Every finding on record at Meth-Wick Health Center

Based on clinical record review, staff interview and review of Medicare guidelines, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 2 residents (Resident #3) whose skilled stay ended and continued to reside in the facility. The facility reported a census of 56 residents.Findings include:The Minimum Data Set (MDS) assessment for Resident #3 dated 4/20/26 identified a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderately impaired cognition. The MDS included anemia, atrial fibrillation (irregular heart beat), coronary artery disease, non-alzheimer's dementia, and chronic kidney disease. The Clinical Record revealed Resident #3 was admitted to the facility for a Medicare Part A skilled stay on 4/13/26, was discharged from Medicare on 5/5/26 and remained in the facility private pay. The Clinical record lacked documentation a SNFABN was given to Resident #3 or a resident representative when Resident #3 was discharged from Medicare Part A to private pay.On 8/11/26, the Administrator reported the facility self identified an error as Resident #3's SNFABN was not completed. The Administrator reported the SNF ABN was completed on 8/11/26.The facility policy/procedure titled Form Instructions Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) dated 2018 documented Medicare requires the Skilled Nursing Facility (SNF's) to issue the SNFABN to Original Medicare, also called fee-for-service, beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care was not medically reasonable and necessary or considered custodial. The SNFABN provides information to the beneficiary so that he or she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNF's must use the SNFABN when applicable for SNF Prospective Payment Services (Medicare Part A).

Based on observation, clinical record review, staff and resident interviews the facility failed to answer a call light and assist a resident to the restroom in a timely manor for one out of two residents reviewed (Resident#23). The facility reported a census of 56 residents.' Findings include: The Minimum Data Set (MDS) assessment for Resident #23 dated 5/19/26 listed diagnoses of coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD).The Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, intact cognition. The MDS reflected Resident#23 required substantial/maximal assistance from staff with toileting hygiene, and partial/moderate assistance from staff to transfers to the restroom. The MDS revealed Resident#23 always continent of bowel. The Care Plan dated 2/18/26 read Resident#23 needed assist of 1 staff for transfers and ambulation. The Care Plan dated 02/20/2026 directed Resident#23 call light within reach. Resident#23 will request to use the bathroom, offer routine toileting around these requests. The Care Report dated 8/11/26 showed Resident#23's room call light on at 11:10 AM and on for 25 minutes. On 8/11/26 at 11:21 AM Resident#23 sat in the chair in her room feet down. Call light on. On 08/11/2026 at 11:23 AM the call light log on the wall at the nurse's desk showed Resident #23's light on for 18 minutes. Staff were not in the room with her. On 08/11/2026 at 11:31 AM staff went in to help Resident#23 after 25 minutes of her call light on. On 08/12/2026 at 3:00 PM Resident #23 reported she waited so long for help yesterday before lunch, she had a bowel movement (BM) in her pants. Resident #23 said she felt embarrassed. Resident #23 said the staff told her they were with another resident and that's why it took so long. Resident#23 said it happens a few times a week. On 08/13/2026 at 10:21 AM Staff E Oral Medication Tech (OMT) Household Coordinator (HHC) reported call light needed to get answered in 10-15 minutes. He pulled the Care Report for Resident #23's room and confirmed her call light on for 25 minutes. On 08/13/2026 at 11:09 AM the Director of Nursing (DON) reported she expected the call lights answered asap but then 15 minutes is the maximum she expected. On 08/13/2026 at 11:29 AM the DON reported the facility did not have a call light policy.

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to ensure medications and biologicals were stored securely and only accessible to authorized staff for 3 of 3 residents reviewed for medication storage (Resident #27, Resident #23, and Resident #1).Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 as severely cognitively impaired. The Care Plan dated 08/10/2022 lacked interventions or a physician's order permitting the resident to self-administer or keep medications at the bedside. The Physician Orders dated 08/12/2026 included an order for Calmosceptine ointment to be applied twice daily by nursing staff.Observation on 08/10/2026 at 10:31 AM revealed a tube of medicated Calmosceptine ointment sitting uncontained on the bedside table while the resident was out of the room.Observation on 08/10/2026 at 1:34 PM revealed the Calmosceptine ointment remained sitting on the bedside table while the resident was napping.Observation on 08/12/2026 at 8:53 AM revealed the Calmosceptine ointment stored inside Resident #27's bedside table drawer.2. The MDS assessment identified Resident #23 with intact cognition. The Care Plan dated 02/13/2026 lacked a self-administration assessment or authorization for bedside medication storage. The Physician Orders dated 08/12/2026 contained no active physician's order for bedside medication or cough drop storage or self-administration.Observation on 08/10/2026 at 10:32 AM revealed several loose cough drops sitting on the bedside table and counter, along with opened wrappers.Observation on 08/12/2026 at 8:50 AM revealed cough drops and wrappers still sitting on Resident #23's table.On 08/10/2026 at 10:32 AM, Resident #23 stated her daughter brought the cough drops in from home and she takes them as needed.On 08/12/2026 at 8:50 AM, Resident #23 stated she had taken a couple of the cough drops the previous night.3. The MDS assessment dated [DATE] identified Resident #1 with intact cognition. The Care Plan dated 03/11/2026 included active orders for Trazodone and Baclofen. The clinical record contained no order for self-administration or permission to keep medications at the bedside.Observation on 08/10/2026 at 2:33 PM revealed prescription bottles of Trazodone and Baclofen, alongside two unmarked medication bottles, inside an unzipped bag near Resident #1's bedside.Observation on 08/12/2026 at 8:35 AM revealed the unzipped bag containing Trazodone, Baclofen, and two unmarked medication bottles remained sitting in Resident #1's room on his bedside table.On 08/10/2026 at 2:33 PM, Resident #1 stated he does not use the medications in the bag but keeps forgetting to have his wife take them home.In an interview on 08/12/2026 at 8:43 AM, Staff A, Licensed Practical Nurse (LPN), stated there were no orders for any resident on the unit to keep medications at the bedside. Staff A confirmed she was unaware Resident #1 had Trazodone, Baclofen, and unmarked medication bottles in his room and stated she would immediately remove them and lock them in the medication room until his spouse could retrieve them.In an interview on 08/12/2026 at 9:57 AM, the Director of Nursing (DON) stated there were no orders for any resident on the unit to keep medications at the bedside. The DON confirmed that a self-administration assessment must be performed and a physician order obtained for a resident to keep medications in their room, and even then, medications must be kept locked so only the resident can access them. The DON further stated staff are expected to remove any medications found in resident rooms immediately.The facility policy revised February 2021, titled Self-Administration of Medications, instructed that residents have the right to self-administer medications only if the interdisciplinary team (IDT) assesses the resident's cognitive and physical abilities and determines that practice is clinically appropriate and safe. The policy directed that self-administered medications must be stored in a safe and secure place not accessible by other residents. The policy further instructed that any medications found at the bedside not authorized for self-administration must be turned over to the nurse in charge.The facility policy revised December 2012, titled Administering Medications, directed that residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to ensure staff performed proper hand hygiene, changed contaminated gloves, and adhered to infection control practices for 1 of 1 resident reviewed for infection control (Resident #6).Findings include:The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 as receiving gastrostomy tube (G-tube) feedings, having an indwelling urinary catheter, and presenting with pressure ulcers/wounds.Continuous observation on 08/10/2026 at 11:46 AM during morning care and preparation for lunch revealed the following:Staff C, Certified Nurse Aide (CNA), touched the inside of a trash can with her gloved hands to move it toward the bed. Staff C failed perform hand hygiene before putting on clean gloves. After a few minutes into the cares, she realized she had forgotten to don a gown so Staff C then entered the bathroom, donned a gown, and changed gloves.Staff C and Staff B, CNAs, performed incontinence care for Resident #6, noting a black, tarry bowel movement. Staff C held dirty, contaminated gloves in her hand while tucking the Hoyer lift sling behind the resident in bed.Staff C washed Resident #6's face and changed gloves without performing hand hygiene before Staff C brushed Resident #6's teeth.Observation on 08/12/2026 at 9:47 AM, conducted in the presence of the Director of Nursing (DON), revealed Staff A, Licensed Practical Nurse (LPN), administering G-tube medications to Resident #6. After removing dirty gloves used to measure the G-tube site for placement, Staff A put on a new pair of clean gloves without performing hand hygiene and proceeded to administer the medications.In an interview on 08/12/2026 at 9:57 AM, the DON acknowledged the glove changes and hand hygiene failures. The DON stated that the glove practices observed were a problem and confirmed the facility expects employees to wash their hands or perform hand hygiene after removing gloves or when changing gloves.The facility policy revised December 2024, titled Enhanced Barrier Precautions, instructed staff to follow standard precautions and perform personal protective equipment (PPE) changes and hand hygiene during high-contact resident care activities, including hygiene/grooming, assisting with toileting, transferring, device care (urinary catheter and feeding tube), and wound care.The facility policy revised September 2010, titled Personal Protective Equipment - Using Gloves Level I, instructed staff to wash hands after removing gloves, noting that gloves do not replace handwashing.

Based on observations, staff interviews and facility policy review, the facility failed to maintain proper food handling practices while serving food for 4 out of 5 meals observed and failed to restrain hair for 3 out of 5 meals observed. The facility reported a census of 61 residents. Findings Include: 1. On 10/23/23 the following observations made during a lunch meal service in the Lynch Dining Room (DR): a. At 12:16 PM Staff F, Food Service Worker served food while she wore a baseball styled hat while several inches of her braided hair hung over the front of both shoulders. Staff F used her gloved hands to to pick up plates from under the counter and with the same gloved hands picked up grilled cheese sandwiches from the pan and placed them on plates. Staff used the same gloved hands to use the scoops to serve the rest of the items. b. At 10/23/23 12:19 PM, Staff F, used the same gloved hand to pick up the grilled cheese sandwich from the tray placed it on a plate. c. At 12:22 PM, Staff F used her gloved right hand to pick up grilled cheese sandwiches, she used the same gloved hand to scoop the food then reached for another plate from under the counter. She used the gloved hand to pick up the grilled cheese sandwich and put it on the plate. Staff F moved out of the kitchen area, obtained plastic wrap to cover a tray. She went back in to the kitchen area with the same gloved hand she took a plate from under the counter and placed the sandwich on the plate and dished up the additional items with multiple scoops and gave the plate to nursing staff for delivery. 2. On 10/24/23 observed the following in the Lynch DR: a. At 8:24 AM, Staff F, served a resident who sat at the table toast as her hair hung in a braid over her right shoulder while she wore a baseball like hat. b. At 12:44 PM, Staff F wore a baseball like hat in the kitchen while several inches of her braided hair hung over her right shoulder. Staff F failed to wear a hairnet. 3. On 10/25/23 the following observed during a lunch meal service a. At 12:04 PM, Staff G, Food Service Worker in the Lynch kitchen used her gloved right hand to grab the hamburger bun and place it on the plate, she used the same gloved hand for the tongs as she placed the tomato on the hamburger. b. At 12:05 PM, Staff G, used the right gloved hand to apply bacon, lettuce, tomato then took a hold of the tongs to dish other food onto the plate. Staff G went to the water dispenser filled a glass, she retrieved from the cupboard to the left of the water dispenser with her gloved hand. c. At 12:07 PM, She used her gloved right hand to pull a slice of cheese from package and put on bun. She grabbed onions from the dish with right gloved hand after she pulled a dish from under the counter and continued to handle scoops for the other meal items. d. At 12:10 PM, Staff G, took her right and left gloved hand, pulled apart the bun, sat it on a plate. She used her left gloved hand to add tomato, cheese, and reached below the serving counter to get another dish and continued to use scoops to serve other menu items. e. At 12:11 PM, Staff G, used her gloved hand to put tomato, lettuce and onions on the hamburger and used utensils to scoop the rest of the meal onto the plate. On 10/25/23 at 12:54 PM, Staff G reported the facility provided her training on glove usage. She stated she knew not to touch the food with her gloved hands. On 10/25/23 at 12:48 PM, Director of Dining Service's reported he expected the staff to use a glove to touch ready to eat food only if they were not touching anything else with that gloved hand. He stated he expected Dietary Staff to have hairnets in place. 48003 4. On 10/25/23 at 12:01 PM, in the [NAME] Wing Kitchen, Staff B, Food Service Worker washed her hands and applied gloves. While wearing the gloves she moved from surface to surface touching the serving utensils, the refrigerator, and a ketchup bottle. With the same gloved hands, she picked up a piece of sliced cheese and put it on a hamburger. She proceeded to handle the sliced cheese with the gloves for six other hamburgers served. On 10/25/23 at 12:15 PM, Staff E, Certified Nurses Aide (CNA) entered the kitchen area during meal services not wearing a hairnet and put juice away in the refrigerator. An interview on 10/25/23 at 12:38 PM, Staff C, Dietary Manager verbalized he expected staff to put clean gloves on or use a utensil when handling sliced cheese. He verbalized no staff should go into the kitchen area during meal service unless they are wearing a hairnet. An interview on 10/25/23 at 12:38 PM, Staff D, Director of Dining Services reported the staff serving in the dining room are educated on proper serving techniques and he expected staff to wear clean gloves or use a utensil when handling sliced cheese. The policy titled Handling Serviceware and Utensils dated 6/2003, directed Dietary Staff don't touch the food contact surface with bare or soiled gloves. The policy titled Personal Hygiene dated 6/01/2002, revealed Dietary Staff to wear proper hair restraints.

Based on clinical record review, staff interviews and facility policy review, the facility failed to revise a Care Plan to accurately reflect a Physician Order for a diet change for 1 of 3 residents reviewed for diets (Resident #17), and failed to revise a Care Clan to accurately reflect the risks of utilizing high-risk medications for 1 of 5 residents reviewed for medications taken (Resident #26). The facility reported a census of 61 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment completed for Resident #17, dated 8/22/23 documented the resident severely cognitive impaired. A Telephone Order signed by the physician dated 8/24/23 documented a Physician Order for diet ground meat and mechanical soft. A review of Resident #17's Care Plan documented the resident received a pureed diet. 2. The MDS Assessment completed for Resident #26, dated 10/3/23 showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS documented Resident #26 received a diuretic medication given 7 of the 7 days during the look back period. A Telephone Order signed by the physician dated 8/08/23 documented a Physician Order for Lasix (diuretic) 20 milligrams (mg) give once daily. A review of the Resident's August, September and October 2023 Medication Administration Records (MARs) dated 10/25/23 documented Resident #26 received a Lasix 20 mg oral tablet daily from 8/09/23 - 10/25/23. A review of Resident #26's Care Plan lacked documentation related to the use of a diuretic and the risk factors for use. An interview on 10/25/23 at 3:48 p.m., Staff A, MDS Coordinator reported any medication that are high-risk and diet changes should be updated on the Care Plan within 7 to 14 days of occurrence. During an interview on 10/25/23 at 4:15 p.m., the Director of Nursing (DON) verbalized she was unsure of how soon the Care Plan should be updated with changes such as diets and high-risk medications. She reported she thought it might be within 7 days but will check. An interview with the DON on 10/25/23 at 4:30 p.m., reported the Care Plans should be updated right away if it is something like an intervention from an incident such as a fall and all other things can be updated within 14 days of any changes to the residents plan of care. A policy titled Care Plans, Comprehensive Person-Centered with a revised date of March 2022 documented assessments of residents are ongoing and Care Plans are revised as information about the residents and the residents' conditions change.

Based on clinical record review, observations, staff interviews and policy review, the facility failed to ensure lorazepam concentrated liquid (anti-anxiety medication) also referred to as Ativan, a level 4 controlled drug that required refrigeration was secured in a separately locked, permanently affixed compartment while refrigerated for 4/5 residents with liquid lorazepam observed during shift count (Res. #5, #6, #7, and #8). Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. The facility reported a census of 62 residents. Findings Include: 1. Review of a Physician's Telephone Order for Resident #5 documented an order dated as received on 4/4/23 for Ativan solution 2 milligrams (mg)/milliliter (ml), administer 0.25 ml (0.5 mg) sublingually every hour as needed for anxiety/restlessness. Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #5 documented 30 ml of Lorazepam concentrate 2 mg/ml was dispensed on 4/4/23. The record further documented on 4/5/23 at 11:20 a.m. 29.75 ml remained. 2. Review of an Electronic Order for Resident #6 documented an order dated 12/7/22 for lorazepam solution 2 mg/ml, administer 0.25 3 times a day for anxiety/restlessness. Review of a Controlled Substance Shift Count and Usage Record for Resident #6 documented 30 ml of Lorazepam 0.25 ml (0.5 mg) was dispensed and on 4/5/23 after the a.m. dose 7.5 ml remained. An observation of the [NAME] Neighborhood Medication Cart on 4/5/23 at 12:20 p.m. Staff A, Registered Nurse (RN) revealed the Lorazepam liquid for Resident #5 and #6 were located in an unlocked medication refrigerator in the locked medication room adjacent to the Nurse's Station. Staff A stated the medication refrigerator, which also contained insulin and other medications should have been locked. Staff A produced a key and locked the medication refrigerator. 3. Review of an Electronic Order for Resident #7 documented an order dated 3/21/23 for Lorazepam (2 mg/ml) concentrate 0.5 ml sublingual every hour as needed for anxiety or nausea for 14 days. Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #7 documented 30 ml of Lorazepam concentrate 2 mg/ml was received on 3/22/23 and on 4/5/23 29.5 ml remained. 4. Review of an Order Sheet for Resident #8 documented an order dated 3/31/23 for Lorazepam 2 mg/ml administer 1 mg by mouth 45 minutes to 1 hour prior to shower on shower days. Reviewed of a Controlled Drug Receipt/Record/Disposition form for Resident #8 documented 30 ml of Lorazepam concentrate 2 mg/ml was received on 3/31/23 and on 4/5/23 30 ml remained. An observation of the Lynch Neighborhood Medication Cart on 4/5/23 at 12:30 p.m. Staff B, RN revealed the Lorazepam liquid for Resident #6 and #7 were located in an unlocked medication refrigerator in the locked medication room adjacent to the Nurse's Station along with other medications. Staff B, RN stated the medication refrigerator should be locked but she was unable to locate the key. In an interview on 4/5/23 at 1:30 p.m., the Director of Nursing (DON) confirmed would expect the medication refrigerator to be behind the locked Medication Room door and would expect the medication refrigerator to be locked by the lock integrated into the door. Review of the facility's Controlled Substances Policy dated September 2022 and revised November 2022 noted the Policy Statement documented the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. Under the Policy Interpretation and Implementation Section of the policy at Point #4 documented - Following Chapter 58.21, Scheduled II Medications remain double locked at all times except during administration and access is recorded, and Schedule III - IV controlled medications are locked and recorded.

Based on facility policy review, clinical record review, observations and staff interviews, the facility failed to ensure care and services were provided for non-pressure related wounds in accordance with accepted standards of nursing practice for Resident #44, one of two sampled residents reviewed for skin conditions. Specifically: a. The facility failed to promptly assess Resident #44's skin tear after it was identified and document the assessment in the Medical Record. b. The facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. The facility failed to monitor and treat Resident #44's skin tear and document efforts to do so in the medical record. Findings Include: A review of the facility's policy titled, Skin Tears - Abrasions and Minor Breaks, Care of, dated September 2013, indicated, Purpose - The purpose of this procedure is to guide the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Preparation: a. Obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Review the resident's care plan, current orders, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] c. Check the treatment record. d. Generate 'Non-Pressure' form and complete. The policy also indicated, Documentation - Record the following information in the resident's Medical Record: a. Complete in-house investigation of causation. b. Generate 'Non-Pressure' form. c. Document physician and family notification, and resident education (if completed) in Medical Record. d. How the resident tolerated the procedure. e. Any problems or resident complaints related to the procedure. f. Any complications related to the abrasion (e.g. [for example] pain, redness, swelling, bleeding, decreased movement). g. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. h. Interventions implemented or modified to prevent additional abrasions (e.g., clothes that cover arms and legs). i. When an abrasion/skin tear/bruise is discovered, complete a 'Report of Incident/Accident'. Review of the Detailed Summary revealed Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #44 severely impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Status. The MDS indicated Resident #44 exhibited behaviors, including physical and verbal behavioral symptoms directed toward others and rejection of evaluation or care on one to three days during the seven-day assessment period. The resident required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. The MDS indicated the resident had skin tears and received application of non-surgical dressings to areas other than the feet. Observation on 06/06/2022 at 9:01 AM, revealed Resident #44 sitting in a wheelchair in the dining area near the Nurses' Station. There was a dime-sized skin tear on the back of the resident's left hand. The skin tear had no dressing or bandage in place. A review of the Care Plan, dated 08/21/2020, revealed Resident #44 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revealed the resident refused to wear Geri-sleeves (devices applied to the legs or arms to protect the skin). The directions were for staff to take extra caution with the resident during transfers. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Interdisciplinary Notes dated from 05/02/2022 through 06/07/2022 revealed no reference to Resident #44 having a skin tear to the left hand. A review of the June 2022 Treatment Record revealed no treatment order for a skin tear to Resident #44's left hand. During an interview on 06/07/2022 at 1:26 PM, Staff A, Licensed Practical Nurse (LPN), stated Resident #44 got skin tears all the time and that the resident picked at the skin tears, which delayed healing. Staff A stated the skin tear to the resident's left hand had been there a couple of weeks, but Resident #44 kept removing the scab. When asked to locate nursing documentation regarding the skin tear, Staff A was unable to find any documentation of the skin tear to the left hand. Staff A could only find documentation related to a right upper arm skin tear. Staff A stated she used normal saline and triple antibiotic for skin tears and had tried putting on a bandage on it, but Resident #44 would pull it off. Staff A stated she could not locate any orders or documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/07/2022 at 2:17 PM, the ADON stated that every Wednesday, he updated any skin sheets. The nurse on the unit was expected to start a skin sheet, and then the ADON followed up on any wounds. The ADON stated he did not do skin rounds and just went by what the nurse reported to him. The ADON stated he was unaware of Resident #44's skin tear because he did not have an open skin report on it. The ADON stated the process should be that when the nurse finds a skin tear, they have a standing order to apply triple antibiotic ointment and steri-strips without the need for additional orders. He stated the nurses could use steri-strips or a Band-aid. The ADON indicated a skin sheet should be opened at the time the skin tear was identified, and they should document the treatment in the nurse's note. The ADON stated Resident #44 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Nurse was also present for this interview and confirmed that Resident #44's Care Plan addressed refusal to wear Geri-sleeves but did not address the resident removing bandages. She also confirmed the current skin tear was not addressed on the Care Plan. During an interview on 06/08/2022 at 11:13 AM, the Director of Nursing (DON) stated the expected process for skin tears was that the nurse would document the skin tear in the Electronic Medical Record (EMR) and notify the responsible party and the physician. The DON stated the nurse should obtain any needed treatment orders and trace the skin tear back to the origin to see how it occurred. In an interview on 06/08/2022 at 2:28 PM, the Director of Post-Acute Care (DPAC) stated she would want to know the origin of any skin tears. She stated Resident #44 was a challenge due to refusing care. The DPAC stated her expectation was that the nurse would start a Skin Sheet and initiate education to prevent additional skin tears.

Based on observation, record review and staff interviews, the facility failed to keep refrigeration temperatures for medication storage at a safe level in 3 out of 3 Medication Rooms reviewed. The facility reported a census of 59 residents. Findings include: 1. During a review of the Medication Room in the Nesetril Area on 3/31/21 at 9:26 a.m. the surveyor observed the medication refrigerator temperature read 32 degrees F (Fahrenheit). The medication refrigerator contained two medications for Resident #305: [MEDICATION(S)] 140 milligrams/milliliter (mg/ml) and [MEDICATION(S)] 0.0015%. The box for [MEDICATION(S)] states to store from 36 degrees F to 46 degrees F. The box for [MEDICATION(S)] states to to store from 36 degrees F to 46 degrees F. The Temperature Log dated for February 2021 showed temperatures out of range (36-46 degrees F) for 26 out of 28 days. The Temperature Log dated for March 2021 showed temperatures out of range for 30 out of 31 days. During an interview on 3/31/21 at 9:28 a.m., Staff E, Licensed Practical Nurse (LPN), stated the correct temperature for the medications in the refrigerator should be 36-46 degrees F. 2. During a review of the Medication Room in the Lynch Area on 3/31/21 at 9:34 a.m., the refrigerator temperature observed at 46 degrees F. The stock [CONDITION(S)] solution stored in the refrigerator states acceptable temperature is between 35 degrees F to 46 degrees F and has a warning stating Do Not Freeze. The refrigerated emergency kit stored in the Lynch refrigerator, contained the following multiple drugs: a. [MEDICATION(S)] Kwikpen b. [MEDICATION(S)] Pen c. [MEDICATION(S)] Flextouch Pen d. Lorazepam Injection e. Lorazepam Oral Solution f. Novolog [MEDICATION(S)] g. [MEDICATION(S)] suppository h. [MEDICATION(S)] i. [MEDICATION(S)] Pen The Emergency Kit lacked external indication of expiration dates. The Temperature Log for the Lynch refrigerator dated for February 2021 revealed temperatures out of range for 22 out of 28 days and the Temperature Log dated for March 2021 revealed temperatures out of range for 20 out of 31 days. During an interview on 3/31/21 at 9:37 a.m., Staff A, Registered Nurse (RN), stated you needed to open the emergency kit to check expiration dates on specific items. During interview on 3/31/21 at 10:05 a.m., Staff A stated the refrigerator should be kept in between 36-46 degrees F. 3. During a review of the Medication Room in [NAME] Hall Area on 3/31/21 at 9:56 a.m., the refrigerator temperature observed at 28 degrees F. The [NAME] Hall medication refrigerator contained an unopened Lorazepam for Resident #21. The bottle states that the temperature should be kept between 36-46 degrees F. The [NAME] Hall medication refrigerator had two types of insulin, [MEDICATION(S)] and Novolog, for Resident #23. The insulin pens state to keep temperature between 36-46 degrees F. The Temperature Log dated for February 2021 revealed temperatures out of range for 26 out of 28 days. The Temperature Log dated for March 2021 revealed temperatures out of range for 29 out of 31 days During an interview on 3/31/21 at 9:58 a.m. Staff F, RN, stated that if she did not know a temperature that a drug was to be kept at she would look it up in the drug book they have. During an interview on 3/31/21 at 10:29 a.m. the Director of Nursing (DON) stated usually they have a sheet to check the temperatures and would expect staff to follow the policy for medication storage. The Temperature Log in all 3 medication storage areas state acceptable range of refrigeration is between 36-46 degrees F. Policy labeled: Storage of Medications revised November 2020 states the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy continues to say under section 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.

Based on observation, staff interview and facility policy review, the facility failed to ensure staff followed infection control practices for 3 of 4 residents reviewed (Resident #12, #37 and #206). Staff failed to wash hands during a wound treatment, ensure residents' washed hands after toileting, after touching their facemask and during laundry distribution. The facility identified a census of 59 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12's Brief Interview for Mental Status (BIMS) score as 12 out of 15 (moderate cognitive impairment). The MDS identified the resident required extensive assistance from staff related to bed mobility, transfer, and dressing. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed a pressure area (wound) identified. On 3/30/21 at 11:43 a.m., Staff B, Licensed Practical Nurse (LPN), entered Resident #12's room and washed hands. Observed a dressing dated 3/28/21 covered the sacrum area (lower back). Staff B proceeded to take off the dressing and cleansed the area with disposable cleansing wipes. The Surveyor visualized two small open areas on the left buttock. Staff B then applied prescribed ointment to the area with the same gloves that she took the old dressing off with. Staff B then changed gloves and applied the new dressing, but did not wash hands. Staff B completed applying the new dressing then proceeded to take gloves off, again did not wash her hands after gloves removed. Staff B handed the resident his television remote, opened the door and walked up the hallway. Staff B then walked to the Nursing Station area and failed to wash or sanitize her hands after the wound treatment was completed. On 3/30/31 at 12:45 p.m. Staff D, Director of Nursing stated she would expect staff wash hands or sanitize their hand after removing a wound dressing and when gloves are removed. On 3/30/21 at 1:26 p.m. Staff B, LPN, acknowledged that she did not wash her hands during the wound dressing change. During review on 3/31/21 of the Facility Policy titled Handwashing/Hand Hygiene revealed staff use alcohol-based hand rub or soap and water when handling clean or soiled dressings. Hand hygiene is the final step after removing and disposing personal protective equipment. 2. During an observation on 3/30/21 at 8:23 a.m., Staff G, Household Coordinator and Staff B, Licensed Practical Nurse (LPN) provided toileting and incontinent cares to Resident #37 without issue. After toileting completed, Staff G and Staff B failed to offer hand washing to the resident. Staff assisted Resident #37 to ambulate back to main lounge area and sit in a chair. During an observation on 3/30/21 at 11:41 a.m., Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA provided toielting and incontinent cares to Resident #206. The staff assisted resident #206 back to the dining room and set up for lunch with an over-the-bed table. Staff H and Staff I both failed to offer to wash the resident's hands. During an interview on 4/1/21 at 9:15 a.m. Staff J, CNA states after toileting is completed with a resident, staff should encourage or assist the resident to wash their hands and if they do not want to wash hands encourage to use a wash cloth. During an interview on 4/1/21 at 9:23 a.m., Staff K, Oral Medication Technician (OMT) states after toileting is completed with a resident staff should offer residents to wash their hands. During an interview on 4/1/21 at 9:50 a.m., the Director of Nursing (DON) states she would expect staff to provide residents hand washing after they are done toileting or assisting residents with toileting. Review of the Facility Policy titled Handwashing/Hand Hygiene revised 2019 states the facility considers hand hygiene the primary means to prevent the spread of infections. Point #7 of the policy- Alternative Interpretation and Implementation directs staff to use an alcohol - based hand rub as an alternative to soap and water after a resident use of the toilet or conducting personal hygiene. 3. During the lunch meal on 3/30/21 at 12:00 p.m., Staff L ,Dietary Server noted with gloved hands, touched her face mask that hung down on one ear. Staff L pulled the sides back up with the gloved hands, pulled on the front center of the mask with the gloved hands. With the same gloved hands Staff L took a loaf of bread from the cupboard, and placed the bread on the counter. At 12:02 p.m., Staff L opened the loaf of bread with her same gloved hands, reached in the bag, removed 2 slices of bread, put lettuce and a tomato on the sandwich with the same gloved hands and placed the sandwich on a plate and served the plate. During an interview on 4/01/21 at 10:09 a.m., Staff M, Registered Nurse (RN)/Infection Preventionist (IP) stated staff are expected to complete hand hygiene after touching their facemask. The facility provided a policy titled Hand Washing/Hand Hygiene policy dated 8/2019, and directed at point # 9 - The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with the routine hand hygiene is recognized as best practice for preventing healthcare -associated infections. 4. During an observation on 3/31/21 at 3:05 p.m., Staff O, Laundry Aid delivered clothes in room [ROOM NUMBER] and 111 with the open hanging laundry cart located in the hall. At 3:08 p.m., Staff O pulled the open laundry cart by the Nurses Station on [NAME] Lounge and down to room [ROOM NUMBER]. Staff O delivered hanging clothes from the open laundry cart to room [ROOM NUMBER],114, and 116, noting a wandering resident and staff walked by the open laundry cart. At 3:21 p.m., Staff O pushed the open hanging laundry cart up the hall back through the [NAME] Lounge to rooms 117, 118, 119 and continued to deliver the hanging cloths. During an interview on 4/1/21 at 9:09 a.m., Staff N, Laundry Aid stated the hanging laundry carts are to be covered when it's taken in the halls. Staff N continued to report leaving the carts open while in the hall delivering cloths to the resident's rooms is not permitted. During an interview on 4/01/21 at 10:01 a.m., Staff M, RN/IP reported the expectation is the clean laundry is covered during the delivering process throughout the hallways.

Based on clinical record review, staff interviews and facility policy the facility failed to submit any Minimum Data Set (MDS) Assessments in a year for 1 of 15 residents (Residents #155). The facility reported a census of 59 residents. Findings Include: During the Recertification Survey completed 3/29/21 to 4/1/21, review of the Medical records for Resident #155 revealed no Minimum Data Set (MDS) Assessments completed in the Long Term Care Survey Program. On 3/29/21 the Surveyor asked Staff D, Director of Nursing (DON) if Resident #155 was a new admit and Staff D, DON stated no, she had been here a long time. On 3/30/21 at 2:58 p.m., Staff B, MDS Nurse and Staff D, the DON asked to speak to the Surveyor. Staff B stated she had not completed Resident #155's MDS Assessments for the past year. Staff B explained the computer system is supposed to remind her when the assessments are due, but there was a glitch in the system and she did not receive a reminder notice for Resident #155. Staff B acknowledged it is not ok the MDS Assessments were not completed in the past year for the resident. On 3/31/21 at 10:56 a.m., Staff B provided the following dates the MDS Assessments were not completed on Resident #155: a. On 5/12/20. b. On 8/14/20. c. On 11/14/20. d. On 2/14/20. During review on 3/31/21 at 2:44 p.m. of the facility Policy MDS Completion and Submission Transfers revealed the facility will conduct and submit resident assessments in accordance with current and federal and state submission timeframe's.

Based on observation of insulin administration, staff interviews, and record review facility staff failed to prime an insulin pen before committed to administering the medication for 1 out of 1 observations. The facility reported a census of 59 residents. Findings included: Review of the [MEDICATION(S)] Insulin order for Resident #54 dated 3/9/21, directed the Nursing Staff to administer [MEDICATION(S)] Insulin 45 units subcutaneous every day. During an observation on 4/1/21 at 7:21 a.m., Staff B Registered Nurse (RN) applied gloves, put the needle on the [MEDICATION(S)] insulin pen for Resident #54. Staff B dialed the [MEDICATION(S)] insulin pen to 45 units, Staff confirmed she was going to administer the [MEDICATION(S)] insulin. During an interview on 4/1/21 at 7:22 a.m., Staff B confirmed forgetting to prime the insulin pen. During an interview on 4/1/21 at 9:27 a.m., Staff A RN described when administering insulin from a pen the need to prime the pen before dialing the ordered dose of insulin. During an interview on 4/1/21 at 9:38 a.m., Staff B reported the insulin pens come from the pharmacy, come in bags and do not contain the directions. During an interview on 4/01/21 at 10:19 a.m., the Director of Nursing stated (DON) reported staff are expected to prime an insulin pen before dialing up the dose to administer. The facility provided the [MEDICATION(S)] Insulin Pen Instructions, directing at part D on how to prime an insulin pen prior to administering the medication: a. Dial up 2 units on the pen. b. Point pen needle up towards the ceiling and tap on it gently. c. Press button on bottom all the way. d. If necessary, repeat steps 1-3 until you see a drop of insulin come out.

Based on observation, staff interviews, and record review the facility failed to maintain a safe environment, free from hazards in 1 of 3 kitchenettes (Stewart Living Area) in the facility. An unlocked cabinet containing chemicals noted left unattended throughout the day. The facility identified a census of 58 residents. Findings include: 1. Observation on 05/13/19 at 11:01 a.m. in(NAME)Living Area Kitchenette revealed a cabinet under the sink with a key sitting in the lock. The unlocked cabinet contained approximately eight bottles of chemicals. Two chemical bottles in the unlocked cabinet had tubing which fed into the adjacent dishwasher. Observation noted Resident # 47 self propelling himself in his wheelchair and entered the kitchenette. Staff E, Certified Nurses Aide (CNA), Household Coordinator, stopped resident #47 before he reached the sink area. Staff E did not notice the key left in the unlocked cabinet. Multiple observations on 5/13/19 from 11:04 a.m. until 3:50 p.m. revealed the key remained in the lock in the cabinet. Different nursing and housekeeping staff came and went during the day, with some staff retrieving items from the kitchenette. The key remained sitting in the lock of the cabinet without any identification. An observation on 05/13/19 at 12:29 p.m. revealed Staff A, Cook, left the kitchenette, while the key remained in the unlocked cabinet which held the chemicals. An observation on 5/15/19 at 10:17 a.m. of the(NAME)Living in kitchenette lower cabinet under the sink (locked) contained the following: a. One gallon Ecolab Rinse Dry- High performance rinse and drying agent. b. One gallon of Ecolab Super Trump detergent. c. One bottle of Ecolab Oasis 146 sanitizer which contained a small amount of fluid. d. One 1 3/4 pound of dry powder, partially filled box of Ecolab Dip It destainer. e. One bottle of Comet Disinfectant Cleaner with Bleach half filled. f. One 1.5 pint bottle with a small amount of Dawn Dish Detergent and 1 full 1.5 pint bottle of Dawn Dish Detergent. g. One half gallon of Ecolab Lime-Away. h. One 32 ounce of Ecolab Lemon-Eze Bathroom Creme Cleanser. i. One 26 ounce container of Clorox Hydrogen Peroxide Disinfecting Wipes half full. During an interview on 05/13/19 at 3:51 p.m., Staff C, Registered Nurse (RN), reported there were 3 residents identified as independently mobile and confused (Resident # 2, # 21, and # 47, noted resident #47 tested memory intact but the resident is confused). Staff C walked past the unlocked cabinet to gather something from the kitchenette. Revealing the key in the lock to Staff C, he acknowledged the key present and noticed the cabinet unlocked. Staff C acknowledged there were 8-10 bottles of chemicals present. Staff C locked the cabinet and placed the key in the appropriate cupboard above the sink. He reported the cabinet should always be locked and the key put away. During an interview on 05/14/19 at 7:42 a.m. Staff D, Director of Dining Services, reported the facility had been informed of the concern of the key left in cabinet and the unlocked cabinet contained chemicals. Staff D acknowledged the key should not have been left in the lock and the cabinet should always be locked. She recognized this as a potential serious problem and will work with educating staff. During an interview on 05/15/19 at 1:57 p.m., the Director of Nursing (DON) reported awareness of the concern with the key being left in the unlocked cabinet which held the chemicals. The DON reported the task of keeping the cabinet locked is the responsibility of the contracted dietary staff. During an interview on 05/15/19 at 2:08 p.m., the Administrator revealed awareness of the concern with the key being left in the unlocked cabinet which held the chemicals. The Administrator reported the expectation is the key did not remain in the lock. The Administrator reported Staff A new to the facility and had been trained and signed off on the education upon hire. The Hazardous Areas, Devices and Equipment Policy, dated (MONTH) (YEAR) directed staff that all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure residents safety and mitigate accident hazards to the extent possible. The Interpretation and Implementation section instructed staff on the following: a. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee. b. The Safety Committee will consist of members from the interdisciplinary team, which will include a representative from the clinical, leadership, maintenance, and environment services teams. The Identification of Hazards section explained, a hazard is identified as anything in the environment that has the potential to cause injury or illness. An example of environmental hazards included: Access to toxic chemicals. The Safety and Supervision of Residents Policy revised (MONTH) (YEAR) stated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, record review and staff interview the facility failed to provide proper storage of food. The facility reported a census of 58 residents. Findings include: During an observation on 5/13/19 at 3:59 p.m. of the Ehlart-Kefer Community room refrigerator revealed the following items open with no dates on them: a. A Coffee Mate Coffee Creamer container. b. A bottle of peach mango V-8 Juice. c A Wendy's cup with chocolate ice cream in the freezer. During an observation on 5/13/19 at 4:08 p.m. of the kitchen in Nesetril Household revealed the following items open with no dates on them: a. A bottle of ranch dressing. b. A bottle of chocolate syrup c. A bottle of strawberry syrup. d. A bottle of Mustard. During an interview on 5/13/19 at 4:15 p.m., Staff I, Activities Staff, revealed the Ehlart-Keffer area is utilized for baking and special occasions. Staff I reported she is responsible for checking dates on food items in this area and does this about 4 times a year. During an interview on 5/14/19 at 11:25 a.m., Staff H, Food Supervisor, stated all food should be dated immediately upon opening. During an interview on 5/15/19 at 2:55 p.m., the Dietician/Clinical Nutrition Manager stated would expect food items to be labeled with dates upon opening. The Dietician explained refrigerator in the Recreation Department is the responsibility of that department and she is unaware what the Recreation Department's policy is and it may be different than the Dietary Department. The Dietician further explains, kitchen staff is responsible for labeling items in the household refrigerators and would expect staff to date all refrigerated items upon opening them. During an interview on 5/15/19 at 3:16 p.m., the Dietician/Clinical Nutrition Manager clarified with the Recreation Supervisor that the Recreation Department does not have a policy in regards to labeling food in the recreation refrigerator. The Dietician stated she will be forwarding the policy from Dietary Department to the Recreation Supervisor. Record review of the facility policy, Diets and Menus Pantries dated (MONTH) (YEAR) directed items are labeled, dated and rotated per facility specific guidelines.

Based on observation, staff interview, and record review the facility failed to maintain proper infection control measures in accordance with professional standards for 1 of 1 residents reviewed for catheter cares (Resident #35). The facility identified a census of 58. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #35 had [DIAGNOSES REDACTED]. Resident #35 had no cognitive impairments. The MDS dated [DATE] revealed Resident #35 required extensive staff assistance with activities of daily living and had an indwelling Foley catheter. The Care Plan dated 3/20/18 identified the resident had potential for reoccurrence of urinary tract infection [MEDICAL CONDITION]/chronic [MEDICAL CONDITION] related to indwelling catheter use. An intervention for this concern included to provide catheter care per protocol and monitor for signs and symptoms of an UTI. The Care Plan further identified the resident with repeated UTI's related to catheter associated organism due to long term use of an indwelling catheter. An intervention for this concern included to educate and remind the resident about the importance of consuming fluids to flush kidneys and bladder. An observation on 5/13/19 at 12:08 p.m., revealed the resident in his wheelchair at the dining room table. The resident's catheter sat in a blue dignity bag strapped under the wheelchair with approximately 2-3 inches of catheter tubing resting directly on the carpeted floor. An observation on 5/13/19 at 12:49 p.m., revealed the resident propelled the wheelchair back through the hall to his room after lunch with the catheter tubing dragging on the carpeted floor. An observation on 5/14/19 at 09:06 a.m., revealed the resident in his wheelchair at the dining room table with the catheter in the dignity bag and 2-3 inches of the catheter tubing and the green clip (which is meant to hold the catheter tubing up) resting directly on the carpeted floor. An observation on 5/14/19 at 10:05 a.m. revealed the resident propelled his wheelchair in the hallway back to his room while the catheter tubing and the green clip dragged on the carpeted floor. An observation on 5/14/19 at 12:23 p.m. revealed the resident at the dining room table in the wheelchair with the catheter bag in the dignity bag while 2-3 inches of catheter tubing and the green clip rested directly on the carpeted floor. An observation on 5/14/19 from 2:37 p.m. until 2:55 p.m. revealed the resident attended the Resident Council Meeting in the sun room. The resident sat up in his wheelchair while the catheter tubing and the green clip rested on the hardwood floor. During an interview on 5/13/19 at 12:57 p.m., Resident # 35 reported two weeks ago he completed taking an antibiotic medication for urinary tract infection. The resident also reported the staff complete catheter care each morning. During an interview on 5/15/19 at 12:40 p.m., Staff G, Certified Nurse Aide (CNA) reported a resident with a catheter should never have the tubing touch the floor. During an interview on 5/15/19 at 12:41 p.m., Staff F, Registered Nurse (RN), reported a resident with a catheter is to have the tubing run down the pant leg and never touch the floor. During an interview on 5/15/19 at 1:57 p.m., the Director of Nursing (DON), reported the expectation is for catheter tubing not be on the floor. The DON reported Resident #35 transferred independently but staff should check for the placement of the catheter tubing. The DON reported staff completes daily cares for the resident but the resident toilets independently. During an interview on 5/15/19 at 2:15 p.m., the Administrator and DON reported this resident transferred self and took pride on self independence. They noted the resident could make own decisions and they had provided education and prevention for urinary tract infections. They also reported the resident requested to speak to surveyors regarding the concern with catheter care. The Administrator and DON reported the resident expressed no concern to them regarding the catheter tubing on the floor. The DON reported the past urinary tract infections were created by a common catheter related organism. During an interview at 5/15/19 at 2:50 p.m., the resident reported no concerns regarding the catheter tubing on the floor. The resident requested proof of increased risk for urinary tract infection by having the catheter tubing on the floor. The resident requested to read the facility's policy Urinary Catheter Care. The policy stated the catheter tubing and bag are to be kept off of the floor. The resident understood the explanation given regarding urinary tract infections and prevention measures. The resident also reported facility staff had never provided education on the importance of keeping the catheter tubing off of the floor. The resident confirmed independent mobility is important. The resident commented the length of catheter tubing may contribute to the tubing on the floor. Record review of Infection Tracking for the resident showed the following: a. On 10/30/18: The resident notified the physician of signs of an elevated temperature. A urine culture completed for the resident showed the organisms Provideneia Rettgeri, (a gram negative bacterium found in water and on land environment) and Escherichia Coli (a gram negative bacterium commonly found in the lower intestine). The physician ordered an antibiotic (Bactrim DS-Double Strength) twice a day for 10 days. b. On 11/16/18: The resident reported complaints of [MEDICAL CONDITION] and requested the catheter to be changed. The nurse reported during the catheter change the urine had an odor, mucous and sediment. A urine culture completed for the resident showed the organism Provideneia Rettgeri. The physician ordered an antibiotic (Bactrim) twice a day for 7 days. c. On 1/2/19: The resident notified the physician regarding bleeding, sediment in the catheter tubing and pain. The physician suggested the resident to go to the emergency department. The emergency department completed a urine culture which showed the organism Provideneia Rettgeri. The physician ordered two antibiotics ([MEDICATION NAME] twice daily and [MEDICATION NAME] daily) for 7 days. d. On 4/16/19: A urine culture obtained due to reported fever and acute pain. The urine culture showed the organism [MEDICATION NAME] Faecalis (a gram positive bacterium found in the gastrointestinal tracts). The physician ordered an antibiotic (Bactrim DS) twice daily for 10 days. On 5/15/19 at 3:00 p.m. the Administrator provided an instruction sheet titled Catheter-Associated Urinary Tract Infection (undated). The Administrator reported this instruction sheet had been provided to the resident for education on urinary tract infections. The instruction sheet failed to identify not allowing catheter tubing on the floor as a part of catheter care. Record review of the Urinary Catheter Care Policy, revised (MONTH) 2014, explained the purpose of the policy is to prevent catheter-associated urinary tract infections. The infection control portion of the policy included the following: a. Use standard precautions when handling or manipulating the drainage (tubing) system. b. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag and be sure the catheter tubing and drainage bag are kept off the floor.

Based on clinical record review, facility document review and staff interview, the facility failed to develop a comprehensive person-centered care plan for resident one resident on a anticoagulant and diuretic medication. (Resident #37). The facility census was 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident # 37 had [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The care plan revealed no problems or interventions listed for cardiac [DIAGNOSES REDACTED]. During interview on 2/14/18 at 1:30 p.m., the MDS Coordinator stated he was responsible for the nursing part of the care plan. Care plans are based off what triggers for care area assessments on the MDS and do not usually care plan for medical problems. The care plan directs staff how to care for residents. During interview on 2/14/18 at 1:37 p.m., the Director of Nursing stated they typically would care plan for anticoagulant medication so staff would know to monitor for problems just basically from nursing knowledge. The facility provided a Care Planning - Interdisciplinary Team Policy Statement directing staff to complete a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being.

Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to provide complete peri care for two of nine residents reviewed (Resident #8 & #34) The facility census was 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #8 had a [DIAGNOSES REDACTED]. The Care Plan dated 7/23/14, directed staff to provide assist for hygiene and peri care. During observation on 2/13/18 at 8:32 a.m., Staff E, Certified Nurse Aide, CNA turned the resident to their left side to reveal bowel movement to the residents right buttock and hip area. Staff E cleansed the resident from the top of the buttocks in a downward direction towards the vaginal area four times with a peri wipe and four times with a wash cloth. During interview on 2/14/18 at 9:44 a.m., Staff F, CNA reported you cleanse in a front to back direction and change surfaces between wipes of the cloth. The facility provided a policy titled Perineal Care dated 2010, at point # 9. (b). directing staff to wash perineal area, wash front to back. At point # 9. e, directing staff wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. During interview on 2/15/18 at 9:05 a.m., the Director of Nursing (DON) reported the facility just completed a skills fair on peri care. 2. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #34 required extensive assistance with toileting, personal hygiene and bathing. The Care Plan dated 7/13/16, documented the resident required assistance with daily living activities related to dementia, [MEDICAL CONDITION] and muscle weakness. An intervention included for staff to encourage and assist in maintenance of good grooming and dressing. Observation on 2/13/18 at 06:47 a.m., Staff A, CNA performed morning cares for the resident in the bathroom. With the resident standing, using a walker, Staff A washed, rinsed and dried, the resident's front peri area and backside using a back and forth movement, up and down the sides and down the middle. Staff A changed the surface of the cloth when going between the front side and backside. During interview on 2/14/18 at 02:11 p.m., Staff G, CNA, reported when performing peri cares staff should wipe from front to back, each side and down the middle, using a new surface with each wipe. During interview on 2/14/18 09:15 a.m., the infection control nurse reported she would expect staff to wash from front to back, changing surfaces with each wipe. She also reported the facility had a skills fair at the end of January 2018 which included peri care.

Based on interviews and record review, the facility failed to assess 2 out of 2 resident's blood pressures (BP) Resident #2 and # 7 before administering medication and failed to assess 1 out of 1 resident's (Resident # 7) pulse before administering a medication. The facility reported a census of 59 residents. Findings included: 1. The Minimum Data Set (MDS) assessment for Resident # 2 dated 10/17/16, listed [DIAGNOSES REDACTED]. The Brief Interview for Mental Statues (BIMS) listed a score of 2 indicating severe cognitive impairments. The physician's orders [REDACTED].# 2 dated 11/2016, directed administration of [MEDICATION NAME] 25 milligrams (mg) 1/2 a tablet 12.5 mg 2 times a day and to hold if systolic BP is below 90. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] Review of the Medication Record dated 11/16, listed dates BP taken: 11/3/16 @ 5:24 pm 11/8/16 @ 4:48 pm 11/13/16 @ 11:43 am 11/15/16 @ 8:20 am 11/16/16 @8:09 am 11/21/16 @7:23 am 11/24/16 @ 8:41 am 11/28/16 @9:09 am 11/19/16 @9:05 am During an interview on 11/30/16 at 3:25 p.m., Staff B, Registered Nurse (RN), reported when assessing a BP or pulse before a medication it is documented in the medication administration sheet or the vitals section of the chart. During an interview on 12/1/16 at 8:40 a.m., Staff A, RN, reported the MAR indicated [REDACTED]. Staff A continued to state staff enters the the BP or pulse in the MAR indicated [REDACTED]. During an interview on 12/1/16 at 11:15 a.m., the Director of Nursing stated if the physician's orders [REDACTED]. The facility policy titled Administering Medications dated 12/2012, directed at point # 3: All medication must be administered in accordance with the orders, including any required time frames. Point # 8 directed: The following information must be checked/verified for each resident prior to administering medications: [REDACTED] 2. The Quarterly MDS with the reference date of 10/03/16 documented that Resident#11 had the [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The MAR for 9/2016 documented blood pressures taken on 9/14/16, 9/21/16, and 9/28/16. The MAR for 10/2016 lacked documentation of a blood pressure, and pulse the first week of the month. The MAR for 10/2016 documented pulses, and blood pressures taken on 10/12/16,10/19/16, and 10/26/16. The MAR for 11/2016 lacked documentation of a blood pressure or pulse the first week of the month. The MAR for 11/2016 documented pulses, and blood pressures taken on 11/16/16, 11/23/16, and 11/30/16.

Based on observation, interview and record review the facility failed to provide complete incontinence care for 2 out of 9 resident reviewed (Resident #2 and #3). The facility reported a census of 59 residents. Findings included: 1. The Minimum Data Set (MDS) assessment for Resident #2 dated 10/17/16, listed [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) listed a score of 2 indicating sever cognitive impairments. The MDS also indicated the resident required extensive assist of 1-2 staff assist with activities of daily living (ADLs). The Care Plan for Resident # 2 dated 7/27/16, directed staff to provide incontinence care after an incontinent episode. During an observation on 11/28/16 at 1:18 p.m., Staff placed Resident # 2 in bed and stated the resident incontinent pad is soiled. Staff D, Certified Nursing Assistant (CNA), washed the resident's buttocks from the gluteal cleft in a down word motion towards the front perineal area. Staff D then washed the right and left buttock and in the same down word motion. 2. The MDS for Resident #3 dated 10/3/16, listed [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) listed short and long term memory problems with moderately impaired daily decision making skills. The MDS indicated the resident required extensive assist of 1-2 staff assist with activities of daily living (ADLs). The Care Plan for Resident #3 dated 10/12/16, directed staff to provide perineal cleaning (incontinence care) and apply protective skin barrier after each incontinent episode with assist of 1 or 2. During an observation on 11/29/16 at 10:07 p.m., after Staff E, CNA, placed Resident # 3 on the toilet. Staff E reported the incontinent product as wet with urine. Staff E washed the the resident's rectal area when Resident # 3 stood up from the toilet but Staff E failed to wash the resident's front perineal area. During an interview on 12/1/16 at 7:49 a.m., Staff D, CNA, reported when completing peri care you wash front to back, wash down in the front and up direction in the back. Staff D continued to report peri-care is done after each time a resident is incontinent. During a interview on 12/1/16 at 8:10 a.m., Staff C, CNA, reported when completing peri care you wash front to back only, wash down in the front and up direction in the back. During an interview on 12/1/16 at 11:15 a.m., the Director of Nursing reported the expectation when completing peri care is washing in a front to back motion, to all surfaces that came in contact with incontinence matter, after each incontinent episode. The facility policy Perineal Care dated October 2010, directed staff under Steps in Procedure at point #9.b: Wash perineal area, wiping front to back.

Based on facility policy, record review, and interview, the facility failed to attempt non-pharmacological interventions prior to giving a resident [MEDICATION NAME] (sedative medication used to treat anxiety), for 1 of 9 residents reviewed. (Resident#7). The facility reported a census of 59 residents. Findings include: The Significant Change Minimum Data Set (MDS) assessment with the reference date of 2/21/16 documented that Resident#7 had [DIAGNOSES REDACTED]. The resident's Care Plan documented a problem on 10/22/15 with impaired behavior related to dementia as evidenced by wandering with potential for elopement and resistance with cares. The Care Paln directed staff to attempt and document effectiveness of three interventions prior to administering as needed Trazadone and [MEDICATION NAME]. The physician's orders [REDACTED]. The Medication Record dated 11/2016 documented that the resident had been given [MEDICATION NAME] 0.5 milligrams on 11/10/16 at 10:00 p.m., 11/11/16 at 7:00 p.m., and 11/21/6 at 8:45 a.m. for anxiety. Upon clinical record review the nurses notes lacked documentation of intervention attempts prior to the administration of the as needed [MEDICATION NAME] for the dates 11/10/16, 11/11/16, and 11/21/16. The Medication Record dated 10/2016 documented the resident given [MEDICATION NAME] 0.5 milligram on 10/10/16 at 10:00 p.m., 10/11/16 at 7:00 p.m., and 10/21/16 at 8:45 p.m. for anxiety. Upon clinical record review the nurses note lacked documentation of intervention attempts prior to the administration of the as needed [MEDICATION NAME] for the dates 10/10/16, 10/11/16, and 10/21/16. During an interview on 12/01/16 at 10:08 a.m. the Director of Nursing reported staff are to attempt three non-pharmacological interventions prior to giving a resident any as needed psych medications. During an interview on 11/30/16 at 9:23 a.m. Staff G, Registered Nurse, reported that before giving a resident an as needed psych medication you should attempt 3 non-pharmacological interventions. The facility Antipsychotic Medication Use policy with revised date March 2015 directed staff to attempt behavioral interventions prior to administration of antipsychotic medications.

Based on observation, clinical record review and interviews, the facility failed to ensure each resident received adequate supervision to prevent an elopement from the facility for one of four residents reviewed (Resident #1). The facility identified three residents used wanderguard bracelets (Resident #1, Resident #2 and Resident #3). On 5/25/16 Resident #1 left the building through non-wanderguard exit door. The exit door Resident #1 left through had a silent alarm which alerted staff's pagers and sent notification to the alarm board at the nurse's station. Staff interviews revealed they were not aware the pagers alert them of the silent door alarm/s; and had not turned off the alarm at the nurse ' s station. Resident #1 had been found by a housekeeper shortly after he/she exited. The findings constitute an immediate jeopardy to residents' health and safety. The facility reported a census of 59 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had moderately impaired cognitive skills for daily decision making, wandering behaviors, hallucinations, delusions. Resident #1 required limited assistance of one staff for transfers and ambulation. The resident had [DIAGNOSES REDACTED]. The Elopement Risk Assessment completed on 3/29/2016 identified Resident #1 had an elopement risk. The Care Plan dated 3/25/16 identified Resident #1 had memory problems, impaired decision making skills, impaired ability to comprehend, impaired behavior related to dementia; and alteration in awareness as evidenced by hallucinations, delusions and paranoia, potential for falls and at risk for elopement. The Care Plan directed staff to redirect Resident #1 from exits, photo and brief description in elopement risk book, wanderguard applied to alert staff of potential elopement initiated 3/25/2016. The updated Care Plan added 1:1 private duty as available and 15 minute checks on 5/25/2016. In the Interdisciplinary Notes dated 5/25/2016 at 10:44 a.m., Staff G., RN (Registered Nurse) documented Resident #1 ate breakfast in the dining room, socialized with staff and residents, returned to room, sleeping now, mood and behavior within normal limits. At 11:14 a.m., staff documented at about 11:00 a.m., the housekeeper called Staff G to the south exit door. Staff G observed Resident #1 walking on the paved walkway (outside) towards the door with three bags in hand (a tote and two other small bags with stuff in them). Resident brought to the nurse's station with 1:1 supervision. Staff G notified the DON (Director of Nursing) and the resident's POA (Power of Attorney)/CEO. The resident ' s POA arrived to the facility and asked the resident where he/she was going. The resident replied I don't even know where I was going. Rochester? Resident last seen at 10:43 a.m. when Staff G checked the resident in the room. The resident used the West exit door that led to the therapy building. Wanderguard in place but failed to sound due to this door had no (wanderguard) alarm. Fifteen minute checks in place. The DON documented on 5/25/16 she had been informed of Resident #1 ' s elopement and went to the door the resident exited and pushed the door open 2-3 times and heard no alarm. The maintenance staff had been asked to contact the alarm company that installed the alarm systems. A representative came out from the alarm company (Hawkeye Communication) and reminder her the door had a silent alarm and the alarm is sent to the nurse ' s station alarm board and the pagers of the CNAs. During an interview on 6/9/2016 at 11:05 a.m., Staff M, Housekeeping reported on 5/25/2016 he/she worked in Lynch in the sunroom. Staff M observed Resident #1 outside, walking on the sidewalk approximately 5 feet from the exit door #8. Staff M yelled for help. Three staff responded, they opened the sunroom door and the resident walked in. Staff M never saw the resident attempt to exit prior. Staff M knew that the resident required supervision when outside. On 6/14/2016 at 1:10 p.m., Staff G indicated at the time Resident #1 exited the facility, he/she failed to check his/her pager's history. Staff G failed to recall shutting of the alarm on the monitor at the nurse's station and had no idea who did. The exit door #8 never showed up on the pager. (Staff G had not scolled down on the pager screen to see the notification.) During an interview on 6/9/2016 at 1:40 p.m., Staff G, RN (Registered Nurse) reported on 5/25/2016 at approximately 10:45 a.m., he/she wrote nurse's notes about Resident #1. Staff G sat at the nurses station on the Lynch unit. Staff G checked on the resident while writing the note and observed the resident lying on the bed. Staff G went back to the desk and answered the phone. The housekeeper called Staff G to the sunroom area. They saw Resident #1 outside walking on the sidewalk. They opened the door and he/she walked in. The resident wore an ankle wanderguard bracelet. Apparently, the beeper failed to sound, it failed to notify Staff G. The wanderguard alarm had not been installed on the exit door at that point, and it failed to buzz. Now, the door had a wanderguard alarm that functioned. Staff G notified the Administrator and the facility fixed the exit the next day. Staff provided 1:1 observation followed by 15 minute checks. During an interview on 6/9/2014 at 3:00 p.m., Staff I, CNA reported working on Lynch on 5/25/2016. The pager Staff I had that day never buzzed or vibrated when Resident #1 exited the facility. The door never had a wanderguard alarm at that time. The facility fixed it a couple of days later. The housekeeper saw Resident #1 outside and called for help. Staff I indicated he/she typically did not work on Lynch. On 6/14/2016 at 12:30 p.m., Staff I stated nobody knew Resident #1 exited the facility because it failed to alarm. Staff I had no knowledge of the silent alarm to pagers. Staff I could not say for sure if he/she had a pager that day at that time. Nobody asked to check his/her pager, the pager goes off if a call light goes on. On 5/25/2016 when Resident #1 exited the facility, Staff I provided cares in a resident room. During an interview on 6/9/2016 at 11:20 a.m., Staff N, CNA worked on 5/25/2016 when Resident #1 exited the facility. Staff N reported seeing the resident approximately 5 minutes prior in his/her room. Staff M told Staff N that the resident had been putting things into grocery bags. Staff N had worked with the resident in the assisted living, and knew the resident had that behavior. The resident never said he/she wanted to leave. When Staff M called for help, Staff N had been charting, and they all ran to the sunroom exit door. Staff N reported the pager he/she had failed to buzz; the pagers had not been set up at that time, but were fixed shortly after the incident. The resident wore an ankle wanderguard bracelet and staff check it daily. Now, the pagers buzz when the door opens. The facility had a brand new system and staff sign out the pagers at the beginning of the shift. They were told when a call light goes off, it shows up on the pager. They were not told or given information about the door alarms. After the incident, they were made aware that the doors were also on the pagers. The other exits on Lynch had sounding door alarms. When Resident #1 went out the door, the courtyard had not been completed yet. At the time of the incident, Staff N never knew that the pagers were for anything but call lights. All staff are responsible for responding to door alarms. They were told that when hired. The Tek-Care Report, a computer print out of 5/25/2016 indicated between 10 and 11 o'clock a.m. the Lynch TC exit door alarmed for 20 minutes and 52 seconds. The Administrator reported on 6/9/16, at 1:25 p.m., the nurse had to cancel the alarm at the nurse's station computerized board. Staff had to cancel the alarm by pressing on the green check mark. The aides could dismiss the (silent) alarm on the pagers. The Administrator indicated the facility realized the exit door only opened one time that day and they were continuing to work on it. During an interview on 6/14/2016 at 1:35 p.m., Hawkeye Communication staff revealed on 5/25/2016 at 5 o'clock p.m., he/she went to the facility to investigate the elopement incident. He prepared to fix the alarm system, but there was no need. He observed none of the CNA's on Lynch had pagers on them, only the charge nurse wore a pager. The pagers were all in a basket at the nurse's station. Two of the pagers were dead and needed new batteries, but the others were live and showing readings. The DON got angry with staff. He opened door #8 and walked into Lynch and observed someone canceling the alarm at the nurse's station without checking it. If staff hit acknowledge on the pager, it silences it. Staff had to cancel the alarm on the monitor at the nurse's station. Every five minutes it sends a page. He reported the elopement incident came down to staff not following protocol; you cannot force people to pay attention to pagers. The report showed the door alarm had been activated for 20 minutes, therefore the pagers worked. When a new page reads on the pager, it pushes the old pages back. Staff can cancel a call light in a resident's room, and that cancels it on the pager. The day before they took the plywood down, the alarms worked. Observation on 6/9/2016 at 10:15 a.m. revealed Resident #1 ambulated in the room without an assistive device. The resident referred to the warm temperature in the room and went to the window. The resident had a wanderguard bracelet on the left wrist. Observation on 6/9/2016 at approximately 10:20 a.m. revealed door #8, (South Vestibule exit door) had a silent alarm that alerted staff when opened and a wanderguard alarm positioned to the right of the door. The Administrator indicated Resident #1 exited the facility through Door #8 on 5/25/2016. During an interview on 6/9/2016 at 11:40 a.m., the Administrator reported the Lynch unit, South Exit door (#8) had a silent alarm to staff pagers, and currently had a wanderguard alarm. Entering the facility through Door #8 required a key. Nurses and Aides carry pagers and it vibrates when a resident had a call light on or an exit door opened. Housekeepers check the wanderguard alarms daily and nurses check the wanderguards daily. The facility is installing key fobs for staff. Some facility doors had sounding alarms, some had pager alerts and some also had wanderguard alarms as well. Resident #1 had delusional and paranoid thoughts with no known attempts to exit the facility. On 5/16/2016, the facility removed the plywood at the end of Lynch West Wing, where Resident #1 resided. On 5/16/2016 the therapy department pools opened, they removed the plywood at the end of the wing where they had installed double doors leading to the vestibule. The vestibule had a door that lead to therapy that required a key to enter, a door to the secure courtyard that had a silent alarm to pagers and door #8 that exited the facility. At the time the resident exited the facility on May 25, the door had a silent alarm to pagers. The Administrator indicated when Resident #1 exited the facility, the facility ordered the wanderguard alarm the same day. On 6/9/16 from 1:10 p.m. to 1:25 p.m., the Administrator and the surveyor checked the facility door alarms. When the Administrator opened door #8, Staff N, CNA (Certified Nurse Aide) responded within seconds and indicated the pager alerted him/her and identified the security alert at Lynch TC (Therapy). On 6/15/2016 at 11:10 a.m., the Administrator reported at the time the facility introduced the pagers and new call light system, prior to last December 2015, and Hawkeye Communication staff came to the facility and educated management and three Household Coordinators. The Household Coordinators were responsible for educated staff within the units (Lynch, Nesetril, Stewart). When the facility introduced the new call light system, they initially left the lights on the outside of resident rooms to give the staff time to adjust. The lights continue to light up outside resident rooms, but without sound. On 5/25/2016, Hawkeye Communication staff came to the facility on second shift in response to the incident. On 5/16/2016, the facility opened the therapy pool, removed the plywood. The silent alarms worked. Door #8 had been pre-wired with a wanderguard but the facility did not install it as they wanted residents to utilize the courtyard freely. On 5/27/2016, the facility installed the wanderguard alarm on door #8. The door leading to the courtyard shows up on staff pagers, therefore staff is made aware that a resident entered the courtyard. The Administrator failed to provide documentation showing staff received training regarding the silent alarms. The Household Coordinators trained unit staff verbally. Each unit had a list of alarms so they knew where they were located. After Resident #1 exited the facility, they provided 1:1 observation and 15 minute checks. On 6/1/16, the Administrator implemented door alarm audits. Staff were directed to set off the door alarm and check staff response times every shift. The audits provided information to ensure staff paid attention to the pagers and that they were not just for call lights. When the facility used agency staff, the off-going nurse needed to train the on-coming staff. From 5/16/16 - 5/26/2016, the facility had no indication they had a problem. Staff noticed Resident #1 outside quickly, and they realized they needed to add the wanderguard alarm to door #8. Residents had no access to the vestibule until 5/16/16 when they removed the plywood, activated the silent alarms and Household Coordinators educated staff. Staff passed on the information during report and they also posted a list of alarms and a floor plan at each unit. During an interview on 6/14/2016 at 10:30 a.m., the Director of Nursing revealed the facility had three residents on the Lynch unit that had wanderguard bracelets. The DON did not know who turned off the alarm at the nurse's station when Resident #1 exited the facility on 5/25/2016. The doors had to be cleared at the nurse's station. At 10:45 a.m. the DON opened door #8 in the vestibule to check staff reaction time. The surveyor stood at the nurse's station. Staff M, Housekeeper walked past the nurse's station but failed to wear a pager. Staff S, CNA exited a resident room and entered the soiled utility room; checked the vibrating pager and said room 128 had a call light on. Staff S indicated he/she heard the pager vibrate when in the resident's room but silenced it while providing cares. After 5 minutes and 30 seconds Staff S came to the nurse's station. The DON indicated the monitor at the nurse's station made no noise when a door opened, only the pagers make the sound by vibrating or beeping. The DON pressed the green check on the alarm monitor to clear and acknowledge the door alarm. The DON indicated Staff S routinely works on Nesetril, the dementia unit where all exit doors had sounding alarms. The pagers display the most current page. Staff had to go to the nurse's station to cancel the exit door alarm, but could turn off the call light in the resident's room. After the incident with Resident #1, the Administrator provided staff education and initiated door audits. The DON indicated when Resident #1 exited the building, the facility failed to complete an incident report since it happened quickly and staff assisted the resident back inside the building without injury. The other two residents with wanderguard's on Lynch never went down the West wing. The other two residents used wheel chairs for locomotion. During an interview on 6/14/2016 at 2:30 p.m., the CEO/Medical POA (Power of Attorney) for Resident #1 revealed the resident had no further attempts to exit the facility. On May 25, 2016 the resident exited the facility and carried grocery bags. She reported the resident had hallucinations and had been having a bad day. After the incident, she hired private duty care, the facility installed the wanderguard alarm on Friday, May 27, 2016. The facility had construction chaos, and had altered door alarms to decrease alarm sounds and avoid alarm fatigue with staff. During an interview on 6/15/2016 at 9:25 a.m., Staff K, CNA, Unit/Household Manager reported all staff were to respond to door alarms if heard. If it's a silent alarm, staff who carry pagers were to respond to the alarms. On 5/25/2016 when Resident #1 exited the facility, Staff K was not on Lynch, but afterwards checked his/her pager and saw the security page functioned. Door #8 had a silent alarm until Resident #1 exited the facility, now it had a wanderguard alarm. Only the doors entering the courtyard had silent alarms currently. Last fall, Hawkeye Communication reviewed the new pager system before they turned off the old call light system. Approximately one month had passed between when they removed the plywood at the end of Lynch - West wing and the resident exited through Door #8. When the doors were added to the pager system, Staff K showed staff what the security pagers included. Staff K showed staff at various times, but failed to have them sign off on the education and failed to include the information in a communication book. During an interview on 6/14/2016 at 9:40 a.m., Staff E, Maintenance reported the facility installed a new door monitoring system that was tied into the nurse call system. On 5/25/2016, they had a greater than 20 minute event. Staff need to clear the alarm at the nurse's station. Staff with pagers can clear the alarm on the pager. On 5/25/2016 when Resident #1 exited the facility, the system worked correctly. Unsure of what happened, the resident got a few steps outside when staff saw the resident. Staff said their pagers failed to function. Staff D, Maintenance revealed the history showed the pagers did alert staff and functioned correctly. With the renovation, lastly, they removed the plywood at the end of Lynch - west wing. All alarms had been activated. Since the incident, the facility added a wanderguard alarm and staff test the system daily. During an interview on 6/15/2016 at 9:40 a.m., Staff D, Maintenance said on May 16, 2016 they removed the plywood at the end of Lynch west, the therapy pools were open for business and doors were in place with alarms. During an interview on 6/14/2016 at 1:35 p.m., Staff E, Maintenance reported that Hawkeye Communication staff told them if the history shows up on the event monitor and the pagers also worked. If the pagers were out of range, the pagers would fail to function. On 6/15/2016 at 9:20 a.m., Staff G reported at the time the facility switched the call light system to the pager system, the old call light system also functioned for a couple of days. Currently, the call lights show up on the pagers and on the monitor at the nurse's station. With the old system, the exit doors, when sounding, were turned off at the nurse's station. Now, the courtyard and door #8 show up on the monitor and pagers, and door #8 had a wanderguard. All staff are to respond to door alarms when they hear it. Staff K, Unit Manager provided instruction when the facility installed the new system. During a phone interview on 6/28/2016 at 10:30 a.m., Staff R, LPN with a staffing agency reported working at the facility 4-5 times in 2016, and worked last the end of May. The facility never said anything about the new alarm system. The facility had a new call light system. The aides wore pagers, but the call lights also lit up outside resident rooms. Staff R failed to wear a pager, but there were pagers at the nurse's station. Staff R heard in report that staff needed to check doors and to document it on a form on a clipboard. When Staff R checked the doors, he/she took an aide and they checked the doors together. One opened the exit door and the other made sure it showed up on the monitor at the nurse's station. The facility never informed Staff R that the door alarms also went to the pagers. During an interview on 6/15/2016 at 10:50 a.m., Staff J, CNA reported the facility initiated the pagers and the new call light system last fall. All staff need to respond to door alarms. The Household Manager at Nesetril educated Staff J about the silent alarms. Staff did door audits, purposely setting off door alarms to make sure they function correctly and to monitor staff response times. During an interview on 6/9/2016 at 12:55 p.m., Staff H, LPN reported working at the facility for [AGE] years. Staff H had 5/25/16 off, but had never seen Resident #1 attempt to exit the facility, and made no comments of wanting to leave. The pagers buzz when a door opens and staff had to turn the alarm off at the nurse's station. During an interview on 6/15/2016 at 2:00 p.m., Staff Q, CNA, Health Services Facilitator indicated he/she completed staffing schedules and the facility used several staffing agencies to fill the empty spaces. The facility identified two other residents on Lynch had wandering behaviors. 2. According to the MDS, Resident #2 had moderately impaired cognitive skills for daily decision making and had short and long term memory impairment. The resident used a wheelchair for locomotion and required extensive assistance of two staff to transfer. The resident had [DIAGNOSES REDACTED]. The Care Plan dated 4/12/16 identified Resident #2 had left sided weakness and wandering behaviors. Staff applied a wanderguard on 6/27/2014 and directed staff to monitor whereabouts. Observation on 6/9/2016 at 10:25 a.m. revealed the resident in the wheelchair in the dining room area, using his/her feet to self propel the wheelchair. The wheelchair had a wanderguard bracelet attached underneath, near the right wheel. At 12:00 noon, the resident self propelled the wheelchair away from the dining room table. On 6/29/2016 at approximately 11:00 a.m., the resident self propelled the wheelchair to the facility front door and staff responded. On 5/26/2016 staff implemented 15 minute visual checks of Resident #2. 3. According to the MDS, Resident #3 required extensive assistance of two staff to transfer and used a wheel chair for locomotion. The resident had [DIAGNOSES REDACTED]. The Elopement Risk Assessment completed in April, 2016 revealed the resident had a high risk. The Care Plan dated 4/12/16 identified Resident #3 had memory impairment and elopement potential. The Care Plan directed staff to apply a wanderguard bracelet, place the resident's photo in the elopement book and redirect away from doors. Observation on 6/9/2016 at 10:50 a.m. revealed Resident #3 seated in a wheel chair with a wanderguard bracelet attached underneath. The resident self propelled the wheel chair without difficulty in the room and throughout Lynch. At 12:30 p.m. the resident ate lunch independently and had pleasant and appropriate conversation with table mates. On 5/26/2016 at 10:00 a.m. staff implemented 15 minute visual checks of Resident #2. A review of the Pager door alarm checks completed on each wing from 6/3/16 - 6/14/2016 revealed staff inconsistently completed the forms every shift, indicating they failed to check the door alarms. The Lynch unit forms revealed no staff checked the door alarms on the night shift of 6/6/16, 6/8/16 and 6/12/2016. The forms revealed no staff checked the door alarms on the evening shift of 6/13/16 and 6/14/2016. The Stewart unit forms for the same time period revealed staff failed to check door alarms on 6/6/16 and 6/12/2016. The Nesetril forms revealed staff failed to check door alarms during the same time period on 6/5/16, 6/6/16, 6/8/16, 6/9/16, 6/10/16, 6/11/16, and 6/12/2016. The revised Pager door alarm checks form received on 6/29/2016 from the Administrator included: the doors must be checked each shift, this is not optional. The nurse is responsible for seeing it is done. During an interview on 6/29/2016 at 2:20 p.m., The Administrator referred to the incomplete door audits on all three wings from 6/3/16 to 6/14/16, and indicated the facility recently revised the forms and educated staff that they were mandatory. The facility recently added key fobs to the garden entrances and ordered 15 second crash bars for door #8 and the community room exit door. They educated all staff regarding the new door alarms and features and issued pagers to housekeepers and managers, alerting them when an exit door opens. It was a burden for nursing staff to be solely responsible for call lights and exit doors. On 6/14/2016 at 3:35 p.m., the DON said all staff were responsible for responding to door alarms. The facility installed the new alarm system with renovation and had it less than a month. Only staff on Lynch are alerted to Lynch door alarms unless the alarm sounds greater than 20 minutes. After 20 minutes the system alerts additional staff. On 5/25/16, after Resident #1 eloped, the facility provided 1:1 supervision. The facility implemented 15 minute visual checks for all three residents at risk for elopement on 5/25/16. On 5/27/16, a wanderguard alarm was added to the therapy door Resident #1 had exited from on 5/25/16 and are checked daily. The facility started educating some staff on 5/25/16 and completed all staff education on 6/15/16 (including agency staff and prn (as needed) staff. Staff were educated on the following Pager Policy which included a directive that everyone who carried a pager must understand how to react when it sounds or vibrates, where to look, and pledged to respond every time it goes off regardless of their position. If staff do not respond, they need to communicate with someone else who has stated he/she will responds. Staff must demonstrate they know which abbreviation on the pager apply to outside (doors) or garden doors. After the incident with Resident #1, the Administrator provided staff education (to not turn off the alarms at the nurses station without checking) and started door audits to monitor staff. The facility abated the IJ on 6/15/16, when they educated on the Pager Policy. These actions lowered the IJ from J severity level to D level with ongoing monitoring of staff's response to pager/door alarms.

Based on observation, clinical record review, and staff interviews, the facility failed develop and or implement care plan intervention(s) to ensure two (2) of four (4) residents received adequate supervision from hazards in the environment (Resident #1 and Resident #2). Unannounced to the nursing home staff, Resident #1 left the nursing on 10/27/13. Staff interviews and record review determined nursing staff had been aware of the resident's elopement on 10/27/13. A day later on 10/28/13, Resident #1 eloped again without the facility staff knowing his/her whereabouts for approximately one hour when staff passing a nearby road observed the resident walking on an outdoor trail towards a pond. Record review identified the resident had a [DIAGNOSES REDACTED]. The findings constitute an immediate jeopardy to the resident's health and safety. The facility census was 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental status (BIMS) score of 3 out of 15, indicating the resident had cognitive impairments. The MDS documented the resident as independent with bed mobility, transfers, ambulation, and required assistance for dressing. The MDS indicated the resident had [DIAGNOSES REDACTED]. An Elopement Risk assessment dated [DATE], revealed the resident scored 4, indicating no Elopement Risk Potential. The Care Plan dated 8/15/13, revealed the resident had memory problems, impaired decision making skills and impaired ability to comprehend. Approaches directed staff to provide verbal and physical prompts with daily routine, provide reminders as needed, provide calendars and any other orientation cues. a). An Incident Report dated 10/27/13 at 2:15 p.m., documented the incident location to be at the campus pond. The resident went to the front door with walker and walked right out. The resident stated he/she went for a walk. The resident was gone for 10 minutes. The resident was educated on the importance of letting staff know when he/she would like to go outside and not to go alone. The alarm did not go off at the front door. Maintenance was notified and was coming to look at the problem. No injury to resident noted. Interdisciplinary notes dated 10/27/13 at 2:48 p.m., revealed the resident went out the front door this afternoon with the walker to go for a walk. The resident was gone 10 minutes when staff found the resident coming in the front door. No incidents reported or noted. Staff conversed with resident about the importance of letting staff know when he/she wants to go outside and not to go alone. The resident stated he/she understood. A facsimile dated 10/27/13 at 2:15 p.m., from the facility to the resident's physician revealed the resident walked out the front door of the facility and went for a walk. The front door alarm did not sound. No injury noted. Interdisciplinary notes dated 10/29/13 at 2:58 p.m., revealed a late entry for Sunday 10/27/13 by Staff K, nurse. Staff K documented he/she was driving into work around 2:00 p.m. when they noted the resident walking independently with a wheeled walker alone. Staff K documented he/she went to park the car when he/she passed the first shift nurse, Staff F, who was in a car. Staff K documented they rolled their windows down and Staff F reported it was Resident #1 and he/she was going to go get the resident. Staff K documented he/she parked the car and walked around the building and watched the resident walking back into the facility. Once the resident was back in the building Staff F did a head to toe assessment. The resident was questioned how they got out of the building and the resident replied he/she just walked out. The resident stated he/she never heard any alarm sounding. Staff K documented he/she went to the front door and checked it 3 times and each time the door alarm did not sound. Staff K documented he/she reported the alarm not working and notified all facility staff of the alarm not working. Staff in the wing were the door alarm panel was located, CCDI (Chronic Confused Dementia Illness), reported the alarm did sound at the panel located in the CCDI unit all 3 times when Staff K checked the front. At approximately 6:00 p.m., Staff K checked the front door and the alarm sounded. The resident was re-educated on notifying staff if and when he/she wants to go out of the building, resident verbalized understanding. Throughout 2nd shift the staff completed 15 minutes safety checks on the resident with no concerns noted. During interview on 11/8/13 at 12:27 p.m., Staff K, Registered Nurse, RN, stated she/he seen Resident #1 around 2:20 p.m. on 10/27/13 at the campus pond as they drove into work. Staff K stated she/he stopped the car and talked to Staff F who was in their car and Staff F told Staff K he/she is going to go get the resident. Staff K stated he/she parked the car and walked to the front of the facility and he/she saw the resident walking into the front entrance of the facility. Staff K reported he/she went to punch into work and went to the wing where the resident's room was located. Staff K indicated when he/she got to the resident's room, Staff F was in room with the resident doing a head to toe assessment. Staff K stated he/she checked the alarm of the front door and the alarm had not sounded when the door was opened three times. Staff K reported staff in the CCDI unit told her the alarm did sound on the panel located in the CCDI all three times but staff said it did not sound earlier when the resident left the building. Staff K stated he/she educated the resident to not leave the building alone and the resident verbalized understanding. Staff K stated he/she did 15 minute checks on the resident per himself, but failed to document it or instruct other staff to do complete 15 minute safety checks. During interview on 11/5/13 at 1:02 p.m., Staff F, Licensed Practical Nurse, LPN stated she worked the day shift on 10/27/13 and was assigned to care for the resident. Staff F stated he/she saw the resident ambulating in the hall towards the hall doorway about 20 minutes before being informed the resident was outside. Staff F stated after giving report to the second shift staff, Staff L, Certified Nurse Aide, CNA told Staff F they saw the resident outside when coming into work around 2:00 p.m. Staff F stated he/she and other staff member immediately checked the facility and Staff F went to his/her car to go locate the resident. Staff F reported driving past the campus pond and did not see the resident until he/she turned the car around on campus by the independent living building and headed back to facility. Staff F stated he/she saw the resident walking into the front door of the facility after a staff member let the resident in. Staff F stated he/she did an assessment on the resident and no injuries were noted. The resident was fully dressed with a long sleeve shirt, sweater, pants and shoes and socks on. It was not wet outside and the temperature was in the 50's. Staff F filled out an incident report, contacted the resident's physician's office, and sent an e-mail to the Director of Nursing. The care plan lacked any interventions to address the resident ' s elopement. During interview on 11/5/13 at 12:38 p.m., Staff D, CNA, stated he/she worked 2nd shift on the resident's wing. Staff D saw the resident around 2:00 p.m. when he/she was passing linens out to the residents. Staff D stated no special instructions were given to him/her regarding the resident and nothing in the communication log book about the resident's elopement on 10/27/13. Staff D indicated he/she did not know the resident eloped on 10/27/13 or 10/28/13 until Staff D received a call from the facility on 11/1/13 asking about scheduling Staff D to do one to one supervision with the resident. b). A written statement dated 10/29/13 by Staff H revealed on 10/28/13 around 4:15 p.m., she was driving to the Woodlands building on campus and as she passed the intersection of Brendel Hill Drive and Brendelwood Drive she looked to her right and saw Resident #1 walking alone on the outdoor trail towards the Brendel Pond. She observed a coworker leaving the Woodlands parking lot driving towards her. By the time Staff parked her car, Resident #1 was standing on the bridge feeding the fish with the other staff. The resident had his/her walker with him/her. During interview on 11/5/13 at 1:35 p.m., Staff H, activity personnel reported on 10/28/13, they were driving on campus going past the pond and towards the facility when they saw the resident on the side walk by the pond. Staff H stated another staff member got out of a car and went to the resident and Staff H parked his/her car and went to the resident who was standing on the bridge by the pond. Staff H stated the resident was dressed in a shirt, sweater, pants, and shoes and socks. Staff H reported the resident told her/him he was feeding the fish in the pond and the resident had fish food in his pockets. Staff H asked the resident where he/she got the fish food and the resident responded from the canister in the multi-Purpose/Chapel room in the facility. Staff H stated she/he asked the resident how they got out of the facility and the resident through the front door letting self out. Staff H indicated the resident raised his/her arm up when telling how they let themselves out the front door and motioned like he/she pushed the silver handicap button that is on the wall in the lobby by the front door. Staff H reported the button allows people to exit the building without setting off an alarm. Staff H stated the resident finished feeding the fish and they walked back to the facility. Staff H reported he/she walked with the resident to the wing were their room was located and reported to Staff J the nurse on duty. Staff H stated he/she and Staff J explained to the resident to let staff know when he/she wanted to go outside so staff could go with them. Staff H reported the resident started to get upset and said "now listen, I pay the bills here, I should be able to go outside when I want". Interdisciplinary notes dated 10/29/13 at 2:26 p.m., revealed Staff J, LPN, documented the resident was brought to him/her by Staff H, activity personnel (on 10/28/13). Staff J documented Staff H reported the resident was observed stepping outside after the activity was finished and the resident did not go anywhere, just sat outside on the patio. Staff J documented they and Staff H advised the resident to make sure they ask for staff to escort them outside. Staff J documented he/she notified all staff members to make sure staff kept an eye on the resident. Staff J documented the resident remained on the unit the entire second shift. During interview on 11/8/13 at 12:46 p.m., Staff J, LPN stated they worked second shift on 10/28/13, coming in at 2:00 p.m., and was assigned to care for the resident. Staff J stated he/she last saw the resident on the wing, where the resident's room was located, around 2:50-3:00 p.m. Staff J stated Staff H brought the resident to him/her around 4:15 p.m. and Staff J thought Staff H reported the resident was seen sitting outside on the patio outside of the activity room. Staff J stated he/she misunderstood Staff H, that the resident had actually been found by the campus pond. Staff J stated he/she did not realize until the next day, 10/29/13 the resident went to the pond on 10/29/13, and if he/she would have understood, they would have followed the elopement policy. Staff J stated the entry he/she made on 10/29/13 was a late entry for what he/she thought occurred with the resident on 10/28/13. Investigation notes dated 10/31/13 at 3:10 p.m., revealed an investigation began on 10/29/13 after the Director of Nursing was notified of the resident seen at the pond on 10/28/13 at 4:15 p.m. by the recreation staff. In talking with the recreational staff member he/she saw the resident at the pond while driving through the facility campus. (The DON ' s investigation revealed another elopement incident had occurred the day prior to this incident.) A facsimile sheet dated 11/1/13, sent from the DON, to the resident's physician, revealed a comment that resident was found at the pond on the campus, approximately 150 yards from facility, on 10/28/13 at 4:15 p.m. Staff escorted the resident back to the facility with no incident. Resident stated he/she wanted to feed the fish. The resident was instructed to ask staff to escort him/her when the resident wanted to go outside. 15 minute visual checks were initiated, staff notified of the resident ' s elopement risk and double doors on resident's wing remained closed. An Elopement Risk assessment dated [DATE], revealed the resident scored 4- indicating no Elopement Risk Potential. The form identified the resident had no attempts and the resident had resided without elopement attempts the last 120 days. During interview on 11/1/13 at 2:40 p.m., the Director of Nursing, DON stated they were aware the resident went out of the facility on 10/27/13 on Monday morning 10/28/13, but did not look into it any further or the alarm system that was reported not working correctly. The DON stated when the resident eloped on 10/28/13, they were in the facility but had not been aware of incident until the next morning when they realized the incident report given to them regarding the 10/27/13 elopement of the resident. The DON stated they asked Staff J to do a late entry regarding the incident on 10/28/13 in the nurses notes. The DON further acknowledged there was no documentation of 15 minutes check completed after the 10/27/13 elopement. The DON stated no incident report was completed on the 10/28/13 elopement, no documentation of the incident, no assessment of the resident completed and nothing implemented for the resident's safety until 10/29/13, that included documentation of 15 minute checks and to leave the double doors closed on the resident's wing. The DON further stated they should have looked further into the incident report given to her on 10/27/13, and agreed the elopement risk assessment completed on 10/29/13 was incorrect, it reflected the resident was not an elopement risk and the DON would redo the elopement risk assessment that should identify the resident as at risk for elopement. 2. The MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 6 out of 15, indicating severe cognitive impairments. The MDS documented the resident had been independent with bed mobility, transfers and supervision for ambulation and toilet use. The MDS revealed the resident had a behavior of wandering that occurred 4 to 6 days, but less than daily. The MDS indicated the resident had [DIAGNOSES REDACTED]. The Elopement Risk assessment dated [DATE], revealed the resident scored 30, with an assumed risk for elopement. The Care Plan dated 8/15/13, revealed the resident wandered with a potential for elopement. Approaches included to administer antidepressant medication as ordered and monitor for adverse effects, encourage the resident's participation in recreational activities, monitor for wandering especially when the resident goes off the unit and place photo in the elopement book, empathy and understanding. Interdisciplinary notes dated 8/14/13 at 9:18 a.m., revealed a quarterly review completed indicating the resident continued as an elopement risk, the resident wandered on and off the unit with staff and to be alert to the resident's whereabouts. Interdisciplinary notes dated 9/1/13 at 8:08 a.m., revealed the resident came out of his/her room and went right out the south door outside. The resident stated he/she was looking for the guys to buy a ticket to get on and go home. The resident was redirected back into facility. Interdisciplinary notes dated 9/13/13 at 9:34 a.m., revealed the resident was seen outside by the front parking lot by staff. The front door alarm did not sound and the resident was unable to explain how he/she got out. Staff redirected the resident back into the building and later the resident was escorted by staff for a walk. Staff educated the resident not to leave the building by self and that staff will go with the resident outside if the resident lets staff know. Staff called resident's family and left message to return call to facility. Interdisciplinary notes dated 9/13/13 at 2:37 p.m., revealed staff witnessed the resident getting out through the back door. The resident stated he needed to get out of here. The resident was difficult to redirect by staff. Interdisciplinary notes dated 9/19/13 at 2:46 p.m., revealed the resident attempted to elope out the unit's south doors. The resident was redirected back to his/her room. Nurse notes revealed staff seen resident on 9/13/13 at 9:30 a.m., outside the front door with no staff members with the resident. Staff redirected the resident into facility. During interview on 11/8/13, the Administrator stated there was no incident report or investigation done on the resident as staff saw the resident right outside the front door. The Administrator stated the do not know how long the resident had been out of facility or how the resident got out. The Administrator stated on the facility had no policy/procedure for staff responding to alarms; staff are orientated when hired on how to respond to a door alarm. Observation on 11/1/13 at approximately 11 a.m., revealed the front door as not visible to the 3 wings of the facility and the alarm only sounded at the CCDI unit panel and not at the other two wings. During interview on 11/8/13 at 10:00 a.m., the DON stated the only thing on Resident #2's elopement on 9/13/13, was a written statement and the Interdisciplinary notes, (no investigation/incident report done.) The facility abated the IJ on 10/29/13 when they implemented the following: The facility updated Resident #1's care plan on 10/29/13 to include multiple supervision interventions to address his/her elopement needs. The facility also planned an intervention to allow staff to accompany the resident outside weather permitting 5 days a week. The facility in-serviced their staff starting on 11/1/13 to 11/7/13 on the Resident #1 care plan interventions for elopement. On 11/1/13 the DON completed an accurate and updated elopement risk assessment for Resident #1. The resident's elopement score now showed he/she scored 14. The DON placed a copy of the missing resident policy at each nurse's station and went around and told staff about it. The DON stated staff were also orientated on it when they are hired. Review of the facility's Missing Residents Policy dated 3/09 revealed procedure that included: a. Attempt to prevent the departure. b. Instruct another staff member to inform the charge nurse that a resident left the premises. c. Return the resident to the facility. d. Examine the resident for injuries. e. Contact the physician and report what happened. d. Complete and file an incident report. e. Make appropriate notations in the resident's medical record. f. Notify the resident's legal representative. g. Notify Director of Nursing, Assistant Director of Nursing, and Administrator. h. Director of Nursing, Assistant Director of Nursing, or Administrator to notify the appropriate State agency within 24 hours of incident. The DON stated on 11/8/13 at 10:00 a.m., the facility implemented 15 minute safety checks on Resident #2 starting on 11/3/13. The DON stated the resident's family bought and applied a MedicAlert and Safe Return ID jewelry to the resident on 9/6/12. Review of the information provided by the facility regarding the MedicaAlert & Safe Return that the family of Resident #2 provided for the resident revealed a 24 hour emergency response for wandering and medical emergencies. The Administrator further stated on 11/8/13 at approximately 9:30 a.m., they disengaged the handicap button to the front door that would open and disengage the door alarm. The Administrator stated the facility had placed a Wanderguard to the double doors of the unit where both Resident #1 and Resident #2 are located and applied a Wanderguard bracelet to Resident #1 and have ordered a bracelet for Resident #2. The Administrator further stated the facility was looking at a Wanderguard system for the front door and activity/chapel door and door in between units and look to have it installed in a month. The Administrator reported the front door was to alarm when opened from inside and the only panel where the front door sounds at is located in the CCDI unit. The Administrator reported no staff at the front lobby/door area after 3:30 p.m. and none on the weekend. The Administrator reported all alarms off the units are checked daily by housekeeping and all alarms on the units are checked every shift by nursing staff. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of intervention(s) for effectiveness.

Based on clinical record review and staff interviews, the facility failed implement care plan interventions to ensure one of nine residents received adequate supervision from hazards in the environment (Resident #5). The facility reported a census of 61 residents. Findings include: The Minimum (MDS) data set [DATE] documented Resident #5 had been admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS identified the resident had moderate cognitive impairments. The assessment revealed the resident required staff assistance with most activities of daily living and had limitation in range of motion to one lower extremity. The test for balance during transition and walking revealed the resident as unsteady and required staff assistance to stabilize when walking, when moving from a seated position to standing, when turning around, and during surface to surface transfers (transfers between the bed and chair or wheelchair). The assessment revealed Resident #1 used a walker and wheelchair for mobility. The interim plan of care dated 11/22/13 documented the resident as a fall risk and directed staff to: a. Transfer and walk with assist of one person b. Keep bed in lowest position with two and a half side rails up c. Pad alarm on at all times d. Follow hip precautions (special care after a repair of a hip fracture) The incident report dated 11/29/13 documented a staff member heard Resident #5 yelling from his/her room at 10:45 p.m. The staff found the resident lying on his/her right side on the bathroom floor. The resident could not move his/her legs and complained of pain with movement. The physician and family were notified and Resident #5 had been transferred to the hospital via ambulance. The report did not have documentation as to whether or not the pad alarm had sounded, or if the pad alarm had been in place. The interdisciplinary notes documented the following on: 11/29/13 at 2:54 p.m., the resident worked with therapy for a left hip fracture and at 4:31 p.m. the resident had been admitted from the hospital following a hip fracture. 11/30/13 at 12:32 a.m., the nurse's aide called the nurse at 10:45 p.m. to the resident's bathroom after hearing the resident calling out. The resident had been lying on his/her right side on the bathroom floor. Resident #5 could not recall what happened. Resident #5 complained of pain to the left hip and lower back and could not move his/her legs. The physician and family were notified. Orders received to send the resident in the emergency room . 11/30/13 at 4:06 a.m., the resident had been admitted to the hospital with [REDACTED]. The hospital orthopedic surgeon consultation report dated 11/30/13 documented the resident had a left hip fracture 12 days earlier. The resident was receiving skilled services (at the nursing home) and apparently had been found on the floor with significant right hip pain. The emergency room x-rays showed a displaced right femoral neck fracture (hip fracture). In an interview on 12/24/13 at 11:12 a.m., the Director of Nursing (DON) reported the resident should have had a pad alarm underneath him/her at all times. The DON reported Staff A, CNA from the agency did not know if the resident should have had the alarm on or not. The DON reported after the fall, the charge nurse reviews the safety precautions personally with aides. The DON reported the nursing home rarely used agency staff and recently 3 new CNAs were hired. During interview on 12/26/13 at 12:06 p.m., Staff A, certified nurse aide, CNA, could not recall if Resident #5 had a pad alarm. Staff A reported she could not could not remember putting one underneath the resident when the resident was assisted to bed at 8:00 p.m. on 11/29/13. Staff A reported she could not recall an alarm sounding when she transferred the resident from the wheelchair to the toilet earlier. Staff A stated that had been the last time she seen Resident #5 prior to her shift ending at 10:00 p.m. Staff A stated the CNA worksheet only had the resident's name penciled in and could not recall seeing any other information on the resident. In an interview on 12/26/13 at 1:48 p.m., Staff B, CNA reported she heard the resident calling out for help on 11/30/13 at 10:35 p.m. Upon entering the resident's room, Staff B found the resident lying on his/her right side and could not move without pain. The nurse assessed the resident and the resident was transported to the hospital by ambulance. Staff B also reported the resident should have had a pad alarm underneath him/her at all times. During interview on 12/30/13 at 10:30 a.m., Staff D, CNA, reported the aide taking care of the resident was responsible for checking placement and function of the pad alarms. Staff D reported staff should document this on the computerized record. Staff D reported she had minimal interaction with Resident #5 who should have had a clip alarm on. In an interview on 12/30/13 at 11:53 a.m., Staff E, licensed practical nurse, LPN, reported she left prior to the resident' s fall on 11/29/13. Staff E stated the last time she saw the resident was at 9:30 p.m. while the resident was in bed. Staff E reported however she did not check to see if the pad alarm was underneath the resident as the resident had not been trying to get out of bed. Staff E also reported the resident should have had the pad alarm on at all times. Staff E reported the same pad alarm was used for both the chair and bed and should have been transferred to the bed from the chair. Staff E reported other facilities she had worked at had two separate alarms for the bed and the chair. The aides were responsible for checking the alarms were in place at the beginning and end of the shift, or after transferring the resident from bed to chair. She could not recall if the CNA worksheet identified Resident #5 needed an alarm. During interview on 12/30/13 at 11:30 a.m. the DON verified the copy of the CNA worksheet dated 11/25/13 identified the resident at high risk for falls due to history of left hip fracture and directed staff to ensure the resident had the pad alarm on at all times. In an interview on 12/30/13 at 11:55 a.m., the DON verified the computerized record showed documentation by Staff A, CNA that the alarm was to be on at all times.

Based on record review, staff and family interviews and review of facility policy/procedures, the facility failed to assess a resident ' s leg when identified to be in an external rotation and provide timely interventions such as contacting the physician. and receiving further orders for 1 of 13 residents (Resident #3). The facility reported a census of 61 residents. Findings Include: 1. According to a history and physical dated 6/5/11, Resident #3 had [DIAGNOSES REDACTED]. The discharge with return anticipated Minimum Data Set (MDS) Assessment tool with a reference date of 6/5/11 revealed, Resident #3 depended upon 2 or more staff persons for transfers to and from the bed and wheel chair, extensive assistance with one staff member for dressing, bathing and depended upon two staff for toileting. The MDS identified [DIAGNOSES REDACTED]. The MDS indicated the resident experienced almost constant pain over the preceding 5 days that effected function and ability to sleep; rated as severe, a 9 level on a scale of 0 to 10 with 10 the highest pain level. An admission form dated 6/3/11 revealed Resident #3 had a [DIAGNOSES REDACTED]. The Nurse's Note entries revealed the following: On 6/3/11 at 3:20 p.m. staff admitted Resident into the facility. The resident transferred to the facility from assisted living center with acute bilateral [MEDICAL CONDITION] (3-4 plus) of the lower extremities, complained of left lower extremity pain whenever moved, showed some external rotation and transferred with 2 to 1 person assistance. The resident could not bear any weight on the left leg as recorded by Staff G. On 6/4/11 at 4:45 a.m. the note indicated the resident ' s left leg painful when moved, repositioned by staff every 2 hour. The staff identified the [MEDICAL CONDITION] as 4 plus (excessive). The staff could not feel pedal pulses. This entry was recorded by Staff H. On 6/4/11 at 3:30 p.m, Staff G documented the resident rated pain a 6 level on a scale of 0 - 10 in the left lower extremity, and paged the physician due to little pain relief. Staff G received physician orders [REDACTED]. The results of the x-ray were telephoned to the physician. The x-ray report identified a subcaptial [MEDICAL CONDITION] proximal femur with lateral displacement of the femoral shaft. The physician ordered medication for pain control. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 6/5/2011 at 4:30 a.m. the resident received [MEDICATION NAME] 5/500 two tablets at 11:15 p.m. At 1:00 a.m. the resident rested soundly. The resident continued to have excessive [MEDICAL CONDITION] to the lower extremities and staff could not feel the pedal pulses. On 6/5/11 at 3:30 p.m. - Staff G recorded the physician gave orders to transfer the resident as a direct admit to the hospital. 6/7/11 (no time) indicated the facility received an update that the resident had surgery on 6/6/2011. An undated policy entitled "Physician Notification" directed staff to notify the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly; and a decision to transfer or discharge the resident from the facility. During an interview on 7/1/11 at 7:45 a.m., Staff G, a registered nurse (RN), indicated the assisted living staff communicated to him/her that the physician was aware of the resident's lower extremity pain, [MEDICAL CONDITION], and inability to bear weight. The resident transferred to the facility due to higher level of care needs with [MEDICAL CONDITION] identified as the pain source, and the resident to receive therapy services for strengthening. Staff G indicated in retrospect she/he should have contacted the physician on 6/3/11 regarding the resident's condition and external rotation of the left leg. During an interview on 6/30/11 at 7:02 p.m., Staff H, a Licensed Practical Nurse (LPN), indicated she/he cared for Resident #3 during the night shift on 6/3 - 6/4/11. The staff log rolled the resident when repositioned due to pain with movement. Staff H confirmed that he/she did not observe external rotation of the left leg, but if had observed that finding, would have notified the physician at that time. During an interview on 7/1/11 at 1:10 p.m., the facility administrator asked if it would be possible for the resident to have a non-displaced [MEDICAL CONDITION] that became displaced when the resident transferred to a chair. During an interview on 7/1/11 at 10:04 a.m., a nurse at Resident #3's physician office indicated with certainty that the physician would want to be notified if a resident had increased pain in 1 leg with inability to bear weight and external rotation of that leg. During an interview on 6/30/11 at 7:15 p.m., a family member indicated the resident had developed the lower leg [MEDICAL CONDITION] over the last few days at the assisted living center but the inability to bear weight seemed like it happened over night. The family member stated the last night the resident lived at the assisted living center; the assisted living staff instructed him/her that a higher level of care was required. The resident was then transferred on the same day.