence on renal (kidney) [MEDICAL TREATMENT] (external process to filter waste from the kidneys), and retention of urine. The Admission Minimum Data Sheet ((MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident did not have any behaviors. The resident required extensive two persons assist for bed mobility, transfers, and supervision for eating/drinking. He/she did not have shortness of breath (SOB), did not have a terminal condition, and was not experiencing a fever, vomiting, dehydration, or internal bleeding. Review of the cognition care area assessments (CAAs) dated 7/20/17, revealed staff monitored the resident for fluid maintenance and he/she at risk for dehydration due to [MEDICAL TREATMENT] with fluid restrictions in place to treat [MEDICAL CONDITION]. The resident was alert and oriented and able to make needs known. The activities of daily living (ADL) CAA dated 7/20/17 revealed the resident had an actual ADL functional deficit and needed extensive assist with most ADLs. Review of the care plan dated 7/24/17 revealed the resident had [MEDICAL CONDITION] with interventions of: [MEDICAL TREATMENT] 3 times per week on Tuesday, Thursday, and Saturday; had a right arm fistula (surgically created passage between) which needed checked for thrill (a fine vibration felt which reflects the blood flow by a [MEDICAL TREATMENT] resident's shunt), and bruit (blowing or swishing sound heard which reflects the blood flow with a [MEDICAL TREATMENT] resident's shunt) and bleeding every shift; refrain from taking blood pressures and lab draws on right arm; vital signs were to be checked before and after [MEDICAL TREATMENT] and a complete [MEDICAL TREATMENT] communication form sent with the resident to [MEDICAL TREATMENT]. Resident was also at risk for weight loss and impaired nutrition with interventions by staff to include: staff should document and chart meal intakes in the record; note and maintain 1200 mL fluid restriction; offer snack/lunch of resident's choice on [MEDICAL TREATMENT] days; no added fat/salt diet restrictions; the resident was able and should be allowed to choose own meals; RD referral shortly after admission and as needed; weigh weekly for the first four weeks post admission, monthly, and PRN thereafter and expect weight fluctuations due to [MEDICAL TREATMENT]. Review of the physician's orders [REDACTED]. brain natriuretic peptide (BNP-used to check for heart failure). The lab report identified a critical creatinine (a compound that is produced by metabolism of [MEDICATION NAME] and excreted in the urine) of 7.11 milligrams/deciliter (mg/dL) (normal values 0.72-1.25 mg/dL) and laboratory staff called the critical value to licensed nurse D on 7/25/17 at 10:50 AM. Review of the progress notes revealed no evidence that staff notified the physician of the critical lab value. The lab report for the HgbA1c ordered on [DATE] had a pending result. The record reviewed on 10/10/17 lacked a final result. Review of the physician orders [REDACTED]. A note on the CBC report dated 9/7/17 at 1:28 PM indicated laboratory staff faxed and called critical results and read back to licensed nurse D. The only critically high value was creatinine 9.84 mg/dL. Review of the record revealed no nurse assessment following notification of the critically high value. The physician's orders [REDACTED].<88% every night shift. Review of the Medication Administration Record [REDACTED]. Review of the progress notes revealed no explanation for the missing assessment. Review of physician orders [REDACTED]. Staff recorded vital signs, including blood pressure, pulse, and temperature on 9/28/17 and not again until 10/10/17, and there were four scheduled [MEDICAL TREATMENT] treatments during that time. Review of the physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of progress notes revealed no evidence of records kept for the resident's actual daily fluid intake. Review of the physician orders [REDACTED]. Review of the August and September 2017 MARs revealed staff initialed completion of the access site checks but the record lacked consistency in the recorded findings. Staff recorded the presence or absence of a bruit and a thrill by using a check mark, yes, a plus (+) sign, positive, negative, a negative (-), and/or no. Review of the nurse's notes (NN) between 8/4/17 and 10/11/17 revealed the following: NN on 8/4/17 at 3:52 PM revealed staff recorded a weight warning with the resident's weight obtained on 8/3/17 at 3:14 PM noted as 225.6 lbs., indicating a +3.0% change in weight over the last 30 days. The notes indicated the resident received a limited concentrated sweets/cardiac diet, a 1200 mL fluid restriction daily, and he/she was not adhering to these restrictions. The notes lacked evidence that fluid intake was monitored and/or recorded to verify the resident stayed within the fluid restrictions. The resident received [MEDICAL TREATMENT] three times a week making weight fluctuations expected. Staff reported the probable weight gain was because the resident's weight was taken early in the morning before leaving for [MEDICAL TREATMENT] and it was three days since the resident's last [MEDICAL TREATMENT] treatment resulting in fluid gain. Review of the nursing notes revealed no evidence of nursing assessment and/or follow-up on weight post [MEDICAL TREATMENT] treatment. Observation on 10/10/17 at 3:50 PM revealed the resident returned to the facility from [MEDICAL TREATMENT]. An outside provider for transportation took the resident directly to his/her room. At 4:00 PM, observation revealed the resident sat in his/her wheelchair in his/her room. He/she appeared groggy, and had wraps in place on both legs and non-slip socks on both feet. No visible [MEDICAL CONDITION] noted. The resident spoke softly with slurred speech and could not effectively communicate his/her needs at this time. Between 4:02 PM and 4:22 PM, the resident remained under observation and no staff entered the resident's room. Observations on 10/11/17 at 9:00 AM revealed the resident sat in his/her room in his/her wheelchair. The resident was alert and oriented with clear speech and not slurred. Breakfast tray was in the room. Juice was spilt on the tray and there was a pitcher halfway full of ice. At 10:08 AM the resident sat in his/her wheelchair in the hallway in a tank top and pants with no shoes on and non-slip socks in place, feet appeared swollen under socks. Attempted interview on 10/10/17 at 3:50 PM with the resident was not successful. The resident was groggy and slurred his speech. He/she was not able to communicate effectively. Interview on 10/11/17 at 9:00 AM was done with the resident. He/she was alert and oriented and he/she was able to discuss the care he/she received and his/her [MEDICAL TREATMENT] treatments. Interview on 10/10/17 at 1:50 PM with direct care staff E revealed he/she had not noticed any changes in the resident's health or behavior. Staff E stated he/she had not received education on how to recognize changes in the resident's status. The aide stated there was no paperwork he/she knew of for tracking the resident's fluid intake each shift. Staff E stated he/she looked for swelling and listened for wheezes on the resident but denied receiving any education on how to recognize signs and symptoms of fluid overload. Interview on 10/10/17 at 4:01 PM with direct care staff F revealed he/she worked mainly on the resident's hall. He/she stated the resident was generally alert and oriented but tired after [MEDICAL TREATMENT]. He/she stated he/she did not know of any intake and output records he/she was supposed to use for recording and monitoring the resident's fluid. The aide denied receiving any training or education regarding what signs and symptoms indicate possible fluid overload. Interview on 10/10/17 at 9:13 AM with licensed nurse C, revealed staff asked the resident for the [MEDICAL TREATMENT] communication form from the [MEDICAL TREATMENT] facility when he/she returned from treatment. Staff C stated the form covered pre and post [MEDICAL TREATMENT] weight, medications given, and any changes to treatment. Staff C stated assessments done upon the resident's return included assessment of cognition and vital signs (VS). Staff C asked if he/she knew the expectations when charting the assessment of the resident's access site and he/she stated, I understand my responsibility in assessing the resident's access site but I haven't received education on what exactly the acceptable wording or signs are that we are supposed to use when charting our assessments. Interview on 10/10/17 at 1:37 PM with licensed nurse D. Nurse D revealed the expectation for stat (immediately) lab was right now and otherwise the next scheduled lab days. At 4:30 PM, when asked if he/she assessed the resident since his/her return from [MEDICAL TREATMENT] and nurse D stated he/she had not made it in yet. He/she stated there was not a designated time frame for nursing assessments to be completed after the resident returned to the facility. Staff D stated the driver who brought the resident back to the facility from [MEDICAL TREATMENT] said he/she seemed off and he/sh(TRUNCATED)