Every finding on record at Mid City Community Nursing and Rehab

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: Food was properly stored, labeled and dated with an open date, or discarded for safety; and Staff documented food temperatures on food served to residents. There were 114 residents who received food served from the kitchen. Review of facility's policy titled, Food Safety Requirements, last revised August 2022, revealed the following, in part:Policy: It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.Policy Explanation and Compliance Guidelines: 1. B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. 3.c. Practices to maintain safe refrigerated storage include: iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/ discarded; and keeping foods covered or in tight containers. 1.On 04/06/2026 at 8:30 a.m. a tour of the kitchen was conducted with S5CK. The following was observed and S5CK confirmed:Walk in refrigerator:An undated, and unlabeled clear, gallon bag of opened purple cabbage and sliced carrots that contained a purple colored liquid;An undated, unsealed half used large stick of butter;An undated, opened, half-full bag of green grapes on a vine that were browning;An undated, and unlabeled gallon bag of garlic toast;A half cut, unsealed orange on the refrigerator shelf; andAn open and undated container of beef base. Dry Storage:An opened, undated, 9.7 ounce bag of sugar. Seasoning shelf next to the stove:An opened and undated 5 pound bag of grits;A hard piece of toasted bread lying on the seasoning shelf; andA white, unlabeled and undated, canister of yellow seasoning that was clumped. On 04/06/2026 at 8:40 a.m., an interview was conducted with S5CK. S5CK confirmed all opened food items should have been in a sealed, labeled and dated container, but were not. She also confirmed the bag of cabbage and carrots, grapes and half of orange should have been discarded and not available for resident consumption. 2.Review of food temperature logs on 04/07/2026 at 11:00 a.m. was conducted with S3DM and revealed the following: 04/02/2026- No documented food temperatures for dinner;04/03/2026- No documented food temperatures for breakfast, lunch or dinner;04/04/2026- No documented food temperatures for breakfast, lunch or dinner;04/05/2026- No documented food temperatures for dinner; and 04/06/2026- No documented food temperatures for dinner. On 04/07/2026 at 11:00 a.m., an interview was conducted with S3DM. He stated 114 residents were served from the kitchen. He stated he was responsible for ensuring staff were obtaining and documenting food temperatures prior to serving each meal, and staff did not document the food temperatures on the log, but should have. He confirmed all opened food items in the kitchen should been sealed, labeled and dated, and the bag of cabbage and carrot, bag of grapes and half of orange should have been discarded and not available for resident consumption. On 04/07/2026 at 1:15 p.m., an interview was conducted with S1ADM. S1ADM confirmed all opened food items in the kitchen refrigerator or dry storage should have been labeled and dated. He stated he expected all kitchen staff, including the dietary manager, to comply and oversee that food temperatures were obtained, and documented, and all opened food was labeled and dated.

Based on observation, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure a medication cart was free of unlabeled capsules for 1 (Cart A) of 2 medication carts reviewed.Review of facility's policy titled, Labeling of Medications and Biologicals, last revised October 2020, revealed the following, in part: Policy: All medications and biologicals in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. On 04/06/2026 at 12:25 p.m., an observation was made of Cart A with an interview from S4LPN. Observation of Cart A revealed an unlabeled, clear, medication cup with 10 unidentified white capsules in the top drawer of the cart. S4LPN confirmed the observation and reported the medications were likely probiotics from the weekend shift. S4LPN further confirmed the medications should have been in a labeled container identifying the medication. S4LPN explained unlabeled medications could lead to a nurse administering the wrong medications. On 04/07/2026 at 1:00 p.m., an interview was conducted with S2DON. S2DON confirmed all medications in the medication carts should have been labeled, and all staff nurses were responsible to clean their medication carts each shift. On 04/07/2026 at 1:15 p.m., an interview was conducted with S1ADM. He stated staff nurses should not remove medications from a labeled bottle to store in a medication cart. He confirmed it is the responsibility of the staff nurses to check the medication carts each shift and all medications should remain labeled.

Based on interviews and record review, the facility failed to develop a trauma-informed, comprehensive person-centered care plan, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (#14) of 30 Residents reviewed in the final sample. The facility failed to develop a care plan for Resident #14's diagnosis of Post-Traumatic Stress Disorder (PTSD).Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of Resident #14's most current care plan revealed no documented evidence of a care plan for diagnosis of PTSD. On 04/08/2026 at 1:25 p.m., an interview was conducted with S4LPN. S4LPN stated he was unaware Resident #14 had a diagnosis of PTSD and confirmed he was not familiar with Resident #14's triggers that may result in a mental health crisis. S4LPN reviewed and confirmed Resident #14's care plan did not include a history of PTSD. On 04/08/2026 at 2:45 p.m., an interview was conducted with S6CNA. S6CNA stated she was unaware Resident #14 had a diagnosis of PTSD and confirmed she was not familiar with Resident #14's triggers that may result in a mental health crisis. On 04/08/2026 at 2:50 p.m., an interview was conducted with S7CNA. S7CNA stated she was unaware Resident #14 had a diagnosis of PTSD and confirmed she was not familiar with Resident #14's triggers that may result in a mental health crisis. On 04/08/2026 at 2:55 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #14's care plan and confirmed all care plans should accurately reflect the resident's status and Resident #14's did not.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#2) of 1 resident reviewed for Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP). Findings:Review of the facility's policy titled, Enhanced Barrier Precautions with a revision date of 04/2024 revealed the following, in part:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high-contact resident care activities.Policy Explanation and Compliance Guidelines:2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i.indwelling medical devices (e.g., feeding tubes)4. High-contact resident care activities include: f. changing briefs or assisting with toiletingReview of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Traumatic Subarachnoid Hemorrhage and Gastrostomy Status.Review of Resident #2's current Physician Orders revealed the following, in part: Start date: 06/02/2025; Enhanced Barrier Precautions when providing high-contact resident care.Review of Resident #2's current Care Plan revealed the following, in part:Focus: I require staff to use EBP.Intervention: Wear required PPE when preforming contact care. On 08/18/2025 at 4:00 p.m., an observation was made of the EBP sign posted on the wall above Resident #2's bed. The sign revealed the following, in part: Providers and staff must also:Wear gloves and a gown for the following high-contact resident care activities.In addition to standard precautions, everyone must gown and glove for these resident care activities - Changing briefs On 08/18/2025 at 4:00 p.m., an observation was made of incontinent care on Resident #2. S2CNA changed Resident #2's brief without wearing a gown. On 08/18/2025 at 4:05 p.m., an interview was conducted with S2CNA. She confirmed Resident #2 had a Percutaneous Endoscopic Gastrostomy (PEG) tube. She further confirmed she did not wear the appropriate PPE while performing incontinent care and should have. On 08/20/2025 at 11:59 a.m., an interview was conducted with S1DON. She confirmed she would expect staff to wear the appropriate PPE when providing incontinent care to a resident with a PEG tube.

Based on record review and interviews, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1(#52) of 22 residents investigated in the final sample. Findings: Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with a diagnosis which included Diabetes. Review of Resident #52's Physician's Orders revealed, in part: Order date 11/25/2024- laboratory blood draw for HGBA1C every three months in March, June, September, December once every 3 months starting on the 25th of each month. Review of Resident #52's clinical record revealed the last collected HGBA1C was performed on 10/26/2024. Review of the Medication Administration Record from November 2024 to present revealed no documented evidence Resident #52's HGBA1C labs were collected. Review of Resident #52's Care Plan Report revealed the following: Focus- I have a History of Diabetes Interventions- Obtain lab work as ordered An interview was conducted on 03/19/2025 at 3:08 p.m. with a local laboratory spokesperson. He stated the last collected lab on record for HGBA1C for Resident #52 was collected on 10/26/2024. An interview was conducted on 03/19/2025 at 3:10 p.m. with S2DON. She reviewed Resident #52's clinical record and confirmed the last documented HGA1C collection was performed on 10/26/2024. She confirmed no additional HGBA1C labs were collected from Admission to present and should have been.

52121 Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#4 and #50) residents out of a total of 22 sampled residents. The facility failed to ensure: 1. Resident #4 was coded correctly for functional abilities and goals; and 2. Resident #50 was coded correctly for medications. Findings: Resident #4 Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #4's Significant Change MDS with an ARD of 02/25/2025 revealed a BIMS of 14, which indicated she was cognitively intact. Further review revealed she was coded as being independent for toileting hygiene, showering/bathing, and putting on/taking off footwear in Section GG: Functional Abilities and Goals. On 03/17/2025 at 11:10 a.m., an interview was conducted with Resident #4. Resident #4 stated she was independent with eating but was dependent for all other ADL care. On 03/19/2025 at 1:37 p.m., an interview was conducted with S4LPN. S4LPN stated Resident #4 was not able to perform toileting hygiene, shower/bathe, nor put on/take off footwear independently. On 03/19/2025 at 1:52 p.m., an interview was conducted with S3MDS. S3MDS stated she was responsible for completing Resident #4's MDS assessments. S3MDS reviewed Resident #4's Significant Change MDS with an ARD of 02/25/2025. S3MDS confirmed toileting hygiene, showering/bathing, and putting on/taking off footwear should have been coded as dependent and was not. On 03/19/2025 at 2:55 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #4's Significant Change MDS with an ARD of 02/25/2025. She confirmed Resident #4 was not coded accurately for toileting hygiene, showering/bathing, and putting on/taking off footwear. Resident #50 Review of Resident #50's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction. Review of Resident #50's Quarterly MDS with an ARD of 02/05/2025 revealed he was coded as receiving antiplatelets and anticoagulants in Section N: Medications. Review of Resident #50's Physician Orders dated January 2025-March 2025 revealed the following, in part: Aspirin 81 mg orally one time a day. Clopidogrel Bisulfate 75 mg orally one time a day. On 03/19/2025 at 1:50 p.m., an interview was conducted with S3MDS. She stated she was responsible for completing Resident #50's MDS assessments. She reviewed Resident #50's Quarterly MDS assessment dated [DATE] and verified he was coded for anticoagulants. She reviewed Resident #50's physician orders and confirmed he had an order for Clopidogrel and Aspirin, which were antiplatelets, not anticoagulants. She stated Resident #50 should not have been coded for anticoagulants. On 03/19/2025 at 2:55 p.m., an interview was conducted with S2DON. She reviewed Resident #50's physician orders dated January 2025-March 2025. She verified Aspirin and Clopidogrel were antiplatelet medications and confirmed Resident #50's Quarterly MDS assessment should not have been coded for anticoagulants.

Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#4) of 22 residents reviewed in the final sample. Findings: Review of Resident #4's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included morbid obesity. Review of Resident #4's Significant Change MDS with an ARD of 02/25/2025 revealed a BIMS of 14, which indicated she was cognitively intact. On 03/17/2025 at 11:05 a.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed. On 03/17/2025 at 11:10 a.m., an interview was conducted with Resident #4. Resident #4 stated she was independent with eating but was dependent for all other ADL care. Resident #4 stated her call light was frequently out of reach and she had to yell out until someone responded. On 03/17/2025 at 1:45 p.m., an observation was made of Resident # 4 in her room. She was lying in bed, with her call light resting on the floor behind the bed. On 03/18/2025 at 10:41 a.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed. On 03/18/2025 at 12:44 p.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed. On 03/19/2025 at 9:42 a.m., an interview was conducted with S4LPN. S4LPN confirmed call lights should be within the resident's reach at all times. She verified Resident #4 was able to use her call light. S4LPN further stated Resident #4's call light was frequently not within reach and resident would yell out for the nurse if needed. On 03/19/2025 at 2:55 p.m., an interview was conducted with S2DON. S2DON was made aware of the above observations and confirmed she expected staff to keep call lights within a resident's reach.

Based on observation, record review, and interview, the facility failed to ensure the results from the most recent complaint survey was readily available for resident review. This deficient practice had the potential to affect the 104 residents who currently resided in the facility. Findings: Review of the facility's Survey History revealed the most recent survey was a Complaint Survey on 02/11/2025. An observation was made on 03/17/2025 at 9:30 a.m. of the facility's Survey Results folder located near the entrance of the facility. Review of the Survey Results folder revealed the last survey posted in the binder was dated 04/18/2024. Further review revealed no documented evidence of the survey results from complaint survey dated 02/11/2025. An interview was conducted on 03/17/2025 at 9:35 a.m. with S1ADM. He reviewed the facility's Survey Results folder. He confirmed the survey results from complaint survey dated 02/11/2025 were not located in the folder.

Based on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Residents with newly diagnosed mental illnesses were reevaluated for PASRR Level II determinations for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASRR; and 2. Allegations of physical abuse were reported to the state agency, immediately but not later than 2 hours after the allegation for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for abuse; and 3. Allegations of physical abuse were reported to the administrator immediately after the allegation for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for abuse. The deficient practice had the potential to affect a census of 110 residents. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025. Findings: Cross Reference F609. Cross Reference F644. 1. Resident #1 A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder. Further review revealed Resident #1 was diagnosed with Unspecified Psychosis on 12/19/2024 and no documentation a Level II evaluation and determination had been submitted after Resident #1 received this diagnosis. Resident #2 A review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #2 was diagnosed with Bipolar Disorder on 01/02/2025 and no documentation a Level II evaluation and determination had been submitted after Resident #2 received this diagnosis. An interview was conducted on 02/11/2025 at 11:10 a.m. with S11SW. She stated she was responsible for filing PASRR Level I and II paperwork in resident records upon admission to the facility. She stated she was unsure who was responsible for completing resident assessments following a new psychiatric diagnosis after admission, and who was responsible for submitting a new Resident Review to determine candidacy for Level II services. An interview was conducted on 02/11/2025 at 11:15 a.m. with S1ADM. He stated he was unsure who was responsible for completing resident assessments following a new psychiatric diagnosis, and who was responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services. He reviewed both Resident #1 and Resident #2's diagnoses and confirmed they acquired new psychiatric diagnoses since Level I approval, and a new Level I Pre-admission Screening and Resident Review was not completed and should have been. An interview was conducted on 02/11/2025 at 2:00 p.m. with S2CON. She stated she was unaware of who was responsible for ensuring residents received evaluations for PASRR determination of services after new psychiatric diagnoses. 2. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia. Review of Resident #1's MDS with an ARD of 11/06/2024 revealed a BIMS of 13, which indicated he was cognitively intact. Resident #4 Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Dementia. Review of Resident #4's MDS with an ARD of 10/09/2024 revealed a BIMS of 13, which indicated he was cognitively intact. Review of the facility's incident report dated 12/18/2024, revealed in part, the following: Incident Description: Resident #1 went to the nurses' station and stated, I f***ed him up. He stated he was referring to Resident #4. Staff immediately went into the residents' room and found Resident #4 with scratches to his left arm. Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. Resident #1 stated, Everyday he is just sleeping and I'm tired of it. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit. Review of Resident #3's MDS with an ARD of 11/13/2024 revealed a BIMS of 13, which indicated she was cognitively intact. Review of the facility's Incident Log dated December 2024 through January 2025 revealed the following: A physical aggression incident between Resident #2 and Resident #3 on 12/24/2024. Review of the facility's incident report dated 12/24/2024, revealed in part, the following: Incident Description: S3LPN was notified by S6CNA at 11:45 a.m. that Resident #2 had slapped Resident #3 in the face. An interview was conducted on 02/10/2025 at 1:45 p.m. with S1ADM. He stated December 2024 through January 2025, S2CON was responsible for reporting to the state agency and he was the DON. He stated he was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. He confirmed the incidents were abuse, should have been reported to state agency, and were not. An interview was conducted on 02/11/2025 at 2:00 p.m. with S2CON. She stated December 2024 through January 2025, she was responsible for reporting to the state agency and was the Administrator during that time. She stated she was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. She stated these incidents were not physical abuse, and therefore she did not report them to the state agency. 3. Review of the facility's incident report dated 01/18/2025, revealed in part, the following: Incident Description: S7CNA reported Resident #1 and Resident #2 were arguing in their room, and Resident #2 hit Resident #1 with a reacher tool at 6:30 p.m. An interview was conducted on 02/10/2025 at 2:15 p.m. with S7CNA. She stated she witnessed Resident #1 punch Resident #2 on 01/18/2025. She stated she notified S4LPN of the altercation immediately on 01/18/2025 around 6:30 p.m. An interview was conducted on 02/10/2025 at 2:20 p.m. with S4LPN. She stated S7CNA notified her immediately of the incident on 01/18/2025 around 6:30 p.m. She stated she did not report the incident to anyone else until 01/20/2025, when Resident #1 was noted to have swelling of his right hand. She stated Resident #1 had a mobile x-ray on 01/20/2025 completed which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. She stated a resident punching another resident was physical abuse and should be reported. She stated she knew to report it, but she failed to do so on 01/18/2025. An interview was conducted on 02/10/2025 at 1:45 p.m. with S1ADM. He stated he was made aware on 01/20/2025 of the incident between Resident #1 and Resident #2 which occurred on 01/18/2025. He confirmed the incident was abuse, should have been reported on 01/18/2025, and was not. An interview was conducted on 02/11/2025 at 2:00 p.m. with S2CON. She stated she was made aware on 01/20/2025 of the incident between Resident #1 and Resident #2 which occurred on 01/18/2025. She stated this incident was not physical abuse.

Based on interviews and record review, the facility failed to ensure allegations of physical abuse were reported to the facility's administrator and the state agency in an appropriate time frame for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for physical abuse. The facility failed to ensure: 1. Staff immediately reported physical abuse to administration when Resident #1 and Resident #2 got into a physical altercation; and 2. The administrator reported 3 separate incidents of physical abuse involving Resident #1 and #2; Resident #2 and #3; and Resident # 1 and #4 to the state survey agency. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025. Findings: Cross Reference F600 Review of the facility's policy dated 02/2025 and titled, Abuse, Neglect, and Exploitation revealed in part, the following: Definitions: Physical Abuse-includes, but is not limited to hitting, slapping, punching. Reporting/Response: 1. Reporting of all alleged violations to the Administrator, state agency .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia. Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cervical Disc Disorder. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit. Resident #4 Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Dementia. 1. Review of the facility's incident report dated 01/18/2025, revealed in part, the following: Incident Description: S7CNA reported Resident #1 and Resident #2, were arguing in their room, and Resident #2 hit Resident #1 with a reacher tool at 6:30 p.m. An interview was conducted on 02/10/2025 at 10:30 a.m., with Resident #1. He stated a few weeks ago, he punched Resident #2 on his face a few times with his right hand. He stated Resident #2 poked him with his reacher tool so he punched him. He stated he did not have any pain or swelling to the right hand after punching Resident #2 until two days later when he was diagnosed with a right finger fracture. An interview was conducted on 02/10/2025 at 2:15 p.m., with S7CNA. She stated she witnessed the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she heard raised voices coming from Resident #1 and Resident #2's room. She stated when she entered the room, Resident #2 was standing at Resident #1's bedside poking him with his reacher tool. She stated Resident #1 then punched Resident #2 three times on the side of his face with a closed fist. She stated she notified S4LPN of the altercation immediately on 01/18/2025 around 6:30 p.m. She stated a resident punching another resident was a type of physical abuse and should be reported. An interview was conducted on 02/10/2025 at 2:20 p.m., with S4LPN. She stated S7CNA notified her immediately of the incident on 01/18/2025 around 6:30 p.m. She stated she did not report the incident to anyone else until 01/20/2025, when Resident #1 was noted to have swelling of his right hand. She stated Resident #1 had a mobile x-ray on 01/20/2025 completed which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. She stated a resident punching another resident was physical abuse and should be reported. She stated she knew to report it, but she failed to do so on 01/18/2025. An interview was conducted on 02/11/2025 at 2:02 p.m., with S9NP. She stated she was the on-call nurse practitioner for 01/18/2025. She reviewed her call logs for 01/18/2025 and confirmed she did not receive a notification of the altercation between Resident #1 and Resident #2 and should have. An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated S4LPN should have reported the physical abuse between Resident #1 and Resident #2 to him on 01/18/2025 and did not until 01/20/2025. He stated all physical abuse should be reported to the DON and Administrator immediately and reported to the state agency within 2 hours. 2. Review of the facility's incident report dated 12/24/2024, revealed in part, the following: Incident Description: S3LPN was notified by S6CNA at 11:45 a.m. that Resident #2 had slapped Resident #3 in the face. An interview was conducted on 02/10/2025 at 1:45 p.m., with S6CNA. She stated she witnessed the incident which occurred on 12/24/2024 at 11:45 a.m. between Resident #2 and Resident #3. She stated on 12/24/2024, Resident #2 slapped Resident #3. She stated she separated both residents and immediately reported the incident to S3LPN on 12/24/2024 at 11:45 a.m. She stated a resident slapping another resident was a type of physical abuse and should be reported. An interview was conducted on 02/10/2025 at 1:55 p.m., with S3LPN. He stated on 12/24/2024, S6CNA notified him around 11:45 a.m. of Resident #2 slapping Resident #3 on the forehead. He stated he immediately reported the incident to S8NP and S1ADM on 12/24/2024. He stated a resident slapping another resident was a type of physical abuse and should be reported. Review of the facility's incident report dated 12/18/2024, revealed in part, the following: Incident Description: Resident #1 went to the nurses' station and stated, I f***ed him up. He stated he was referring to Resident #4. Staff immediately went into the residents' room and found Resident #4 with scratches to his left arm. Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. Resident #1 stated, Everyday he is just sleeping and I'm tired of it. An interview was conducted on 02/10/2025 at 10:10 a.m., with S5LPN. She stated on 12/18/2024, around midnight, Resident #1 and Resident #4 got into an altercation. She stated she immediately separated them, and placed Resident #1 in another room. She stated 1:1 monitoring began on both residents. She stated Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024. She stated she notified the NP, DON, and RP of the incident on 12/19/2024 around 7:00 a.m. She stated a resident scratching another resident was a type of physical abuse and should be reported. An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated in December 2024 through January 2025, S2CON was responsible for reporting to the state agency and he was the DON. He stated he became the Administrator later in January 2025 after the aforementioned incidents. He stated he was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. He confirmed the incidents were abuse, should have been reported, and were not. An interview was conducted on 02/11/2025 at 2:00 p.m., with S2CON. She stated in December 2024 through January 2025, she was responsible for reporting to the state agency and was the Administrator during that time. She stated she was aware of the incidents which occurred on 12/18/2024, 12/24/2024, and 01/18/2025. She stated these incidents were not physical abuse, and therefore she did not report them to the state agency.

Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents reviewed for physical abuse. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025. Findings: Review of the facility's policy dated 02/2025 and titled, Abuse, Neglect, and Exploitation revealed in part, the following: Definitions: Physical Abuse-includes, but is not limited to hitting, slapping, punching. Prevention of Abuse-The facility will implement policies and procedures to prevent and prohibit all types of abuse. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia. Review of Resident #1's MDS with an ARD of 11/06/2024 revealed a BIMS of 13, which indicated he was cognitively intact. Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cervical Disc Disorder. Review of Resident #2's MDS with an ARD of 01/07/2025 revealed a BIMS of 15, which indicated he was cognitively intact. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit. Review of Resident #3's MDS with an ARD of 11/13/2024 revealed a BIMS of 13, which indicated she was cognitively intact. Resident #4 Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Dementia. Review of Resident #4's MDS with an ARD of 10/09/2024 revealed a BIMS of 13, which indicated he was cognitively intact. Review of the facility's Incident Log dated December 2024 through January 2025 revealed the following: 1. A physical aggression incident between Resident #1 and Resident #4 on 12/18/2024. 2. A physical aggression incident between Resident #2 and Resident #3 on 12/24/2024. 3. A physical aggression incident between Resident #1 and Resident #2 on 01/18/2025. On 02/10/2025, review of the facility's incident report dated 12/18/2024, revealed in part, the following: Incident Description: Resident #1 went to the nurses' station and stated, I f***ed him up. He stated he was referring to Resident #4. Staff immediately went into the residents' room and found Resident #4 with scratches to his left arm. Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. Resident #1 stated, Everyday he is just sleeping and I'm tired of it. Immediate Action Taken: Staff assessed both residents and no injuries were noted. The residents were immediately separated and Resident #1 was placed in another room. 1:1 monitoring began on both residents. Monitoring was discontinued when Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024 when the NP, DON, and RP were notified. Resident #4 was treated in-house with antibiotic cream and had no complaints of pain or being fearful of Resident #1. An interview was conducted on 02/10/2025 at 10:10 a.m., with S5LPN. She stated on 12/18/2024, around midnight, Resident #1 came to the nurses' station and stated, I f***ed him up. She stated Resident #1 stated he was referring to Resident #4. She stated she immediately went into the residents' room and found Resident #4 with scratches to his left arm. She stated Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. She stated Resident #1 stated, Everyday he is just sleeping and I'm tired of it. She stated she assessed both residents. She stated she immediately separated them, and placed Resident #1 in another room. She stated 1:1 monitoring began on both residents on 12/18/2024. She stated Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024 when the NP, DON, and RP were notified. She stated Resident #4 was treated in-house with antibiotic cream and had no complaints of pain or being fearful of Resident #1. She stated after Resident #1 returned to the facility, he had a new diagnosis, a medication was added to his orders, and his care plan was updated. She stated Resident #1 was also placed in a new room. 1:1 monitoring continued for days, and psychiatric staff began to assess him further. She stated all staff felt these changes were effective for Resident #1. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. An interview was conducted on 02/10/2025 at 10:30 a.m., with Resident #1. He stated in December 2024, he scratched Resident #4 on his arm several times because he would not stop sleeping all day. He stated Resident #4 then pinched him on his hand. An interview was conducted on 02/10/2025 at 10:41 a.m., with Resident #4. He stated in December 2024, Resident #1 scratched him on his arm several times. He stated he pinched Resident #1 on his hand. An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated on 12/18/2024 around midnight, Resident #1 came to the nurses' station and stated, I f***ed him up. He stated Resident #1 stated he was referring to Resident #4. He stated S5LPN immediately went into the residents' room and found Resident #4 with scratches to his left arm. He stated Resident #1 had a deep laceration between his thumb and pointer finger on his right hand. He stated Resident #1 stated, Everyday he is just sleeping and I'm tired of it. He stated S5LPN assessed both residents. He stated S5LPN immediately separated the residents, and placed Resident #1 in another room. He stated 1:1 monitoring began on both residents. He stated Resident #1 was sent to a behavioral hospital on the morning of 12/19/2024 when the NP, DON, and RP were notified. He stated Resident #4 was treated in-house with antibiotic cream and had no complaints of pain or being fearful of Resident #1. He stated after Resident #1 returned to the facility, he had a new diagnosis, a new medication was added to his orders, and his care plan was updated. Resident #1 was also placed in a new room, 1:1 monitoring continued for two days, and psychiatric staff began to assess him further. He stated all staff felt these changes were effective for Resident #1. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. On 02/10/2025, review of the facility's incident report dated 12/24/2024, revealed in part, the following: Incident Description: S3LPN was notified by S6CNA that Resident #2 had slapped Resident #3 in the face. Immediate Action Taken: Staff assessed both residents and no injuries were noted. The residents were immediately separated. S3LPN notified S8NP and S1ADM of the altercation. 1:1 monitoring began on both residents and was discontinued when Resident #2 was sent to a behavioral hospital on 12/24/2024. Resident #3 had no complaints of pain or being fearful of Resident #2. An interview was conducted on 02/10/2025 at 10:37 a.m., with Resident #2. He stated in December 2024, he slapped Resident #3 on the forehead when he wanted to be assisted instead of her. An interview was conducted on 02/10/2025 at 10:41 a.m., with Resident #3. She stated in December 2024, Resident #2 slapped her on the forehead when she received assistant and not him. An interview was conducted on 02/10/2025 at 1:45 p.m., with S6CNA. She stated she witnessed the incident which occurred on 12/24/2024 between Resident #2 and Resident #3. She stated on 12/24/2024, Resident #2 slapped Resident #3 on the forehead because Resident #2 wanted the resident who was assisting Resident #3 to assist him instead. She stated she separated both residents and immediately reported the incident to S3LPN. She stated Resident #3 had no complaints of pain or being fearful of Resident #2. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. An interview was conducted on 02/10/2025 at 1:55 p.m., with S3LPN. He stated on 12/24/2024, S6CNA notified him of Resident #2 slapping Resident #3 on the forehead. He stated S6CNA immediately separated the residents. He stated he assessed both residents and no injuries were noted. He stated he reported the incident to S8NP and S1ADM who were located nearby. He stated both residents were placed on 1:1 monitoring on 12/24/2024, and monitoring was discontinued when Resident #2 was sent to a behavioral hospital on 12/24/2024. He stated Resident #3 had no complaints of pain or being fearful of Resident #2. He stated after Resident #2 returned to the facility, he had a new diagnosis, a medication was added to his orders, and his care plan was updated. He stated 1:1 monitoring continued for two days and psychiatric staff began to assess him further. He stated all staff felt these changes were effective for Resident #2. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated on 12/24/2024, S3LPN notified him of Resident #2 slapping Resident #3 in the forehead. He stated S6CNA immediately separated the residents. He stated S3LPN assessed both residents and no injuries were noted. He stated both residents were placed on 1:1 monitoring on 12/24/2024, and monitoring was discontinued when Resident #2 was sent to a behavioral hospital on 12/24/2024. He stated Resident #3 had no complaints of pain or being fearful of Resident #2. He stated after Resident #2 returned to the facility, he had a new diagnosis, a medication was added to his orders, and his care plan was updated. He stated 1:1 monitoring continued for two days and psychiatric staff began to assess him further. He stated all staff felt these changes were effective for Resident #2. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. Review of S7CNA's written statement dated 01/18/2025 revealed in part, the following: Resident #2 hit Resident #1 with a reacher tool, and Resident #1 punched Resident #2 in the face. S7CNA immediately reported the altercation to S4LPN. On 02/10/2025, review of the facility's incident report dated 01/18/2025 revealed in part, the following: Incident Description: S7CNA reported Resident #1 and Resident #2, were arguing in their room, and Resident #2 hit Resident #1 with a reacher tool. Immediate Action Taken: Staff assessed both residents and no injuries were noted. The residents were immediately separated. S7CNA notified S4LPN of the altercation. 1:1 monitoring began on both residents. On 01/20/2025, Resident #1 was noted to have swelling of his right hand. Resident #1 had a mobile x-ray completed, which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. Resident #1 was sent to a local hospital on 01/20/2025. Resident #2 had no complaints of pain or being fearful of Resident #1. An interview was conducted on 02/10/2025 at 10:30 a.m., with Resident #1. He stated a few weeks ago, he punched Resident #2 on his face a few times. He stated Resident #2 poked him with his reacher tool. He stated he did not have any pain until two days later. An interview was conducted on 02/10/2025 at 10:37 a.m., with Resident #2. He stated a few weeks ago, he poked Resident #1 with his reacher tool and Resident #1 punched him in the side of his face. He stated S7CNA witnessed this incident. An interview was conducted on 02/10/2025 at 2:15 p.m., with S7CNA. She stated she witnessed the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she heard raised voices coming from Resident #1 and Resident #2's room. She stated when she entered the room, Resident #2 was standing at Resident #1's bedside poking him with his reacher tool. She stated Resident #1 then punched Resident #2 three times on the side of his face with a closed fist. She stated she separated them, and notified S4LPN of the altercation immediately on 01/18/2025. She stated her witness statement was completed on 01/18/2025 and placed in the shift report box. She stated both residents had no complaints of pain. She stated Resident #2 denied being fearful of Resident #1. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. She stated Resident #1 did not exhibit behaviors that would indicate physical altercations from the time of the 12/18/2024 until 01/18/2024. She stated Resident #2 did not exhibit behaviors that would indicate physical altercations from the time of the 12/24/2024 until 01/18/2024. An interview was conducted on 2/10/2025 at 2:20 p.m., with S4LPN. She stated S7CNA notified her immediately of the incident on 01/18/2025. She stated S7CNA separated the residents. She stated she assessed both residents and no injuries were noted. She stated both residents were placed on 1:1 monitoring on 01/18/2025. She stated on 01/20/2025, Resident #1 was noted to have swelling of his right hand. She stated Resident #1 had a mobile x-ray completed which resulted as a 5th Metacarpal Neck Fracture of the Right Hand. She stated Resident #1 was sent to a local hospital on 01/20/2025. She stated Resident #2 had no complaints of pain or being fearful of Resident #1. She stated after Resident #2 returned to the facility, 1:1 monitoring continued for two days and psychiatric staff began to assess him further. She stated both residents now attend a day program, attend 1:1 counseling with administrative staff, and both of the residents' care plans were updated. She stated all staff felt these changes were effective for Resident #2. She stated she received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. She stated Resident #1 did not exhibit behaviors that would indicate physical altercations from the time of the 12/18/2024 until 01/18/2024. She stated Resident #2 did not exhibit behaviors that would indicate physical altercations from the time of the 12/24/2024 until 01/18/2024. An interview was conducted on 02/10/2025 at 1:45 p.m., with S1ADM. He stated on 01/20/2025, Resident #1 began to have swelling to his right hand. He stated he was then notified of Resident #1 punching Resident #2 in the face on 01/18/2025 and also received S7CNA's written statement dated 01/18/2025. He stated on 01/18/2025 after the incident, S7CNA immediately separated the residents. He stated S4LPN assessed both residents and no injuries were noted. He stated both residents were placed on 1:1 monitoring on 01/18/2025, until Resident #1 was sent to a local hospital on 01/20/2025 after a mobile x-ray resulted as a 5th Metacarpal Neck Fracture of the Right Hand. He stated Resident #2 had no complaints of pain or being fearful of Resident #1. He stated after Resident #2 returned to the facility, 1:1 monitoring continued for two days and psychiatric staff began to assess him further. He stated both residents now attend a day program, attend 1:1 counseling with administrative staff, and both residents' care plans were updated. He stated all staff felt these changes were effective for Resident #2. He stated he received an in-service and posttest on reporting abuse, types of abuse, and de-escalation on 01/20/2025. He stated monitoring started on 01/20/2025 and will be ongoing weekly until 02/20/2025. Throughout the survey from 02/10/2025 to 02/11/2025, observations, record review, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, and the effect of staff approach in relation to resident's behaviors. Interviews revealed staff were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately. The facility had implemented the following actions to correct the deficient practice: 1. Corrective actions were accomplished on 01/20/2025 for residents found to be affected by the alleged deficient practice include: a. Resident #2 was moved to another room. Monitoring tool in place for both residents. b. Both residents were to behavioral hospital. c. Both residents continue to be seen by psychiatric, attend the day program, and 1:1 counseling with administrative staff. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The measures put into place to prevent this alleged deficient practice from re-occurring on 01/20/2025: a. In-service all staff regarding policy and procedure for abuse prevention and prohibition. b. Residents with a BIMS of 9-15 interviewed by staff to ensure that the resident has not felt abused and that each resident feels safe. 4. Facility will monitor its performance to ensure sustained compliance starting on 01/20/2025 weekly for 4 weeks, by the following: a. Administrator and or designee will have a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition. b. Administrator and or designee will follow-up in morning meeting for 4 weeks and as needed to ensure a resident has not voiced concerns of potential abuse. c. Additional in-servicing and/or progressive disciplinary action will occur if further noncompliance is noted. 5. Corrective action will be completed by 01/21/2025.

Based on record review and interviews, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASARR. Findings: Review of the facility's policy dated 02/2025 and titled, Resident Assessment-Coordination with PASARR Program revealed in part, the following: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State's Medicaid rules for screening. 1ai. Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. Resident #1 A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder. Further review revealed additional medical diagnosis of Unspecified Psychosis (onset date of 12/19/2024). Further review revealed Resident #1 was diagnosed with Unspecified Psychosis on 12/19/2024 and no review for a Level II evaluation and determination had been submitted after Resident #1 received this diagnosis. Resident #2 A review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cervical Disc Disorder with Myelopathy. Further review revealed additional medical diagnosis of Bipolar Disorder (onset date of 01/02/2025). Further review revealed Resident #2 was diagnosed with Bipolar Disorder on 01/02/2025 and no review for a Level II evaluation and determination had been submitted after Resident #2 received this diagnosis. An interview was conducted on 02/11/2025 at 11:10 a.m., with S11SW. She stated she was responsible for filing PASARR Level I and II paperwork in resident records. She stated she was unsure who was responsible for completing resident assessment following a new psychiatric diagnosis, and who was responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services. An interview was conducted on 02/11/2025 at 11:15 a.m., with S1ADM. He stated he was unsure of who was responsible for completing resident assessment following a new psychiatric diagnosis, and who was responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services. He stated S10PNP may have more information regarding roles/responsibilities pertaining to psychiatric services and PASARR. He reviewed both Resident #1 and Resident #2's diagnoses and confirmed that they acquired new psychiatric diagnoses since Level I approval, and a new Level I Pre-admission Screening and Resident Review was not completed and should have been. An interview was conducted on 02/11/2025 at 11:38 a.m., with S10PNP. She stated she was responsible for assessing and treating residents with psychiatric diagnoses on a routine basis. She stated any evaluations, new diagnoses, treatment notes, and recommendations were reported via email to the Administrative staff. She further stated she was not responsible for submitting a new Level I Pre-admission Screening and Resident Review to determine candidacy for Level II services.

Based on record review and interviews, the facility to ensure nursing staff communicated a significant change in status to the residents' nurse practitioner for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for notification of change. Findings: Review of the facility's policy dated 02/2025 and titled, Notification of a Change in a Patient's Condition or Status revealed the following, in part: Procedure: The Nurse will notify the patient's Attending Physician or On-Call Physician when there has been: An accident or incident involving a patient Resident #1 A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder. A review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 13, which indicated Resident #1 was cognitively intact. Resident #2 A review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder. A review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/07/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #2 was cognitively intact. A review of an Incident Report dated 01/18/2025 at 6:30 p.m. revealed following, in part: S7CNA reported Resident #1 and Resident #2 were arguing in their room and Resident #2 hit Resident #1 with a reacher tool. S4LPN assessed the situation and the residents had no injuries. Resident #2 was moved to another room and was monitored. A review of S7CNA's written statement revealed the following, in part: On 01/18/2025, Resident #2 hit Resident #1 with a reacher tool, and Resident #1 punched Resident #2 in the face. S7CNA immediately reported the altercation to S4LPN. An interview was conducted on 02/10/2025 at 2:15 p.m., with S7CNA. She stated she witnessed the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she separated the residents and notified S4LPN of the altercation immediately on 01/18/2025. An interview was conducted on 2/10/2025 at 2:20 p.m., with S4LPN. She stated S7CNA notified her immediately of the altercation between Resident #1 and Resident #2 on 01/18/2025. She stated she did not notify the on-call nurse practitioner of the incident until 01/20/2025 when Resident #1 began to have swelling in his right hand. She stated she should have notified the on-call nurse practitioner of the incident on 01/18/2025. An interview was conducted on 02/11/2025 at 2:00 p.m., with S9NP. She stated she was the on-call nurse practitioner for 01/18/2025. She reviewed her call logs for 01/18/2025 and confirmed she did not receive a notification of the altercation between Resident #1 and Resident #2 and should have.

Based on observation, record review, and interviews the facility failed to protect the resident's right to be free from verbal and mental abuse by a staff member for 1 (#116) of 22 residents reviewed in the final sample. This deficient practice resulted in psychosocial harm on 04/18/2024 at 11:24 a.m. when surveyor observed S10CNA provide care to Resident #116, a [AGE] year old moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome. Upon S10CNA entering the room, Resident #116 became visibly tense throughout her body, hands clenched into tight fist around the side rail, and her eyes filled with tears. S10CNA rushed through care then became argumentative with a rude, aggressive tone and tense body language after the resident requested to have her teeth brushed. This interaction left Resident #116 tearful and her body language tense. Resident #116 stated S10CNA made her feel worthless. Resident #116 reported S10CNA and other CNA staff spoke to her with harsh tones, exhibited negative attitudes and harsh body language towards her. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #116, it could be determined a reasonable person would have experienced psychosocial harm as a result of the staff's behaviors, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. Findings: Resident #116 Review of Resident #116's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses; which included, in part, Guillain Barre Syndrome, Muscle Wasting and Atrophy, Generalized Muscle Weakness, Lack of Coordination, Cognitive Communication Deficit, Abnormalities of Gait and Mobility, and Neuralgia. Review of Resident #116's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 10, which indicated the resident was moderately cognitively impaired. Further review revealed the resident required two person physical assist plus hoyer lift for transfers; and one to two person assist for repositioning and activities of daily living (ADLs). An interview was conducted on 04/18/2024 at 8:30 a.m. with Resident #116. She stated S10CNA was rough when assisting her with care. She said when she asked her not to be so rough, she would be rude to her. Resident #116 was observed to become tearful during the interview as she stated some of the staff, specifically S10CNA made her feel like less of a person because she needed assistance. She stated on days when she could not help staff with her ADL care due to her condition, she would have to ask for more help and S10CNA would frequently respond with a negative attitude and tell her you know you can do that. Resident #116 stated S10CNA made her feel judged when she provided assistance to her because S10CNA thought she shouldn't need so much help at her age. She stated S10CNA made her feel like she was bothering her when she called for assistance or needed to be changed. She explained it was not what S10CNA said but the tone and body language in which she said it. She stated S10CNA's facial expressions and body language made her feel like S10CNA did not want to provide the assistance requested. She stated S10CNA would rush her and the care she needed in order to get out of her room as fast as possible. She said S10CNA would not meet all of her needs and when she would try to stop her for more help, she was met with a negative attitude or ignored all together. She stated she had never spoken with anyone in an administrative role at the facility or her family about the issues because she was fearful things would get worse if she told anyone. An observation and interview was conducted on 04/18/2024 at 11:25 a.m. when Resident #116 was being transferred from the shower bed to her bed by S10CNA with the assistance of another staff member. When S10CNA entered the room, Resident #116 became visibly tense throughout her body, hands clenched into tight fist around the side rail, and her eyes filled with tears. Upon completion of the transfer and as S10CNA began walking out of the room, Resident #116 was observed asking S10CNA to assist her with brushing her teeth before she left. S10CNA stated in a very gruff, aggressive tone you already did that today and then quickly turned and began walking back towards the door to exit the room. Resident #116 stated No, they didn't get a chance to while I was in the shower so I still need to do it. S10CNA was observed arguing in a short, abrupt tone with Resident #116 about whether or not she needed to brush her teeth right now. S10CNA was observed turning to exit and looked at this surveyor standing in the corner then turned back to Resident #116, loudly exhaled and huffed then gruffly stated fine, let me go get what you need then quickly exited the room. S10CNA returned to the room visibly aggravated with a tense angry facial expression and tense body movements as she prepared to assist Resident #116 with brushing her teeth. S10CNA told the resident, with an aggressive tone of voice, go ahead and get this done real quick. After S10CNA exited the room, Resident #116 stated S10CNA made her feel worthless because of the way she spoke down to her and got an attitude when she asked for assistance. Resident #116 stated there were days when she was having a bad day and wasn't able to remember things so she would ask staff questions. She stated they would respond rudely and tell her she should know that information then refuse to tell her. She stated other times she couldn't move her legs or arms like usual and they would fuss at her telling her not to be lazy. An interview was conducted on 04/18/2024 at 8:30 a.m. with Resident #116's roommate. She stated she had overheard interactions between Resident #116 and S10CNA. She stated S10CNA would get rude with Resident #116 when she asked for assistance. She stated S10CNA talked to Resident #116 like a dog, and explained she meant the tone and manner in which she talked to her, not specifically what she said to her. She stated the way S10CNA spoke to Resident #116 made it very clear she did not want to be doing what Resident #116 was asking from her. Review of Resident #116's roommate's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. An interview was conducted on 04/18/2024 at 2:30 p.m. with S2DON. She confirmed she would expect all members of staff to speak to and handle a resident with the utmost respect. She stated it was unacceptable for staff to verbally communicate with or demonstrate body language that made a resident tearful and feel bad about themselves. Upon being provided with the observation made on 04/18/2024 at 11:25 a.m., she agreed Resident #116 was not treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life. An interview was conducted on 04/18/2024 at 3:10 p.m. with S1ADM. She confirmed a resident should never be made to feel bad about themselves due to the way a staff member speaks to them or treats them during their interactions.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Recommendations from PASRR Level II Determinations and PASRR Evaluation Reports were incorporated into a resident's assessment, care plan and transitions of care for 3 (#12, #24, #63) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR; and 2. The coding accuracy for Minimum Data Set assessments regarding PASRR Level II for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR. The deficient practice had the potential to affect a census of 110 residents. Cross Reference F641. Cross Reference F644. Findings: 1. Resident #12 Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Disorder and Bipolar Type (05/06/2022). Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following: Recommended Lesser Services: Training in Activities of Daily Living; Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual); and Outpatient Therapy (Group). Review of Resident #12's Clinical Record revealed no documented evidence the facility created or implemented any of the following: Training in Activities of or Outpatient Therapy (Individual), Outpatient Therapy (Group). Review of Resident #12's current Care Plan revealed no documented care plan for any of the following services: in Activities of Daily Living, Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, Outpatient Therapy (Individual), or Outpatient Therapy (Group). Resident #24 Review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Affective Disorder, Other Symptoms and Signs with Cognitive Functions and Awareness. Review of Resident #24's OBH-PASRR Level II Summary and Determination Notice, dated 09/07/2023, revealed, in part, the following: Recommended Lesser Services: Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual). Review of Resident #24's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). Review of Resident #24's current Care Plan revealed no documented care plan present for any of the following services; Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). Resident #63 Review of Resident #63's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Major Depressive Disorder (11/07/2019), Major Depressive Disorder Severe with Psychotic Symptoms (11/15/2019), and Paranoid Schizophrenia (03/16/2022). Review of Resident #63's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated resident was cognitively intact. Review of Resident #63's OBH-PASRR Level II Summary and Determination Notice, dated 11/29/2023, effective 12/08/2023 through 12/06/2024, revealed, in part, the following: Recommended Lesser Services: Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual). Review of Resident #63's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). Review of Resident #63's current Care Plan revealed no documented care plan present any of the following services: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). An interview was conducted on 04/17/2024 at 12:20 p.m. with S1ADM. She stated she was not in charge of handling resident PASRRs, her social workers were. She stated once a resident was granted Level II PASRR, the facility was only required to give them medications and have them seen by the Behavioral Health Specialist. She reviewed Resident #12, #24 and #63's PASRR II Determinations and stated she had no idea what the services indicated as necessary were, so there was no way the facility could have implemented them. She stated she would speak with her social workers and see if they knew what any of the OBH identified interventions meant but she did not think they would because the facility had never done anything like this with a Level II. An interview was conducted on 04/17/2024 at 9:50 a.m. with S5SSD. She stated the social workers were not responsible for handling and processing PASSR documents for the facility. She stated S1ADM handled everything to do with those. She stated she knew some PASRRs were kept in S1ADM's office, some were kept in the business office and some were located in some old binders she found in her office from the previous social worker. She stated the Form 142's were kept separate from the determinations and were located in S1ADM's office. She stated did not know which ones were kept where or why; she just knew they were in several locations throughout the facility. She stated she just located a more recent PASRR response with a level upgrade for one of the residents in the business office then found the same resident's Form 142 in S1ADM's office. She stated them being so difficult to locate was probably why the most up to date documents were not provided by S1ADM upon initial request. She confirmed S1ADM handled the PASSR documents and processed them once received, not the social workers. 2. Resident #12 Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizoaffective Disorder, Bipolar Type (05/06/2022). Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed the following in Section A1500 PASRR: Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition with an entry of 0 (No). Section A1510A: Serious Mental Illness Level II PASRR conditions was blank. Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following: Evaluation Placement Recommendations: The individual has a serious mental illness and is recommended nursing home admission. An interview was conducted on 04/18/2024 at 3:47 p.m. with S13MDSC. She confirmed she did not handle PASRRs and did not know who did. She stated she could not MDS code for a Level II PASRR if she was not provided with the documentation to know she should do so and confirmed she was not provided with the documentation for Resident #12, #24 and #63 or many other residents in the facility. An interview was conducted on 04/18/2024 at 4:20 p.m. with S2DON. She confirmed she did not handle PASRR and did not know who did. She confirmed she would expect a system to be in place to ensure all residents received services and were MDS coded correctly for their diagnoses and PASRR status. An interview was conducted on 04/18/2024 at 4:45 p.m. with S1ADM. She confirmed there could not be a system in place to ensure all residents received services and were MDS coded correctly for their diagnoses and PASRR status because she was not aware the facility was responsible for providing anything more than administering medications and having them seen by the Behavioral Health Specialist once a resident was granted a Level II PASRR.

Based on observations and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions by failing to maintain a clean kitchen environment. There were 109 facility residents residing in the facility who received food from the facility's kitchen. Findings: An initial tour was conducted of the facility's kitchen with S11KC on 04/16/2024 beginning at 8:56 a.m. There was a slug moving on the floor under the mixer on the electrical cord of the mixer. There were three slugs actively moving on the floor behind the plate warmer between the tile and the wall. There was food debris on the floor throughout the kitchen. There was accumulated food debris under the oven, stove, plate warmer, steam table, and dishwasher. There were four french fries on the floor between the steam table and plate warmer. An interview was conducted with S11KC during the observations. S11KC confirmed the observation of the slugs. S11KC stated the french fries were from supper the night before. She stated the kitchen floor should have been cleaned nightly. A tour was conducted of the facility's kitchen with S3DM on 04/16/2024 at 9:16 a.m. S3DM confirmed there was food debris on the floor throughout the kitchen and under the kitchen appliances. S3DM stated it was evident the floor had not been cleaned nightly, especially under the kitchen appliances. S3DM stated the kitchen floor should have been cleaned nightly. An interview was conducted with S1Adm on 04/17/2024 at 10:48 a.m. She stated the kitchen should have been maintained in a sanitary manner and the kitchen staff were responsible for cleaning the floor, which included under appliances.

48184 Based on interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning and transitions of care for 3 (#12, #24 and #63) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101 ) reviewed for PASRR. Findings: Resident #12 Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Disorder and Bipolar Type (05/06/2022). Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following: Recommended Lesser Services: Training in Activities of Daily Living; Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual); and Outpatient Therapy (Group). Review of Resident #12's Clinical Record revealed no documented evidence the facility created or implemented any of the following: Training in Activities of or Outpatient Therapy (Individual), Outpatient Therapy (Group). Review of Resident #12's current Care Plan revealed no documented care plan for any of the following services: in Activities of Daily Living, Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, Outpatient Therapy (Individual), or Outpatient Therapy (Group). An interview was conducted on 04/18/2024 at 1:00 p.m. with S12LPN. He stated the only psychiatric services Resident #12 received is provided was a Psychology Nurse Practitioner visit once a month. An interview was conducted on 04/18/2024 at 11:04 a.m., with S1ADM. She stated she did not have documentation of PASRR level II recommendations offered for Resident #12. An interview was conducted on 04/18/2024 at 11:07 a.m. with S2DON. She stated she did not have documentation of PASRR level II recommendations offered for Resident # 12. She stated Resident #12's BHSF Form 142 document could not be provided. An interview was conducted on 04/18/2024 at 11:08 a.m. with S5SSD. She stated she did not have documentation of PASRR level II recommendations offered for Resident #12. Resident #24 Review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Affective Disorder, Other Symptoms and Signs with Cognitive Functions and Awareness. Review of Resident #24's OBH-PASRR Level II Summary and Determination Notice, dated 09/07/2023, revealed, in part, the following: Recommended Lesser Services: Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual). Review of Resident #24's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). Review of Resident #24's current Care Plan revealed no documented care plan present for any of the following services; Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). Resident #63 Review of Resident #63's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Major Depressive Disorder (11/07/2019), Major Depressive Disorder Severe with Psychotic Symptoms (11/15/2019), and Paranoid Schizophrenia (03/16/2022). Review of Resident #63's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated resident was cognitively intact. Review of Resident #63's OBH-PASRR Level II Summary and Determination Notice, dated 11/29/2023, effective 12/08/2023 through 12/06/2024, revealed, in part, the following: Recommended Lesser Services: Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual). Review of Resident #63's Clinical Record revealed no documented evidence to indicate the facility created or implemented any of the following: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). Review of Resident #63's current Care Plan revealed no documented care plan present any of the following services: Training in Independent Living Skills, Crisis Intervention Plan/Safety Plan, or Outpatient Therapy (Individual). An interview was conducted on 04/17/2024 at 9:45 a.m. with Resident #63. She stated she did not wish to stay at this facility and planned to go live in a group home or out in the community. An interview was conducted on 04/17/2024 at 10:40 a.m. with S6LPN. She confirmed she was Resident #63's nurse and was very familiar with the services and care she received. She confirmed she had multiple psychiatric diagnoses and desired to eventually go live somewhere outside of a nursing home. She confirmed the resident did not leave the facility to participate in any outpatient therapy services and had never done so since she was her patient. She confirmed she was not aware of and had not received resident specific training for a Crisis Intervention Plan or a Safety Plan for Resident #63. She confirmed she never witnessed or assisted with providing Resident #63 any training in independent living skills. An interview was conducted on 04/17/2024 at 1:30 p.m. with S1ADM. She confirmed the facility did not provide the services indicated in the individual PASRR Level II Determination Letters for Resident #12, #24 and #63 or any of the Level II residents currently in the facility; including a Crisis Intervention Plan/Safety Plan. She stated she thought the facility was only required to handle medication management and ensure the mental health specialist saw the Level II PASRR residents.

Based on interviews and record review, the facility failed to ensure that appealing options of similar nutritive value were offered to residents who choose not to eat food that is initially served or who request a different meal choice for 1 (#45) of 32 sampled residents reviewed in the initial pool. Findings: Review of the Clinical Record revealed Resident #45 was admitted to the facility on [DATE]. Review of the Quarterly MDS with an ARD of 10/27/2023 revealed Resident #45 had a BIMS of 13, which indicated he was cognitively intact. Review of the current Care Plan revealed Resident # 45 was care planned for the following problems: Problems: My current diet is regular. Approaches: Offer food alternatives when appropriate On 04/17/2024 at 12:36 p.m., an interview was conducted with Resident #45. He stated his food was cold. He stated he asked kitchen staff for it to be heated or substituted. He stated the kitchen did not honor his request. On 04/18/2024 at 9:29 a.m., an interview was conducted with Resident #45. He stated his food was cold. He stated he asked kitchen staff for substitutes or to reheat his tray. The kitchen did not honor his request. On 04/18/2024 at 9:34 a.m., an interview was conducted with S8LPN. She stated she was aware of Resident #45 complaining about his food preferences and choices. She confirmed sometimes the food was cold and needing substitutes frequently. She stated sometimes Resident #45's request was missed by the kitchen staff. On 04/18/2024 at 4:45 p.m., an interview was conducted with S2DON. She confirmed Resident #45 should have received alternative options, and should have had his meals reheated when requested and did not. On 04/18/2024 9:43 a.m., an interview was conducted with S3DM. He stated Resident #45 complained about the food being cold and needing a substitute frequently. He stated sometimes Resident #45's request was missed by the kitchen staff. He confirmed Resident #45 should be provided a substitute or his meals heated on request.

Based on observations, interviews, and record review, the facility failed to implement a comprehensive person-centered plan of care by failing to follow Physician's Orders for 1 (#45) of 4 (#4, #43, ##66, #114) residents reviewed for nutrition. The facility failed to ensure Resident #45 received a House Supplement with Meals three times daily. Findings: Review of Resident #45's medical records revealed he was admitted to the facility on [DATE]. Review of the Quarterly MDS with an ARD of 10/27/2023 revealed Resident #45 had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #45's current physician orders revealed: House Supplement with Meals; Three times daily. On 04/18/2024 at 09:29 a.m., an interview was conducted with Resident #45. He stated his physician ordered a house supplement to be given with meals, three times a day. He stated he was not receiving his house supplement. On 04/17/2024 at 12:36 p.m. an observation was made of Resident #45's lunch tray. His house supplement was not on his meal tray or his bedside. On 04/18/2024 at 09:29 a.m., an observation was made of Resident #45's breakfast tray. His house supplement was not on his meal tray or his beside. On 04/18/2024 09:43 a.m., an interview was conducted with S3DM. He stated he observed Resident #45's meal tray, and there was no house supplement on his tray or his bedside. He confirmed a house supplement was ordered and not provided to Resident #45. On 04/18/2024 at 4:45 p.m. and interview was conducted with S2DON. She confirmed Resident #45 should receive his house supplement three times a day with meals, as ordered and he was not. 48184

Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR Level II (Pre-admission Screening and Resident Review) for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101) sampled residents reviewed for PASRR. Findings: Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizoaffective Disorder, Bipolar Type (05/06/2022). Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed the following in Section A1500 PASRR: Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition with an entry of 0 (No). Section A1510A: Serious Mental Illness Level II PASRR conditions was blank. Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following: Evaluation Placement Recommendations: The individual has a serious mental illness and is recommended nursing home admission. An interview was conducted on 04/18/2024 at 5:16 p.m. with S4MDSC. She verified Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed he was issued a Level II PASRR and has a serious mental illness. She reviewed Resident #12's Yearly MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. An interview was conducted with S2DON on 04/18/2024 at 5:33 p.m. She reviewed Resident #12's Yearly MDS assessment dated [DATE]. S2DON confirmed Resident #12 was evaluated by Level II PASRR and was determined to have a serious mental illness. S2DON confirmed Section A1500 should have been coded as 1-Yes, and was not.

Based on observation, interview and record review, the facility failed to ensure administration used its resources effectively and efficiently to ensure the resident's environment remained free from accident hazards by allowing the use of portable electric space heaters in 8 (# R4, # R5, # R6, # R7, # R8, # R9, # R10 and #R11) of 16 (#1, #2, #3, #4, #5, #R1, #R2, #R3, # R4, # R5, # R6, # R7, # R8, # R9, # R10 and #R11) sampled residents rooms. An Immediate Jeopardy situation began on 01/27/2023 at 10:55 a.m. when a portable electric space heater was observed in use in Resident R4's room. The space heater was approximately 2 feet from Resident R4's bed and blanket. Resident R4 required extensive one person assistance with transfers and has a diagnosis that includes Muscle Weakness and Hemiplegia. Additional observations were made of space heaters in use approximately 2 feet from each resident's beds and blankets in the rooms of Residents R5, R6, R7, R8, R9, R10, and R11. Resident #R5, #R6, and #R9 required extensive 2 person assistance with transfers. The use of these portable electric heaters in resident rooms two feet from the resident's bed and bedding had the likelihood to cause severe injury and/or death. The Administrator was notified of the Immediate Jeopardy situation on 01/27/2023 at 6:31 p.m. The facility provided the following plan of removal: Plan of Removal 1. Space Heaters were removed from R4, R5, R6, R7, R8, R9, R10 and R11 and locked in storage room. Maintenance staff is the only staff with key, and they were instructed that no staff is to get heater from storage room. 2. All Residents had the potential to be affected but no others identified. All residents' rooms were checked for space heaters. None found in any other resident's room. 3. A. Don/Designee- In-Service started on 01/27/2023 with staff- Will complete 01/30/2023. Will add to new hire orientation. No space heaters allowed in residents rooms. Facility has one entrance. Which is the front entrance where staff and visitors sign in. Ward clerks in-serviced that no one is to bring in space heaters into facility. 4. A. Administrator/Designee will check all resident rooms 2 times weekly x 4 weeks to ensure there is no space heaters in rooms. Start Date 01/30/2023 B. Regional Director will monitor Administrator weekly x4 weeks to ensure Administrator is following plan. Start Date 02/02/2023 In-Service done with Administrator by Regional Director on 01/27/2023 01/30/2023- Completion Date Through observations, interviews, and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on 01/30/2023 at 4:15 p.m. Findings: Cross Reference F689. Review of the on-line manufacturer's Important Safety Instructions for the 2 1/2 foot tall portable oscillating heaters revealed the following, in part: This heater is HOT when in use. To avoid burns, do not let bare skin touch hot surfaces .Keep combustible materials, such as furniture pillows, bedding, papers, clothes and curtains at least 3 feet (0.9 m) from the front and at least 1 foot from the sides and rear. An observation was made of the temperatures in random resident rooms on 01/27/2023 at approximately 8:30 a.m. During the observation of Resident #R8's room the resident stated it was cold in his room. Resident #R8 stated he had a heater in his room but they had taken it. At this time S3ADON entered Resident #R8's room. S3ADON stated she was conducting her Ambassador rounds and would make sure they got a heater. An interview was conducted on 01/27/2023 at 9:28 a.m. with S6CNA. She stated the facility has some space heaters that are placed in resident's rooms when a resident states their room is cold. An interview was conducted on 01/27/2023 at 9:48 a.m. with S7HK. She stated space heaters were used during the cold fronts back in November and December on the A Hall where she worked. She stated since then the space heaters get passed around as needed to different resident's room when residents complain their room is cold. An interview was conducted on 01/27/2023 at 9:55 a.m. with S8HK. She stated space heaters were used during the cold fronts back in November and December while she worked around that time. She stated since then the space heaters get passed around as needed to different resident's room when residents complain their room is cold. An interview was conducted on 01/27/2023 at 10:17 a.m. with S9HK. She stated space heaters were used during the cold fronts back in November and December throughout the facility. She stated since then the space heaters are passed around as needed to different resident's room when residents complain their room is cold. An interview was conducted with S1ADM on 01/27/2023 at 12:57 p.m. S1ADM confirmed space heaters were in use in the resident rooms. S1ADM stated the facility had purchased the portable electric space heaters from a local hardware store on 12/23/2022 when the weather got cold. S1ADM stated the heaters were purchased around Christmas to help keep the residents warm. S1ADM stated some residents wanted it warmer than the heater could provide. S1ADM stated the portable space heaters were not approved by the State Fire Marshall. S1ADM stated when the temperatures drop low you make arrangements to keep the residents warm.

Based on observations, interviews and record reviews the facility failed to ensure the resident's environment remained free from accident hazards by allowing the use of portable electric space heaters in 8 (# R4, # R5, # R6, # R7, # R8, # R9, # R10 and #R11) of 16 (#1, #2, #3, #4, #5, #R1, #R2, #R3, # R4, # R5, # R6, # R7, # R8, # R9, # R10 and #R11) sampled residents rooms. An Immediate Jeopardy situation began on 01/27/2023 at 10:55 a.m. when a portable electric space heater was observed in use in Resident R4's room. The space heater was approximately 2 feet from Resident R4's bed and blanket. Resident R4 required extensive one person assistance with transfers and has a diagnosis that includes Muscle Weakness and Hemiplegia. Additional observations were made of space heaters in use approximately 2 feet from each resident's beds and blankets in the rooms of Residents R5, R6, R7, R8, R9, R10, and R11. Resident #R5, #R6, and #R9 required extensive 2 person assistance with transfers. The use of these portable electric heaters in resident rooms two feet from the resident's bed and bedding had the likelihood to cause severe injury and/or death. The Administrator was notified of the Immediate Jeopardy situation on 01/27/2023 at 6:31 p.m. The facility provided the following plan of removal: Plan of Removal 1. Space Heaters were removed from R4, R5, R6, R7, R8, R9, R10 and R11 and locked in storage room. Maintenance staff is the only staff with key to storage and they were instructed that no staff is to get heaters from storage room. 2. All Residents had the potential to be affected but no others identified. All residents' rooms were checked for space heaters. None found in any other resident's room. 3. An In-Service started 01/27/2023 with staff- Will complete by 01/30/2023. Will add to new hire orientation. No space heaters allowed in residents rooms. Facility has one entrance. Which is the front door entrance where staff and visitors sign in. Ward Clerks In-serviced that no one is to bring in space heaters into facility. 4. A. Administrator/Designee will check all residents' rooms 2 times weekly x 4 weeks to ensure there is no space heaters in rooms. Start date 01/30/2023. B. Administrator will monitor the process weekly. To ensure it is effective. Start Date 02/02/2023 01/30/2023 Completion Date Through observations, interviews, and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on 01/30/2023 at 4:15 p.m. Findings: Review of the on-line manufacturer's Important Safety Instructions for the 2 1/2 foot tall portable oscillating heaters revealed the following, in part: This heater is HOT when in use. To avoid burns, do not let bare skin touch hot surfaces .Keep combustible materials, such as furniture pillows, bedding, papers, clothes and curtains at least 3 feet (0.9 m) from the front and at least 1 foot from the sides and rear. An observation was made of the temperatures in random resident rooms on 01/27/2023 at approximately 8:30 a.m. During the observation of Resident #R8's room the resident stated it was cold in his room. Resident #R8 stated he had a heater in his room but they had taken it. At this time S3ADON entered Resident #R8's room. S3ADON stated she was conducting her Ambassador rounds and would make sure they got a heater. An interview was conducted on 01/27/2023 at 9:28 a.m. with S6CNA. She stated the facility has some space heaters that are placed in resident's rooms when a resident states their room is cold. An interview was conducted on 01/27/2023 at 9:48 a.m. with S7HK. She stated space heaters were used during the cold fronts back in November and December on the A Hall where she worked. She stated since then the space heaters get passed around as needed to different resident's room when residents complain their room is cold. An interview was conducted on 01/27/2023 at 9:55 a.m. with S8HK. She stated space heaters were used during the cold fronts back in November and December while she worked around that time. She stated since then the space heaters get passed around as needed to different resident's room when residents complain their room is cold. An interview was conducted on 01/27/2023 at 10:17 a.m. with S9HK. She stated space heaters were used during the cold fronts back in November and December throughout the facility. She stated since then the space heaters are passed around as needed to different resident's room when residents complain their room is cold. Resident #R4 Review of Resident #R4's clinical record revealed the resident had diagnoses which included Muscle Weakness, Other Lack of Coordination, Ataxic Gait, and Hemiplegia, Unspecified Affecting Left Dominant Side. Review of Resident #R4's MDS with an ARD of 12/20/2022 revealed the resident had a BIMS of 13 which indicated the resident had intact cognition. Further review revealed the resident was assessed as having required extensive one person assistance with transfers and used a wheelchair. An observation was made on 01/27/2023 at 10:55 a.m. in Resident #R4's room. A 2 1/2 foot tall black oscillating space heater was observed in use. The resident was sitting on the side of the bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted on 01/27/2023 at 10:56 a.m. with Resident #R4. He stated he requested a space heater when his room became chilly about a week ago and they gave him one. He stated staff supply him with plenty of blankets when he asked for them. Resident #R5 Review of Resident #R5's clinical record revealed the resident had diagnoses which included Hemiplegia, Unspecified Affecting Left Dominant Side, Muscle Weakness (Generalized), and Other Abnormalities of Gait and Mobility. Review of Resident #R5's MDS with an ARD of 12/13/2022 revealed the resident had a BIMS of 15 which indicated the resident had intact cognition. Further review revealed the resident was assessed to require extensive two person assistance with transfers and used a wheelchair. An observation was made on 01/27/2023 at 11:00 a.m. in Resident R#5's room. A 2 1/2 foot tall black oscillating space heater was observed in use. The resident was lying in bed and a space heater was noted to be about oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. Resident #R6 Review of Resident #R6's clinical record revealed the resident had diagnoses which included Paraplegia, Complete. Review of Resident #R6's MDS with an ARD of 12/21/2022 revealed the resident had a BIMS of 15 which indicated the resident had intact cognition. Further review revealed the resident required extensive two person assistance with transfers and used a wheelchair. An observation was made on 01/27/2023 at 11:04 a.m. in Resident R#6's room. A 2 1/2 foot tall black oscillating space heater was observed in use. The resident was lying in bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted on 01/27/2023 at 11:05 a.m. with Resident #R6. He stated he had the space heater for a few days since he called his mother and told her his room was cold. He stated his mother called the facility and a space heater was brought to his room. Resident #R7 Review of Resident #R7's clinical record revealed the resident had diagnoses which included Acquired Absence of Right Leg Below the Knee, Acquired Absence of Left Leg Below the Knee, Muscle Weakness (Generalized), and Other Lack of Coordination. Review of Resident #R7's MDS with an ARD of 11/17/2022 revealed the resident had a BIMS of 15 which indicated the resident had intact cognition. Further review revealed the resident required limited one person assistance with transfers and use a wheelchair. An observation was made on 01/27/2023 at 1:55 p.m. of Resident #R7's room. A 2 1/2 foot black oscillating space heater was observed in use. The resident was lying in bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted on 01/27/2023 at 1:56 p.m. with Resident #R7. She stated she likes to keep her room warmer than most residents and asked for a space heater to be in her room. She stated she does not recall when the space heater was given to her by staff. Resident #R8 Review of Resident #R8's clinical record revealed the resident had diagnoses which included Metabolic Encephalopathy, Unspecified Lack of Coordination, and Cognitive Communication Disorder. Review of Resident #R8's MDS with an ARD of 12/20/2022 revealed the resident had a BIMS of 9 which indicated the resident had moderate cognitive impairment. Further review revealed the resident required supervision with transfers and did not use mobility devices. An observation was made on 01/27/2023 at 4:37 p.m. in Resident #R8's room. A 2 1/2 foot tall black oscillating space heater was observed in use. The resident was sitting quietly on the side of the bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted on 01/27/2023 at 4:38 p.m. with Resident #R8. He stated he complained about the room being cold last night and staff brought him a space heater. Resident #R9 Review of Resident #R9's clinical record revealed the resident had diagnoses which included Wedge Compression Fracture Third Lumbar Vertebra, Muscle Weakness, Other abnormalities of Gait and Mobility, and Other Lack of Coordination. Review of Resident #R9's MDS with an ARD of 01/05/2023 revealed the resident had a BIMS of 14 which indicated the resident had intact cognition. Further revealed the resident required extensive two person assistance with transfers and used a walker and a wheelchair for mobility. An observation was made on 01/27/2023 at 4:42 p.m. in Resident #R9's room. A 2 1/2 foot tall black oscillating space heater was observed in use. The resident was lying in bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted on 01/27/2023 at 4:43 p.m. with Resident #R9. He stated he was given a space heater a few days prior when he asked for one. Resident #R10 Review of Resident #R10's clinical record revealed the resident had diagnoses which included Unspecified Sequelae of Unspecified Cerebrovascular Disease, Other Lack of Coordination, and Undifferentiated Schizophrenia. Review of Resident #R10's MDS with an ARD of 12/20/2022 revealed the resident had a BIMS of 15 which indicated the resident had intact cognition. Further review revealed the resident required extensive one person assistance with transfers and used a wheelchair for mobility. An observation was made on 01/27/2023 at 4:45 p.m. in Resident #R10's room. A 2 1/2 foot tall black oscillating space heater was observed in used. The resident was lying in bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted on 01/27/2023 at 4:46 p.m. with Resident #R10. She stated she was given a space heater last night when she told the CNA she was chilly. Resident #R11 Review of Resident #R11's clinical record revealed the resident had diagnoses which included Expressive Language Disorder, Other Schizoaffective Disorders, and Extrapyramidal and Movement Disorder, Unspecified. Review of Resident #R11's MDS with an ARD of 10/31/2022 revealed the resident had a BIMS of 9 which indicated the resident had moderately impaired cognition. Further review revealed the resident required limited one person assistance with transfers and did not use a mobility device. An observation was made on 01/27/2023 at 4:34 p.m. in Resident R#11's room. A 2 1/2 foot tall black oscillating space heater was observed in use. The resident was lying in bed and a space heater was noted to be oscillating about 2 foot from resident's bed and blanket. The heater was directed towards the resident's bed. An interview was conducted with S1ADM on 01/27/2023 at 12:57 p.m. S1ADM confirmed space heaters were in use in the resident rooms. S1ADM stated the facility had purchased the portable electric space heaters from a local hardware store on 12/23/2022 when the weather got cold. S1ADM stated the heaters were purchased around Christmas to help keep the residents warm. S1ADM stated some residents wanted it warmer than the heater could provide. S1ADM stated the portable space heaters were not approved by the State Fire Marshall. S1ADM stated when the temperatures drop low you make arrangements to keep the residents warm.

Based on interviews and record reviews, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1(#2) of 5 sampled residents (#1, #2, #3, #4, #5) reviewed for diabetes as evidenced by failing to: 1. Ensure the resident's physician/practitioner was notified of HI blood sugar readings and a significant change in the resident's physical and mental condition; 2. Notify the physician/practitioner of the resident's significant change in conditions on 8/15/16; and 3. Report HI blood sugar values to the Director of Nursing or Assistant Director of Nursing staff nurse. The deficient practices resulted in an actual harm for Resident #2 on 8/14/16, when the facility failed to notify the resident's physician/practitioner of the 6:00 a.m. HI glucometer reading. On 8/15/16, when his blood sugar was checked, the 6:00 a.m. and the re-check reading at 7:50 a.m, the glucometer readings were HI. Resident #2's condition changed from being coherent and independent of activities of daily living on 8/14/16 to being dependent, confused, disoriented, and wearing a brief due to being incontinent of bowel and bladder on 8/15/16. The resident's physician or the nurse practitioner was not notified of the high glucometer readings on 8/14/16 and 8/15/16 or the change in the resident's condition on 8/15/16. Resident #2 was transferred to the hospital on [DATE] at 12:25 p.m. where laboratory results dated [DATE] at 17:47 (5:47 p.m.) revealed Resident #2 had blood capillary glucose of 1090 mg/dL. Resident #2 was admitted to the Intensive Care Unit (ICU) on a Diabetic ketoacidosis (DKA) protocol and was placed on an intravenous (IV) insulin drip for a diagnose of Acute Metabolic [MEDICAL CONDITION] secondary to DKA. Findings: A review of the facility's Acute Care Transfer and Unplanned hospitalization Log dated August 2016 revealed Resident #2 was sent to the a local hospital for [MEDICAL CONDITION]. A review of the facility's Obtaining a Fingerstick Glucose Level policy, revealed in part: Reporting 1. Report results promptly to the supervisor and attending physician 3. Report . in accordance with facility policy and professional standards of practice. A review of the manufacturer's Blood Glucose Monitoring System User Manual Instructions revealed in part: Hi and Lo Message The meter displays results between 20-600 mg/dL (milligram/deciliter). HI appears when the blood glucose level is greater than 600 mg/dL and indicates severe [MEDICAL CONDITION] (much higher than normal glucose levels). If HI is displayed again upon retesting, please contact the patient's healthcare provider immediately. A review of the clinical record for Resident #2 revealed in part, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the August 2016 physician's orders [REDACTED]. A1C q 3 months Diet: Diabetic Insulin [MEDICATION NAME] subcutaneous (SQ) ([MEDICATION NAME]) 38 units (u) SQ before (AC) breakfast for Type 2 DM at 630 am Humalog Insulin 8 units SQ AC for Type 2 DM 7am, 11am, 4pm Sliding Scale before meals 150-200 = 2u 201-250 = 4u 250-300 = 6u 301 - 350 = 8u 351 - 400 = 10 u Accuchek before meals A review of the Minimum Data Set (MDS) Section G - Functional Status - Activities of Daily Living (ADLs) revealed: 8/10/16 revealed Resident #2 status was coded 0 for walking, locomotion, dressing and eating for self-performance and support. Eating was coded 1 for self-performance and support. 8/15/16 Resident #2's functional status was coded 2 for support and 3 for self-performance for ADLs. MDS 3.0 Coding Legend for Activities of Daily Living, coding is as follows: ADL Self-Performance 0 = independent - no help or staff oversight at any time 1 = supervision - oversight, encouragement or cueing 2 = limited assistance - resident highly involved in activity, staff provided guided maneuvering of limbs or other non - weight bearing assistance 3 = extensive assistance = resident involved in activity, staff provide weight-bearing support A review of hospital records revealed in summary Resident #2 was admitted from 7/8/16 - 8/7/16 for medical detoxification. Resident #2's blood glucose lab values revealed a range between 90 - 437 mg/dL. Reference Range (70 - 100 mg/dL). A Review of Laboratory Report Chemistry Panel dated 8/9/16 revealed in part, Glucose 90 mg/dL. Reference Range (70-100 mg/dL). A review of August 2016 Diabetic Monitoring Record from 8/8/16 - 8/13/16 revealed in part, the following: Finger stick frequency order: before meals. Hi/Lo Parameters to call MD: facility's doctor Values: 8/8/16 4pm - 233 mg/dL HS (hour of sleep) - 251mg/dL 8/9/16 6 am - 85mg/dL 11am 137 mg/dL 4pm - 446 mg/dL HS - 269mg/dL 8/10/16 6am - 240mg/dL 11am - 445mg/dL 4pm - 277 mg/dL HS - 140 mg/dL Comments: recheck 286 (no date/time/initials documented) 8/11/16 6am - 138mg/dL 11am - 251mg/dL 4pm - 130 mg/dL HS - 120 mg/dL 8/12/16 6am - 424mg/dl 11am - 83mg/dL 4pm - 291mg/dL HS - 116mg/dL Comments: recheck 246 at 6:00am (no date/initials documented). 8/13/16 6am -378mg/dL 11am - 140mg/dL 4pm - 186mg/dL HS - 333mg/dL 8/14/16 6am - Hi; 10units given by S6LPN 11am - 523 mg/dL (verified by S2DON) 4pm - 278mg;dL HS - 228 mg/dL Comments: No documentation noted 8/15/16 6am - HI; 10 units given by S5LPN 11am - HI; no documentation noted of sliding scale insulin given Comments: recheck HI (no date, time, or initials documented). A review of the facility's Bowel and Bladder form dated 8/9/16 - 8/15/16 revealed Resident #2 was continent of bowel and bladder except on 8/14/16 beginning at 13:18 (1:18pm) where documentation revealed Resident #2 was incontinent of bladder and incontinent of bowel and bladder at 19:10 (7:10 pm). There was no documentation of Resident #2's bowel and bladder function for 8/15/16. A review of the Nurse's Notes dated 8/10/16 - 8/15/16 revealed the following: There were no documented entries for 8/14/16. 8/15/16 at 7 a.m. - Resident noted confused, disoriented unable to groom self, noted with unsteady gait, noted with incontinent episode of urine and bowel movement (bm), resident with Hi blood sugar (BS), no signs and symptoms (s/s) of [DIAGNOSES REDACTED] noted. - S5LPN 8/15/16 at 7:50 a.m. - After resident received insulin, BS remains in Hi, resident given insulin, remains in bed, confused. - S5LPN 8/15/16 at 11:00 a.m. - Rechecked resident BS, BS remains Hi, resident continues to be confused. - S5LPN 8/15/16 at 11:30 a.m. - Placed a call to facility physician on call, spoke with S11NP. Informed that resident BS remains Hi after given insulin and noted with .Hi (S5LPN unsure of documentation), received an order to send resident to local hospital for evaluation and treatment. 8/15/16 at 11:40 a.m. - . Ambulance called .S5LPN 8/15/16 at 12:25 p.m. - . Ambulance arrived . - S5LPN A Review of Physician's Telephone Orders revealed: 8/15/16 - Send out to local hospital for decreased level of consciousness (LOC) A Review of the hospital's emergency room Note dated 8/15/16 revealed in part, Resident #2 was admitted in serious condition with a [DIAGNOSES REDACTED]. A review of the hospital's History and Physical (H&P) dated 8/15/16 revealed in summary, Resident #2 presented from the nursing home with altered mental status. Resident #2 was found this morning trembling in his bed and not responding to verbal prompts. Blood capillary glucose (BCG) was checked twice and registered High. Per the nursing home, Resident #2 is fully independent in all ADLs at baseline Further review of the H&P revealed laboratory results dated [DATE] that Resident #2 had BCG of 1090 mg/dL. The Impression/Plan revealed Resident #2 was admitted to Intensive Care Unit (ICU) on DKA protocol and was placed on intravenous (IV) insulin drip. Resident #2s admit [DIAGNOSES REDACTED]. On 8/24/16 at 11:00 a.m., an interview was held with S8CNA. She said she worked the 6am - 2pm shift and had cared for Resident #2 since his admission. S8CNA said Resident #2 would normally walked independently, clean and bathe himself and was continent of bowel and bladder. S8CNA explained on the morning of 8/15/16 she went to get Resident #2 up for breakfast and noticed he was not responding normally. She said he did not get out of bed and he was confused and did not eat much. S8CNA said she also noticed Resident #2 was wearing a diaper which was not normal. S8CNA said she reported it S5LPN On 8/24/16 at 11:30 a.m., an interview was held with S5LPN who worked the 6a - 2p shift on Monday - Friday. S5LPN said she had cared for Resident #2 since his admission. S5LPN said Resident #2 was ambulatory and independent of activities of daily living. She said Resident #2 attended every smoke break and needed his cell phone charged all of the time. She said when she left work on Friday, 8/12/16, Resident #2 was fine. S5LPN explained upon returning to work on 8/15/16, it was reported to her by a CNA that Resident #2 did not feel well over the weekend as he was not his normal self. S5LPN said it was also reported that Resident #2 had become incontinent. S5LPN explained when she saw Resident #2 on the morning of 8/15/16, he was lying in bed and was not responding well to verbal stimuli. S5LPN said Resident #2 was confused. She said, he would usually jump out of bed when she greeted him, but this day he didn ' t. She said he was just not his normal self. S5LPN explained between 640am - 650am on 8/15/16, she had obtained Resident #2's 6am accuchek and received a HI value. She said she administered Resident #2's scheduled insulins and 10 units of insulin per sliding scale parameters. At this time, S5LPN said she did not notify the physician. S5LPN went on to explain that she waited an hour and re-checked Resident #2's blood sugar and received a HI value reading again. She said, then she attempted to notify the provider on call around 8am, however, was unsuccessful. During the interview, S5LPN reviewed the Nurse's Notes dated 8/15/16 and acknowledged there was no documentation of attempting to notify the doctor on-call. S5LPN said Resident #2 was still showing signs of confusion. S5LPN then said when she checked his BS at 11am, the value remained at HI . She said she did not administer any sliding scale insulin at this time and Resident #2 remained in the bed. S5LPN acknowledged that she did not report the HI blood sugar values at 6am and at the re-check to the on-call doctor/practitioners nor did she seek assistance from S1DON and S3ADON. S5LPN also said she did not think to send Resident #2 to the hospital. On 8/24/16 at 2:29 p.m., an interview was held with S6LPN who had cared for Resident #2. S6LPN said she worked the 10pm - 6am shift. She reviewed the Diabetic Monitoring Sheet for Resident #2 on 8/14/16 and recalled obtaining a HI reading between 5am - 6am. She said the on-call doctor/practitioner was not able to be reached. She said she called S2DON. S6LPN said S2DON informed her to continue to try calling the doctor. S6LPN reported that her shift had ended at 6am. On 8/25/16 at 10:21 a.m., an interview was held with S7LPN. She said she worked weekend shifts and had cared for Resident #2. S7LPN acknowledged that she worked the 6am - 2pm shift on 8/14/16. She said S6LPN did not report that Resident #2 had a HI value blood sugar reading during shift change, therefore, she was not aware. S7LPN said if a resident had a blood sugar over 400 mg/dL, the nurse was to notify the physician and recheck the blood sugar in 2 hours and notify the physician again. S7LPN said Resident #2 was up ambulating, ate throughout the day, and attended every smoke break which was normal. S7LPN said Resident #2 was continent of bowel and bladder. S7LPN explained if she was not able to contact the on-call physician/practitioners, she would send the resident to the hospital. S7LPN said a HI value indicated a blood sugar reading over 600 mg/dL. On 8/24/16 at 2:03 p.m., an interview was held with S3ADON. She verified that she worked on the day shift on 8/15/16. She reviewed the HI values on Resident #2's Diabetic Monitoring Record and confirmed no one had reported to her that Resident #2 had HI blood sugar readings. On 8/24/16 at 1:34p.m, an interview was held with S2DON. S2DON explained if a resident's blood sugar revealed a HI value, sliding scale insulin should be administered and the physician should be notified. S2DON reviewed Resident #2's Diabetic Monitoring Record noting the HI results documented on 8/14/16 at 6am obtained by S6LPN and on 8/15/16 at 6am, the re-check, and 11am obtained by S5LPN. S2DON also noted the highest parameter for Resident #2 was 400 mg/dL. S2DON reviewed the facility's standing orders, and noted if blood sugar (BS) greater than 450mg/dL to call the physician. S2DON continued to review the Diabetic Monitoring Record and noted there was no documentation indicating Resident #2's blood sugar had been rechecked 2 hours after 6am on 8/14/16. S2DON said S6LPN should have contacted the physician. S2DON reviewed the Nurse's Notes and verified there was no documentation indicating S6LPN attempted to notify the physician/practitioner. S2DON, then, reviewed the Nurse's Notes on 8/15/16 noting the HI values at 6am and at the recheck and said S5LPN should have notified the physician. S2DON said if the nurse was unable to contact the on-call physician/practitioners, the nurse should have sent Resident #2 to the hospital and/or notified either himself or S3ADON. S2DON said no one had reported to him Resident #2 was having HI blood sugar values. On 8/24/16 at 12:13 p.m., an interview was held with S4NP. She said on 8/15/16 her phone was not working, however, she said there was always someone on-call 24/7 if she was not able to be reached. On 8/24/16 at 3:25 p.m., an interview was held with S1Adm. She said that she was made aware of Resident #2's HI blood sugars readings during the survey. S1Adm verified S5LPN should have notified the physician/practitioner and one of the Registered Nurse staff for assistance so that Resident #2 could be sent to the hospital sooner. S1Adm said if the physician/practitioner could not be reached, the LPN staff should have notified her, S2DON or S3ADON and we would worry about obtaining the order afterwards.

Based on record reviews and interviews, the facility failed to ensure services were provided to meet the professional standards of quality for 1 ( #2) of 5 (#1, #2, #3, #4, #5) sampled diabetic residents by nursing staff not using sound judgment and critical thinking skills to act upon a resident's HI blood sugar values. The facility failed to: 1. Notify the physician/practitioner of the HI glucometer readings on 8/14/16 8/15/16; 2. Notify the physician/practitioner of the resident's significant change in conditions on 8/15/16; and 3. Follow their Policy and Procedures for Obtaining a Fingerstick Glucose Levels. The deficient practices resulted in an actual harm for Resident #2 on 8/14/16 at 6:00 a,m, when checking his blood sugar, a reading of HI was obtained on the glucometer. On 8/15/16 the 6:00 a.m. accuchek read HI on the glucometer. Documentation in the resident's record revealed a nurses note which read, at 7 a.m. resident noted confused, disoriented unable to groom self, noted with unsteady gait, noted with incontinent episode of urine and bowel movement (bm), resident with Hi blood sugar (BS). There was documentation in the record that the HI readings were again obtained via glucometer at 7:50 a.m. and 11:00 a.m. The resident's physician or the nurse practitioner was not notified of the HI glucometer readings on 8/14/16 and 8/15/16 or the change in the resident's condition. Resident #2's was admitted to a local hospital on [DATE] with a [DIAGNOSES REDACTED]. Findings: Title 46 Professional and Occupational Standards Part XLVII. Nurses. Subpart 2. Registered Nurses. Chapter 39. Legal Standards of Nursing Practice. 3901. Legal Standards. A. The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The standards of nursing practice provide a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a registered nurse or by a registered nurse in conjunction with other licensed or unlicensed personnel as provided in LAC 46:XLVII.3703 (Amended June 2016). A review of the facility's Acute Care Transfer and Unplanned hospitalization Log dated August 2016 revealed Resident #2 was sent to the a local hospital for [MEDICAL CONDITION]. A review of the facility's Obtaining a Fingerstick Glucose Level policy, revealed in part: Reporting 1. Report results promptly to the supervisor and attending physician. 3. Report . in accordance with facility policy and professional standards of practice. A review of the manufacturer's Blood Glucose Monitoring System User Manual Instructions revealed in part: Hi and Lo Message The meter displays results between 20-600 mg/dL (milligram/deciliter). HI appears when the blood glucose level is greater than 600 mg/dL and indicates severe [MEDICAL CONDITION] (much higher than normal glucose levels). If HI is displayed again upon retesting, please contact the patient's healthcare provider immediately. A review of the clinical record for Resident #2 revealed in part, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the August 2016 physician's orders [REDACTED]. A1C q 3 months Diet: Diabetic Insulin [MEDICATION NAME] subcutaneous (SQ) ([MEDICATION NAME]) 38 units (u) SQ before (AC) breakfast for Type 2 DM at 630 am Humalog Insulin 8 units SQ AC for Type 2 DM 7am, 11am, 4pm Sliding Scale before meals 150-200 = 2u 201-250 = 4u 250-300 = 6u 301 - 350 = 8u 351 - 400 = 10 u Accuchek before meals A review of the Minimum Data Set (MDS) Section G - Functional Status - Activities of Daily Living (ADLs) revealed: 8/10/16 revealed Resident #2 status was coded 0 for walking, locomotion, dressing and eating for self-performance and support. Eating was coded 1 for self-performance and support. 8/15/16 Resident #2's functional status was coded 2 for support and 3 for self-performance for ADLs. MDS 3.0 Coding Legend for Activities of Daily Living, coding is as follows: ADL Self-Performance 0 = independent - no help or staff oversight at any time 1 = supervision - oversight, encouragement or cueing 2 = limited assistance - resident highly involved in activity, staff provided guided maneuvering of limbs or other non - weight bearing assistance 3 = extensive assistance = resident involved in activity, staff provide weight-bearing support A review of hospital records revealed in summary Resident #2 was admitted from 7/8/16 - 8/7/16 for medical detoxification. Resident #2's blood glucose lab values revealed a range between 90 - 437 mg/dL. Reference Range (70 - 100 mg/dL). A Review of Laboratory Report Chemistry Panel dated 8/9/16 revealed in part, Glucose 90 mg/dL. Reference Range (70-100 mg/dL). A review of August 2016 Diabetic Monitoring Record from 8/8/16 - 8/13/16 revealed in part, the following: Finger stick frequency order: before meals. Hi/Lo Parameters to call MD: facility's doctor Values: 8/8/16 4pm - 233 mg/dL HS (hour of sleep) - 251mg/dL 8/9/16 6 am - 85mg/dL 11am 137 mg/dL 4pm - 446 mg/dL HS - 269mg/dL 8/10/16 6am - 240mg/dL 11am - 445mg/dL 4pm - 277 mg/dL HS - 140 mg/dL Comments: recheck 286 (no date/time/initials documented) 8/11/16 6am - 138mg/dL 11am - 251mg/dL 4pm - 130 mg/dL HS - 120 mg/dL 8/12/16 6am - 424mg/dl 11am - 83mg/dL 4pm - 291mg/dL HS - 116mg/dL Comments: recheck 246 at 6:00am (no date/initials documented). 8/13/16 6am -378mg/dL 11am - 140mg/dL 4pm - 186mg/dL HS - 333mg/dL 8/14/16 6am - Hi; 10units given by S6LPN 11am - 523 mg/dL (verified by S2DON) 4pm - 278mg;dL HS - 228 mg/dL Comments: No documentation noted 8/15/16 6am - HI; 10 units given by S5LPN 11am - HI; no documentation noted of sliding scale insulin given Comments: recheck HI (no date, time, or initials documented). A review of the facility's Bowel and Bladder form dated 8/9/16 - 8/15/16 revealed Resident #2 was continent of bowel and bladder except on 8/14/16 beginning at 13:18 (1:18pm) where documentation revealed Resident #2 was incontinent of bladder and incontinent of bowel and bladder at 19:10 (7:10 pm). There was no documentation of Resident #2's bowel and bladder function for 8/15/16. A review of the Nurse's Notes dated 8/10/16 - 8/15/16 revealed the following: There were no documented entries for 8/14/16. 8/15/16 at 7 a.m. - Resident noted confused, disoriented unable to groom self, noted with unsteady gait, noted with incontinent episode of urine and bowel movement (bm), resident with Hi blood sugar (BS), no signs and symptoms (s/s) of [DIAGNOSES REDACTED] noted. - S5LPN 8/15/16 at 7:50 a.m. - After resident received insulin, BS remains in Hi, resident given insulin, remains in bed, confused. - S5LPN 8/15/16 at 11:00 a.m. - Rechecked resident BS, BS remains Hi, resident continues to be confused. - S5LPN 8/15/16 at 11:30 a.m. - Placed a call to facility physician on call, spoke with S11NP. Informed that resident BS remains Hi after given insulin and noted with .Hi (S5LPN unsure of documentation), received an order to send resident to local hospital for evaluation and treatment. 8/15/16 at 11:40 a.m. - . Ambulance called .S5LPN 8/15/16 at 12:25 p.m. - . Ambulance arrived . - S5LPN A Review of Physician's Telephone Orders revealed: 8/15/16 - Send out to local hospital for decreased level of consciousness (LOC) A Review of the hospital's emergency room Note dated 8/15/16 revealed in part, Resident #2 was admitted in serious condition with a [DIAGNOSES REDACTED]. A review of the hospital's History and Physical dated 8/15/16 revealed in summary, Resident #2 presented from the nursing home with altered mental status. Resident #2 was found this morning trembling in his bed and not responding to verbal prompts. Blood capillary glucose (BCG) was checked twice and registered High. Per the nursing home, Resident #2 is fully independent in all ADLs at baseline Further review of the H&P revealed laboratory results dated [DATE] that Resident #2 had BCG of 1090 mg/dL. The Impression/Plan revealed Resident #2 was admitted to Intensive Care Unit (ICU) on DKA protocol and was placed on intravenous (IV) insulin drip. Resident #2s admit [DIAGNOSES REDACTED]. On 8/24/16 at 11:00 a.m., an interview was held with S8CNA. She said she worked the 6am - 2pm shift and had cared for Resident #2 since his admission. S8CNA said Resident #2 would normally walk independently, clean and bath himself and was continent of bowel and bladder. S8CNA explained on the morning of 8/15/16 she went to get Resident #2 up for breakfast and noticed he was not responding normally. She said he did not get out of bed and he was confused and did not eat much. S8CNA said she also noticed Resident #2 was wearing a diaper which was not normal. S8CNA said she reported it S5LPN. On 8/24/16 at 11:30 a.m., an interview was held with S5LPN who worked the 6a - 2p shift on Monday - Friday. S5LPN said Resident #2 was ambulatory and independent of activities of daily living. She said Resident #2 attended every smoke break and needed his cell phone charged all of the time. She said when she left work on Friday, 8/12/16, Resident #2 was fine. S5LPN explained upon returning to work on 8/15/16, it was reported to her by a CNA that Resident #2 did not feel well over the weekend as he was not his normal self. S5LPN said it was also reported that Resident #2 had become incontinent. S5LPN explained when she saw Resident #2 on the morning of 8/15/16, he was lying in bed and was not responding well to verbal stimuli. S5LPN said Resident #2 was confused. She said, he would normally jump out of bed when she greeted him, but this day he didn't. She said he was just not his normal self. S5LPN explained between 640am - 650am on 8/15/16, she had obtained Resident #2's 6am accuchek and received a HI value. She said she administered Resident #2's scheduled insulins and 10 units of insulin per sliding scale parameters. At this time, S5LPN said she did not notify the physician. S5LPN went on to explain that she waited an hour and re-checked Resident #2's blood sugar. Resident #2's blood sugar value was HI again. She said, she then attempted to notify the provider on call around 8am, however, was unsuccessful. S5LPN said Resident #2 was still showing signs of confusion. S5LPN then said when she checked his BS at 11am, the value remained at HI . She said she did not administer any sliding scale insulin at this time. Resident #2 remained in the bed. S5LPN acknowledged that she did not report the HI blood sugar values at 6am and at the re-check to the on-call doctor/practitioners nor did she seek assistance from S1DON and S3ADON. On 8/24/16 at 12:13 p.m., an interview was held with S4NP. She said on 8/15/16 her phone was not working, however, she said there was always someone on-call 24/7 if she was not able to be reached. On 8/24/16 at 2:03 p.m., an interview was held with S3ADON. She verified that she worked on the day shift on 8/15/16. She reviewed the HI values on Resident #2's Diabetic Monitoring Record and confirmed no one had reported to her that Resident #2 had HI blood sugar values. On 8/24/16 at 1:34p.m, an interview was held with S2DON. S2DON explained if a resident's blood sugar revealed a HI value, sliding scale insulin should be administered and the physician should be notified. S2DON reviewed Resident #2's Diabetic Monitoring Record noting the HI results documented on 8/14/16 at 6am obtained by S6LPN and on 8/15/16 at 6am, the re-check, and 11am obtained by S5LPN. S2DON also noted the highest parameter for Resident #2 was 400 mg/dL. S2DON reviewed the facility's standing orders, and noted if blood sugar (BS) greater than 450mg/dL to call the physician. S2DON continued to review the Diabetic Monitoring Record and noted there was no documentation indicating Resident #2's blood sugar had been rechecked 2 hours after 6am on 8/14/16. S2DON said S6LPN should have contacted the physician. S2DON reviewed the Nurse's Notes and verified there was no documentation indicating S6LPN attempted to notify the physician/practitioner. S2DON, then, reviewed the Nurse's Notes on 8/15/16 noting the HI values at 6am and at the recheck and said S5LPN should have notified the physician. S2DON said if the nurse was unable to contact the on-call physician/practitioners, the nurse should have sent Resident #2 to the hospital and/or notified either himself or S3ADON. S2DON said no one had reported to him Resident #2 having HI blood sugar values. On 8/24/16 at 3:25 p.m., an interview was held with S1Adm. She said that she was made aware of Resident #2's HI blood sugars readings during the survey. S1Adm verified S5LPN should have notified the physician/practitioner and one of the Registered Nurse staff for assistance so that Resident #2 could be sent to the hospital sooner. S1Adm said if the physician/practitioner could not be reached, the LPN staff should have notified her, S2DON or S3ADON and we would worry about obtaining the order afterwards.

Based on record reviews and interviews, the facility failed to ensure the resident's physician/practitioner was notified of HI blood sugar values and a significant change in the resident's physical and mental condition for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for diabetes. The deficient practices resulted in an actual harm for Resident #2 on 8/14/16 at 6:00 a,m, when checking his blood sugar, a reading of HI was obtained on the glucometer. On 8/15/16 the 6:00 a.m. accuchek read HI on the glucometer. Documentation in the resident's record revealed a nurses' note which read, at 7 a.m. resident noted confused, disoriented unable to groom self, noted with unsteady gait, noted with incontinent episode of urine and bowel movement (bm), resident with Hi blood sugar (BS). There was documentation in the record that the HI reading again obtained via glucometer at 7:50 a.m. and 11:00 a.m. The resident's physician or nurse practitioner was not notified of the high glucometer readings on 8/14/16 and 8/15/16 or the change in the resident's condition on 8/15/16. Resident #2 was admitted to a local hospital on [DATE] with a [DIAGNOSES REDACTED]. Findings: A review of the facility's Acute Care Transfer and Unplanned hospitalization Log dated August 2016 revealed Resident #2 was sent to the a local hospital for [MEDICAL CONDITION]. A review of the facility's Obtaining a Fingerstick Glucose Level policy, revealed in part: Reporting 1. Report results promptly to the supervisor and attending physician 3. Report . in accordance with facility policy and professional standards of practice. A review of the manufacturer's Blood Glucose Monitoring System User Manual Instructions revealed in part: Hi and Lo Message The meter displays results between 20-600 mg/dL (milligram/deciliter). HI appears when the blood glucose level is greater than 600 mg/dL and indicates severe [MEDICAL CONDITION] (much higher than normal glucose levels). If HI is displayed again upon retesting, please contact the patient's healthcare provider immediately. A review of the clinical record for Resident #2 revealed in part, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the August 2016 physician's orders [REDACTED]. A1C q 3 months Diet: Diabetic Insulin [MEDICATION NAME] subcutaneous (SQ) ([MEDICATION NAME]) 38 units (u) SQ before (AC) breakfast for Type 2 DM at 630 am Humalog Insulin 8 units SQ AC for Type 2 DM 7am, 11am, 4pm Sliding Scale before meals 150-200 = 2u 201-250 = 4u 250-300 = 6u 301 - 350 = 8u 351 - 400 = 10 u Accuchek before meals A review of the Minimum Data Set (MDS) Section G - Functional Status - Activities of Daily Living (ADLs) revealed: 8/10/16 Resident #2 status was coded 0 for walking, locomotion, dressing and eating for self-performance and support. Eating was coded 1 for self-performance and support. 8/15/16 Resident #2's functional status was coded 2 for support and 3 for self-performance for ADLs. MDS 3.0 Coding Legend for Activities of Daily Living, coding is as follows: ADL Self-Performance 0 = independent - no help or staff oversight at any time 1 = supervision - oversight, encouragement or cueing 2 = limited assistance - resident highly involved in activity, staff provided guided maneuvering of limbs or other non - weight bearing assistance 3 = extensive assistance = resident involved in activity, staff provide weight-bearing support A review of hospital records revealed in summary Resident #2 was admitted from 7/8/16 - 8/7/16 for medical detoxification. Resident #2's blood glucose lab values revealed a range between 90 - 437 mg/dL. Reference Range (70 - 100 mg/dL). A Review of Laboratory Report Chemistry Panel dated 8/9/16 revealed in part, Glucose 90 mg/dL. Reference Range (70-100 mg/dL). A review of August 2016 Diabetic Monitoring Record from 8/8/16 - 8/13/16 revealed in part, the following: Finger stick frequency order: before meals. Hi/Lo Parameters to call MD: facility's doctor Values: 8/8/16 4pm - 233 mg/dL HS (hour of sleep) - 251mg/dL 8/9/16 6 am - 85mg/dL 11am 137 mg/dL 4pm - 446 mg/dL HS - 269mg/dL 8/10/16 6am - 240mg/dL 11am - 445mg/dL 4pm - 277 mg/dL HS - 140 mg/dL Comments: recheck 286 (no date/time/initials documented) 8/11/16 6am - 138mg/dL 11am - 251mg/dL 4pm - 130 mg/dL HS - 120 mg/dL 8/12/16 6am - 424mg/dl 11am - 83mg/dL 4pm - 291mg/dL HS - 116mg/dL Comments: recheck 246 at 6:00am (no date/initials documented). 8/13/16 6am -378mg/dL 11am - 140mg/dL 4pm - 186mg/dL HS - 333mg/dL 8/14/16 6am - Hi; 10units given by S6LPN 11am - 523 mg/dL (verified by S2DON) 4pm - 278mg;dL HS - 228 mg/dL Comments: No documentation noted 8/15/16 6am - HI; 10 units given by S5LPN 11am - HI; no documentation noted of sliding scale insulin given Comments: recheck HI (no date, time, or initials documented). A review of the facility's Bowel and Bladder form dated 8/9/16 - 8/15/16 revealed Resident #2 was continent of bowel and bladder except on 8/14/16 beginning at 13:18 (1:18pm) where documentation revealed Resident #2 was incontinent of bladder and incontinent of bowel and bladder at 19:10 (7:10 pm). There was no documentation of Resident #2's bowel and bladder function for 8/15/16. A review of the Nurse's Notes dated 8/10/16 - 8/15/16 revealed the following: There were no documented entries for 8/14/16. 8/15/16 at 7 a.m. - Resident noted confused, disoriented unable to groom self, noted with unsteady gait, noted with incontinent episode of urine and bowel movement (bm), resident with Hi blood sugar (BS), no signs and symptoms (s/s) of [DIAGNOSES REDACTED] noted. - S5LPN 8/15/16 at 7:50 a.m. - After resident received insulin, BS remains in Hi, resident given insulin, remains in bed, confused. - S5LPN 8/15/16 at 11:00 a.m. - Rechecked resident BS, BS remains Hi, resident continues to be confused. - S5LPN 8/15/16 at 11:30 a.m. - Placed a call to facility physician on call, spoke with S11NP. Informed that resident BS remains Hi after given insulin and noted with .Hi (S5LPN unsure of documentation), received an order to send resident to local hospital for evaluation and treatment. 8/15/16 at 11:40 a.m. - . Ambulance called .S5LPN 8/15/16 at 12:25 p.m. - . Ambulance arrived . - S5LPN A Review of Physician's Telephone Orders revealed: 8/15/16 - Send out to local hospital for decreased level of consciousness (LOC) A Review of the hospital's emergency room Note dated 8/15/16 revealed in part, Resident #2 was admitted in serious condition with a [DIAGNOSES REDACTED]. A review of the hospital's History and Physical dated 8/15/16 revealed in summary, Resident #2 presented from the nursing home with altered mental status. Resident #2 was found this morning trembling in his bed and not responding to verbal prompts. Blood capillary glucose (BCG) was checked twice and registered High. Per the nursing home, Resident #2 is fully independent in all ADLs at baseline Further review of the H&P revealed laboratory results dated [DATE] that Resident #2 had BCG of 1090 mg/dL. The Impression/Plan revealed Resident #2 was admitted to Intensive Care Unit (ICU) on DKA protocol and was placed on intravenous (IV) insulin drip. Resident #2s admit [DIAGNOSES REDACTED]. On 8/24/16 at 11:00 a.m., an interview was held with S8CNA. She said she worked the 6am - 2pm shift and had cared for Resident #2 since his admission. S8CNA said Resident #2 would normally walked independently, clean and bath himself, and was continent of bowel and bladder. S8CNA explained on the morning of 8/15/16 she went to get Resident #2 up for breakfast and noticed he was not responding normally. She said he did not get out of bed and he was confused and did not eat much. S8CNA said she also noticed Resident #2 was wearing a diaper which was not normal. S8CNA said she reported it S5LPN. On 8/24/16 at 11:30 a.m., an interview was held with S5LPN who worked the 6a - 2p shift on Monday - Friday. S5LPN said she had cared for Resident #2 since his admission. S5LPN said Resident #2 was ambulatory and independent of activities of daily living. She said Resident #2 attended every smoke break and needed his cell phone charged all of the time. She said when she left work on Friday, 8/12/16, Resident #2 was fine. S5LPN explained upon returning to work on 8/15/16, it was reported to her by a CNA that Resident #2 did not feel well over the weekend as he was not his normal self. S5LPN said it was also reported that Resident #2 had become incontinent. S5LPN explained when she saw Resident #2 on the morning of 8/15/16, he was lying in bed and was not responding well to verbal stimuli. S5LPN said Resident #2 was confused. She said, he would normally jump out of bed when she greeted him, but this day he didn t. She said he was just not his normal self. S5LPN explained between 640am - 650am on 8/15/16, she had obtained Resident #2's 6am accuchek and received a HI value. She said she administered Resident #2's scheduled insulins and 10 units of insulin per sliding scale parameters. At this time, S5LPN said she did not notify the physician. S5LPN went on to explain that she waited an hour and re-checked Resident #2's blood sugar and received a HI value reading again. She said, she then attempted to notify the provider on call around 8am, however, was unsuccessful. During the interview, S5LPN reviewed the Nurse's Notes dated 8/15/16 and acknowledged there was no documentation of attempting to notify the doctor on-call. S5LPN said Resident #2 was still showing signs of confusion. S5LPN then said when she checked his BS at 11am, the value remained at HI. She said she did not administer any sliding scale insulin at this time and Resident #2 remained in the bed. S5LPN acknowledged that she did not report the HI blood sugar values at 6am and at the re-check to the on-call doctor/practitioners nor did she seek assistance from S1DON and S3ADON. S5LPN also said she did not think to send Resident #2 to the hospital. On 8/24/16 at 2:29 p.m., an interview was held with S6LPN who had cared for Resident #2. S6LPN said she worked the 10pm - 6am shift. She reviewed the Diabetic Monitoring Sheet for Resident #2 on 8/14/16 and recalled obtaining a HI reading between 5am - 6am. She said the on-call doctor/practitioner was not able to be reached. She said she called S2DON. S6LPN said S2DON informed her to continue to try calling the doctor. S6LPN reported that her shift had ended at 6am. On 8/25/16 at 10:21 a.m., an interview was held with S7LPN. She said she worked weekend shifts and had cared for Resident #2. S7LPN acknowledged that she worked the 6am - 2pm shift on 8/14/16. She said S6LPN did not report that Resident #2 had a HI value blood sugar reading during shift change, therefore, she was not aware. S7LPN said if a resident had a blood sugar over 400 mg/dL, the nurse was to notify the physician and recheck the blood sugar in 2 hours and notify the physician again. S7LPN said Resident #2 was up ambulating, ate throughout the day, and attended every smoke break which was normal. S7LPN said Resident #2 was continent of bowel and bladder. S7LPN explained if she was not able to contact the on-call physician/practitioners, she would send the resident to the hospital. S7LPN said a HI value indicated a blood sugar reading over 600 mg/dL. On 8/25/16 at 9:35 a.m., an interview was held with S9CNA. She said she had cared for Resident #2. S9CNA said Resident #2 ambulated steady without assistance, took care of himself with minimal cueing and reminders, and usually did not remain in bed. S9CNA said Resident #2 was not normally confused and was continent of bowel and bladder. On 8/25/16 at 9:30 a.m., an interview was held S10CNA. She said Resident #2 was normally independent and took care of himself. S10CNA said he was continent of bowel and bladder. She said Resident #2 was at every smoke break and always needed his cell phone charged. On 8/24/16 at 2:03 p.m., an interview was held with S3ADON. She verified that she worked on the day shift on 8/15/16. She reviewed the HI values on Resident #2's Diabetic Monitoring Record and confirmed no one had reported to her that Resident #2 had HI blood sugar readings. On 8/24/16 at 1:34p.m, an interview was held with S2DON. S2DON explained if a resident's blood sugar revealed a HI value, sliding scale insulin should be administered and the physician should be notified. S2DON reviewed Resident #2's Diabetic Monitoring Record noting the HI results documented on 8/14/16 at 6am obtained by S6LPN and on 8/15/16 at 6am, the re-check, and 11am obtained by S5LPN. S2DON also noted the highest parameter for Resident #2 was 400 mg/dL. S2DON reviewed the facility's standing orders, and noted if blood sugar (BS) greater than 450mg/dL to call the physician. S2DON continued to review the Diabetic Monitoring Record and noted there was no documentation indicating Resident #2's blood sugar had been rechecked 2 hours after 6am on 8/14/16. S2DON said S6LPN should have contacted the physician. S2DON reviewed the Nurse's Notes and verified there was no documentation indicating S6LPN attempted to notify the physician/practitioner. S2DON, then, reviewed the Nurse's Notes on 8/15/16 noting the HI values at 6am and at the recheck and said S5LPN should have notified the physician. S2DON said if the nurse was unable to contact the on-call physician/practitioners, the nurse should have sent Resident #2 to the hospital and/or notified either himself or S3ADON. S2DON said no one had reported Resident #2 having HI blood sugar values. On 8/24/16 at 12:13 p.m., an interview was held with S4NP. She said on 8/15/16 her phone was not working, however, she said there was always someone on-call 24/7 if she was not able to be reached. On 8/24/16 at 3:25 p.m., an interview was held with S1Adm. She said that she was made aware of Resident #2's HI blood sugars readings during the survey. S1Adm verified S5LPN should have notified the physician/practitioner and one of the Registered Nurse staff for assistance so that Resident #2 could be sent to the hospital sooner. S1Adm said if the physician/practitioner could not be reached, the LPN staff should have notified her, S2DON or S3ADON and we would worry about obtaining the order afterwards.

Based on observations, record review and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently in order to ensure residents received adequate supervision for: a. 1 (#3) of 4 (#1, #2, #3, #7) sampled residents reviewed that was NPO from a total of 5 residents reviewed with percutaneous endoscopic gastrostomy (PEG) tubes (#1, #2, #3, #7, #8); b. 1 (#3) of 1 (#3) sampled residents reviewed with physician orders [REDACTED]. c. 1 (#4) of 5 sampled residents (#4, #5, #6, #9, #10) reviewed for elopement from a total of 11 elopement risk residents that resided in the general population (#4, #5, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6, #R7). The facility failed to: 1. Ensure a resident that was NPO and had a history of [REDACTED].#3); 2. Ensure assistive devices (mittens) were utilized to assist in preventing the resident from placing non-edible items in his mouth (#3); 3. Ensure a resident identified as an elopement risk was adequately supervised to prevent the resident from eloping from the facility (#4); 4. Ensure immediate interventions were implemented to increase monitoring and supervision for remaining elopement risk residents that resided in the general population (#5, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6, #R7); 5. Ensure that 5 (DR#2, DR#3, DR#5, DR#6, DR#7) of 7 doors (DR#1-DR#7) that did not have the wander-guard system were monitored to prevent the remaining elopement risk residents that resided in the general population from elopement (#5, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6, #R7); 6. Ensure a door (DR#6) was monitored when it was identified that it was not properly locking on 12/23/2013 through 12/30/2013. This resulted in Resident #3 being placed in an Immediate Jeopardy situation when the facility failed to ensure the resident was supervised and assistive devices (mittens) were utilized to assist in preventing the resident from swallowing foreign objects. The Immediate Jeopardy began on 12/5/13 at 2 p.m. when Resident #3 was found to have chest congestion. A chest x-ray was obtained on 12/5/13 at 3:36 p.m. that indicated "metallic foreign bodies situated in the stomach". The resident was transferred to the hospital. While hospitalized , Resident #3 underwent two surgical procedures to remove a large mass of foreign material from the stomach. The Immediate Jeopardy ended on 12/5/13 at 5 p.m. when Resident #3 was transferred to the hospital. The deficient practice remains as an isolacted, actual harm for Resident #3. S1Administrator and S2DON were notified of the Immediate Jeopardy situation for Resident #3 on 1/3/14 at 2:35 p.m. Resident #4 was placed in an Immediate Jeopardy Situation on 12/22/2013 when he eloped from the facility at approximately 4:15 p.m. and was not located until 12/23/2013 at 2:33 a.m. He was noticed by random bystanders to be wandering the streets and stumbling around. EMS (Emergency Medical Service) was then notified and called to the scene where they found the resident was soaking wet and violently shivering. The resident was admitted to a local ER (emergency room ) with Hypothermia, Abnormal Lab Values, Clouded Consciousness, Acute Confusion, Acute [MEDICAL CONDITION] Syndrome and [MEDICAL CONDITION]. According to hospital records, the weather the night the resident eloped was raining with a temperature of approximately 40 degrees Fahrenheit. While the resident was in the ER, he underwent a septic work up that included venous puncture blood draws to obtain a CBC (Complete Blood Count), CMP (Complete Metabolic Panel) and Blood Cultures. Resident #4 also received warming therapy, was treated with IV (intravenous) fluid hydration, Intravenous Calcium [MEDICATION NAME] and multiple diagnostic tests that included a Chest X-Ray, EKG (Electrocardiogram) and Urine Cultures. The lab work obtained in the ER revealed a Critical High Potassium Level of 6.5 mEq/L (milliequivillants/Liter) for which he received Intravenous Insulin. He was also found to have a Critical Low Glucose Level of 41 mg/dL (milligrams/deciliter) for which he received Intravenous [MEDICATION NAME] 50%. S1Administrator was notified of the Immediate Jeopardy situation on 1/3/2014 at 2:35 p.m. The Immediate Jeopardy was lifted for Resident #4 on 12/23/2013 at 4:15 a.m. when the facility was notified by the hospital he had been located and admitted to the ER. The Immediate Jeopardy remained in place for 10 other residents residing in the general population of facility that were identified by the facility as an elopement risk until 1/3/2014 at 4:30 p.m. when the facility presented an acceptable plan of removal that included: 1. Each resident at risk for elopement had been reassessed as of the 12/30/2013. 2. A full census check would be done at the end of each shift. 3. Staff was in-serviced for close supervision, checking doors, when to notify MD(Medical Doctor)/Administration, when to place a resident on elopement precautions, communicating with team, prevention of abuse/neglect/mistreatment. Nurses received a separate in-service by the RDCO (Corporate) and DON in include med admin, close observation, notifying DON/Admin. 4. The Social Worker was in-serviced for administering the BIMS. 5. The residents on elopement risk are being checked every 1 hour. 6. Administration will make frequent rounds to check the doors to ensure they are secure. 7. The door with a time lapse to lock has been repaired. 8. An estimate would be obtained to place the Wander-guard device on every door. Until then, staff will be posted to monitor any door that goes to the outside (except courtyards). The deficient practice remains at a level 2 pattern for the 10 residents in the general population who were at risk for elopement. Findings: Resident #3 Review of the clinical record revealed Resident #3 was a [AGE] year old male that had [DIAGNOSES REDACTED]. Review of the Casemix / Skilled Nursing Notes dated 12/5/13 included: 2 p.m.: Noted chest congestion upon checking peg for patency - HOB raised higher, feeding stopped. S19NP called new orders for CXR. Review of the chest x-ray results dated 12/5/13 and timed at 3:36 p.m. revealed in part: Single metallic device which appear to represent screw and additional curvilinear small metallic density projected at the left upper abdomen. Review of the Transfer Form revealed in part: To: __ (local hospital) Date: 12/5/13 Resident: ___ (#3) Primary Diagnosis: [REDACTED]. Vital Signs: BP: 124/88, P: 79, R: 18, T: 98.4 Functioning Status: - Bathing: Dependent - Dressing: Dependent - Toileting: Dependent - Transferring: Dependent - Bowel Function: Incontinent, Ostomy, last BM 12/5/13 - Bladder Function: Incontinent - Eating/Feeding: Dependent, Tube Fed - Walking: Dependent Resident left facility at 5 p.m. via stretcher Name of transport provider: Ambulance RP Notified: ___ (sister of Resident #3) on 12/5/13 at 4:20 p.m. Notified by: S12LPN Review of the hospital records included: Emergency Department (ED) notes Visit Date: 12/5/13 17:10 (5:10 p.m.) Primary Diagnosis: [REDACTED]. Chief Complaint: Swallowed foreign body Summary: Pt (patient) is a [AGE] year old who has Mental [MEDICAL CONDITION]. He is a Nursing Home patient who was sent to the ED after swallowing a foreign body. He was trying to eat his armband. Physical Exam: ...Full range of motion in all extremities... KUB Abdomen - Single View: The examination findings are metallic screw in stomach. RN Continuation Notes: 12/5/13 18:00 (6 p.m.): Patient continues to pull monitoring equipment off and chew cords despite therapeutic interventions. Patient chewing wrist band. Piece of paper removed from mouth. New orders received. Soft wrist restraints applied to bilateral upper extremities. Progress Notes: 12/5/13 22:31 (10:31 p.m.) per Medical Doctor (MD): Pt has multiple foreign bodies in the stomach including hay. History and Physical Chief Complaint: Foreign body in stomach. History of Present Illness: A [AGE] year old male with history of [MEDICAL CONDITION], severe mental [MEDICAL CONDITIONS] disorder, [MEDICAL CONDITION], dysphasia, gastric tube, and [MEDICAL CONDITION] was sent from Nursing Home for x-ray showing metallic foreign bodies in fundus of the stomach. In the emergency room , they did a chest x-ray which showed a metallic screw over the gastric fundus. Dr. __ (hospital physician) was consulted who did a EGD (Esophagogastroduodenoscopy) and found copious amounts of paper, trash, and straws in the stomach but did not find a screw. He states that he went in and out of the pharynx and the esophagus many times over the course of 2 hours and only managed to remove one-third of the contents. States that he is concerned that with all this gastric content, the patient would develop pressure necrosis. States that he is an aspiration risk and also that the arytenoids are quite swollen from the in and out EGD. He said it was prudent to leave the patient intubated and thus ICU (Intensive Care Unit) was consulted for ventilator management. Assessment: A [AGE] year old male with mental [MEDICAL CONDITION], pica and foreign bodies in the gastric fundus. Operative Report Date: 12/5/13 Procedure: Esophagogastroduodenoscopy Indications: Foreign body in the stomach. The patient swallowed a metallic screw. In the stomach, could see copious amounts of foreign objects. There was no actual food or food debris. There was plastic and paper. There was evidence of a sponge. There were multiple plastic straws. The metallic screw itself was probably within this mass of foreign debris. We (hospital staff) worked for approximately 2 hours removing parts of plastic. We (hospital staff) removed plastic wrap. There were parts of sponge and possibly a Brillo pad. After 2 hours, only a third of the material was removed. The mucosa of the stomach esophagus was markedly [MEDICAL CONDITION] and friable (easily broken) and had some oozing. At this point the procedure was terminated. Impression: Copious amounts of foreign material in the stomach. Only part of material removed after 2 hours. Recommendations: The patient will remain intubated and will go to the ICU. Surgical consultation. Operative Report Date: 12/6/13 Preoperative Diagnosis: [REDACTED]. Operative Procedure: Laparotomy, gastrotomy and removal of multiple gastric foreign bodies, excision of gastrocutaneous fistula and closure, and new gastrostomy tube placement. Anesthesia: General endotracheal anesthesia Clinical Indications: The patient is a mentally challenged [AGE] year old male who apparently eats multiple foreign bodies. He was admitted to the hospital and evaluated after a metallic bolt was found on x-ray. The patient was taken to endoscopy and found to have large gastric bezoar with multiple foreign bodies. An attempt was made by the endoscopist to remove portions of the foreign body without complete success. He was subsequently scheduled for a laparotomy. Operative Procedure: ...Multiple pieces of foreign bodies including paper, plastic, metallic bolt, cloth-like material and other trash and debris as well as hair was removed from the stomach. This filled a medium sized bucket. There was [DIAGNOSES REDACTED] to the lining of the gastric mucosa... Surgical Pathology Report Date Collected: 12/7/13 Specimen: Stomach contents foreign bodies: Received 15 cm (centimeter) aggregate of hair, gloves, sponges, metallic nails, and plastic tubing admixed with normal gastric secretions. Further review of the hospital records revealed Resident #3 underwent two more procedures. One on 12/8/13 and another on 12/23/13. The resident was returned to the Intensive Care Unit following the 12/23/13 procedure. During the onsite investigation, Resident #3 remained in the hospital. Review of the quarterly MDS with ARD of 9/24/13 revealed Resident #3 had severe cognitive impairment with behaviors of [MEDICAL CONDITION], inattention, continuously present. The resident required one person, total assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, personal hygiene, eating, and bathing. The resident had impaired range of motion to both upper and lower extremities. He was always incontinent of bladder and had an ostomy for bowel. Resident #3 had a swallowing disorder and received nutrition via tube feeding. Review of the Care Plan included: Problem Onset: 9/24/13 Problem: Potential for injury - limb restraint, resident requires bilateral hand mittens at this time due to pulling PEG tube. Goal & Target Date: 12/22/13 Approaches: - Apply limb restraint as ordered by the physician - Check on resident at least every 30 minutes Problem Onset: "12/30/1899" Problem: Episodes of [MEDICAL CONDITION] as manifested by inattention, yelling aloud, and banging on wheelchair lap tray, pulling items off of tables, walls in day room Goal & Target Date: 12/22/13 Approaches: - 3/16/13: Hand mitten to bilateral hands Problem Onset: "12/30/1899" Problem: Socially inappropriate/disruptive behavior related to mental [MEDICAL CONDITION] as evidenced by smiling and yelling loudly when redirected by staff. Resident has history of pulling things down in the lobby area. Goal & Target Date: 12/22/13 Approaches: - Place resident in area where constant observation is possible. Review of the Nurse's Notes revealed in part: 2/8/13 at 12:06 p.m.: LPN, assigned nurse, walked in patient's room to find him chewing. LPN assessed patient only to find his [MEDICAL CONDITION] bag was not attached to his stoma. Searched the bed and the room and the [MEDICAL CONDITION] bag was not found. Incident reported to S2DON and Nurse Practitioner. 3/16/13 at 1:15 p.m.: Resident's [MEDICAL CONDITION] bag has been changed four times due to him pulling them off and trying to eat them. Notified Nurse Practitioner and gave order for bilateral hand mittens. 4/4/13 at 10:15 a.m.: ... wears mittens to bilateral hands due to resident trying to put fingers in mouth and chew them... 4/14/13 (time illegible): ... Resident propels gerichair about hall and room... 5/14/13 at 9 a.m.: ... noisy, moving about in w/c (wheelchair)... 6/11/13 at 8:10 p.m.: CNA reported resident had pulled his peg tube out of his stomach... 7/1/13 at 1 p.m.: Called to room per CNA. Resident pulled peg tube out... 7/6/13 at 5 p.m.: Frequently pushing tray (lap tray) to floor today... 7/9/13 at 9:45 p.m.: Reported by CNA that resident was on floor in room E. Resident had been moved for night secondary to maintenance in room C. Upon assessment noted 3 cm (centimeter) hematoma above left eye. 7/13/13 at 11 p.m.: ...[DEVICE] out, [MEDICAL CONDITION] bag removed by resident. Mittens on bed. Resident asked to spit object out of mouth which appeared to be plastic... 7/14/13 at 12:45 a.m.: ...hands covered with two pair of socks... 7/25/13 at 8 p.m.: Noted [DEVICE] lying on resident's abdomen... Attempted [DEVICE] reinsertion, found insertion area had closed... 8/22/13 at 2 p.m.: Entered resident's room and noted resident with peg tube in hand... 8/22/13 at 8 p.m.: Found [DEVICE] lying on resident's abdomen. Balloon completely deflated. Stoma closed. 8/23/13 at 6:30 a.m.: Noted resident's peg tube out of place. 8/24/13 at 2:05 (a.m./p.m. not indicated): Resident sitting in gerichair in day room. Noted abdomen binder and dressing removed and put at the side. Peg tub lying down on his abdomen out of place. 8/25/13 at 9:24 a.m.: CNA notified nurse that resident's peg tube fell off when she removed the abd (abdomen) binder. 8/31/13 at 12:08 a.m.: Resident noted on floor by bedside... 9/1/13 (no time): Resident was noted standing naked by the bed. He was holding on the rail. Nurse was summoned by housekeeper. Nurse went into room and got resident dressed, put him in the gerichair and brought him to the day room. 9/1/13 (no time): Reported by resident that he was eating the tape. Nurse took resident into the room. Noted peg tube lying on his abdomen. Peg site closed. 9/22/13 at 6 p.m.: Sitting in gerichair in room. Noted pulling over bedside table in room from gerichair. Staff redirected and moved to hallway... Review of the Physician order [REDACTED]. NPO (nothing by mouth) [MEDICATION NAME] 1.5 - two cans per PEG tube three times daily Flush PEG tube with 250ml of water four times daily Hand mittens to bilateral hands - monitor skin every shift An interview was held with S12LPN on 12/30/13 at 1:35 p.m. She stated she did not routinely work with Resident #3 and on 12/5/13, she was filling in for a nurse that had called in. She stated when she went to give Resident #3 his tube feeding, she noticed that he had chest congestion. She said she raised the head of the bed more and called for S20ADON to assess the resident as well. She said S20ADON assessed Resident #3 and observed the chest congestion as well. S12LPN stated she called S19NP and received an order for [REDACTED]. She said the resident was then transferred to the hospital where he has remained since 12/5/13. S12LPN stated Resident #3 had behaviors of yelling out loud and banging on the lap tray that was attached to the gerichair he used for mobility. She stated the resident would grab at things around him, but she had never observed the resident put anything in his mouth. She stated at one time the resident wore hand mittens but she was unsure as to what happened to the mittens. She stated she had made rounds to check on the resident approximately every 1- 2 hours on 12/5/13. On 12/30/13 at 1:45 p.m., an interview was held with S13CNA. She recalled providing care to Resident #3 when the resident resided in room D. She stated she had cared for the resident on both day and evening shifts. She described Resident #3 as having behaviors of yelling out loud, hitting the lap tray that was on his chair, grabbing at anything around him, pulling things off of the walls, turning things over, etc. She stated the resident would put anything he could reach in his mouth. She said he wore hand mittens at one time, but the mittens had to be thrown away because the resident had chewed holes in them and the stuffing was coming out. She said she couldn't remember the nurse's name but the nurse told her that she would have to order the resident more mittens and to put socks on the resident's hands until the mittens were received. S13CNA stated the mittens were discarded several months ago. She stated she did as the nurse directed her to do, but the resident could take the socks off his hands. She said to mittens were not replaced prior to the resident moving to another room on another hall. She stated the resident changed rooms several months ago. S13CNA stated that when she cared for Resident #3, she made rounds to check on the resident every 1-2 hours. An interview was held with S3CNA on 12/30/13 at 1:50 p.m. S3CNA stated she had provided care to Resident #3 while he resided on both A and B halls. She described Resident #3 to have behaviors of yelling loudly, hitting on his chair, and grabbing at others. She stated the resident's chair had a lap tray and the resident would hit on the tray repetitively. She recalled the resident having hand mittens at one time but further stated she did not know what happened to the mittens. She said the mittens were to prevent the resident from eating things that he was not supposed to eat. S3CNA stated that she made rounds to check on Resident #3 every 1 1/2 - 2 hours when she was assigned to him. On 12/30/13 at 1:55 p.m., an interview was held with S8CNA. S8CNA stated Resident #3 had behaviors of hitting on the lap tray and yelling out loud. S8CNA said the resident liked attention from staff and would calm if staff spoke to him or propelled him in his chair. S8CNA said the resident also would grab at people or things surrounding him and therefore had to be placed away from others and objects. S8 stated the resident wore hand mittens at one time but had chewed on the mittens, creating a hole and therefore the mittens were thrown away. S8 said the resident was moved to another room and was unsure if the mittens were replaced. S8CNA stated rounds were made to check on Resident #3 every hour. An interview was held with S16CNA on 12/30/13 at 2:05 p.m. S16CNA stated she was familiar with Resident #3 and had worked with the resident routinely prior to his transfer to the hospital. S16CNA stated Resident #3 frequently yelled out loud and hit on the lap tray. She said the resident was able to move the chair without staff assistance. She stated the resident had a history of [REDACTED]. She stated in the past, she had found Resident #3 chewing on his [MEDICAL CONDITION] bag. She said she immediately notified the nurse. S16CNA could not recall the nurse's name she had notified, but said the nurses were well aware the resident would put foreign objects in his mouth. S16CNA stated she made rounds to check on Resident #3 approximately every 30 minutes to one hour. She stated sometimes the resident would be in his room and sometimes the resident would be sitting in the day room. She recalled Resident #3 having hand mittens at one time but further stated she did not know what happened to the mittens. On 12/30/13 at 2:35 p.m. an interview was held with S17LPN. S17LPN stated he was a routine nurse that provided care to Resident #3 during the evening shifts. S17LPN said Resident #3 would usually be up in the chair upon his arrival around 2 p.m. He stated the resident had behaviors of yelling, hitting on the lap tray attached to his chair, grabbing at others / things surrounding him and putting things in his mouth. He stated the resident would be placed in the day room or in front of the front nurses' station so staff could watch him as much as possible. S17LPN said the resident would remain in the chair until around 8 p.m. and then the staff would place him in the bed. He said the resident would tear at his incontinent brief so bad that he eventually instructed the CNAs to stop putting the briefs on him. He said he never found the resident eating the incontinent brief but he had a history of [REDACTED]. S17LPN stated the staff made rounds to check on residents every two hours. S17LPN stated Resident #3 wore bilateral hand mittens at one time but he was unsure what had happened to the mittens. He said he thought he remembered the resident having the mittens on at different times. During the interview, observed two medication carts placed in front of the front nurses' station that S17LPN had indicated Resident #3 had been placed at for observation. The medication carts contained straws, plastic cups, and paper items. S17LPN stated the medication carts were maintained in that area when they were not in use. When S17LPN asked if Resident #3 could have obtained any of the plastic/paper items from the medication carts when he was placed near them, S17LPN stated he could not say for certain if the resident had gotten items off of the medication carts because staff were "coming and going" from the nurses' station but it was a possibility. He stated S2DON and the nurse practitioner were aware of Resident #3's behaviors. An interview was held with S14LPN at 2:50 p.m. on 12/30/13. S14LPN stated she had routinely cared for Resident #3 during the evening shifts. She stated Resident #3 had behaviors that included yelling, hitting on his chair, and pulling his peg tube/[MEDICAL CONDITION]. S14LPN said the resident had a history of [REDACTED]. She stated she was certain this had been reported to the DON and the nurse practitioner. She stated the resident had bilateral hand mittens. She said the resident did chew on the mittens. She could not recall if the mittens were torn or had holes from the resident chewing on them. S14LPN stated she made rounds to check on the resident hourly. She said sometimes the resident would be sitting in his room and other times he would be in the day room or near the front nurses' station. An interview was held with S18LPN on 1/2/14 at 9:05 a.m. She said she started working in the facility with Resident #3 in March 2013. She said she worked with the resident mostly weekends on Saturdays and Sundays from 2 p.m. - 6 a.m. She said the resident was nonverbal, but he seemed to understand when you talked to him. She said the resident was usually up in the gerichair by the nurses' station when she arrived to the facility at 2:00 p.m. She said the resident had attention seeking behaviors of pulling on his shirt and banging his hands on the lap tray of the gerichair. She said he would stop banging on the lap tray when a staff member approached and spoke to him, but would continue the behavior when the staff member walked away. She said the resident liked attention from the staff. She said he enjoyed being rolled around in his gerichair. She said the staff would put the resident to bed at 5:00 p.m. She said she would provide his feeding at this time as well. She said the resident would try to grab the syringe and the tubing but he would let go if she talked to him. She said she had frequently seen the resident pull on his incontinent brief, but only once on his [MEDICAL CONDITION] bag. She recalled the resident wearing hand mittens and stated he would chew on them. She said the resident could wiggle his hands out of his mittens. She said she had not seen him eat or swallow anything. She said she did not report the resident's behavior to anybody because he had not sustained any injuries and because she thought the resident's behaviors were normal due to his mental [MEDICAL CONDITION]. She said the resident needed extra attention. An interview was held with Resident #R8 on 1/2/14 at 9:45 a.m. Resident #R8 was alert and oriented throughout the entire interview. Resident #R8 recalled Resident #3 and indicated that he and Resident #3 used to reside near one another in the facility. Resident #R8 stated that Resident #3 would yell out loudly and bang on the tray of his chair as long as he was in the chair. He stated the staff did not watch Resident #3. He said the resident would put anything he could get his hands on in his mouth. He said the staff would just put the resident in his room, close the door, and leave him. He said Resident #3's family visited several times and complained about the resident being alone in his room. Review of quarterly MDS with ARD 10/8/13 revealed Resident #R8 had a BIMS score of 14. This indicated Resident #R8 was cognitively intact. On 1/2/14 at 10:05 a.m., an interview was held with Resident #R9. Throughout the interview, Resident #R9 remained alert and oriented. Resident #R9 stated that he and Resident #3 were roommates for a couple of months. He stated Resident #3 was eventually moved to another room but some of his personal belongings still remained in his room. He indicated hanging clothes and shoes on the other side of the room that belonged to Resident #3. He stated Resident #3 was moved to another room because the resident was always getting into his personal belongings. Resident #R9 further explained that he could not leave anything out because Resident #3 would eat it. He said, "he would eat anything". Resident #R9 demonstrated with a plastic spoon. He stated, "Ma'am, if I left this lying on my table, the man would eat it." He stated the resident would eat buttons from clothing, paper, plastic, etc. He stated the resident would even chew on clothing and try to eat that. Resident #R9 stated the nursing staff were aware of the resident's behaviors of eating non-edible materials. He stated he had seen the staff remove things from the resident's mouth and hands. Resident #R9 said he could not recall specific times and incidents of Resident #3 eating foreign materials because it was a continuous behavior. Resident #R9 stated, "if he could reach it, it was going straight to his mouth". Resident #R9 stated he don't remember Resident #3 wearing mittens when he resided in the room with him. He said the resident made a lot of noise by yelling and banging on the tray attached to the chair he sat in. He stated the staff would leave the resident in the room at times and then sometimes they would bring him to the day room area. During the interview, observed the room that was Resident #R9 and Resident #3 had shared. Resident #R9 had plastic utensils, straws, plastic cups, styrofoam cups and snacks wrapped in plastic wrap scattered on the bedside table, over bed table, and bathroom sink. Resident #R9 confirmed during interview that he maintained his side of the room in the same manner as noted during the observation when Resident #3 roomed with him. Review of annual MDS with ARD 12/3/13 revealed Resident #R9 had a BIMS score of 13. This indicated Resident #R9 was cognitively intact. On 1/2/14 at 11 a.m. an interview was held with S20ADON. She recalled being called to Resident #3's room on 12/5/13 by S12LPN. She stated she assessed Resident #3 and found the resident to have some chest congestion. She said she instructed S12LPN to notify S19NP. She said S19NP ordered a chest x-ray. She said the chest x-ray indicated something metallic in the resident's upper stomach. She said the resident was transferred to the hospital once the results were received. S20ADON stated Resident #3 had behaviors of yelling loudly and hitting on his lap tray. She said she was not aware of behaviors that included the resident eating foreign materials. An interview was held with S26LPN on 1/2/14 at 2 p.m. S26LPN stated she was familiar with Resident #3 and had provided care to the resident on the evening and night shifts. She stated she could not remember if Resident #3 wore hand mittens. She recalled when she would provide the resident with feedings and medications through the PEG tube, he would try to pull at the tube. She said when he would do this, she would stop and return at another time when the resident had calmed down. S26LPN stated the resident was usually in the bed when she cared for him. She stated she had not witnessed him placing anything in his mouth but verified the resident had full range of motion of his hands and arms. She stated she made rounds to check on the resident every two hours. She stated S2DON and the nurse practitioner were aware of Resident #3's behaviors. On 1/2/14 at 2:30 p.m., an interview was held with S2DON. She stated she had been employed as the facility's Director of Nursing for approximately one year. She stated Resident #3 had behaviors that included banging on the lap tray and yelling out at times. She stated the behaviors were not constantly and occurred only at intervals. She stated Resident #3 had full range of motion of his extremities. She stated she was not aware of Resident #3 having behaviors of placing foreign materials in his mouth and/or eating non-edible items. She said she had not been made aware of those behaviors. S2DON confirmed an x-ray obtained by the facility on 12/5/13 indicated a metallic object in the resident's stomach and the resident was transferred to the hospital. She said the nursing staff had knowledge that the resident underwent [REDACTED]. S2DON stated that Resident #3 was supervised by being placed in "common" areas of the facility. She stated common areas were areas within the facility that staff pass through frequently and were able to observe residents. She said examples of common areas were the day rooms, dining rooms, and near the nurses' stations. S2DON reviewed Resident #3's clinical record and verified the resident was ordered bilateral hand mittens since 3/16/13. She stated the resident's mittens should still be in the facility because he was the only resident with orders to wear hand mittens. She said the resident was ordered to wear mittens because he would hit on the lap tray a

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for: a. 1 (#3) of 4 (#1, #2, #3, #7) sampled residents reviewed that was NPO from a total of 5 residents reviewed with percutaneous endoscopic gastrostomy (PEG) tubes (#1, #2, #3, #7, #8); b. 1 (#3) of 1 (#3) sampled residents reviewed with physician orders [REDACTED]. c. 1 (#4) of 5 sampled residents (#4, #5, #6, #9, #10) reviewed for elopement from a total of 11 elopement risk residents that resided in the general population (#4, #5, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6, #R7). The facility failed to: 1. Ensure a resident that was NPO and had a history of [REDACTED].#3); 2. Ensure assistive devices (mittens) were utilized to assist in preventing the resident from placing non-edible items in his mouth (#3); 3. Ensure a resident identified as an elopement risk was adequately supervised to prevent the resident from eloping from the facility (#4); 4. Ensure immediate interventions were implemented to increase monitoring and supervision for remaining elopement risk residents that resided in the general population (#5, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6, #R7); 5. Ensure that 5 (DR#2, DR#3, DR#5, DR#6, DR#7) of 7 doors (DR#1-DR#7) that did not have the wander-guard system were monitored to prevent the remaining elopement risk residents that resided in the general population from elopement (#5, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6, #R7); 6. Ensure a door (DR#6) was monitored when it was identified that it was not properly locking on 12/23/2013 through 12/30/2013. This resulted in Resident #3 being placed in an Immediate Jeopardy situation when the facility failed to ensure the resident was supervised and assistive devices (mittens) were utilized to assist in preventing the resident from swallowing foreign objects. The Immediate Jeopardy began on 12/5/13 at 2 p.m. when Resident #3 was found to have chest congestion. A chest x-ray was obtained on 12/5/13 at 3:36 p.m. that indicated "metallic foreign bodies situated in the stomach". The resident was transferred to the hospital. While hospitalized , Resident #3 underwent two surgical procedures to remove a large mass of foreign material from the stomach. The Immediate Jeopardy ended on 12/5/13 at 5 p.m. when Resident #3 was transferred to the hospital. The deficient practice remains as an isolated, actual harm for Resident #3. S1Administrator and S2DON were notified of the Immediate Jeopardy situation for Resident #3 on 1/3/14 at 2:35 p.m. Resident #4 was placed in an Immediate Jeopardy Situation when he eloped from the facility on 12/22/2013 at approximately 4:15 p.m. and was not located until 12/23/2013 at 2:33 a.m. He was noticed by random bystanders to be wandering the streets and stumbling around. EMS (Emergency Medical Service) was then notified and called to the scene where they found the resident was soaking wet and violently shivering. The resident was admitted to a local ER (emergency room ) with Hypothermia with Abnormal Lab Values, Clouded Consciousness, Acute Confusion, Acute renal failure syndrome and Hyperkalemia. According to hospital records, the weather the night the resident eloped was raining with a temperature of approximately 40 degrees Fahrenheit. While the resident was in the ER, he underwent a septic work up that included venous puncture blood draws to obtain a CBC (Complete Blood Count), CMP (Complete Metabolic Panel) and Blood Cultures. Resident #4 also received warming therapy, was treated with IV (intravenous) fluid hydration, Intravenous Calcium Gluconate and multiple diagnostic tests that included a Chest X-Ray, EKG (Electrocardiogram) and Urine Cultures. The lab work obtained in the ER revealed a Critical High Potassium Level of 6.5 mEq/L (milliequivillants/Liter) for which he received Intravenous Insulin. He was also found to have a Critical Low Glucose Level of 41 mg/dL (milligrams/deciliter) for which he received Intravenous Dextrose 50%. S1Administrator was notified of the Immediate Jeopardy situation on 1/3/2014 at 2:35 p.m. The Immediate Jeopardy was lifted for Resident #4 on 12/23/2013 at 4:15 a.m. when the facility was notified by the hospital he had been located and admitted to the ER. The Immediate Jeopardy remained in place for 10 other residents residing in the general population of facility that were identified by the facility as an elopement risk until 1/3/2014 at 4:30 p.m. when the facility presented an acceptable plan of removal that included: 1. Each resident at risk for elopement had been reassessed as of the 12/30/2013. 2. A full census check would be done at the end of each shift. 3. Staff was in-serviced for close supervision, checking doors, when to notify MD(Medical Doctor)/Administration, when to place a resident on elopement precautions, communicating with team, prevention of abuse/neglect/mistreatment. Nurses received a separate in-service by the RDCO and DON in include med admin, close observation, notifying DON/Admin. 4. The Social Worker was in-serviced for administering the BIMS. 5. The residents on elopement risk are being checked Q 1 hour. 6. Administration will make frequent rounds to check the doors to ensure they are secure. 7. The door at the back with a time lapse to lock has been repaired. 8. An estimate would be obtained to place the Wander-guard device on every door. Until then, staff will be posted to monitor any door that goes to the outside (except courtyards). The deficient practice remains at a level 2 pattern for the 10 residents in the general population who were at risk for elopement. Findings: Resident #3 Review of the clinical record revealed Resident #3 was a [AGE] year old male that had [DIAGNOSES REDACTED]. Review of the Casemix / Skilled Nursing Notes dated 12/5/13 included: 2 p.m.: Noted chest congestion upon checking peg for patency - HOB raised higher, feeding stopped. S19NP called new orders for CXR. Review of the chest x-ray results dated 12/5/13 and timed at 3:36 p.m. revealed in part: Single metallic device which appear to represent screw and additional curvilinear small metallic density projected at the left upper abdomen. Review of the Transfer Form revealed in part: To: __ (local hospital) Date: 12/5/13 Resident: ___ (#3) Primary Diagnosis: [REDACTED]. Vital Signs: BP: 124/88, P: 79, R: 18, T: 98.4 Functioning Status: - Bathing: Dependent - Dressing: Dependent - Toileting: Dependent - Transferring: Dependent - Bowel Function: Incontinent, Ostomy, last BM 12/5/13 - Bladder Function: Incontinent - Eating/Feeding: Dependent, Tube Fed - Walking: Dependent Resident left facility at 5 p.m. via stretcher Name of transport provider: Ambulance RP Notified: ___ (sister of Resident #3) on 12/5/13 at 4:20 p.m. Notified by: S12LPN Review of the hospital records included: Emergency Department (ED) notes Visit Date: 12/5/13 17:10 (5:10 p.m.) Primary Diagnosis: [REDACTED]. Chief Complaint: Swallowed foreign body Summary: Pt (patient) is a [AGE] year old who has Mental Retardation. He is a Nursing Home patient who was sent to the ED after swallowing a foreign body. He was trying to eat his armband. Physical Exam: ...Full range of motion in all extremities... KUB Abdomen - Single View: The examination findings are metallic screw in stomach. RN Continuation Notes: 12/5/13 18:00 (6 p.m.): Patient continues to pull monitoring equipment off and chew cords despite therapeutic interventions. Patient chewing wrist band. Piece of paper removed from mouth. New orders received. Soft wrist restraints applied to bilateral upper extremities. Progress Notes: 12/5/13 22:31 (10:31 p.m.) per Medical Doctor (MD): Pt has multiple foreign bodies in the stomach including hay. History and Physical Chief Complaint: Foreign body in stomach. History of Present Illness: A [AGE] year old male with history of [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], seizure disorder, aphasia, dysphasia, gastric tube, and colostomy was sent from Nursing Home for x-ray showing metallic foreign bodies in fundus of the stomach. In the emergency room , they did a chest x-ray which showed a metallic screw over the gastric fundus. Dr. __ (hospital physician) was consulted who did a EGD (Esophagogastroduodenoscopy) and found copious amounts of paper, trash, and straws in the stomach but did not find a screw. He states that he went in and out of the pharynx and the esophagus many times over the course of 2 hours and only managed to remove one-third of the contents. States that he is concerned that with all this gastric content, the patient would develop pressure necrosis. States that he is an aspiration risk and also that the arytenoids are quite swollen from the in and out EGD. He said it was prudent to leave the patient intubated and thus ICU (Intensive Care Unit) was consulted for ventilator management. Assessment: A [AGE] year old male with mental retardation, pica and foreign bodies in the gastric fundus. Operative Report Date: 12/5/13 Procedure: Esophagogastroduodenoscopy Indications: Foreign body in the stomach. The patient swallowed a metallic screw. In the stomach, could see copious amounts of foreign objects. There was no actual food or food debris. There was plastic and paper. There was evidence of a sponge. There were multiple plastic straws. The metallic screw itself was probably within this mass of foreign debris. We (hospital staff) worked for approximately 2 hours removing parts of plastic. We (hospital staff) removed plastic wrap. There were parts of sponge and possibly a Brillo pad. After 2 hours, only a third of the material was removed. The mucosa of the stomach esophagus was markedly edematous and friable (easily broken) and had some oozing. At this point the procedure was terminated. Impression: Copious amounts of foreign material in the stomach. Only part of material removed after 2 hours. Recommendations: The patient will remain intubated and will go to the ICU. Surgical consultation. Operative Report Date: 12/6/13 Preoperative Diagnosis: [REDACTED]. Operative Procedure: Laparotomy, gastrotomy and removal of multiple gastric foreign bodies, excision of gastrocutaneous fistula and closure, and new gastrostomy tube placement. Anesthesia: General endotracheal anesthesia Clinical Indications: The patient is a mentally challenged [AGE] year old male who apparently eats multiple foreign bodies. He was admitted to the hospital and evaluated after a metallic bolt was found on x-ray. The patient was taken to endoscopy and found to have large gastric bezoar with multiple foreign bodies. An attempt was made by the endoscopist to remove portions of the foreign body without complete success. He was subsequently scheduled for a laparotomy. Operative Procedure: ...Multiple pieces of foreign bodies including paper, plastic, metallic bolt, cloth-like material and other trash and debris as well as hair was removed from the stomach. This filled a medium sized bucket. There was [DIAGNOSES REDACTED] to the lining of the gastric mucosa... Surgical Pathology Report Date Collected: 12/7/13 Specimen: Stomach contents foreign bodies: Received 15 cm (centimeter) aggregate of hair, gloves, sponges, metallic nails, and plastic tubing admixed with normal gastric secretions. Further review of the hospital records revealed Resident #3 underwent two more procedures. One on 12/8/13 and another on 12/23/13. The resident was returned to the Intensive Care Unit following the 12/23/13 procedure. During the onsite investigation, Resident #3 remained in the hospital. Review of the quarterly MDS with ARD of 9/24/13 revealed Resident #3 had severe cognitive impairment with behaviors of delirium, inattention, continuously present. The resident required one person, total assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, personal hygiene, eating, and bathing. The resident had impaired range of motion to both upper and lower extremities. He was always incontinent of bladder and had an ostomy for bowel. Resident #3 had a swallowing disorder and received nutrition via tube feeding. Review of the Care Plan included: Problem Onset: 9/24/13 Problem: Potential for injury - limb restraint, resident requires bilateral hand mittens at this time due to pulling PEG tube. Goal & Target Date: 12/22/13 Approaches: - Apply limb restraint as ordered by the physician - Check on resident at least every 30 minutes Problem Onset: "12/30/1899" Problem: Episodes of delirium as manifested by inattention, yelling aloud, and banging on wheelchair lap tray, pulling items off of tables, walls in day room Goal & Target Date: 12/22/13 Approaches: - 3/16/13: Hand mitten to bilateral hands Problem Onset: "12/30/1899" Problem: Socially inappropriate/disruptive behavior related to mental retardation as evidenced by smiling and yelling loudly when redirected by staff. Resident has history of pulling things down in the lobby area. Goal & Target Date: 12/22/13 Approaches: - Place resident in area where constant observation is possible. Review of the Nurse's Notes revealed in part: 2/8/13 at 12:06 p.m.: LPN, assigned nurse, walked in patient's room to find him chewing. LPN assessed patient only to find his colostomy bag was not attached to his stoma. Searched the bed and the room and the colostomy bag was not found. Incident reported to S2DON and Nurse Practitioner. 3/16/13 at 1:15 p.m.: Resident's colostomy bag has been changed four times due to him pulling them off and trying to eat them. Notified Nurse Practitioner and gave order for bilateral hand mittens. 4/4/13 at 10:15 a.m.: ... wears mittens to bilateral hands due to resident trying to put fingers in mouth and chew them... 4/14/13 (time illegible): ... Resident propels gerichair about hall and room... 5/14/13 at 9 a.m.: ... noisy, moving about in w/c (wheelchair)... 6/11/13 at 8:10 p.m.: CNA reported resident had pulled his peg tube out of his stomach... 7/1/13 at 1 p.m.: Called to room per CNA. Resident pulled peg tube out... 7/6/13 at 5 p.m.: Frequently pushing tray (lap tray) to floor today... 7/9/13 at 9:45 p.m.: Reported by CNA that resident was on floor in room E. Resident had been moved for night secondary to maintenance in room C. Upon assessment noted 3 cm (centimeter) hematoma above left eye. 7/13/13 at 11 p.m.: ...[DEVICE] out, colostomy bag removed by resident. Mittens on bed. Resident asked to spit object out of mouth which appeared to be plastic... 7/14/13 at 12:45 a.m.: ...hands covered with two pair of socks... 7/25/13 at 8 p.m.: Noted [DEVICE] lying on resident's abdomen... Attempted [DEVICE] reinsertion, found insertion area had closed... 8/22/13 at 2 p.m.: Entered resident's room and noted resident with peg tube in hand... 8/22/13 at 8 p.m.: Found [DEVICE] lying on resident's abdomen. Balloon completely deflated. Stoma closed. 8/23/13 at 6:30 a.m.: Noted resident's peg tube out of place. 8/24/13 at 2:05 (a.m./p.m. not indicated): Resident sitting in gerichair in day room. Noted abdomen binder and dressing removed and put at the side. Peg tub lying down on his abdomen out of place. 8/25/13 at 9:24 a.m.: CNA notified nurse that resident's peg tube fell off when she removed the abd (abdomen) binder. 8/31/13 at 12:08 a.m.: Resident noted on floor by bedside... 9/1/13 (no time): Resident was noted standing naked by the bed. He was holding on the rail. Nurse was summoned by housekeeper. Nurse went into room and got resident dressed, put him in the gerichair and brought him to the day room. 9/1/13 (no time): Reported by resident that he was eating the tape. Nurse took resident into the room. Noted peg tube lying on his abdomen. Peg site closed. 9/22/13 at 6 p.m.: Sitting in gerichair in room. Noted pulling over bedside table in room from gerichair. Staff redirected and moved to hallway... Review of the Physician order [REDACTED]. NPO (nothing by mouth) Jevity 1.5 - two cans per PEG tube three times daily Flush PEG tube with 250ml of water four times daily Hand mittens to bilateral hands - monitor skin every shift An interview was held with S12LPN on 12/30/13 at 1:35 p.m. She stated she did not routinely work with Resident #3 and on 12/5/13, she was filling in for a nurse that had called in. She stated when she went to give Resident #3 his tube feeding, she noticed that he had chest congestion. She said she raised the head of the bed more and called for S20ADON to assess the resident as well. She said S20ADON assessed Resident #3 and observed the chest congestion as well. S12LPN stated she called S19NP and received an order for [REDACTED]. She said the resident was then transferred to the hospital where he has remained since 12/5/13. S12LPN stated Resident #3 had behaviors of yelling out loud and banging on the lap tray that was attached to the gerichair he used for mobility. She stated the resident would grab at things around him, but she had never observed the resident put anything in his mouth. She stated at one time the resident wore hand mittens but she was unsure as to what happened to the mittens. She stated she had made rounds to check on the resident approximately every 1- 2 hours on 12/5/13. On 12/30/13 at 1:45 p.m., an interview was held with S13CNA. She recalled providing care to Resident #3 when the resident resided in room D. She stated she had cared for the resident on both day and evening shifts. She described Resident #3 as having behaviors of yelling out loud, hitting the lap tray that was on his chair, grabbing at anything around him, pulling things off of the walls, turning things over, etc. She stated the resident would put anything he could reach in his mouth. She said he wore hand mittens at one time, but the mittens had to be thrown away because the resident had chewed holes in them and the stuffing was coming out. She said she couldn't remember the nurse's name but the nurse told her that she would have to order the resident more mittens and to put socks on the resident's hands until the mittens were received. S13CNA stated the mittens were discarded several months ago. She stated she did as the nurse directed her to do, but the resident could take the socks off his hands. She said to mittens were not replaced prior to the resident moving to another room on another hall. She stated the resident changed rooms several months ago. S13CNA stated that when she cared for Resident #3, she made rounds to check on the resident every 1-2 hours. An interview was held with S3CNA on 12/30/13 at 1:50 p.m. S3CNA stated she had provided care to Resident #3 while he resided on both A and B halls. She described Resident #3 to have behaviors of yelling loudly, hitting on his chair, and grabbing at others. She stated the resident's chair had a lap tray and the resident would hit on the tray repetitively. She recalled the resident having hand mittens at one time but further stated she did not know what happened to the mittens. She said the mittens were to prevent the resident from eating things that he was not supposed to eat. S3CNA stated that she made rounds to check on Resident #3 every 1 1/2 - 2 hours when she was assigned to him. On 12/30/13 at 1:55 p.m., an interview was held with S8CNA. S8CNA stated Resident #3 had behaviors of hitting on the lap tray and yelling out loud. S8CNA said the resident liked attention from staff and would calm if staff spoke to him or propelled him in his chair. S8CNA said the resident also would grab at people or things surrounding him and therefore had to be placed away from others and objects. S8 stated the resident wore hand mittens at one time but had chewed on the mittens, creating a hole and therefore the mittens were thrown away. S8 said the resident was moved to another room and was unsure if the mittens were replaced. S8CNA stated rounds were made to check on Resident #3 every hour. An interview was held with S16CNA on 12/30/13 at 2:05 p.m. S16CNA stated she was familiar with Resident #3 and had worked with the resident routinely prior to his transfer to the hospital. S16CNA stated Resident #3 frequently yelled out loud and hit on the lap tray. She said the resident was able to move the chair without staff assistance. She stated the resident had a history of [REDACTED]. She stated in the past, she had found Resident #3 chewing on his colostomy bag. She said she immediately notified the nurse. S16CNA could not recall the nurse's name she had notified, but said the nurses were well aware the resident would put foreign objects in his mouth. S16CNA stated she made rounds to check on Resident #3 approximately every 30 minutes to one hour. She stated sometimes the resident would be in his room and sometimes the resident would be sitting in the day room. She recalled Resident #3 having hand mittens at one time but further stated she did not know what happened to the mittens. On 12/30/13 at 2:35 p.m. an interview was held with S17LPN. S17LPN stated he was a routine nurse that provided care to Resident #3 during the evening shifts. S17LPN said Resident #3 would usually be up in the chair upon his arrival around 2 p.m. He stated the resident had behaviors of yelling, hitting on the lap tray attached to his chair, grabbing at others / things surrounding him and putting things in his mouth. He stated the resident would be placed in the day room or in front of the front nurses' station so staff could watch him as much as possible. S17LPN said the resident would remain in the chair until around 8 p.m. and then the staff would place him in the bed. He said the resident would tear at his incontinent brief so bad that he eventually instructed the CNAs to stop putting the briefs on him. He said he never found the resident eating the incontinent brief but he had a history of [REDACTED]. S17LPN stated the staff made rounds to check on residents every two hours. S17LPN stated Resident #3 wore bilateral hand mittens at one time but he was unsure what had happened to the mittens. He said he thought he remembered the resident having the mittens on at different times. During the interview, observed two medication carts placed in front of the front nurses' station that S17LPN had indicated Resident #3 had been placed at for observation. The medication carts contained straws, plastic cups, and paper items. S17LPN stated the medication carts were maintained in that area when they were not in use. When S17LPN asked if Resident #3 could have obtained any of the plastic/paper items from the medication carts when he was placed near them, S17LPN stated he could not say for certain if the resident had gotten items off of the medication carts because staff were "coming and going" from the nurses' station but it was a possibility. He stated S2DON and the nurse practitioner were aware of Resident #3's behaviors. An interview was held with S14LPN at 2:50 p.m. on 12/30/13. S14LPN stated she had routinely cared for Resident #3 during the evening shifts. She stated Resident #3 had behaviors that included yelling, hitting on his chair, and pulling his peg tube/colostomy. S14LPN said the resident had a history of [REDACTED]. She stated she was certain this had been reported to the DON and the nurse practitioner. She stated the resident had bilateral hand mittens. She said the resident did chew on the mittens. She could not recall if the mittens were torn or had holes from the resident chewing on them. S14LPN stated she made rounds to check on the resident hourly. She said sometimes the resident would be sitting in his room and other times he would be in the day room or near the front nurses' station. An interview was held with S18LPN on 1/2/14 at 9:05 a.m. She said she started working in the facility with Resident #3 in March 2013. She said she worked with the resident mostly weekends on Saturdays and Sundays from 2 p.m. - 6 a.m. She said the resident was nonverbal, but he seemed to understand when you talked to him. She said the resident was usually up in the gerichair by the nurses' station when she arrived to the facility at 2:00 p.m. She said the resident had attention seeking behaviors of pulling on his shirt and banging his hands on the lap tray of the gerichair. She said he would stop banging on the lap tray when a staff member approached and spoke to him, but would continue the behavior when the staff member walked away. She said the resident liked attention from the staff. She said he enjoyed being rolled around in his gerichair. She said the staff would put the resident to bed at 5:00 p.m. She said she would provide his feeding at this time as well. She said the resident would try to grab the syringe and the tubing but he would let go if she talked to him. She said she had frequently seen the resident pull on his incontinent brief, but only once on his colostomy bag. She recalled the resident wearing hand mittens and stated he would chew on them. She said the resident could wiggle his hands out of his mittens. She said she had not seen him eat or swallow anything. She said she did not report the resident's behavior to anybody because he had not sustained any injuries and because she thought the resident's behaviors were normal due to his mental retardation. She said the resident needed extra attention. An interview was held with Resident #R8 on 1/2/14 at 9:45 a.m. Resident #R8 was alert and oriented throughout the entire interview. Resident #R8 recalled Resident #3 and indicated that he and Resident #3 used to reside near one another in the facility. Resident #R8 stated that Resident #3 would yell out loudly and bang on the tray of his chair as long as he was in the chair. He stated the staff did not watch Resident #3. He said the resident would put anything he could get his hands on in his mouth. He said the staff would just put the resident in his room, close the door, and leave him. He said Resident #3's family visited several times and complained about the resident being alone in his room. Review of quarterly MDS with ARD 10/8/13 revealed Resident #R8 had a BIMS score of 14. This indicated Resident #R8 was cognitively intact. On 1/2/14 at 10:05 a.m., an interview was held with Resident #R9. Throughout the interview, Resident #R9 remained alert and oriented. Resident #R9 stated that he and Resident #3 were roommates for a couple of months. He stated Resident #3 was eventually moved to another room but some of his personal belongings still remained in his room. He indicated hanging clothes and shoes on the other side of the room that belonged to Resident #3. He stated Resident #3 was moved to another room because the resident was always getting into his personal belongings. Resident #R9 further explained that he could not leave anything out because Resident #3 would eat it. He said, "he would eat anything". Resident #R9 demonstrated with a plastic spoon. He stated, "Ma'am, if I left this lying on my table, the man would eat it." He stated the resident would eat buttons from clothing, paper, plastic, etc. He stated the resident would even chew on clothing and try to eat that. Resident #R9 stated the nursing staff were aware of the resident's behaviors of eating non-edible materials. He stated he had seen the staff remove things from the resident's mouth and hands. Resident #R9 said he could not recall specific times and incidents of Resident #3 eating foreign materials because it was a continuous behavior. Resident #R9 stated, "if he could reach it, it was going straight to his mouth". Resident #R9 stated he don't remember Resident #3 wearing mittens when he resided in the room with him. He said the resident made a lot of noise by yelling and banging on the tray attached to the chair he sat in. He stated the staff would leave the resident in the room at times and then sometimes they would bring him to the day room area. During the interview, observed the room that was shared between Resident #R9 and Resident #3. Resident #R9 had plastic utensils, straws, plastic cups, styrofoam cups and snacks wrapped in plastic wrap scattered on the bedside table, over bed table, and bathroom sink. Resident #R9 confirmed during interview that he maintained his side of the room in the same manner as noted during the observation when Resident #3 roomed with him. Review of annual MDS with ARD 12/3/13 revealed Resident #R9 had a BIMS score of 13. This indicated Resident #R9 was cognitively intact. On 1/2/14 at 11 a.m. an interview was held with S20ADON. She recalled being called to Resident #3's room on 12/5/13 by S12LPN. She stated she assessed Resident #3 and found the resident to have some chest congestion. She said she instructed S12LPN to notify S19NP. She said S19NP ordered a chest x-ray. She said the chest x-ray indicated something metallic in the resident's upper stomach. She said the resident was transferred to the hospital once the results were received. S20ADON stated Resident #3 had behaviors of yelling loudly and hitting on his lap tray. She said she was not aware of behaviors that included the resident eating foreign materials. An interview was held with S26LPN on 1/2/14 at 2 p.m. S26LPN stated she was familiar with Resident #3 and had provided care to the resident on the evening and night shifts. She stated she could not remember if Resident #3 wore hand mittens. She recalled when she would provide the resident with feedings and medications through the PEG tube, he would try to pull at the tube. She said when he would do this, she would stop and return at another time when the resident had calmed down. S26LPN stated the resident was usually in the bed when she cared for him. She stated she had not witnessed him placing anything in his mouth but verified the resident had full range of motion of his hands and arms. She stated she made rounds to check on the resident every two hours. She stated S2DON and the nurse practitioner were aware of Resident #3's behaviors. On 1/2/14 at 2:30 p.m., an interview was held with S2DON. She stated she had been employed as the facility's Director of Nursing for approximately one year. She stated Resident #3 had behaviors that included banging on the lap tray and yelling out at times. She stated the behaviors were not constantly and occurred only at intervals. She stated Resident #3 had full range of motion of his extremities. She stated she was not aware of Resident #3 having behaviors of placing foreign materials in his mouth and/or eating non-edible items. She said she had not been made aware of those behaviors. S2DON confirmed an x-ray obtained by the facility on 12/5/13 indicated a metallic object in the resident's stomach and the resident was transferred to the hospital. She said the nursing staff had knowledge that the resident underwent [REDACTED]. S2DON stated that Resident #3 was supervised by being placed in "common" areas of the facility. She stated common areas were areas within the facility that staff pass through frequently and were able to observe residents. She said examples of common areas were the day rooms, dining rooms, and near the nurses' stations. S2DON reviewed Resident #3's clinical record and verified the resident was ordered bilateral hand mittens since 3/16/13. She stated the resident's mittens should still be in the facility because he was the only resident with orders to wear hand mittens. She said the resident was ordered to wear mittens because he

Based on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of quality for 1 (#2) of 5 (#1-#5) residents who were reviewed for elopement. Twelve residents (#1- #12), in the general population, were identified by the facility as an elopement risk. The facility failed to ensure: 1. A wheelchair bound resident who was assessed as at risk for elopement was provided increased supervision and monitoring. 2. The LPN provided care according to a resident's plan of care during the LPN ' s 8 hour shift. 3. Staff knew to report a resident as missing and attempt to locate a resident when the resident was not seen in the facility by the LPN (Licensed Practical Nurse) or CNA (Certified Nursing Assistant) for 8 hours. 4. A resident who required extensive assistance with ADL ' s was provided care by the CNA during an 8 hours shift. 5. Staff promptly followed facility policy and procedures for elopement when a resident, who was known to be an elopement risk, was seen leaving the premises by reporting the information to the Charge Nurse or Director of Nursing 6. Staff began looking for a resident who was seen leaving the premises before eight hours had elapsed. This resulted in an Immediate Jeopardy situation for Resident#2 on 12/4/13 at 1:57 p.m. when S4CNA reported to work and was assigned the care of Resident#2. S4CNA had observed Resident#2 off the premises of the facility when reporting to work and did not notify the Charge Nurse or the DON. The CNA did not see the resident the entire 8 hour shift and left the facility at 10:01 p.m. without providing care to the resident or informing anyone the resident had not been seen for the 8 hours he was assigned to him. S3LPN was assigned the resident from 2:00 p.m. until 10:00 p.m. on 12/4/13. The LPN did not give Resident#2 his medications that were ordered, did not see him the entire 8 hour shift, did not notify anyone that he had not seen the resident for 8 hours and did not begin a search for the resident until 10:00 p.m. after the night shift questioned the resident ' s whereabouts. The resident was found by an unknown person at a local fast food restaurant located 0.68 miles from the facility. In order for Resident #2, who was wheelchair bound, to reach the restaurant, he had to cross a busy 6 lane highway. A passerby called an ambulance and the resident was admitted to the hospital as a "John Doe" with a [DIAGNOSES REDACTED]. The resident's blood alcohol level was 324.3 mg/dl (milligrams/deciliter). Levels greater than 100mg/dl indicate toxic levels. The staff of the facility did not locate and identify the resident until 12/5/13 at 12:35 a.m. The S1Administrator was notified of the Immediate Jeopardy situation on 12/13/13 at 4:55 p.m. The Immediate Jeopardy situation ended for Resident#2 on 12/5/13 at 12:35 a.m. when the facility located the resident at a local hospital. The IJ situation remained in place for the other 11 residents in the general population, identified by the facility as an elopement risk, until 12/16/13 at 3:50 p.m. once the facility presented an acceptable plan of removal which included: 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Resident was placed the on the secure unit without any other issues. 2. How will you identify other residents having potential to be affected by the same practice and what corrective action will be taken: Each resident has the potential to be affected. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: In-service Nurses/CNA's on making rounds at least every 2 hours. In-service nurses/CNAs notification of DON/CN (Charge Nurse) of any resident not in the building. In-service nurses if resident is not available for medications at designated times, then staff have to locate the resident. In-service nurses/CNA's on wandering and elopement policies. Staff that has not been in-serviced will be prior to returning to work. 4. How the corrective actions will be monitored to ensure the practice will not recur, i.e. what quality assurance program will be put into place. DON/Designee will randomly round by observation to ensure rounds are done every 2 hours weekly X 2 weeks then randomly. DON/Designee will review ADL flow sheets to ensure the documentation of rounds are done. The deficient practice remains at a level 2 pattern for the 11 residents in the general population who were at risk for elopement. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part: 3. ...development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self-awareness, sound judgment, prudence, ethical thing and behaviors, problem solving and critical thinking abilities... 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to: the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team... Review of the facility ' s policy and procedure entitled Elopements revealed the following, in part: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary, and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident had left the premises ... Review of the clinical record for Resident#2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident#2 ' s most recent MDS (Minimum Data Set), with an ADR (Assessment Reference Date) of 9/17/13, revealed the resident was assessed as having a BIMS (Brief Interview for Mental Status) score of 12 (moderately impaired). The MDS also revealed the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The resident ' s mobility device was coded as a wheelchair. The resident had limitation of range of motion impairment in his upper and lower extremities on one side. Review of Resident#2's Risk Assessment for Elopement revealed the following (Elopement risk if score is 10 or greater): Date: 6/18/13 Score 6 Date: 9/17/13 Score 6 Date 11/21/13 Score 16 (If at risk, interventions implemented to attempt to prevent elopement): Left facility without signing out. Wife brought him back to facility. Wanderguard bracelet placed. Review of the resident's care plan revealed, in part, the following: Problem Onset: 11/21/13 Problem/Need: Resident has history of wandering, with attempt to elope facility grounds. Goal and target date: Resident will not elope from the facility grounds. Resident will suffer no injury if elopes from facility (3/18/14). Approaches: Place monitoring device on resident that sounds alarms when resident leaves building. Alert staff to resident ' s wandering behavior. Approach resident in calm, accepting manner. Note which exits resident favors for elopement from facility. Alert staff working near those areas. If resident elopes from facility, implement facility protocol for locating resident. Social Services to evaluate resident quarterly and as needed. Activities staff to visit with resident and provide divisional activities. 11/23/13: Refused Wanderguard. Would not allow staff to replace. 12/5/13: Place on secure unit. Problem Onset: 7/11/13 Problem/Need: Demonstrates cognitive loss as evidenced by BIMS score Goal and target date: Resident will remain alert and oriented to person and clinical setting through next review (3/18/14) ... Problem Onset: 7/11/13 Problem/Need: Potential for skin breakdown secondary to bowel incontinence and needs assistance with ADL's/Transfers. Goal and Target Date: Maintain intact skin integrity by next review date. 3/18/14 Approaches: Assist with ADL's as needed. Provide diet as ordered. Record food intake %..., Problem Onset: 7/11/13 Problem/Need: Resident at risk for injury related to [MEDICAL CONDITION] disorder Goal and Target Date: Resident will suffer no injury related to [MEDICAL CONDITION] through next review date. Resident will not experience any [MEDICAL CONDITION] activity through next review date. 3/18/14. Approaches: Administer resident ' s anticonvulsant medication as ordered. Protect resident from injury during witnessed [MEDICAL CONDITION] ... Problem Onset: 7/11/13 Problem/Need: At risk for acute cardio- or cerebro-vascular complications/altered fluid balance related to hypertension. Goal and Target Date: Resident will remain free from acute cardio- cerebro-vascular complication through next review date. 3/18/14 Approaches: ...Administer medications as ordered by physician. Observe for and report signs/symptoms of acute cardio-cerebro-vascular complications-altered mental status, chest pain, headache, shortness of breath, cool/clammy skin, evidence of poor peripheral perfusion, asymmetrical facial expressions, and numbness in extremities. Etc. Problem Onset: 7/11/13 Problem/Need: At risk for behavioral disturbances, delusion, hallucinations, disordered thinking and speech secondary to [MEDICAL CONDITION]. Goal and Target Date: Resident will have complications minimized through next review date. 3/18/13 Approaches: Administer medication as ordered ...Observe for effectiveness ... Review of the facility's Incident Accident Tracking Log for December 2013 revealed the following, in part: Resident#2: Date of Incident 12/4/13. Time of Incident 10:30 p.m. Type of Incident: Elopement ... Review of Resident#2's Resident Incident Report completed by S5LPN and dated 12/4/13 at 10:20 p.m. revealed, in part, the following: Location of Occurrence: Resident left facility ... Narrative of incident and description of injuries: 10:20 p.m. LPN making round. Resident noted not in bed. Search made unable to locate resident. Call placed to local hospitals. Resident found at ER (emergency room ) at local hospital. Report per ER nurse. Resident had fallen forward out of wheelchair on parking lot of fast food restaurant. Assessment made no injury. Review of the Incident Witness Statement completed by S7CNA revealed the following: Incident type: Elopement. Statement: I came to work at 10:00 p.m. Did my rounds and discovered Resident#2 was not in his room. I walked around the nursing home and he wasn ' t nowhere in here. I figure he was out on pass so I asked the 2-10 nurse where he was and he said he not in bed. I said no so we did a room to room of the nursing home and still no Resident#2. Review of Resident#2 ' s Resident Incident Follow-up Report dated 12/4/13 revealed in part, the following: Incident type: Elopement. Mobility: Wheelchair/Self. Mental: No change in mentation noted. 24 hour condition and injury appearance: Up in w/c (wheelchair) seated quietly. No s/s (signs or symptoms) of pain noted. No behaviors present at this time. Additional follow-ups: Transferred to secured unit due to refusal to comply with wearing Wanderguard ... Review of the nurses ' notes for Resident#2 revealed the following, in part: 12/4/13 10:00 p.m. Making rounds noted resident not in room at this time. Did not see resident on premises ... Room search initiated. Unable to locate resident. Also searched around building and in local vicinity. Unable to locate resident. Resident ' s spouse called. Stated she had not seen or heard from resident. Signed by S3LPN 12/4/13 10:45 pm. Police called. Officer B______ responded. Face sheet and photograph of resident given to officer ... Officer stated they will attempt to locate resident. Signed by S3LPN 12/5/13. 12:10 a.m. Call placed to local hospitals. Noted missing person admitted to ER at local hospital (name of hospital) spoke with nurse K_____RN (Registered Nurse). 12/5/13 12:35 a.m. Noted resident found lying on stretcher bed in ER section ... IV 0.9NS (normal saline) going left arm. O2 (Oxygen) at 2l per N/C (2 liters per minute nasal cannula). Resident could be D/C ' ed (discharged ). ER nurse K______ reported resident found in parking lot near fast food restaurant (name of restaurant) .... Report resident noted fallen from w/c forward on parking lot .... Dx. (Diagnosis) acute [MEDICAL CONDITION] and [MEDICAL CONDITION] .... 12/5/13 1:25 a.m. Resident discharged from local hospital (named) ... Review of Resident#2's Emergency Department Chart dated 12/4/13 revealed, in part, the following: Arrival Date: 12/4/13 16:09 (4:09 p.m.) Physician ' s progress notes: Primary Diagnoses: [REDACTED]. 1. History of fall 2. Continuous chronic alcoholism 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION] disorder Chief Complaint 1. Fall History of Present illness: Summary: Patient fell out of his wheelchair and had what witnesses described as a [MEDICAL CONDITION]. History is very limited. HPI (History of Present Illness): Exam started at 16:15 (4:15 p.m.). Unreliable history concerning any possible head injury. Injury can be coded as occurring in a transportation environs. Complete history not available. Some of the history is supplied by the ambulance crew. Presenting problem started minutes ago. Patient "just" fell -no identified proximate cause. Underlying neurologic deficit leads to chronic falls. The patient is a chronic alcoholic, who is at risk for multiple falls and unreported head injuries. Other Vital Signs: Glasgow Coma Scale: 12/4/13 7:16 p.m. 9-Vocalizes no words, localizes noxious stimuli, opens eyes to noxious stimuli-very marked mental status change. 12/4/13 11:51 p.m. 12-Confused not fully oriented, localizes noxious stimuli opens eyes to speech. Medication Ordered: Banana Bag: 1 liter Normal Saline, Magnesium Sulfate 2 grams, 1000 ml Intravenous bolus, add [MEDICATION NAME] 100 milligrams and Folate 1 milligram. B12 1000 micrograms intramuscular 1000 milliliters of Normal Saline Intravenous Bolus Review of the Non-Medication orders revealed the resident received CT (computerized tomography) scans, x-rays, blood work, and urine screens. Resident#2's blood alcohol ([MEDICATION NAME]) level at 5:50 p.m. on 12/4/13 was 324.3mg/dl (milligrams/deciliter). Levels greater than 100 mg/dl = Toxic. Resident#2 left the hospital Emergency department on 12/5/13 at 1:25 a.m. An interview was held on 12/13/13 at 10:30 a.m. with Resident#2 in his room on the secure unit. The resident had difficulty speaking. He was seated in a wheelchair and said he could not move his right arm or leg. Resident#2 was asked about leaving the facility on 12/4/13. He stated he left the facility and did not notify staff he was leaving or sign out. He said he left the facility to get drunk and he " f___d " up. He said he fell out of his wheelchair and ended up in the hospital. He further stated that was not the first time he had left the facility and the staff did not know where he was. An interview was held on 12/13/13 at 11:15 a.m. with S3LPN. He was asked to explain the events that occurred 12/4/13 regarding Resident#2. The LPN stated he was assigned to Resident#2 on 12/4/13 for the 2:00 p.m. to 10:00 p.m. shift. He explained that he did not see the resident during those times because " things were going on " . He said he did not see the resident the entire 8 hour shift, did not give him his medications that were due during that time, did not see him for the supper meal and did not know where the resident was. S3LPN stated when he was ready to leave work on 12/4/13 at 10:00 p.m., the oncoming nurse, S5LPN, asked where the resident was. He stated he told her the resident was not in the facility and a search was begun. He said the resident's wife was called and asked if she knew where Resident#2 was, but she did not. The LPN continued to explain S4CNA who was assigned the resident on the 2:00 p.m. to 10:00 p.m. shift that day had already left when the night shift asked about the missing resident. He said he called the CNA on the telephone to see if he knew the location of the resident. He stated he was told, at that time, by S4CNA that he had seen the resident leaving the facility at about 1:30 p.m. when the CNA was arriving to work on 12/4/13. S3LPN said S4CNA said he had not notified the LPN the resident was leaving the facility because it had "slipped his mind " . S3LPN also said that the incident on 12/4/13 was not the first time the resident left the facility and staff was not aware he had left or where he was. He said the first incident occurred on11/21/13 and a Wanderguard was placed on the resident. The LPN said he found the resident outside of the facility the next day without the Wanderguard on and he tried to put it back but the resident refused to wear it. Review of the MAR (Medication Administration Record) for Resident#2 revealed he was scheduled to receive the following medication at 8:00 p.m. on 12/4/13: [MEDICATION NAME] 500mg (milligrams) - [MEDICAL CONDITION] medication [MEDICATION NAME] 50mg- a blood pressure medication [MEDICATION NAME] 40mg- a cholesterol medication [MEDICATION NAME] 1 mg- an antipsychotic medication Xarelto 15mg- an anticoagulant for the prevention of [MEDICAL CONDITION] Embolism Review of the documentation on the MAR indicated [REDACTED]. (The hospital records showed the resident was in the emergency room from 4:09 p.m. on 12/4/13 until 1:25 a.m. on 12/5/13.) An interview was held on12/13/13 at 2:10 p.m. with S4CNA. S4CNA was asked if he saw Resident#2 during his shift on 12/4/13. The CNA explained he was on his way to the facility that day to work the 2:00 p.m. to 10:00 p.m. shift. He stated he arrived at the facility at about 1:30 p.m. and saw the resident in his wheelchair on the street behind the facility leaving the premises. He continued to explain he was assigned to care for the resident that day during his shift, but he did not look for him, nor did he see him for the entire 8 hour shift. He said the nurse responsible for Resident#2's care that shift never asked about the resident or if he was in the facility. S4CNA said during his shift he never went in the resident's room to check on him because he was busy. He said he did not provide the resident with any care for the 8 hour shift because he did not see the resident. He continued to say that he was unaware if the resident signed out or not that day because that was "the nurse's responsibility". Review of the Case Mix ADL (Activities of Daily Living) Data Tracking Tool by Shift for Resident#2, dated December 2013, revealed no documentation the resident was provided care during 3:00 p.m.-11:00 p.m. for bed mobility, transferring, eating, and toilet use. In an interview on 12/13/13 at 2:45p.m.with S2DON, she stated she was notified on 12/4/13 Resident#2 was missing from the facility after the night nurse did rounds at 10:00 p.m. She stated she became aware at that time the evening shift staff assigned to the resident, S3LPN and S4CNA, had not seen the resident, attempted to look for him or reported him missing from 2:00 p.m. to 10:00 p.m. She continued to say the resident was missing from the premises of the facility for about 8 hours before anyone questioned the whereabouts of the resident. S2DON stated the nurse and CNA should have checked at least every 2 hours for the resident. She said the resident should have been reported missing sooner than 8 hours after he was seen leaving the premises. In an interview on 12/13/13 at 2:55 p.m. with S1Administrator, he stated S2DON notified him after she was told Resident#2 was missing from the facility on 12/4/13. The Administrator said he felt that it was "irresponsible" the LPN and CNA did not look for or report the resident was missing for 8 hours. He said more should have been done when the resident was not on the premises and a "red flag should have been put up sooner in this case". He stated he did not file an OTIS (Online Tracking and Incident System) report related to this incident. A follow up interview was held on 12/13/14 at 3:15 p.m. with S2DON. She stated the resident had left the facility in November 2013 without the staff knowing and had gone to his wife ' s place of business. She said after the incident in November, a Wanderguard was placed on Resident#2 as in intervention for elopement. The DON continued to explain the resident refused the Wanderguard and nothing else was put into place to increase monitoring and supervision of the resident until the resident eloped again on 12/4/13. She said the resident was then placed on the secure unit as an intervention for elopement. A telephone interview was held on 12/16/13 at 10:05 a.m. with Resident#2's wife. She stated she was called at10:56 p.m. on 12/4/13 by the facility staff asking her if she knew where Resident#2 was. She said she asked the staff if they knew where the resident was and was told he had been missing from the facility since 8:00-9:00 p.m. The resident's wife said she spoke to the DON and was told that the resident would be put on the secure unit because he had refused the Wanderguard and if there was no bed available for him on the unit "they would ship him" . Resident#2's wife said the resident had left the facility in November 2013 and the facility was not aware he was missing. She said she was notified by a fast food restaurant that was located 0.6 miles from the facility that the resident was there. She said she went and picked up Resident#2 from the restaurant and brought him back to the facility. She said the staff was not aware where the resident had been. The resident's wife said when the resident left the facility alone she was afraid he would get hurt or hit by a car. In an interview on 12/16/13 at 12:50 p.m. with S5LPN she stated when she reported to work on 12/4/13 for the night shift Resident#2 could not be found. She explained she and the CNA for the night shift checked the hall and did not see the resident. She said when she asked S3LPN were the resident was, he did not know. S5LPN said the resident was located by phone at the hospital. She said she and a CNA had to go to the hospital to identify the resident because the hospital had two unidentified residents listed as " John Doe".

Based on interviews and record review, the facility failed to ensure a resident was free from neglect by failing to provide services including increased monitoring and supervision for 1 (#2) of 5 (#1-#5) residents reviewed for elopement. Twelve residents (#1- #12) in the general population were identified by the facility as an elopement risk. The facility failed to ensure: 1. The resident was provided care and services by the LPN and CNA, including medication administration, for an 8 hour shift. 2. Interventions were put in place to increase monitoring and supervision for a resident who had refused a Wanderguard and had a history of [REDACTED]. 3. The staff promptly implemented the facility Elopement policy by not reporting a resident as missing to the Director of Nursing or Charge Nurse when the resident, who was assessed at risk and care planned for elopement, was seen by staff leaving the premises. 4. The staff knew to report a resident as missing and promptly attempt to locate a resident when the resident was not seen in the facility by the LPN (Licensed Practical Nurse) or CNA (Certified Nursing Assistant) for 8 hours. This resulted in an Immediate Jeopardy situation for Resident#2 on 12/4/13 at 1:57 p.m. when S4CNA reported to work and was assigned the care of Resident#2. S4CNA had observed Resident#2 off the premises of the facility when reporting to work and did not notify the Charge Nurse or the DON. The CNA did not see the resident the entire 8 hour shift and left the facility at 10:01 p.m. without providing care to the resident or informing anyone the resident had not been seen for the 8 hours he was assigned to him. S3LPN was assigned the resident from 2:00 p.m. until 10:00 p.m. on 12/4/13. The LPN did not give Resident#2 his medications that were ordered, did not see him the entire 8 hour shift, did not notify anyone that he had not seen the resident for 8 hours and did not begin a search for the resident until 10:00 p.m. after the night shift questioned the resident's whereabouts. The resident was found by an unknown person at a local fast food restaurant located 0.68 miles from the facility. In order for Resident #2, who was wheelchair bound, to reach the restaurant, he had to cross a busy 6 lane highway. A passerby called an ambulance and the resident was admitted to the hospital as a "John Doe" with a [DIAGNOSES REDACTED]. The resident's blood alcohol level was 324.3 mg/dl (milligrams/deciliter). Levels greater than 100mg/dl indicate toxic levels. The staff of the facility did not locate and identify the resident until 12/5/13 at 12:35 a.m. The S1Administrator was notified of the Immediate Jeopardy situation on 12/13/13 at 4:55 p.m. The Immediate Jeopardy situation ended for Resident#2 on 12/5/13 at 12:35 a.m. when the facility located the resident at a local hospital. The IJ situation remained in place for the other 11 residents in the general population, identified by the facility as an elopement risk, until 12/16/13 at 3:50 p.m. once the facility presented an acceptable plan of removal which included: 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Resident was placed the on the secure unit without any other issues. 2. How will you identify other residents having potential to be affected by the same practice and what corrective action will be taken: Each resident has the potential to be affected. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: In-service Nurses/CNA's on making rounds at least every 2 hours. In-service nurses/CNAs notification of DON/CN (Charge Nurse) of any resident not in the building. In-service nurses if resident is not available for medications at designated times, then staff have to locate the resident. In-service nurses/CNA's on wandering and elopement policies. Staff that has not been in-serviced will be prior to returning to work. 4. How the corrective actions will be monitored to ensure the practice will not recur, i.e. what quality assurance program will be put into place. DON/Designee will randomly round by observation to ensure rounds are done every 2 hours weekly X 2 weeks then randomly. DON/Designee will review ADL flow sheets to ensure the documentation of rounds are done. The deficient practice remains at a level 2 pattern for the 11 residents in the general population who were at risk for elopement. Findings: Review of the facility's policy and procedure entitled Elopements revealed the following, in part: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary, and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident had left the premises ... Review of the clinical record for Resident#2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident#2's most recent MDS (Minimum Data Set), with an ADR (Assessment Reference Date) of 9/17/13, revealed the resident was assessed as having a BIMS (Brief Interview for Mental Status) score of 12 (moderately impaired). The MDS also revealed the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The resident's mobility device was coded as a wheelchair. The resident had limitation of range of motion impairment in his upper and lower extremities on one side. Review of Resident#2's Risk Assessment for Elopement revealed the following (Elopement risk if score is 10 or greater): Date: 6/18/13 Score 6 Date: 9/17/13 Score 6 Date 11/21/13 Score 16 (If at risk, interventions implemented to attempt to prevent elopement): Left facility without signing out. Wife brought him back to facility. Wanderguard bracelet placed. Review of the resident's care plan revealed, in part, the following: Problem Onset: 11/21/13 Problem/Need: Resident has history of wandering, with attempt to elope facility grounds. Goal and target date: Resident will not elope from the facility grounds. Resident will suffer no injury if elopes from facility (3/18/14). Approaches: Place monitoring device on resident that sounds alarms when resident leaves building. Alert staff to resident's wandering behavior. Approach resident in calm, accepting manner. Note which exits resident favors for elopement from facility. Alert staff working near those areas. If resident elopes from facility, implement facility protocol for locating resident. Social Services to evaluate resident quarterly and as needed. Activities staff to visit with resident and provide divisional activities. 11/23/13: Refused Wanderguard. Would not allow staff to replace. 12/5/13: Place on secure unit. Problem Onset: 7/11/13 Problem/Need: Demonstrates cognitive loss as evidenced by BIMS score Goal and target date: Resident will remain alert and oriented to person and clinical setting through next review (3/18/14) ... Problem Onset: 7/11/13 Problem/Need: Potential for skin breakdown secondary to bowel incontinence and needs assistance with ADL's/Transfers. Goal and Target Date: Maintain intact skin integrity by next review date. 3/18/14 Approaches: Assist with ADL's as needed. Provide diet as ordered. Record food intake%..., Problem Onset: 7/11/13 Problem/Need: Resident at risk for injury related to [MEDICAL CONDITION] disorder Goal and Target Date: Resident will suffer no injury related to [MEDICAL CONDITION] through next review date. Resident will not experience any [MEDICAL CONDITION] activity through next review date. 3/18/14. Approaches: Administer resident's anticonvulsant medication as ordered. Protect resident from injury during witnessed [MEDICAL CONDITION] ... Problem Onset: 7/11/13 Problem/Need: At risk for acute cardio- or cerebro-vascular complications/altered fluid balance related to hypertension. Goal and Target Date: Resident will remain free from acute cardio- cerebro-vascular complication through next review date. 3/18/14 Approaches: ...Administer medications as ordered by physician. Observe for and report signs/symptoms of acute cardio-cerebro-vascular complications-altered mental status, chest pain, headache, shortness of breath, cool/clammy skin, evidence of poor peripheral perfusion, asymmetrical facial expressions, and numbness in extremities. Etc. Problem Onset: 7/11/13 Problem/Need: At risk for behavioral disturbances, delusion, hallucinations, disordered thinking and speech secondary to [MEDICAL CONDITION]. Goal and Target Date: Resident will have complications minimized through next review date. 3/18/13 Approaches: Administer medication as ordered ...Observe for effectiveness ... Review of the facility ' s Incident Accident Tracking Log for December 2013 revealed the following, in part: Resident#2: Date of Incident 12/4/13. Time of Incident 10:30 p.m. Type of Incident: Elopement ... Review of Resident#2's Resident Incident Report completed by S5LPN and dated 12/4/13 at 10:20 p.m. revealed, in part, the following: Location of Occurrence: Resident left facility ... Narrative of incident and description of injuries: 10:20 p.m. LPN making round. Resident noted not in bed. Search made unable to locate resident. Call placed to local hospitals. Resident found at ER (emergency room ) at local hospital. Report per ER nurse. Resident had fallen forward out of wheelchair on parking lot of fast food restaurant. Assessment made no injury. Review of the Incident Witness Statement completed by S7CNA revealed the following: Incident type: Elopement. Statement: I came to work at 10:00 p.m. Did my rounds and discovered Resident#2 was not in his room. I walked around the nursing home and he wasn't nowhere in here. I figure he was out on pass so I asked the 2-10 nurse where he was and he said he not in bed. I said no so we did a room to room of the nursing home and still no Resident#2. Review of Resident#2's Resident Incident Follow-up Report dated 12/4/13 revealed in part, the following: Incident type: Elopement. Mobility: Wheelchair/Self. Mental: No change in mentation noted. 24 hour condition and injury appearance: Up in w/c (wheelchair) seated quietly. No s/s (signs or symptoms) of pain noted. No behaviors present at this time. Additional follow-ups: Transferred to secured unit due to refusal to comply with wearing Wanderguard ... Review of the nurses' notes for Resident#2 revealed the following, in part: 12/4/13 10:00 p.m. Making rounds noted resident not in room at this time. Did not see resident on premises ... Room search initiated. Unable to locate resident. Also searched around building and in local vicinity. Unable to locate resident. Resident's spouse called. Stated she had not seen or heard from resident. Signed by S3LPN 12/4/13 10:45 pm. Police called. Officer B______ responded. Face sheet and photograph of resident given to officer ... Officer stated they will attempt to locate resident. Signed by S3LPN 12/5/13. 12:10 a.m. Call placed to local hospitals. Noted missing person admitted to ER at local hospital (name of hospital) spoke with nurse K_____RN (Registered Nurse). 12/5/13 12:35 a.m. Noted resident found lying on stretcher bed in ER section ... IV 0.9NS (normal saline) going left arm. O2 (Oxygen) at 2l per N/C (2 liters per minute nasal cannula). Resident could be D/C ' ed (discharged ). ER nurse K______ reported resident found in parking lot near fast food restaurant (name of restaurant) .... Report resident noted fallen from w/c forward on parking lot .... Dx. (Diagnosis) acute [MEDICAL CONDITION] and [MEDICAL CONDITION] .... 12/5/13 1:25 a.m. Resident discharged from local hospital (named) ... Review of Resident#2's Emergency Department Chart dated 12/4/13 revealed, in part, the following: Arrival Date: 12/4/13 16:09 (4:09 p.m.) Physician ' s progress notes: Primary Diagnoses: [REDACTED]. 1. History of fall 2. Continuous chronic alcoholism 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION] disorder Chief Complaint 1. Fall History of Present illness: Summary: Patient fell out of his wheelchair and had what witnesses described as a [MEDICAL CONDITION]. History is very limited. HPI (History of Present Illness): Exam started at 16:15 (4:15 p.m.). Unreliable history concerning any possible head injury. Injury can be coded as occurring in a transportation environs. Complete history not available. Some of the history is supplied by the ambulance crew. Presenting problem started minutes ago. Patient "just" fell -no identified proximate cause. Underlying neurologic deficit leads to chronic falls. The patient is a chronic alcoholic, who is at risk for multiple falls and unreported head injuries. Other Vital Signs: Glasgow Coma Scale: 12/4/13 7:16 p.m. 9-Vocalizes no words, localizes noxious stimuli, opens eyes to noxious stimuli-very marked mental status change. 12/4/13 11:51 p.m. 12-Confused not fully oriented, localizes noxious stimuli opens eyes to speech. Medication Ordered: Banana Bag: 1 liter Normal Saline, Magnesium Sulfate 2 grams, 1000 ml Intravenous bolus, add [MEDICATION NAME] 100 milligrams and Folate 1 milligram. B12 1000 micrograms intramuscular 1000 milliliters of Normal Saline Intravenous Bolus Review of the Non-Medication orders revealed the resident received CT (computerized tomography) scans, x-rays, blood work, and urine screens. Resident#2's blood alcohol ([MEDICATION NAME]) level at 5:50 p.m. on 12/4/13 was 324.3mg/dl (milligrams/deciliter). Levels greater than 100 mg/dl = Toxic. Resident#2 left the hospital Emergency department on 12/5/13 at 1:25 a.m. An interview was held on 12/13/13 at 10:30 a.m. with Resident#2 in his room on the secure unit. The resident had difficulty speaking. He was seated in a wheelchair and said he could not move his right arm or leg. Resident#2 was asked about leaving the facility on 12/4/13. He stated he left the facility and did not notify staff he was leaving or sign out. He said he left the facility to get drunk and he " f___d " up. He said he fell out of his wheelchair and ended up in the hospital. He further stated that was not the first time he had left the facility and the staff did not know where he was. An interview was held on 12/13/13 at 11:15 a.m. with S3LPN. He was asked to explain the events that occurred 12/4/13 regarding Resident#2. The LPN stated he was assigned to Resident#2 on 12/4/13 for the 2:00 p.m. to 10:00 p.m. shift. He explained that he did not see the resident during those times because "things were going on" . He said he did not see the resident the entire 8 hour shift, did not give him his medications that were due during that time, did not see him for the supper meal and did not know where the resident was. S3LPN stated when he was ready to leave work on 12/4/13 at 10:00 p.m., the oncoming nurse, S5LPN, asked where the resident was. He stated he told her the resident was not in the facility and a search was begun. He said the resident's wife was called and asked if she knew where Resident#2 was, but she did not. The LPN continued to explain S4CNA who was assigned the resident on the 2:00 p.m. to 10:00 p.m. shift that day had already left when the night shift asked about the missing resident. He said he called the CNA on the telephone to see if he knew the location of the resident. He stated he was told, at that time, by S4CNA that he had seen the resident leaving the facility at about 1:30 p.m. when the CNA was arriving to work on 12/4/13. S3LPN said S4CNA said he had not notified the LPN the resident was leaving the facility because it had "slipped his mind". S3LPN also said that the incident on 12/4/13 was not the first time the resident left the facility and staff was not aware he had left or where he was. He said the first incident occurred on11/21/13 and a Wanderguard was placed on the resident. The LPN said he found the resident outside of the facility the next day without the Wanderguard on and he tried to put it back but the resident refused to wear it. Review of the MAR (Medication Administration Record) for Resident#2 revealed he was scheduled to receive the following medication at 8:00 p.m. on 12/4/13: [MEDICATION NAME] 500mg (milligrams) - [MEDICAL CONDITION] medication [MEDICATION NAME] 50mg- a blood pressure medication [MEDICATION NAME] 40mg- a cholesterol medication [MEDICATION NAME] 1 mg- an antipsychotic medication Xarelto 15 mg- an anticoagulant for the prevention of [MEDICAL CONDITION] Embolism Review of the documentation on the MAR indicated [REDACTED]. (The hospital records showed the resident was in the emergency room from 4:09 p.m. on 12/4/13 until 1:25 a.m. on 12/5/13.) An interview was held on12/13/13 at 2:10 p.m. with S4CNA. S4CNA was asked if he saw Resident#2 during his shift on 12/4/13. The CNA explained he was on his way to the facility that day to work the 2:00 p.m. to 10:00 p.m. shift. He stated he arrived at the facility at about 1:30 p.m. and saw the resident in his wheelchair on the street behind the facility leaving the premises. He continued to explain he was assigned to care for the resident that day during his shift, but he did not look for him, nor did he see him for the entire 8 hour shift. He said the nurse responsible for Resident#2's care that shift never asked about the resident or if he was in the facility. S4CNA said during his shift he never went in the resident ' s room to check on him because he was busy. He said he did not provide the resident with any care for the 8 hour shift because he did not see the resident. He continued to say that he was unaware if the resident signed out or not that day because that was " the nurse ' s responsibility " . Review of the Case Mix ADL (Activities of Daily Living) Data Tracking Tool by Shift for Resident#2, dated December 2013, revealed no documentation the resident was provided care during 3:00 p.m.-11:00 p.m. for bed mobility, transferring, eating, and toilet use. In an interview on 12/13/13 at 2:45p.m.with S2DON, she stated she was notified on 12/4/13 Resident#2 was missing from the facility after the night nurse did rounds at 10:00 p.m. She stated she became aware at that time the evening shift staff assigned to the resident, S3LPN and S4CNA, had not seen the resident, attempted to look for him or reported him missing from 2:00 p.m. to 10:00 p.m. She continued to say the resident was missing from the premises of the facility for about 8 hours before anyone questioned the whereabouts of the resident. S2DON stated the nurse and CNA should have checked at least every 2 hours for the resident. She said the resident should have been reported missing sooner than 8 hours after he was seen leaving the premises. In an interview on 12/13/13 at 2:55 p.m. with S1Administrator, he stated S2DON notified him after she was told Resident#2 was missing from the facility on 12/4/13. The Administrator said he felt that it was "irresponsible" the LPN and CNA did not look for or report the resident was missing for 8 hours. He said more should have been done when the resident was not on the premises and a "red flag should have been put up sooner in this case". He stated he did not file an OTIS (Online Tracking and Incident System) report related to this incident. A follow up interview was held on 12/13/14 at 3:15 p.m. with S2DON. She stated the resident had left the facility in November 2013 without the staff knowing and had gone to his wife's place of business. She said after the incident in November, a Wanderguard was placed on Resident#2 as in intervention for elopement. The DON continued to explain the resident refused the Wanderguard and nothing else was put into place to increase monitoring and supervision of the resident until the resident eloped again on 12/4/13. She said the resident was then placed on the secure unit as an intervention for elopement. A telephone interview was held on 12/16/13 at 10:05 a.m. with Resident#2's wife. She stated she was called at10:56 p.m. on 12/4/13 by the facility staff asking her if she knew where Resident#2 was. She said she asked the staff if they knew where the resident was and was told he had been missing from the facility since 8:00-9:00 p.m. The resident ' s wife said she spoke to the DON and was told that the resident would be put on the secure unit because he had refused the Wanderguard and if there was no bed available for him on the unit "they would ship him" . Resident#2's wife said the resident had left the facility in November 2013 and the facility was not aware he was missing. She said she was notified by a fast food restaurant that was located 0.6 miles from the facility that the resident was there. She said she went and picked up Resident#2 from the restaurant and brought him back to the facility. She said the staff was not aware where the resident had been. The resident's wife said when the resident left the facility alone she was afraid he would get hurt or hit by a car. In an interview on 12/16/13 at 12:50 p.m. with S5LPN she stated when she reported to work on 12/4/13 for the night shift Resident#2 could not be found. She explained she and the CNA for the night shift checked the hall and did not see the resident. She said when she asked S3LPN were the resident was, he did not know. S5LPN said the resident was located by phone at the hospital. She said she and a CNA had to go to the hospital to identify the resident because the hospital had two unidentified residents listed as "John Doe".

Based on record review and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#2) of 5 (#1-#5) residents reviewed for elopement. Twelve residents (#1- #12) in the general population were identified by the facility as an elopement risk. The facility failed to: 1) Ensure interventions were put in place to increase monitoring and supervision for a resident who had refused a Wanderguard and had a history of [REDACTED]. 2) Ensure the staff promptly implemented the facility Elopement policy by not reporting a resident as missing to the Director of Nursing or Charge Nurse when the resident, who was assessed at risk and care planned for elopement, was seen by staff leaving the premises. 3) Ensure a search for the resident was conducted promptly. The staff did not begin looking for the resident until he was missing from the facility for 8 hours even though he was seen leaving the premises. 4) Ensure staff knew to report a resident as missing and attempt to locate a resident when the resident was not seen in the facility by the LPN (Licensed Practical Nurse) or CNA (Certified Nursing Assistant) for 8 hours. 5) Ensure the LPN provided care according to a resident's plan of care during the LPN's 8 hour shift. 6) Ensure a resident who required extensive assistance with ADL's was provided care by the CNA during an 8 hours shift This resulted in an Immediate Jeopardy situation for Resident#2 on 12/4/13 at 1:57 p.m. when S4CNA reported to work and was assigned the care of Resident#2. S4CNA had observed Resident#2 off the premises of the facility when reporting to work and did not notify the Charge Nurse or the DON. The CNA did not see the resident the entire 8 hour shift and left the facility at 10:01 p.m. without providing care to the resident or informing anyone the resident had not been seen for the 8 hours he was assigned to him. S3LPN was assigned the resident from 2:00 p.m. until 10:00 p.m. on 12/4/13. The LPN did not give Resident#2 his medications that were ordered, did not see him the entire 8 hour shift, did not notify anyone that he had not seen the resident for 8 hours and did not begin a search for the resident until 10:00 p.m. after the night shift questioned the resident's whereabouts. The resident was found by an unknown person at a local fast food restaurant located 0.68 miles from the facility. In order for Resident #2, who was wheelchair bound, to reach the restaurant, he had to cross a busy 6 lane highway. A passerby called an ambulance and the resident was admitted to the hospital as a "John Doe" with a [DIAGNOSES REDACTED]. The resident's blood alcohol level was 324.3 mg/dl (milligrams/deciliter). Levels greater than 100mg/dl indicate toxic levels. The staff of the facility did not locate and identify the resident until 12/5/13 at 12:35 a.m. The S1Administrator was notified of the Immediate Jeopardy situation on 12/13/13 at 4:55 p.m. The Immediate Jeopardy situation ended for Resident#2 on 12/5/13 at 12:35 a.m. when the facility located the resident at a local hospital. The IJ situation remained in place for the other 11 residents in the general population, identified by the facility as an elopement risk, until 12/16/13 at 3:50 p.m. once the facility presented an acceptable plan of removal which included: 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Resident was placed the on the secure unit without any other issues. 2. How will you identify other residents having potential to be affected by the same practice and what corrective action will be taken: Each resident has the potential to be affected. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: In-service Nurses/CNA's on making rounds at least every 2 hours. In-service nurses/CNAs notification of DON/CN (Charge Nurse) of any resident not in the building. In-service nurses if resident is not available for medications at designated times, then staff have to locate the resident. In-service nurses/CNA's on wandering and elopement policies. Staff that has not been in-serviced will be prior to returning to work. 4. How the corrective actions will be monitored to ensure the practice will not recur, i.e. what quality assurance program will be put into place. DON/Designee will randomly round by observation to ensure rounds are done every 2 hours weekly X 2 weeks then randomly. DON/Designee will review ADL flow sheets to ensure the documentation of rounds are done. The deficient practice remains at a level 2 pattern for the 11 residents in the general population who were at risk for elopement. Findings: 1. Cross reference to findings at F224 2. Cross reference to findings at F281 3. Cross reference to findings at F323 Review of the facility's policy and procedure entitled Elopements revealed the following, in part: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary, and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident had left the premises... Review of the clinical record for Resident#2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Incident Accident Tracking Log for December 2013 revealed the following, in part: Resident#2: Date of Incident 12/4/13. Time of Incident 10:30 p.m. Type of Incident: Elopement ... Review of Resident#2's Resident Incident Report completed by S5LPN and dated 12/4/13 at 10:20 p.m. revealed, in part, the following: Location of Occurrence: Resident left facility ... Narrative of incident and description of injuries: 10:20 p.m. LPN making round. Resident noted not in bed. Search made unable to locate resident. Call placed to local hospitals. Resident found at ER (emergency room ) at local hospital. Report per ER nurse. Resident had fallen forward out of wheelchair on parking lot of fast food restaurant. Assessment made no injury. Review of the Incident Witness Statement completed by S7CNA revealed the following: Incident type: Elopement. Statement: I came to work at 10:00 p.m. Did my rounds and discovered Resident#2 was not in his room. I walked around the nursing home and he wasn't nowhere in here. I figure he was out on pass so I asked the 2-10 nurse where he was and he said he not in bed. I said no so we did a room to room of the nursing home and still no Resident#2. Review of Resident#2's Resident Incident Follow-up Report dated 12/4/13 revealed in part, the following: Incident type: Elopement. Mobility: Wheelchair/Self. Mental: No change in mentation noted. 24 hour condition and injury appearance: Up in w/c (wheelchair) seated quietly. No s/s (signs or symptoms) of pain noted. No behaviors present at this time. Additional follow-ups: Transferred to secured unit due to refusal to comply with wearing Wanderguard ... An interview was held on 12/13/13 at 10:30 a.m. with Resident#2 in his room on the secure unit. The resident had difficulty speaking. He was seated in a wheelchair and said he could not move his right arm or leg. Resident#2 was asked about leaving the facility on 12/4/13. He stated he left the facility and did not notify staff he was leaving or sign out. He said he left the facility to get drunk and he " f___d " up. He said he fell out of his wheelchair and ended up in the hospital. He further stated that was not the first time he had left the facility and the staff did not know where he was. In an interview on 12/13/13 at 2:45 p. m. with S2DON, she stated she was notified on 12/4/13 Resident#2 was missing from the facility after the night nurse did rounds at 10:00 p.m. She stated she became aware at that time the evening shift staff assigned to the resident, S3LPN and S4CNA, had not seen the resident, attempted to look for him or reported him missing from 2:00 p.m. to 10:00 p.m. She continued to say the resident was missing from the premises of the facility for about 8 hours before anyone questioned the whereabouts of the resident. S2DON stated the nurse and CNA should have checked at least every 2 hours for the resident. She said the resident should have been reported missing sooner than 8 hours after he was seen leaving the premises. In an interview on 12/13/13 at 2:55 p.m. with S1Administrator, he stated S2DON notified him after she was told Resident#2 was missing from the facility on 12/4/13. The Administrator said he felt that it was "irresponsible" the LPN and CNA did not look for or report the resident was missing for 8 hours. He said more should have been done when the resident was not on the premises and a "red flag should have been put up sooner in this case". He stated he did not file an OTIS (Online Tracking and Incident System) report related to this incident. A follow up interview was held on 12/13/14 at 3:15 p.m. with S2DON. She stated the resident had left the facility in November 2013 without the staff knowing and had gone to his wife's place of business. She said after the incident in November, a Wanderguard was placed on Resident#2 as an intervention for elopement. The DON continued to explain the resident refused the Wanderguard and nothing else was put into place to increase monitoring and supervision of the resident until the resident eloped again on 12/4/13. She said the resident was then placed on the secure unit as an intervention for elopement. A telephone interview was held on 12/16/13 at 10:05 a.m. with Resident#2's wife. She stated she was called at 10:56 p.m. on 12/4/13 by the facility staff asking her if she knew where Resident#2 was. She said she asked the staff if they knew where the resident was and was told he had been missing from the facility since 8:00-9:00 p.m. The resident's wife said she spoke to the DON and was told that the resident would be put on the secure unit because he had refused the Wanderguard and if there was no bed available for him on the unit "they would ship him". Resident#2's wife said the resident had left the facility in November 2013 and the facility was not aware he was missing. She said she was notified by a fast food restaurant that was located 0.6 miles from the facility that the resident was there. She said she went and picked up Resident#2 from the restaurant and brought him back to the facility. She said the staff was not aware where the resident had been. The resident's wife said when the resident left the facility alone she was afraid he would get hurt or hit by a car. In an interview on 12/17/13 at 9:15 a.m., S1DON stated S1Administrator was responsible for filing OTIS reports. She stated the only thing she did to investigate the incident that occurred on 12/4/13 with Resident#2 was to get statements from the night CNA and LPN. The DON was asked if an investigation was conducted regarding S4CNA who saw the resident leaving the premises and did not report it and did not provide care to the resident for his 8 hour shift. She replied she had not. She was also asked if an investigation was conducted regarding S3LPN who did not see the resident or provide care to the resident for 8 hours or report him missing. She also replied she had not.

Based on record review and interviews, the facility failed to provide adequate supervision and monitoring to prevent 1(#2) resident , who had a history of [REDACTED].#1-#5) residents reviewed for elopement. Twelve residents (#1- #12) in the general population were identified by the facility as an elopement risk. The facility failed to ensure: 1) Interventions were put in place to increase monitoring and supervision for a resident who had refused a Wanderguard and had a history of [REDACTED]. 2) The facility policy for elopement was followed when the resident was observed by staff leaving the premises of the facility by not promptly reporting this to the Charge Nurse or DON (Director of Nursing). 3) A search for the resident was conducted promptly. The staff did not begin looking for the resident until he was missing from the facility for 8 hours even though he was seen leaving the premises. 4) Staff knew to report a resident as missing and attempt to locate a resident when the resident was not seen in the facility by the LPN (Licensed Practical Nurse) or CNA (Certified Nursing Assistant) for 8 hours. This resulted in an Immediate Jeopardy situation for Resident#2 on 12/4/13 at 1:57 p.m. when S4CNA reported to work and was assigned the care of Resident#2. S4CNA had observed Resident#2 off the premises of the facility when reporting to work and did not notify the Charge Nurse or the DON. The CNA did not see the resident the entire 8 hour shift and left the facility at 10:01 p.m. without providing care to the resident or informing anyone the resident had not been seen for the 8 hours he was assigned to him. S3LPN was assigned the resident from 2:00 p.m. until 10:00 p.m. on 12/4/13. The LPN did not give Resident#2 his medications that were ordered, did not see him the entire 8 hour shift, did not notify anyone that he had not seen the resident for 8 hours and did not begin a search for the resident until 10:00 p.m. after the night shift questioned the resident's whereabouts. The resident was found by an unknown person at a local fast food restaurant located 0.68 miles from the facility. In order for Resident #2, who was wheelchair bound, to reach the restaurant, he had to cross a busy 6 lane highway. A passerby called an ambulance and the resident was admitted to the hospital as a "John Doe" with a [DIAGNOSES REDACTED]. The resident's blood alcohol level was 324.3 mg/dl (milligrams/deciliter). Levels greater than 100mg/dl indicate toxic levels. The staff of the facility did not locate and identify the resident until 12/5/13 at 12:35 a.m. The S1Administrator was notified of the Immediate Jeopardy situation on 12/13/13 at 4:55 p.m. The Immediate Jeopardy situation ended for Resident#2 on 12/5/13 at 12:35 a.m. when the facility located the resident at a local hospital. The IJ situation remained in place for the other 11 residents in the general population, identified by the facility as an elopement risk, until 12/16/13 at 3:50 p.m. once the facility presented an acceptable plan of removal which included: 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Resident was placed the on the secure unit without any other issues. 2. How will you identify other residents having potential to be affected by the same practice and what corrective action will be taken: Each resident has the potential to be affected. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: In-service Nurses/CNA's on making rounds at least every 2 hours. In-service nurses/CNAs notification of DON/CN (Charge Nurse) of any resident not in the building. In-service nurses if resident is not available for medications at designated times, then staff have to locate the resident. In-service nurses/CNA ' s on wandering and elopement policies. Staff that has not been in-serviced will be prior to returning to work. 4. How the corrective actions will be monitored to ensure the practice will not recur, i.e. what quality assurance program will be put into place. DON/Designee will randomly round by observation to ensure rounds are done every 2 hours weekly X 2 weeks then randomly. DON/Designee will review ADL flow sheets to ensure the documentation of rounds are done. The deficient practice remains at a level 2 pattern for the 11 residents in the general population who were at risk for elopement. Findings: Review of the facility's policy and procedure entitled Elopements revealed the following, in part: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary, and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident had left the premises ... Review of the clinical record for Resident#2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident#2's most recent MDS (Minimum Data Set), with an ADR (Assessment Reference Date) of 9/17/13, revealed the resident was assessed as having a BIMS (Brief Interview for Mental Status) score of 12 (moderately impaired). The MDS also revealed the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The resident's mobility device was coded as a wheelchair. The resident had limitation of range of motion impairment in his upper and lower extremities on one side. Review of Resident#2's Risk Assessment for Elopement revealed the following (Elopement risk if score is 10 or greater): Date: 6/18/13 Score 6 Date: 9/17/13 Score 6 Date 11/21/13 Score 16 (If at risk, interventions implemented to attempt to prevent elopement): Left facility without signing out. Wife brought him back to facility. Wanderguard bracelet placed. Review of the resident ' s care plan revealed, in part, the following: Problem Onset: 11/21/13 Problem/Need: Resident has history of wandering, with attempt to elope facility grounds. Goal and target date: Resident will not elope from the facility grounds. Resident will suffer no injury if elopes from facility (3/18/14). Approaches: Place monitoring device on resident that sounds alarms when resident leaves building. Alert staff to resident ' s wandering behavior. Approach resident in calm, accepting manner. Note which exits resident favors for elopement from facility. Alert staff working near those areas. If resident elopes from facility, implement facility protocol for locating resident. Social Services to evaluate resident quarterly and as needed. Activities staff to visit with resident and provide divisional activities. 11/23/13: Refused Wanderguard. Would not allow staff to replace. 12/5/13: Place on secure unit. Problem Onset: 7/11/13 Problem/Need: Demonstrates cognitive loss as evidenced by BIMS score Goal and target date: Resident will remain alert and oriented to person and clinical setting through next review (3/18/14) ... Review of the facility's Incident Accident Tracking Log for December 2013 revealed the following, in part: Resident#2: Date of Incident 12/4/13. Time of Incident 10:30 p.m. Type of Incident: Elopement ... Review of Resident#2 ' s Resident Incident Report completed by S5LPN and dated 12/4/13 at 10:20 p.m. revealed, in part, the following: Location of Occurrence: Resident left facility ... Narrative of incident and description of injuries: 10:20 p.m. LPN making round. Resident noted not in bed. Search made unable to locate resident. Call placed to local hospitals. Resident found at ER (emergency room ) at local hospital. Report per ER nurse. Resident had fallen forward out of wheelchair on parking lot of fast food restaurant. Assessment made no injury. Review of the Incident Witness Statement completed by S7CNA revealed the following: Incident type: Elopement. Statement: I came to work at 10:00 p.m. Did my rounds and discovered Resident#2 was not in his room. I walked around the nursing home and he wasn ' t nowhere in here. I figure he was out on pass so I asked the 2-10 nurse where he was and he said he not in bed. I said no so we did a room to room of the nursing home and still no Resident#2. Review of Resident#2 ' s Resident Incident Follow-up Report dated 12/4/13 revealed in part, the following: Incident type: Elopement. Mobility: Wheelchair/Self. Mental: No change in mentation noted. 24 hour condition and injury appearance: Up in w/c (wheelchair) seated quietly. No s/s (signs or symptoms) of pain noted. No behaviors present at this time. Additional follow-ups: Transferred to secured unit due to refusal to comply with wearing Wanderguard ... Review of the nurses' notes for Resident#2 revealed the following, in part: 12/4/13 10:00 p.m. Making rounds noted resident not in room at this time. Did not see resident on premises ... Room search initiated. Unable to locate resident. Also searched around building and in local vicinity. Unable to locate resident. Resident's spouse called. Stated she had not seen or heard from resident. Signed by S3LPN 12/4/13 10:45 pm. Police called. Officer B______ responded. Face sheet and photograph of resident given to officer ... Officer stated they will attempt to locate resident. Signed by S3LPN 12/5/13. 12:10 a.m. Call placed to local hospitals. Noted missing person admitted to ER at local hospital (name of hospital) spoke with nurse K_____RN (Registered Nurse). 12/5/13 12:35 a.m. Noted resident found lying on stretcher bed in ER section ... IV 0.9NS (normal saline) going left arm. O2 (Oxygen) at 2l per N/C (2 liters per minute nasal cannula). Resident could be D/C 'ed (discharged ). ER nurse K______ reported resident found in parking lot near fast food restaurant (name of restaurant) .... Report resident noted fallen from w/c forward on parking lot .... Dx. (Diagnosis) acute alcohol intoxication and seizures .... 12/5/13 1:25 a.m. Resident discharged from local hospital (named) ... Review of Resident#2's Emergency Department Chart dated 12/4/13 revealed, in part, the following: Arrival Date: 12/4/13 16:09 (4:09 p.m.) Physician's progress notes: Primary Diagnoses: [REDACTED]. 1. History of fall 2. Continuous chronic alcoholism 3. Alcohol intoxication 4. Seizure disorder Chief Complaint 1. Fall History of Present illness: Summary: Patient fell out of his wheelchair and had what witnesses described as a seizure. History is very limited. HPI (History of Present Illness): Exam started at 16:15 (4:15 p.m.). Unreliable history concerning any possible head injury. Injury can be coded as occurring in a transportation environs. Complete history not available. Some of the history is supplied by the ambulance crew. Presenting problem started minutes ago. Patient " just " fell -no identified proximate cause. Underlying neurologic deficit leads to chronic falls. The patient is a chronic alcoholic, who is at risk for multiple falls and unreported head injuries. Other Vital Signs: Glasgow Coma Scale: 12/4/13 7:16 p.m. 9-Vocalizes no words, localizes noxious stimuli, opens eyes to noxious stimuli-very marked mental status change. 12/4/13 11:51 p.m. 12-Confused not fully oriented, localizes noxious stimuli opens eyes to speech. Medication Ordered: Banana Bag: 1 liter Normal Saline, Magnesium Sulfate 2 grams, 1000 ml Intravenous bolus, add thiamine 100 milligrams and Folate 1 milligram. B12 1000 micrograms intramuscular 1000 milliliters of Normal Saline Intravenous Bolus Review of the Non-Medication orders revealed the resident received CT (computerized tomography) scans, x-rays, blood work, and urine screens. Resident#2's blood alcohol (Ethanol) level at 5:50 p.m. on 12/4/13 was 324.3mg/dl (milligrams/deciliter). Levels greater than 100 mg/dl = Toxic. Resident#2 left the hospital Emergency department on 12/5/13 at 1:25 a.m. An interview was held on 12/13/13 at 10:30 a.m. with Resident#2 in his room on the secure unit. The resident had difficulty speaking. He was seated in a wheelchair and said he could not move his right arm or leg. Resident#2 was asked about leaving the facility on 12/4/13. He stated he left the facility and did not notify staff he was leaving or sign out. He said he left the facility to get drunk and he " f___d " up. He said he fell out of his wheelchair and ended up in the hospital. He further stated that was not the first time he had left the facility and the staff did not know where he was. An interview was held on 12/13/13 at 11:15 a.m. with S3LPN. He was asked to explain the events that occurred on 12/4/13 regarding Resident#2. The LPN stated he was assigned to Resident#2 on 12/4/13 for the 2:00 p.m. to 10:00 p.m. shift. He explained that he did not see the resident during those times because " things were going on " . He said he did not see the resident the entire 8 hour shift, did not give him his medications that were due during that time, did not see him for the supper meal and did not know where the resident was. S3LPN stated when he was ready to leave work on 12/4/13 at 10:00 p.m., the oncoming nurse, S5LPN, asked where the resident was. He stated he told her the resident was not in the facility and a search was begun. He said the resident's wife was called and asked if she knew where Resident#2 was, but she did not. The LPN continued to explain S4CNA who was assigned the resident on the 2:00 p.m. to 10:00 p.m. shift that day had already left when the night shift asked about the missing resident. He said he called the CNA on the telephone to see if he knew the location of the resident. He stated he was told, at that time, by S4CNA that he had seen the resident leaving the facility at about 1:30 p.m. when the CNA was arriving to work on 12/4/13. S3LPN said S4CNA said he had not notified the LPN the resident was leaving the facility because it had " slipped his mind " . S3LPN also said that the incident on 12/4/13 was not the first time the resident left the facility and staff was not aware he had left or where he was. He said the first incident occurred on11/21/13 and a Wanderguard was placed on the resident. The LPN said he found the resident outside of the facility the next day without the Wanderguard on and he tried to put it back but the resident refused to wear it. Review of the MAR (Medication Administration Record) for Resident#2 revealed he was scheduled to receive the following medications at 8:00 p.m. on 12/4/13: Keppra 500mg (milligrams) - seizure medication Lopressor 50mg- a blood pressure medication Pravachol 40mg- a cholesterol medication Risperidone 1 mg- an antipsychotic medication Xarelto 15mg- an anticoagulant for the prevention of Pulmonary Embolism Review of the documentation on the MAR revealed the doses were circled indicating the resident did not receive the medications. (The hospital records showed the resident was in the emergency room from 4:09 p.m. on 12/4/13 until 1:25 a.m. on 12/5/13.) An interview was held on12/13/13 at 2:10 p.m. with S4CNA. S4CNA was asked if he saw Resident#2 during his shift on 12/4/13. The CNA explained he was on his way to the facility that day to work the 2:00 p.m. to 10:00 p.m. shift. He stated he arrived at the facility at about 1:30 p.m. and saw the resident in his wheelchair on the street behind the facility leaving the premises. He continued to explain he was assigned to care for the resident that day during his shift, but he did not look for him, nor did he see him for the entire 8 hour shift. He said the nurse responsible for Resident#2 ' s care that shift never asked about the resident or if he was in the facility. S4CNA said during his shift he never went in the resident ' s room to check on him because he was busy. He said he did not provide the resident with any care for the 8 hour shift because he did not see the resident. He continued to say that he was unaware if the resident signed out or not that day because that was " the nurse's responsibility " . Review of the Case Mix ADL (Activities of Daily Living) Data Tracking Tool by Shift for Resident#2, dated December 2013, revealed no documentation the resident was provided care during 3:00 p.m.-11:00 p.m. for bed mobility, transferring, eating, and toilet use. In an interview on 12/13/13 at 2:45p.m.with S2DON, she stated she was notified on 12/4/13 Resident#2 was missing from the facility after the night nurse did rounds at 10:00 p.m. She stated she became aware at that time the evening shift staff assigned to the resident, S3LPN and S4CNA, had not seen the resident, attempted to look for him or reported him missing from 2:00 p.m. to 10:00 p.m. She continued to say the resident was missing from the premises of the facility for about 8 hours before anyone questioned the whereabouts of the resident. S2DON stated the nurse and CNA should have checked at least every 2 hours for the resident. She said the resident should have been reported missing sooner than 8 hours after he was seen leaving the premises. In an interview on 12/13/13 at 2:55 p.m. with S1Administrator, he stated S2DON notified him after she was told Resident#2 was missing from the facility on 12/4/13. The Administrator said he felt that it was " irresponsible " the LPN and CNA did not look for or report the resident was missing for 8 hours. He said more should have been done when the resident was not on the premises and a "red flag should have been put up sooner in this case". He stated he did not file an OTIS (Online Tracking and Incident System) report related to this incident. A follow up interview was held on 12/13/14 at 3:15 p.m. with S2DON. She stated the resident had left the facility in November 2013 without the staff knowing and had gone to his wife's place of business. She said after the incident in November, a Wanderguard was placed on Resident#2 as an intervention for elopement. The DON continued to explain the resident refused the Wanderguard and nothing else was put into place to increase monitoring and supervision of the resident until the resident eloped again on 12/4/13. She said the resident was then placed on the secure unit as an intervention for elopement. A telephone interview was held on 12/16/13 at 10:05 a.m. with Resident#2's wife. She stated she was called at10:56 p.m. on 12/4/13 by the facility staff asking her if she knew where Resident#2 was. She said she asked the staff if they knew where the resident was and was told he had been missing from the facility since 8:00-9:00 p.m. The resident's wife said she spoke to the DON and was told that the resident would be put on the secure unit because he had refused the Wanderguard and if there was no bed available for him on the unit "they would ship him" . Resident#2's wife said the resident had left the facility in November 2013 and the facility was not aware he was missing. She said she was notified by a fast food restaurant that was located 0.6 miles from the facility that the resident was there. She said she went and picked up Resident#2 from the restaurant and brought him back to the facility. She said the staff was not aware where the resident had been. The resident's wife said when the resident left the facility alone she was afraid he would get hurt or hit by a car. In an interview on 12/16/13 at 12:50 p.m. with S5LPN she stated when she reported to work on 12/4/13 for the night shift Resident#2 could not be found. She explained she and the CNA for the night shift checked the hall and did not see the resident. She said when she asked S3LPN were the resident was, he did not know. S5LPN said the resident was located by phone at the hospital. She said she and a CNA had to go to the hospital to identify the resident because the hospital had two unidentified residents listed as "John Doe".

Based on observations, interview and record review, the facility failed to ensure that the facility was administered in a manner that ensured the highest practicable physical well-being was maintained for 2 (#3 and #5) residents identified as non-compliant with smoking out of a total of 5 sampled residents. The administration failed to ensure: 1. that a resident identified by the facility as a non-compliant smoker, did not smoke while actively utilizing oxygen and did not bring a combustible into an area where it may come into contact with flammable materials (resident #3); 2. that a quadriplegic resident identified by the facility as a non-compliant smoker consistently received staff supervision/assistance with smoking (resident #5) 3. that all areas of the facility where smoking was allowed were monitored to ensure that residents who are actively utilizing oxygen are prevented from bringing a combustible substance (oxygen) into areas with flammable materials (lit cigarettes and lighters). 4. that their Smoking Policy and Procedure was consistently implemented to prevent actual/potential accident hazards for each resident identified and care planned by the facility on 12/7/12 as requiring supervision/assistance during smoking. Residents #3 was placed in Immediate Jeopardy (IJ) on 12/7/12 when resident #3's oxygen tubing caught fire on the facility's front porch while resident #3 was smoking. Resident #5 was known by the facility to smoke on the front porch and reassessed by the facility on 12/7/12 as requiring staff supervision/assistance with smoking. The facility was aware that resident #5 continued to obtain cigarettes from other residents who lit his cigarettes after 12/7/12. Resident #5 was placed in an IJ situation on 12/19/12 at 1:16pm when he was observed smoking without staff supervision on the front porch. During this observation, the wind increased and blew the resident's smoking apron up knocking the cigarette from resident #5's mouth. The facility had no fire extinguisher on the porch on 12/7/12 nor was a fire extinguisher installed on the porch thereafter. The facility identified 36 residents who smoke without required supervision and 13 residents, including resident #5, who require supervision with smoking. The facility identified 5 residents who use oxygen, 3 of whom were not included on the list of smokers. The facility had no outside areas of the facility where smoking was prohibited prior to notification of the IJ situation on 12/19/12. The facility was notified of the IJ situation on 12/19/12 at 4:38pm. The IJ was lifted on 12/19/12 at 6:45pm when the facility provided a plan to increase supervision of residents requiring supervision/assistance with smoking. Findings: Resident #3: A review of the clinical record for resident #3 revealed the resident was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. A review of the facility ' s Smoking Policy revealed, in part, the following: This facility shall establish and maintain safe resident smoking practices. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas. No-Smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Any smoking related privileges, restrictions, and concerns shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues. On 12/18/12, 12/19/12 and 12/20/12 residents were observed smoking cigarettes in the following three (3) areas of the facility: Front Porch, Courtyard and Back patio with screened sitting area. There were no observable No-Smoking signs posted in any of these areas. A portable fire extinguisher was observed on the Courtyard patio. There was no observable fire extinguisher on the Back patio or the Front Porch of the facility. A review of the December 2012 Physician order [REDACTED]. Oxygen (O2) at 2Liters/Minute via nasal cannula as needed for Shortness of Breath (SOB) and wheezing. A review of the Nursing assessment dated [DATE] for resident #3 revealed the following: Respiratory related: Continuous O2. Behaviors: Non-Compliant with smoking. A review of resident #3 ' s Assessment for Safe Smoking dated 10/21/12 revealed the following: Cognitive Status: Independent - decisions consistent/reasonable - yes Medication: Is the resident on medications with the potential to cause sedation? - yes Risk Factors: Does the resident use O2 - yes Resident may smoke unsupervised in designated smoking areas. A review of the Nurse ' s Notes regarding resident #3 revealed the following: 12/7/12, 1:30pm: Resident was ordered for evaluation at ____ Hospital. Resident was noted by LPN smoking with O2 on, black residue was noted on resident hands. 12/7/12, 5:25pm: Resident returned from hospital. On 12/19/12 at 1:20pm an interview was conducted with S3CNA. She stated that on 12/7/12, resident #3 was wearing his oxygen container while smoking and burned himself. A review of the Client Incident Report that the facility submitted to State Office revealed the following: Incident ID: , Occurred: 12/7/12, 1:00pm, Reported in Facility: 12/7/12, 1:00pm, Entered: 12/7/12, 1:24pm; CEO Finding/Determination: 12/10/12 Accused/Allegation: Neglect: Caregiver Findings: Unsubstantiated Victim: Resident #3 Description: Resident #3 smoked out on the front porch of the facility with his nasal cannula and oxygen tank. This caused a fire slightly burning resident ' s index and middle finger on right hand. Summary: On 12/7/12 at approximately 1:00pm, resident #3 went out to smoke on the front porch of the facility. While smoking, the nasal cannula for resident #3 ' s oxygen tank caught fire. S3CNA noticed this and immediately called for help and extinguished the fire. Resident was assessed and taken to the hospital for evaluation. Resident #3 returned around 5:30pm. It was noted he had small blister on right index finger and small burn mark on right middle finger. Investigation revealed that resident #3 did not remove O2 and cannula before going out to smoke as he had done every other day. Resident #3 had been educated prior to incident on not taking oxygen with him to smoke due to safety issues. This was the first time he had done this. Upon completion of investigation, the allegation of caregiver neglect is unsubstantiated. On 12/19/12 at 3:00pm an interview was conducted with S1Adm. and S4Corp. Dir. Surveyor requested to review the facility ' s investigation regarding resident #3 ' s burn injury while smoking on 12/7/12. S1Adm. stated that the facility was advised by their legal department that they could not provide surveyor with documentation of facility ' s investigations of accidents and/or incidents. Surveyor was provided with a written statement from the facility which read as follows: 12/19/12 - We are unable to provide the requested material concerning accident investigations. Our investigation is on an internal document. A review of resident #3 ' s Medical Record from ___ Hospital dated 12/7/12 revealed the following: Arrival Date: 12/7/12 with Chief Complaint: Soft tissue injury to dorsum of right hand. Procedures: Debridement of blisters and dead skin less than 9% body surface, area was wrapped with an occlusive antibiotic dressing. Primary Diagnosis: [REDACTED]. discharge date : 12/7/12 A review of resident #3 ' s Care Plan revealed the following: Smoking, 6/4/12 Problem/Need: Resident wishes to smoke and is designated as safe smoker; Resident needs Observation while smoking. Target Date of 2/29/13. Approaches: Resident will demonstrate safe technique for putting out matches or lighter and disposing of ash, ability to physically hold the smoking device while smoking, and will verbalize understanding that smoking materials are for use only in designated smoking areas. Resident oriented to smoking procedures and areas. Provide resident with observation while smoking. Behavior, 6/4/12 Problem/Need: Behavior Problem - Resists Care as evidenced by noncompliance with O2 therapy and leaving O2 tank in lobby to smoke. Target Date of 2/29/13. Approaches: Educated on safe use of O2 tank and storage and safety, i.e. potential for injury, fire hazard and harm to others. Cognitive Loss, 6/4/12 Problem/Need: Resident has impaired cognitive skills as evidenced by Short term memory problem and requires cues with recall. Target Date of 2/29/13. Approaches: Provide cues, prompting and demonstrating; Remind and escort to activity programs consistent with resident ' s interests. Activity Preferences, 6/4/12 Problem/Need: Resident attends activities of choice. Target Date of 2/29/13 Approaches: Resident has indicated the following activity preferences are important to him: sitting outdoors; Encourage resident to sit on porch/in courtyard/on patio. On 12/21/12 at 10:55am an interview was conducted with resident #3 while in his room. The resident was alert and oriented to person, place and time. He was utilizing O2 via nasal cannula during this interview. The resident stated that he uses O2 because he has [MEDICAL CONDITION]. The resident had healing wounds observed on his right hand to his inside thumb and top portions of his index and third fingers. Resident #3 stated that a couple of weeks ago, he went outside on the facility ' s front porch to smoke a cigarette. He stated that he had his O2 cylinder attached to the back of his wheelchair. The resident stated that he always brought his O2 canister outside when he smoked. He stated that his O2 was turned on and he was receiving the O2 via his nasal cannula. He stated he didn't remove the nasal cannula and forgot to turn the O2 off before he lit his cigarette. He stated that when he lit the cigarette, a fire started in the middle section of his O2 tubing. He stated that his fingers got burned when he pinched the O2 tubing to put out the fire. He stated that when the fire began, another resident went and got the nurse and S3CNA who turned off his oxygen when they arrived. Surveyor asked what type of O2 canister he used on the date of the fire. The resident pointed to a portable E Cylinder which was next to his bed. On 12/20/12 at 2:40pm an interview was conducted with S1Adm. He stated that residents assessed as not requiring supervised smoking were allowed to smoke on the facility ' s front porch. He stated that there was no fire extinguisher located on the front porch on 12/7/12. He stated that prior to 12/7/12 resident #3 did not require supervision with smoking. He stated that resident #3 was one of two residents residing in the facility who smoke and use O2. He stated that there were non-smoking residents in the facility who use O2 and are allowed to go outside to the Courtyard, Front Porch and Back Patio with screened sitting area. He confirmed that there was no separate outside area for residents to use where smoking was not allowed. Surveyor asked what system the facility had in place to prevent residents from bringing O2 into areas where flammable materials were utilized. S1Adm. stated that staff watch to see that the smoking residents remove their O2 prior to going out to smoke. S1Adm. stated that there was no system in place to ensure that residents with O2 in use are not allowed in areas where residents are smoking. Resident #5: A review of the clinical record for resident #5 revealed [DIAGNOSES REDACTED]. A review of the facility's Assessment for Safe Smoking, dated 12/7/12 for resident #5 revealed the requiring staff assistance to hold his cigarette. A review of the facility's List of Supervised Smokers provided to the surveyor on 12/19/12, revealed resident #5 was included on this list. A review of the Smoking Times for Smoking Program Residents revealed the following: 8:00am, 10:00am, 12:00pm, 2:00pm, 4:00pm, 6:00pm, and 8:00pm - All residents on smoking program must be supervised. Supervised smokers will be conducted in Courtyard area. A review of the Care Plan for resident #5 revealed the following: Problem/Need: Smoking - Impaired smoker, resident needs observation, constant supervision and protective gear while smoking. Non-compliant with smoking program. Target date 12/21/12 Approaches include: Resident will ask for smoking materials Will demonstrate ability to verbalize understanding that smoking materials are for use only in designated smoking areas Oriented to smoking procedures and areas Provide resident with observation, constant supervision and protective gear while smoking. Problem/Need: Behavior - Resists Care, history of sitting outside drinking alcohol, refusing medications and cursing staff/residents. Approaches include: Report behavioral changes to doctor, Provide non-confrontational environment, Anticipate care needs, Educate the resident on causal factors of behavior, reapproach later when he becomes agitated. Problem/Need: Cognitive Loss - Refuses smoking apron. Target date 12/21/12 Approaches include: Report changes in cognition to doctor, explain all care, invite to activity programs, provide cues, promote dignity. On 12/19/12 at 10:00am an observation was made of residents sitting on the facility's front porch. One of these residents was sitting in a wheelchair, his feet were elevated on the footrests, his hands were not visible under the smoking apron he was wearing and he had a lit cigarette in his mouth. This resident was later identified as resident #5. There was no staff observed with the residents on the porch at this time. On 12/19/12 at 11:55am an observation was made of resident #5 on the front porch of the facility. He was sitting in his wheelchair with his feet elevated on the footrests, his hands were not visible under the smoking apron he was wearing. He had a lit cigarette in his mouth. There was no staff observed with the residents on the porch at this time. On 12/19/12 at 11:56am, S1Adm. came out of the facility onto the front porch. He walked up to resident #5 and removed the cigarette from the resident's mouth and extinguished the cigarette. On 12/19/12 at 12:20pm an interview was conducted with S16LPN. She stated that resident #5 was paralyzed and required supervision with smoking and that he has a smoking apron. She stated that he is difficult because he wants to smoke when he want to. She stated that he will pull (inhale) on his cigarettes. She stated that the CNAs light his cigarettes for him and that staff would stay with him the entire time he's smoking and then take it out of his mouth or he would spit the cigarette out. She stated that he keeps his own cigarettes and probably wouldn't let anyone keep his cigarettes. On 12/19/12 at 1:05pm an observation was made of resident #5 sitting on the front porch of the facility. He was not smoking and no staff was observed with the residents on the porch. At this time, another resident, R3 came onto the porch. R3 was observed as she lit a cigarette and put it in resident #5's mouth, then lit a cigarette for herself. During this observation, S1Adm. walked past the residents and went inside the facility. A review of the facility's Independent Smokers List revealed R3's name was included on the list. On 12/19/12 at 1:16pm S3CNA was observed as she walked outside the facility onto the front porch. She walked up to resident #5 and stood next to him. At this time, the wind began to increase causing resident #5's lower portion of his smoking apron to lift up into his face. When this occurred, the resident's cigarette dropped out of his mouth onto the ground. On 12/19/12 at 1:20pm an interview was conducted with S3CNA. She stated that resident #5 was a supervised smoker. She stated that he wears a smoking apron to keep him from getting burned. She stated that resident #5 was unable to use his hands. She stated that supervised smoking for resident #5 is to make sure he's safe during his cigarette breaks which are at 8a, 10a, 12p, 2p, 4p and 6p. She stated that we get his cigarettes for him and we light the cigarette for him. She stated that we keep his cigarettes on the cart. She stated that when resident #5 was observed smoking on 12/19/12 at 1:16pm, she had not lit his cigarette or provided cigarettes to the resident. On 12/19/12 at 5:10pm an interview was conducted with S17LPN for resident #5. She stated that resident #5 was paralyzed and required total care. She stated that the resident's wheelchair is pushed outside by staff. She stated that the resident has been outside all day because that is his preference. She stated that we put a smoking apron on him which is velcroed at the shoulders. Surveyor and S17LPN walked to the front porch to view resident #5's smoking apron. Surveyor observed the resident's contracted hands which were under his smoking apron. An attempt was made by surveyor to interview the resident at this time. The resident stated, "You are very interested in me, why, just go on, everything is fine." On 12/19/12 at 3:20pm an interview was conducted with S1Adm. He stated that resident #5 was a supervised smoker. He stated that resident #5 was non-compliant at times and would get other residents to light a cigarette for him.

Based on observations, interview and record review, the facility failed to ensure that each resident's environment remained free of accident hazards by (a)failing to ensure that a resident identified by the facility as a non-compliant smoker, did not smoke while actively utilizing oxygen (resident #3); (b)failing to ensure that a resident identified by the facility and care planned for staff supervision during smoking as he was a quadraplegic and unable to hold a cigarette for himself, consistently received staff supervision/assistance with smoking (resident #5) and (c) failing to ensure that a resident with a history of psychosis was supervised to ensure that he did not bring weapons into the facility (R1). Resident #3 was placed in Immediate Jeopardy (IJ) on 12/7/12 when resident #3's oxygen tubing caught fire on the facility's front porch while resident #3 was smoking. The facility had no fire extinguisher on the porch on 12/7/12 nor was a fire extinguisher installed on the porch thereafter. The facility identified 49 residents in the facility as smokers and were aware that residents, including resident #5 continued to smoke on the facility's front porch after 12/7/12. On 12/7/12, resident #5 was re-assessed by the facility as requiring staff supervision/assistance with smoking. Resident #5 was placed in an IJ situation on 12/19/12 at 1:16pm when he was observed smoking without staff supervision on the front porch. During this observation, the wind increased and blew the resident's smoking apron up knocking the cigarette from resident #5's mouth. This deficient practice had the potential to affect all residents (smokers and non-smokers) who utilized the facility's front porch. The facility was notified of the IJ situation on 12/19/12 at 4:38pm. The IJ was lifted on 12/19/12 at 6:45pm when the facility provided a plan to increase supervision of residents requiring supervision/assistance with smoking. The deficient practice continues at a scope and severity of D as the facility has not put a system in place to increase supervision to ensure that oxygen canisters are not allowed near flammable/combustible objects and to increase supervision for residents with a history of non-compliance with smoking. Findings: Resident #3: A review of the clinical record for resident #3 revealed the resident was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. A review of the facility ' s Smoking Policy revealed, in part, the following: This facility shall establish and maintain safe resident smoking practices. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas. No-Smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Any smoking related privileges, restrictions, and concerns shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues. On 12/18/12, 12/19/12 and 12/20/12 residents were observed smoking cigarettes in the following three (3) areas of the facility: Front Porch, Courtyard and Back patio with screened sitting area. There were no observable No-Smoking signs posted in any of these areas. A portable fire extinguisher was observed on the Courtyard patio. There was no observable fire extinguisher on the Back patio or the Front Porch of the facility. A review of the December 2012 Physician order [REDACTED]. Oxygen (O2) at 2Liters/Minute via nasal cannula as needed for Shortness of Breath (SOB) and wheezing. A review of the Nursing assessment dated [DATE] for resident #3 revealed the following: Respiratory related: Continuous O2. Behaviors: Non-Compliant with smoking. A review of resident #3 ' s Assessment for Safe Smoking dated 10/21/12 revealed the following: Cognitive Status: Independent - decisions consistent/reasonable - yes Medication: Is the resident on medications with the potential to cause sedation? - yes Risk Factors: Does the resident use O2 - yes Resident may smoke unsupervised in designated smoking areas. A review of the Nurse ' s Notes regarding resident #3 revealed the following: 12/7/12, 1:30pm: Resident was ordered for evaluation at ____ Hospital. Resident was noted by LPN smoking with O2 on, black residue was noted on resident hands. 12/7/12, 5:25pm: Resident returned from hospital. On 12/19/12 at 1:20pm an interview was conducted with S3CNA. She stated that on 12/7/12, resident #3 was wearing his oxygen container while smoking and burned himself. A review of the Client Incident Report that the facility submitted to State Office revealed the following: Incident ID: , Occurred: 12/7/12, 1:00pm, Reported in Facility: 12/7/12, 1:00pm, Entered: 12/7/12, 1:24pm; CEO Finding/Determination: 12/10/12 Accused/Allegation: Neglect: Caregiver Findings: Unsubstantiated Victim: Resident #3 Description: Resident #3 smoked out on the front porch of the facility with his nasal cannula and oxygen tank. This caused a fire slightly burning resident ' s index and middle finger on right hand. Summary: On 12/7/12 at approximately 1:00pm, resident #3 went out to smoke on the front porch of the facility. While smoking, the nasal cannula for resident #3 ' s oxygen tank caught fire. S3CNA noticed this and immediately called for help and extinguished the fire. Resident was assessed and taken to the hospital for evaluation. Resident #3 returned around 5:30pm. It was noted he had small blister on right index finger and small burn mark on right middle finger. Investigation revealed that resident #3 did not remove O2 and cannula before going out to smoke as he had done every other day. Resident #3 had been educated prior to incident on not taking oxygen with him to smoke due to safety issues. This was the first time he had done this. Upon completion of investigation, the allegation of caregiver neglect is unsubstantiated. On 12/19/12 at 3:00pm an interview was conducted with S1Adm. and S4Corp. Dir. Surveyor requested to review the facility ' s investigation regarding resident #3 ' s burn injury while smoking on 12/7/12. S1Adm. stated that the facility was advised by their legal department that they could not provide surveyor with documentation of facility ' s investigations of accidents and/or incidents. Surveyor was provided with a written statement from the facility which read as follows: 12/19/12 - We are unable to provide the requested material concerning accident investigations. Our investigation is on an internal document. A review of resident #3 ' s Medical Record from ___ Hospital dated 12/7/12 revealed the following: Arrival Date: 12/7/12 with Chief Complaint: Soft tissue injury to dorsum of right hand. Procedures: Debridement of blisters and dead skin less than 9% body surface, area was wrapped with an occlusive antibiotic dressing. Primary Diagnosis: [REDACTED]. discharge date : 12/7/12 A review of resident #3 ' s Care Plan revealed the following: Smoking, 6/4/12 Problem/Need: Resident wishes to smoke and is designated as safe smoker; Resident needs Observation while smoking. Target Date of 2/29/13. Approaches: Resident will demonstrate safe technique for putting out matches or lighter and disposing of ash, ability to physically hold the smoking device while smoking, and will verbalize understanding that smoking materials are for use only in designated smoking areas. Resident oriented to smoking procedures and areas. Provide resident with observation while smoking. Behavior, 6/4/12 Problem/Need: Behavior Problem - Resists Care as evidenced by noncompliance with O2 therapy and leaving O2 tank in lobby to smoke. Target Date of 2/29/13. Approaches: Educated on safe use of O2 tank and storage and safety, i.e. potential for injury, fire hazard and harm to others. Cognitive Loss, 6/4/12 Problem/Need: Resident has impaired cognitive skills as evidenced by Short term memory problem and requires cues with recall. Target Date of 2/29/13. Approaches: Provide cues, prompting and demonstrating; Remind and escort to activity programs consistent with resident ' s interests. Activity Preferences, 6/4/12 Problem/Need: Resident attends activities of choice. Target Date of 2/29/13 Approaches: Resident has indicated the following activity preferences are important to him: sitting outdoors; Encourage resident to sit on porch/in courtyard/on patio. On 12/21/12 at 10:55am an interview was conducted with resident #3 while in his room. The resident was alert and oriented to person, place and time. He was utilizing O2 via nasal cannula during this interview. The resident stated that he uses O2 because he has COPD. The resident had healing wounds observed on his right hand to his inside thumb and top portions of his index and third fingers. Resident #3 stated that a couple of weeks ago, he went outside on the facility ' s front porch to smoke a cigarette. He stated that he had his O2 cylinder attached to the back of his wheelchair. The resident stated that he always brought his O2 canister outside when he smoked. He stated that his O2 was turned on and he was receiving the O2 via his nasal cannula. He stated he didn't remove the nasal cannula and forgot to turn the O2 off before he lit his cigarette. He stated that when he lit the cigarette, a fire started in the middle section of his O2 tubing. He stated that his fingers got burned when he pinched the O2 tubing to put out the fire. He stated that when the fire began, another resident went and got the nurse and S3CNA who turned off his oxygen when they arrived. Surveyor asked what type of O2 canister he used on the date of the fire. The resident pointed to a portable E Cylinder which was next to his bed. A review of the List of residents who use O2 revealed the facility identified a total of 5 residents who utilize O2. On 12/20/12 at 2:40pm an interview was conducted with S1Adm. He stated that residents assessed as not requiring supervised smoking were allowed to smoke on the facility ' s front porch. He stated that there was no fire extinguisher located on the front porch on 12/7/12. He stated that prior to 12/7/12 resident #3 did not require supervision with smoking. He stated that resident #3 was one of two residents residing in the facility who smoke and use O2. He stated that there were non-smoking residents in the facility who use O2 and are allowed to go outside to the Courtyard, Front Porch and Back Patio with screened sitting area. He confirmed that there was no separate outside area for residents to use where smoking was not allowed. Surveyor asked what system the facility had in place to prevent residents from bringing O2 into areas where flammable materials were utilized. S1Adm. stated that staff watch to see that the smoking residents remove their O2 prior to going out to smoke. S1Adm. verified that there was no system in place as of 12/20/12 to ensure that residents with O2 in use are not allowed in areas where residents are smoking. Resident #5: A review of the clinical record for resident #5 revealed [DIAGNOSES REDACTED]. A review of the facility's Assessment for Safe Smoking, dated 12/7/12 for resident #5 revealed the requiring staff assistance to hold his cigarette. A review of the facility's List of Supervised Smokers provided to the surveyor on 12/19/12, revealed resident #5 was included on this list. A review of the Smoking Times for Smoking Program Residents revealed the following: 8:00am, 10:00am, 12:00pm, 2:00pm, 4:00pm, 6:00pm, and 8:00pm - All residents on smoking program must be supervised. Supervised smokers will be conducted in Courtyard area. A review of the Care Plan for resident #5 revealed the following: Problem/Need: Smoking - Impaired smoker, resident needs observation, constant supervision and protective gear while smoking. Non-compliant with smoking program. Target date 12/21/12 Approaches include: Resident will ask for smoking materials Will demonstrate ability to verbalize understanding that smoking materials are for use only in designated smoking areas Oriented to smoking procedures and areas Provide resident with observation, constant supervision and protective gear while smoking. Problem/Need: Behavior - Resists Care, history of sitting outside drinking alcohol, refusing medications and cursing staff/residents. Approaches include: Report behavioral changes to doctor, Provide non-confrontational environment, Anticipate care needs, Educate the resident on causal factors of behavior, reapproach later when he becomes agitated. Problem/Need: Cognitive Loss - Refuses smoking apron. Target date 12/21/12 Approaches include: Report changes in cognition to doctor, explain all care, invite to activity programs, provide cues, promote dignity. On 12/19/12 at 10:00am an observation was made of residents sitting on the facility's front porch. One of these residents was sitting in a wheelchair, his feet were elevated on the footrests, his hands were not visible under the smoking apron he was wearing and he had a lit cigarette in his mouth. This resident was later identified as resident #5. There was no staff observed with the residents on the porch at this time. On 12/19/12 at 11:55am an observation was made of resident #5 on the front porch of the facility. He was sitting in his wheelchair with his feet elevated on the footrests, his hands were not visible under the smoking apron he was wearing. He had a lit cigarette in his mouth. There was no staff observed with the residents on the porch at this time. On 12/19/12 at 11:56am, S1Adm. came out of the facility onto the front porch. He walked up to resident #5 and removed the cigarette from the resident's mouth and extinguished the cigarette. On 12/19/12 at 12:20pm an interview was conducted with S16LPN. She stated that resident #5 was paralyzed and required supervision with smoking and that he has a smoking apron. She stated that he is difficult because he wants to smoke when he want to. She stated that he will pull (inhale) on his cigarettes. She stated that the CNAs light his cigarettes for him and that staff would stay with him the entire time he's smoking and then take it out of his mouth or he would spit the cigarette out. She stated that he keeps his own cigarettes and probably wouldn't let anyone keep his cigarettes. On 12/19/12 at 1:05pm an observation was made of resident #5 sitting on the front porch of the facility. He was not smoking and no staff was observed with the residents on the porch. At this time, another resident, R3 came onto the porch. R3 was observed as she lit a cigarette and put it in resident #5's mouth, then lit a cigarette for herself. During this observation, S1Adm. walked past the residents and went inside the facility. A review of the facility's Independent Smokers List revealed R3's name was included on the list. On 12/19/12 at 1:16pm S3CNA was observed as she walked outside the facility onto the front porch. She walked up to resident #5 and stood next to him. At this time, the wind began to increase causing resident #5's lower portion of his smoking apron to lift up into his face. When this occurred, the resident's cigarette dropped out of his mouth onto the ground. On 12/19/12 at 1:20pm an interview was conducted with S3CNA. She stated that resident #5 was a supervised smoker. She stated that he wears a smoking apron to keep him from getting burned. She stated that resident #5 was unable to use his hands. She stated that supervised smoking for resident #5 is to make sure he's safe during his cigarette breaks which are at 8a, 10a, 12p, 2p, 4p and 6p. She stated that we get his cigarettes for him and we light the cigarette for him. She stated that we keep his cigarettes on the cart. She stated that when resident #5 was observed smoking on 12/19/12 at 1:16pm, she had not lit his cigarette or provided cigarettes to the resident. On 12/19/12 at 5:10pm an interview was conducted with S17LPN for resident #5. She stated that resident #5 was paralyzed and required total care. She stated that the resident's wheelchair is pushed outside by staff. She stated that the resident has been outside all day because that is his preference. She stated that we put a smoking apron on him which is velcroed at the shoulders. Surveyor and S17LPN walked to the front porch to view resident #5's smoking apron. Surveyor observed the resident's contracted hands which were under his smoking apron. An attempt was made by surveyor to interview the resident at this time. The resident stated, "You are very interested in me, why, just go on, everything is fine." On 12/19/12 at 3:20pm an interview was conducted with S1Adm. He stated that resident #5 was a supervised smoker. He stated that resident #5 was non-compliant at times and would get other residents to light a cigarette for him. R1: A review of the clinical record for R1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nurses notes for R1 revealed the following: 11/30/12, time not documented - Resident had possession of knife. A review of the Nurses notes for resident R1 revealed the following: 12/15/12, 5:50am - Reported per CNA "I saw R1 with a lit cigarette in his hand pushing another resident. I ask him why is he walking with it and he told me that it's none of my business so don't worry about it." 12/15/12, 7:00am - Resident was seen by the Weekend RN Supervisor with a knife on him, she asked for the knife, but he refuses to give knife to RN Supervisor. Notified Nurse Practitioner (NP) on call. He stated to call police department, but to notify S1Adm. first. Called S1Adm. and he stated to call the police at this time. Notified police department at this time. 12/15/12, 7:40am - Police arrived to facility, but resident had left. Police was given a copy of picture of resident as well as a description of what resident has on at this time. Nursing staff has been sent to keep eyes on resident until the police have him in their custody. Nursing staff are with resident at this time awaiting police arrival. Nursing staff reported that resident is calm at this time. 12/15/12, 6:02pm - Resident returned to facility, no agitation noted, no knife noted in resident possession. When assessed, resident stated, "S1Adm. informed him that no weapons are allowed in this facility and he won't do it again." A review of the list of residents scheduled to see the NP on 12/18/12 revealed the following: R1 (follow-up) for increased agitation/verbally abusive towards staff/difficult to redirect/increased erratic complaints about everything, (see attached letters). A review of the attached letters written by R1 revealed that the resident wrote letters to the facility on [DATE], 12/17/12, 12/18/12 and 12/19/12. A review of the computerized December 2012 Physician order [REDACTED]. Thorazine 10mg qhs - 8:00pm (antipsychotic) Loibra 200mg 1 qd - 8:00am Metformin Hcl 500mg bid - 8:00am & 4:00pm MVI qd - 8:00am Actos 30mg qd - 8:00am Tamsulosin Hcl. 0.4mg bid - 8:00am & 4:00pm Seroquel 150mg bid - 8:00am & 4:00pm A review of the handwritten Physician order [REDACTED]. 12/11/12: Depakote ER 250mg bid Thorazine 5mg qam Continue Thorazine 10mg qhs 12/15/12: OK not to send resident out for Psychiatric Evaluation A review of the December 2012 Medication Administration Record for R1 revealed the following: 12/3/12, 8:00am - Resident out of facility, no medications given 12/5/12, 8:00am - Resident out of facility, no medications given 12/7/12, 8:00am - Resident out of facility, no medications given 12/12/12, 8:00am - Resident out of facility 12/14/12, 8:00am - Resident out of facility 12/15/12, 8:00am - Resident out of facility 12/16/12, 8:00am - Refused all morning medications, stated, "I'll take them later" 12/17/12, 8:00am - Resident refused all medications. On 12/20/12 at 5:00pm an interview was conducted with R1. He stated that a lot of times he skips his medications, but it doesn't matter. A review of the Psychiatric Progress Note for R1 revealed the following: 12/11/12 - Staff report increasingly agitated yesterday Patient Report: People have been stealing from him, very angry, phone stolen yesterday Mood: Angry, Irritable Thought Content: Suspicious Behavior: Escalating Psychomotor: Restless Judgement: Impaired Insight: Impaired Attention: Impaired Assessment: Escalating Plan: Add Thorazine 5mg qam, Depakote 250mg bid Current Psychiatric Medications: Thorazine 10mg qhs, Seroquel 150mg bid 11/27/12 - Staff report increased agitation, verbally abusive toward staff, collecting cans, labile mood and affect Patient Report: States he is collecting this and selling them to get money. Mood: Irritable Thought content: Appropriate Behavior: Calm, cooperative Psychomotor: Normal Judgement: Impaired Insight: Impaired Attention: Impaired Assessment: Elevated and irritable Plan: Increase Seroquel to 150mg bid Current Psychiatric Medications: Thorazine 10mg qhs, Seroquel 100mg bid A review of the Care Plan for R1 revealed the following: Problem/Need: Psychotropic Drug Use - Antipsychotics, Diagnosis: [REDACTED]. Approaches include: Administer medications as prescribed 12/11/12 - New medications added by NP Problem/Need: Behavior 6/14/12 - Unlocking doors after hours, Drinking beer and cursing 7/7/12 - Allegedly touched female resident's breast and requested oral sex 11/22/12 - Verbal Altercation with staff 11/29/12 - Threatening Staff 11/30/12 - Verbal Altercation with staff 11/3/12 - Wandering in other resident room 12/2/12 - Resident seen with knife 12/15/12 - Smoking in hallway, knife seen on person Approaches: 7/7/12 - Family notified and resident taken out on pass with family, Investigation initiated, police notified 7/8/12 - 1:1 supervision 11/22/12 - Resident will see psychiatric NP 11/30/12 - Counseled resident on behavior, educated resident on technique to decrease anger 11/30/12 - Redirected by staff 12/2/12 - Redirected, Knife given to staff member, put in appropriate place. Further review of this Care Plan revealed no documented evidence that R1 had a knife in his possession on 11/30/12 A review of the facility's Firearms and Other Weapons Policy revealed, in part, the following: Our facility prohibits employees, residents, visitors or others from possessing firearms or other weapons while in/on our facility's premises. Our Policy prohibits any employee, resident, visitor or any other individual from possessing firearms or other weapons designated to do bodily harm (e.g. knives with blades longer than four inches) while in or on our facility's premises. Violations of this policy will result in immediate termination of employment, discharge from the facility, etc. as each situation may apply. On 12/20/12 at 3:00pm an interview was conducted with S13CNA for R1. She stated that the resident was not usually in the facility at this time of day. She stated that the resident can sign himself out. She stated that he usually returns to the facility after supper. She stated that the resident wears a jacket with ____ Security written on it. She stated that the resident is loud, curses and will curse at staff. She stated that the resident had never had an altercation with other residents to her knowledge. She stated that she had never seen the resident with a knife. She stated she heard that the resident had a knife. She stated that it was said he pulled a knife one day before her shift started. On 12/20/12 at 3:05pm an interview was conducted with S1Adm. Surveyor asked for a description of the type knife the resident was seen with in the facility. S1Adm. stated that it wasn't a basic kitchen knife or a pocket knife, it's bigger than a butter knife and made of metal. He stated that the resident was told not to keep the knife on the premises. He stated that the resident was told if he brought it on the premises that it would be taken away from him, He stated that the resident told him he kept the knife for protection at the part that he goes to during the day. He stated that the resident hangs out at at park during the day talking to people. He stated that on 12/15/12, the police went out and talk to R1. He stated that the resident answered all their questions correctly and stated that he had no intention of harming himself or anyone else. He stated that he did not know why the resident took the knife out in front of the nurse on 12/15/12. He stated that he did not know who the resident gave the knife to or what was done with it on 12/2/12. S1Adm. stated that the resident's room had not been searched for weapons. On 12/20/12 at 3:30pm an interview was conducted with S2ADON. She stated that R1 leaves the facility every day. She stated that she asked him about it and he told her that it was none of her business. She stated that the park the resident goes to every day is a recreational park, like a YMCA. She stated that she did an incident report on 12/15/12 regarding the resident having a knife in the facility. She stated that she talked to the resident and he stated that he was offended that we called the police on him. She stated that she had never seen the resident's knife. She stated that S1Adm. went to the park on 12/15/12 and met with the resident and the police. She stated that the police deemed R1 wasn't suicidal or homicidal and they felt that it was OK for him to have the knife because of personal protection at the park. She stated that on 12/2/12, the knife was taken from the resident, but there was no documentation of a description of the knife or where it went. On 12/20/12 at 3:45pm an interview was conducted with S14LPN for R1. She stated that on 12/15/12, she was working, but that she didn't see the resident with the knife. She stated that she didn't have any contact with the resident on that date. She stated that the Weekend Supervisor saw the knife in R1's inside jacket pocket. On 12/20/12 at 3:55pm an interview was conducted with S12SSD. She stated that R1 had been leaving bizarre notes under her door. She stated that she gave a copy of the notes to the NP because R1 had complained about a lot of random things. She stated she scheduled him to see the NP on 12/18/12, but that the NP didn't see him because he wasn't in the facility. She stated that the resident was notified about the appointment. She stated that the NP saw the resident on 12/11/12 and she made a change to one of his medications. She stated that she wasn't told that the resident had a knife on 12/2/12. She stated that she was notified on 12/15/12 that he was having some behaviors, but wasn't told that he had a knife on him. She stated that she contacted the NP on 12/15/12 because of his behaviors and the NP said to send R1 to the ER and PEC him when he got to the hospital. S12SSD stated that when she arrived at the facility on Monday 12/17/12, the resident was still there. She stated she then made an appointment for the resident to see the NP on 12/18/12. She stated that the resident having a knife in the facility was a safety issue. On 12/20/12 at 4:10pm an interview was conducted with S15NP. She stated that she didn't see R1 on 12/15/12. She stated that the police talked to him on 12/15/12 and they said he was fine, that he wasn't homicidal or suicidal. She stated she had never seen the resident's knife, but was told it was a steak knife, maybe. She stated that the resident had never brandished a knife at anyone in the facility. She stated that R1 gets upset, but has never threatened anyone. S15NP further stated that residents carry knives to their rooms all the time. She stated from her standpoint, she didn't have the grounds to say that R1 can't have a knife or confiscate it from him. She stated that R1 says the knife is to protect himself at the park, not when he's at the nursing home. She stated that she did not see R1 on 12/18/12 as he was not in the facility at the time of the appointment. On 12/21/12 at 1:25pm an interview was conducted with S2ADON. She stated that the weekend nurse who worked on 12/15/12 didn't leave a description as to what type of a knife R1 had on 12/15/12. She stated that R1 had not been harmed or attacked while at the park that she knew of. She stated that he doesn't want people in his personal business and he feels it's his right to carry a weapon to protect himself. She stated that the resident was in excellent shape and very able to take care of his own. She stated that he has periods of psychosis, but he's very smart. She stated that you have to be careful how you approach him. On 12/21/12 at 2:15pm an interview was conducted with S1Adm. He stated that per the facility policy, a resident is allowed to have a 4 inch blade knife with them in the facility. He stated he was made aware of the situation with R1 on 12/15/12 when he was called by the nurse. He stated that resident R1 had the knife with him when he went to the park to talk to him on 12/15/12. He stated that it was a metal knife, longer than a butter knife and it had a sharp point. He stated that R1 had the knife in his inside chest pocket of his jacket. He stated that the resident told him he was going to leave the knife at the park. He stated that he did not know what the resident did with the knife on 12/15/12 as the resident didn't return to the facility with him. He stated that the police were at the park and spoke with the resident and then spoke to him. He stated that the police didn't feel that the resident was a danger to himself or others. He stated that he did not know if the park was located in a high crime area. He stated that he had not asked the resident if he had been attacked or threatened while at the park. He stated that the resident wasn't approachable about talking about the park. On 12/20/12 at 5:00pm an interview was conducted with R1. The resident stated that everything is good. He stated that he works at the park from 8:00am to 5:00pm. He stated that some of the CNAs in the facility call him curse words. He stated that if it was a man, he would let them have it and that he's not wrong in no way. He stated that most of the time when he gets into it with other people, he is right. He stated that there are some skin heads in the facility. He stated that everyday he returns to the facility somebody starts with him. He stated that he told the police he had the knife for his protection. He stated that it was better for him to protect himself than to get hurt by somebody else.

Based on record review and interview the facility failed to ensure that staff provided services that met professional standards of quality in the care of 1(#1) of 5 (#1, #2, #3, #4, #5) residents reviewed. The facility failed to: 1. Ensure that supervision/monitoring was increased for a resident with a history of falls (#1), 2. Ensure that Resident #1 was assessed and monitored after each of two falls on 11/19/12, 3. Ensure that the LPN (Licensed Practical Nurse) conducted and completed a physical assessment after each fall on 11/19/12 on a resident who experienced two falls from his wheel chair on 11/19/12 (#1), 4. Timely notify family/responsible party of Resident #1's falls, injury and transport to the hospital, and 5. Ensure that the resident was assessed for the less restrictive restraint before allowing the resident to be tied to the chair by the CNA (Certified Nursing Assistant) on 11/19/12. Resident #1 was in Immediate Jeopardy on 11/19/12 at 5:55 p.m. when he experienced his first fall. The facility failed to increase supervision of a resident identified as a fall risk on his Pre-Admission Record Review. The Immediate Jeopardy for Resident #1 was lifted on 11/19/12 at 6:30 p.m. when Resident #1 was transferred to the hospital. The Immediate Jeopardy was lowered to actual harm for Resident #1 when he sustained a cervical fracture and [MEDICAL CONDITION] as a result of the falls on 11/19/12. The deficient practice remains at a potential for more than minimal harm for all 28 residents (#2, #3, #4, #5 - #29) identified by the facility as having experienced a fall. Findings: Review of the Louisiana State Board of Nursing website revealed the Delegation Decision-Making Process from the Registered Nurse to the Licensed Practical Nurse (http://www.lsbn.state.la.us/Portals/1/Documents/DelegationTree.pdf) with the following information: In Louisiana, R.S. 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for the implementation of the statutory mandate. The term "delegating nursing interventions" is defined and criteria are provided for all delegatory activities, for delegation to licensed practical nurses, and for delegation to unlicensed nursing personnel. The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures. Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse's responsibility and accountability. Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses Subpart, I. Practical Nurse, under subchapter E.Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and working as a member of the interdisciplinary health care team..." Resident #1 was a [AGE] year old male admitted to the Secure Unit on 11/19/12 at 4:10 p.m. with a history of [MEDICAL CONDITION], Cognitive Impairment, Gastritis, [MEDICAL CONDITIONS] (Not Otherwise Specified) and Dementia. Review of the Pre-Admission Record Review completed by the Director of Clinical Evaluations RN on 11/16/12 was sent to the facility and revealed that Resident #1 had been identified as a fall risk. This information is sent to S5SSD, who disseminates the Pre-Admission packet to the DON, Administrator, ADON, MDS Coordinator and the business office for financial reasons. The Director of Nursing or Assistant Director of Nursing ensures that the unit nurse receives the Admission report before the resident gets to the facility. Review of the Nurse's Notes revealed the following documentation in part: 11/19/12 at 4:10 p.m.: admitted to Secure Unit... Local Hospital record state resident was readmitted to their Geri Psych unit for violent behavior from another long term care nursing facility. Resident. is up in wheel chair at this time. Quiet, skin is warm to touch; respirations are even & unlabored. Resident is alert but non-verbal. Medications verified per Nurse Practitioner. Obtained order to admit to Secure Unit. Medication orders faxed to pharmacy. No date/time Resident sitting in wheel chair in hallway. Heard another resident yelling. Resident on floor in front of wheel chair. Resident assisted back to wheel chair to assess cut and initiate neuro checks. Resident shows no sign or symptom of pain at this time. CNA asked to sit by resident until Emergency Medical Service arrives. 6p: Call placed to Nurse Practitioner. Order noted to send to emergency room (ER) for evaluation and treatment. 6:20 p.m.: Resident attempted to get out of wheel chair. CNA lowered resident to floor. Resident assisted. back to chair and temporarily restrained for patient safety until EMS (Emergency Medical Service) arrived. 6:30 p.m.: Resident left facility via Emergency Medical Service. Unable to reach family; no numbers in chart for family. Review of Resident Investigative Report revealed in part the following:Incident Date: 11/19/12 Time: 5 p.m. Category: Fall Describe Injury: Cut over left eye Incident Level: fell from wheel chair unwitnessed. Temperature: 98 Pulse: 117 Respirations: 14 Blood Pressure: 167/95 Pain Scale: ? Notified: Physician: Nurse Practitioner Date/Time Contact Initiated: 6 p.m. 11/19/12 Other current conditions: Confusion/Disorientation Narrative of Incident and description of injuries: Resident. was sitting in hallway in wheel chair; fell forward to floor and cut L (left) eye. Date of Incident: 11/19/12 Time of Incident: 5:50 p.m. Immediate intervention put into place to prevent further incidents: Resident assisted to chair. Pressure to eye until it stopped bleeding. Sat aide next to patient. to prevent him from trying to get up until Emergency Medical Service (EMS) arrived. Assessment, Vital Signs, Neuro checks Incident Witness Statement Resident: #1 Incident type: Unwitnessed fall Date/Time: 11/19/12 5:50 p.m. Witness: S6LPN Position:. LPN Statement: Resident sitting in hallway in wheel chair, heard another resident yelling resident. on floor. Cut noted above left eye, assist to chair to assess cut; initiated neuro checks, CNA at resident's side to wait for EMS. Resident attempted to get out of chair; lowered to floor per CNA; assisted. back to chair per CNA and this LPN. Temporarily restrained for resident's. safety until Emergency Medical Service arrived. Incident Witness Statement Date/Time: 11/19/12 5:57 pm. Witness: S8CNA . Position: CNA Comment: I, S8CNA was putting resident to bed when I heard another call my name and I ran out of the room and saw Resident #1on the floor. Signed by S8CNA Incident Witness Statement Date/Time: 11/20/12, 5:40 p.m. Witness: S9CNA Position: CNA Statement: I was in another resident's room helping with patient care. Another resident yelled for help who was sitting in the t.v. room. I ran out and Resident #1 had fallen face down out of his wheel chair. The other aides and I helped Resident #1off the floor. I sat and watched him until EMS arrived. Continuation of Inverstigative Report revealed that a Pain Evaluation in Advanced Dementia (Pain-AD) was completed by S6LPN and documented the following:: Category: Breathing Independent of Vocalization: Score: 0 Vocalization Score: 0 Facial Expressions Score: 1 Body Language: Score: 1 Consolation: 0 Total Score: 2 Interventions: no evidence of pain, resident to be re-evaluated as needed (Checked) Review of Facility's Nursing Admission assessment dated [DATE] was not completed by S6LPN and revealed the following hand written statement by S6LPN in part:: Assessment Date: 11/19/12 Birth date: 2/16/41 Gender: Male Age: 71 Race: 1 Facility's Nursing Admit Packet: Unable to complete. Resident out to emergency room . Review of OTIS report revealed the following in part..: Occurred: 11/19/2012 05:50 pm Discovered: 11/19/2012 05:50 pm Reported in facility: 11/20/2012 09:00 am Entered: 11/20/2012 02:36 pm CEO/finding/determination: 11/22/2012 Findings: Facility/CEO: Substantiated Accused/Allegation: S6LPN Neglect: Caregiver Substantiated Victims: Resident #1 DOB: SSN: Injury: Fracture Description: On November 19, 2012, resident #1fell in the facility, fracturing his C-7 vertebrae: Summary: On the morning of November 20, 2012, Administrator and DON were advised that resident had suffered a fractured C-7 vertebra. At this time, a thorough investigation began. CNAs and Nurse were suspended pending investigation. Interviews were conducted with nurse and CNAs on duty in the area. All confirmed that none actually saw the resident fall the first time due to being in other resident rooms but did hear it along with another resident calling them for help. In review of the surveillance tape, it was noted that resident climbed out of his wheel chair to his hands and knees on the floor. At that point he began to lose balance and fell face down to the floor. Nurse and CNA's came to resident's side. Resident was then lifted back into wheel chair and was noted to have a cut over right eye. At this point, S9CNA sat by resident monitoring him. S10CNA was sitting in another chair monitoring the rest of the hall. During this time, resident was seen constantly trying to kick S9CNA. S6LPN then came over and assessed the resident's eye. Resident moved his wheel chair a short distance from S9CNA. He then attempted to get out of the wheel chair again. Both S9CNA and S10CNA caught Resident #1 and lowered him to the floor. Again resident was put back in chair by CNAs and Nurse. At this time, S10CNA took a gown and tied it around the waist of the resident while other CNA and nurse S6LPN were standing there. In her interview, CNA stated that she knew we did not do restraints but saw him in one earlier in the hospital when she went to pick him up. She stated that she was only doing that for his protection and safety until EMTs (Emergency Medical Transport) could arrive. CNA stayed with resident until EMT's arrived. Then EMT's arrived, restraint was removed and resident was transported to hospital via stretcher. Conclusion: The allegation of neglect is substantiated as S6LPN neglected to assess resident twice on floor before having resident moved back to wheel chair. She also allowed S10CNA to restrain resident in her presence, although only for a short time. Final Report: After receiving the fall report with injury this warranted to viewing the security cameras due to information not clear on report. Upon reviewing the tape, resident was noted to have had 2 falls and it was witnessed it is classified as a fall due to resident being moved from one level to the next. No immediate assessment was done by assigned nurse S6LPN or first aid. S10CNA verbalized cleaning resident's eye. There was a delay in calling the EMS (Emergency Medical Servicec) until after resident's 2nd fall. No restraints should have been allowed by any staff on a resident. Nurse was present during the restraining of the resident for his safety per the CNAs and nurse. Otis Report is substantiated. Review of the facility's Fall Report for 9/1/12 through 11/23/12 revealed a total of 43 falls. Review of local hospital's emergency room report for Resident #1 revealed the following in part.. Arrival Date: 11/19/2012 18:48 Primary Diagnosis 1) Fracture of cervical spine Chief Complaint 1) Fall History of Present Illness in part...: Summary: [AGE] year old male s/p (status [REDACTED]. 3 centimeters laceration over left eye. No active bleeding on arrival. Patient not able to communicate. HPI: Exam started at 19:02. It is unclear when the presenting problem started. The patient is poorly responsive and therefore unable to give a reliable history. The patient fell from wheel chair landing on head. It is estimated that the patient fell approximately 2 feet. Injury can be coded as occurring in a health care environment. Review of Radiology Report with an order date of 11/19/2012 revealed the following in part..: CT Cervical Spine W/Ext cuts Cervical spine CT without contrast. History: Trauma. Neck pain Technique: Axial CT of the spine with coronal and sagittal reformations. Findings: There is a fracture involving the left lateral mass of T1 as well as the left C7 pedicle near the most inferior aspect of the left vertebral artery canal. No additional fractures. Review of the hospital's Discharge Summary dated 11/23/2012 revealed the following: Hospital Course: This is a [AGE] year old, Caucasian male with a history of profound dementia with aggressive hostile features. The patient apparently just arrived at A. Nursing Home when he fell out of a bed and had a fracture of his C7 pedicle fracture (nondisplaced near the vertebral artery canal). He also had a [MEDICAL CONDITION] mass ([MEDICATION NAME] process). He has no evidence of spondylolisthesis. The patient is able to move all extremities. A cervical collar has been placed on this patient. An interview was held with S2DON on 12/3/12 at 12:13 p.m. regarding incident with Resident #1. She stated that typically, they do not admit residents in restraints and that the resident must be without restraints for 24 hours prior to admittance to the facility. She stated that she was informed that they were sending the resident to the hospital after falling on 11/19/12 but did not get full details until 11/20/12 during the morning nursing meeting. She stated that the incident report was reviewed as well as chart documentation and other follow-ups. She said that they reviewed the documentation and that there were some things missing. The nurse normally worked 2-10 and a call was placed toS6LPN on 11/20/12, but she did not get an answer. She said that S6LPN did not complete the nursing admission assessment and that the nurse wrote on the assessment that she was unable to complete the assessment due to the resident having to go to the hospital. S2DON further stated that that was the reason she called the nurse. She stated that staff reported that when they went to get the resident, he was in restraints. She stated that she was not present but that S6LPN was interviewed by the Administrator, Regional Nurse and Regional Vice President and S3ADON where S6LPN was suspended pending the investigation. On 12/3/12 at 10:45 a.m., an interview was conducted with S4ClinicalCoordinator/Risk Manager. She stated that S6LPN did not complete any assessments of Resident #1 at the time of admission on 11/19/12 and that was one of the reasons she was no longer with the facility. She said that after the incident, she conducted in-services on Use of Restraints and Emergency Transfers as directed by the Regional Director of Clinical Operations. An interview was conducted with S1Administrator on 12/3/12 at 3:50 p.m. regarding falls of Resident #1. He stated that S6LPN was interviewed by him, along with the Corporate Nurse on 11/20/12, the next day after they had looked at the camera. According to S1Administrator, S6LPN said she was at the nurse's station and heard a resident and looked and saw that he (Resident #1) had fallen and she noted a cut to his eye. He said S6LPN stated that they moved Resident #1 back to his wheelchair. S1Administrator said S6LPN then called the ambulance at that time and that the CNA was seated with him. He stated that the resident had a 2nd fall shortly thereafter. He stated that the first fall was when he suspected the injuries occurred. He said the resident was not placed on any special observations and had only been in the building approximately 2 ? hours. He said that the CNA saw that he was restrained when he was at the hospital. He said the facility required that residents were required to be restraint free for 24 hours prior to being admitted to the facility. He then stated that the Assessment nurse went to the hospital and assessed him at the hospital before he was admitted to the facility. He stated that S6LPN did not tell them why she did not document both falls and gave no excuse. According to S1Administrator, Resident #1 sustained injuries and returned from the hospital with a cervical collar. On 12/3/12 at 4:12 p.m. an interview was conducted with the Regional Director of Clinical Operations. She stated that she was told that there were 2 falls and S6LPN had only reported one. She stated that she interviewed the nurse and asked what happened that night step by step and what she did and how soon she did it. She said S6LPN stated that the resident had fallen; that he had gotten out of his chair, got on the floor and then fell on his face. She stated that there were a lot of discrepancies in what S6LPN reported and said that she put her on a suspension. The Regional Director then stated that there were no admit assessment or documentation completed by S6LPN. She said that she asked S6LPN to show her the documentation and the nurse stated that she had to leave her shift and was going to do it the next day. She said she stated to S6LPN that it was a basic nursing function that when an incident occurred she was required to document what happened. She again stated that S6LPN was not forthcoming about the events of the fall and said that there was only one fall and then acknowledged that there were two. At that point, the Regional Director stated that she did not feel comfortable with S6LPN taking care of the residents. She said she told S6LPN that it looked like when she got Resident #1 off the floor, she did not do an assessment and had not done what her nursing judgment told her. The Regional Director revealed that S6LPN said she couldn't assess him on the floor. The Regional Director of Clinical Operations said she asked S6LPN if an emergency restraint was allowed and the LPN stated that S10CNA put it on, but there was no documentation that she tried any other interventions. She further said that she believed that the CNA did what she thought was best for safety reasons, however, she did not have the oversight and that S6LPN should have made that call. The Regional Director said she then asked the nurse how she thought that was okay, and asked if she put the resident in a geri chair or what else did she try, and she (S6LPN) did not answer. The Regional Director further stated that from the start, supervision should have been increased for Resident #1. According to the Regional Director the resident had only been at the facility for a couple of hours. She said that the facility did not know about the resident being in restraints at the hospital before being admitted to the facility. She then stated that she then talked to the Vice President, Administrator and DON and informed them that S6LPN should have been able to manage the unit and should have had better judgment and she felt that she could not take care of the residents. The Regional Director also stated that she informed S6LPN of her responsibilities after the two falls of which included reporting of incidents, restraints, emergency transferring and not moving a person with a fall without being assessed. The Regional Director stated that S6LPN told her that Resident #1's family was not contacted because the number was not on the face sheet. She then asked S6LPN if she called anybody else and she replied "no". When asked who determined what in-services were taught to staff the Regional Director said she did. When asked if assessment, documentation and reporting were included in the in-services, she stated she only instructed S4Risk Manager to in-service the staff regarding restraints and transfers. An interview was conducted with the Director of Clinical Evaluations for the facility on 12/3/12 at 5:20 p.m. She said that her job entailed responding to the referral source by evaluating a resident at whatever facility they were in. She stated that she has a referral form that is completed, along with the Pre-Admission Record Review. She further stated the criteria for medical acceptance was that the facility must be able to take care of the resident and provide for the need of a resident in the facility. The Director of Clinical Evaluations said that restraints are not permitted in a long-term facility. She then stated that the Admission Form which is inclusive of emergency contacts should be at the facility, along with the clinical record; and that this information is generally a copy or faxed record. She further stated that concerns are communicated verbally and written to the Admission's Coordinator. She said if a resident is found in restraints at a facility, she request that the restraint be discontinued a minimum of 24 hours prior to admission to the facility and that information is communicated to the admitting staff. An interview was conducted with S3ADON on 12/3/12 at 5:41 p.m. regarding the Admission's Process. She said that once S5SSD received the paper work from the Director of Clinical Evaluations, S5SSD disseminated it to the DON to be reviewed. S3ADON stated that S5SSD would then give a copy of that faxed info to S2DON and she and the DON reviewed the information. According to S3ADON, the Admit information is on the resident's chart. She said that she or the DON would communicate any concerns with the pre-admit and that this information was also communicated to the Social Worker and nurse on the unit. An interview was conducted with S5SSD on 12/4/12 at 8:35 a.m. regarding the intake process. S5SSD stated that the intake process involved the Director of Clinical Evaluations being contacted from the hospital. She stated that she scans and e-mail the information to the Director of Clinical Evaluations because they (facility) don't determine, accept or deny residents. S5SSD said that when the Director of Clinical Services get a referral packet completed she then determines if they are medically cleared. According to S5SSD, the packet comes to her and she gives the packet to the DON, Administrator, ADON, MDS Coordinator and business office for financial reasons. S5SSD said that if there were any psychiatric behaviors, S2DON and nurses reviewed all intake information for clinical appropriateness and needs and then determine if the resident goes on the secure or open unit. S5SSD said that S7LPN makes sure that this information is in the chart. On 12/4/12 at 9:24 a.m., an interview was held with S2DON regarding the intake process. She stated that there is a liaison that does the intake. S2DON was asked what was done when an assessment was received. S2DON said that a determination is made as to whether the resident is medically approved and when they get the paper work, they were to determine what the resident's needs were and what area was appropriate for the resident. S2DON said that the nurse is called to the unit and she takes the report. According to S2DON, S7LPN then sets up the chart. S2DON stated that this information is communicated in the nursing meeting. She stated that the unit nurse gets the admission report S2DON was asked whose job was it to ensure that staff received the admission packet and she revealed that S5SSD normally disseminated the packets and she (S2DON) hands it to the nurse and if there was any additional information, S5SSD would also get that information to them. She stated that before the resident gets to the facility, the nurse has a copy of the admissions packet. According to S2DON, a CNA was sent there with transportation. She stated that if the CNA got to the hospital and saw the resident in restraints, she should have known to call the facility to report what she had observed and those observations should have been communicated to the staff. An interview was held with S7LPN on 12/4/12 at 9:53 a.m. S7LPN said that she receive the Admission packet from S5SSD. She said that the Interdisciplinary Team determines where the patient is going. She said that S6LPN should have had the admissions packet which would have contained all the pertinent information about Resident #1. An interview was conducted with S10CNA. She stated that she went to the hospital to pick Resident #1 up, but did not know what condition he was in. When she got there she said she asked hospital staff questions because he was in a geri chair and they had a vest on him and saw that the bottom of the vest was tied to the geri chair. She said before they left the hospital the nurse had given him his medication and he was cooperative during the transport. She said when she arrived to the facility she let the aides and S6LPN know what she had observed and what kind of situation she saw while she was at the hospital. S10CNA said she was told by hospital staff that the resident was a fighter and when they came out of the room he was in a geri chair with a vest applied to him. She stated that she gave S6LPN the admissions packet from the hospital and informed her that the patient was in a geri chair with a vest on that was tied to the chair. She said the S6LPN named the type of vest as a posey vest. She said after she told the nurse everything all she (S6LPN) said was okay. S10CNA said that one of the aides was sitting with the resident after the first fall because he could not sit by himself. She said it was about 6 and she got up to do rounds and asked the other aide for help. One of the residents called S8CNA and when she made it to the hall she said "Oh my God" and S9CNA and S8CNA assisted by helping to get Resident #1 up off the floor. She said the resident was lying on the floor on his stomach. She said that she looked at him and the nurse was doing his vitals and she noticed that the resident had a gash on his eye. S10CNA stated that she got a warm towel and cleaned his face up. She said the resident bent over as if he was picking up a piece of paper the second time and she said that he needed something around him. She looked at the nurse and she didn't tell her no, so she put the gown around him and the nurse (S6LPN) said "at least he ain't going anywhere". S10CNA said that she had never been told that she was not to receive a patient in restraints because this was a restraint free facility. She said that the Restorative Aide told her that once she got to the hospital and saw the resident in restraints, she should have called the facility and not bring him to the facility. A telephone interview was held with S6LPN on 12/4/12 at 10:20 a.m. She stated that she was told in report that she was receiving Resident #1 to the unit. She said that she did not receive an admission packet. She stated that she did receive information on the residents' medications, history and stuff like that. She said the aide (S10CNA )told her that the patient had a restraint on when she arrived at the hospital to pick him up. S6LPN said Resident #1 was only on the unit for approximately 2? hours before he fell . S6LPN acknowledged that she did not intervene or stop her (S10CNA) when she applied the gown on the resident. S6LPN said that the facility's policy was to do an assessment as well as to perform neurological checks on a resident after a fall. S6LPN stated, " I screwed up and I know I did ". She acknowledged that she did not assess him before she moved him after the first fall. She stated that she witnessed only one fall. According to S6lPN, the first time Resident #1 fell the aides got him up and blood was observed over the residents' eye. She then stated the aides sat with him after the fall. She stated that she had not done his admission assessment or anything because he came right before med pass. She said that she did not know that a patient would have to have been restraint free before being admitted to the facility. She also said that she got a report from the hospital where the nurse mentioned the resident was placed in a geri chair, but she did not recall the nurse saying anything about restraints. S6LPN further stated that Resident #1 was sent to the ER around 6:30 p.m. on 11/19/12 and had sustained fractures of the vertebrae. An interview with S8CNA was held on 12/4/12 at 12:04 p.m. She said she did not see Resident #1 fall because she was with another resident. She said that another resident called for her and told her that a patient was on the floor. She said that she walked out of the room and saw Resident #1 on the floor. At this point, she called the nurse. She said that she called for S9CNA and S10CNA and then waited until the nurse came and assisted the resident back into the wheel chair. She said when the nurse came over she asked if he was okay and the resident was mumbling and they then got him off the floor and sat him back in the wheel chair. She said the nurse got vital signs and called the front desk to call the ambulance. An interview was held with S9CNA on 12/4/12 at 2:10 p.m. regarding the incidents surrounding the fall of Resident #1. She stated that he was sitting in his wheel chair and she and two other aides heard another patient yell for help and they all ran out. Resident #1 was on the floor, face down. S9CNA stated that she picked him up and sat him in his chair. She said that S6LPN was sitting at her desk and ran over with the aides. S9CNA said that Resident #1 had a cut on his eyebrow and it was bleeding. She said after that she sat with him until EMS came. She said he started leaning over and the nurse and other aide told her to unlock the chair so he could move around. She further said that S10CNA moved him from the wall and locked only one side of the chair. She said Resident #1 leaned over in his chair and she ran to catch him because he was about to fall again. She said that she lowered him to the floor with S10CNA. According to S9CNA the nurse came and she didn't do anything. She said when Resident #1 sat in his wheel chair the 2nd time, S10CNA suggested to tie something around him so that he would not fall again. She said that S10CNA went and got a gown and tied it around him. She also stated that S10CNA thought it was okay because she had reported to them that she saw him at the hospital and saw him with a vest on and tied to the chair. She said that she and the nurse stood by Resident #1's chair while S10CNA tied him down. S9CNA stated that S6LPN did not tell S10CNA not to do it.

Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 1 (#1) of 5 (#1, #2, #3, #4, & #5) sampled residents after a fall. Administration failed to: 1. Have a system in place to ensure that nursing staff assessed and implemented protective measures for a cognitively impaired resident who had been assessed as being at risk for falls.(#1) 2. Have a system in place to ensure that supervision/monitoring was increased for a resident with a history of falls on 11/19/12. (#1) 3. Have a system in place to ensure that a resident was assessed and monitored after each fall on 11/19/12. (#1) Resident #1 was a [AGE] year old with the [DIAGNOSES REDACTED]. Review of the Pre-Admission Record Review completed by the Director of Clinical Evaluations RN on 11/16/12 was sent to the facility and revealed that Resident #1 had been identified as a fall risk. This information is sent to S5SSD, who disseminates the Pre-Admission packet to the DON, Administrator, ADON, MDS Coordinator and the business office for financial reasons. The Director of Nursing or Assistant Director of Nursing ensures that the unit nurse receives the Admission report before the resident gets to the facility. Resident #1 was in Immediate Jeopardy on 11/19/12 at 5:55 p.m. when he experienced his first fall.. The facility failed to increase supervision of a resident identified as a fall risk on his Pre-Admission Record. The Immediate Jeopardy for Resident #1 was lifted on 11/19/12 at 6:30 p.m. when Resident #1 was transferred to the hospital.when the resident was sent to the hospital. The Immediate Jeopardy (IJ) ended on 11/19/12 at 6:30 p.m. when he was transferred to the hospital. The Administrator was informed of the IJ for Resident #1 on 12/4/12 at 12:45 p.m. The Immediate Jeopardy was lowered to actual harm for Resident #1 when he sustained a cervical fracture and [MEDICAL CONDITION] as a result of the falls on 11/19/12.. The deficient practice remains at a potential for more than minimal harm for all 28 residents (#2, #3, #4, #5 - #29) identified by the facility as having experienced a fall. Findings: Review of the clinical record revealed Resident #1 was a [AGE] year old with the following Diagnoses: [REDACTED]. Review of Resident #1's Investigative Report revealed the following: Incident Date: 11/19/12 Time: 5 p.m. Category: Fall Describe Injury: Cut over left eye Location of Occurrence: Unit hallway Equipment in use: Wheelchair Property Involved: Resident 's wheelchair Activity: Sitting in hallway Incident reported by: S6LPN Incident Level: fell from wheelchair unwitnessed. Associate Involved: None Immediate Action Taken First Aid given by: S6LPN Position: LPN Date: 11/19/12 Time: 5:55 p.m. Type of Aid: Assessment, VS (Vital Signs), Wound Care Temperature: 98 Pulse: 117 Respiration. 14 Blood Pressure: 167/95 Pain Scale: ? Notified: Physician: Medical Doctor/Nurse Practitioner Date/Time Contact Initiated: 6 p.m. 11/19/12 Date/Time Responded: 11/19/12 6pm Resident Condition at Time of Incident Physical Restraint: Not checked Bedrails: Up (checked) Bed Height: Adjustable (checked) Meds taken during first 8 hours: [MEDICAL CONDITION]/Antipsychotics (Checked); Tranquilizers/Sedatives (Checked) Mobility: wheel/chair Mental: Alert & Oriented x 1 Other current conditions: Confusion/Disorientation Narrative of Incident and description of injuries: Resident was sitting in hallway in wheel/chair; fell forward to floor and cut L(Left) eye. Witnessed by: Unwitnessed Documented by: S6LPN Title: LPN (Licensed Practical Nurse) Date: 11/19/12 Fall Investigation: Nursing Home - Internal Report Resident Name: Resident #1 Room #: 77-A Date of Incident: 11/19/12 Time of Incident: 5:50 p.m. Staff Completing Report: S6LPN 1. Contributing factors (Check all that apply): Non-compliant resident, Wheelchair; Resident is non-communicative/aphasic 2. Location: Hallway, Unit 3. Did anyone witness the fall? No; neuro checks initiated 4. Level of Injury: Minor Injury Describe the injury: small cut over L (Left) eye. 5. Describe the incident (Check all that apply): Found on floor 6. Was the resident using bed rails? No 7. In what position was the bed? N/A (Not Applicable) 8. Appliances/assistive devices use for ambulation (Check all that apply): If physical restraints were used, list the type(s): none 9. Activity status: Up in chair Immediate intervention put into place to prevent further incidents: Resident assisted to chair. Pressure to eye until it stopped bleeding. Sat aide next to pt. to prevent him from trying to get up until EMS (Emergency Medical Service) arrived. Assessment, Vital Signs, Neuro checks Review of the Nurse's Notes revealed the following documentation in part: 11/19/12 at 4:10 p.m.: admitted to Secure Unit... Local Hospital record state resident was readmitted to their Geri Psych unit for violent behavior from another long term care nursing facility. Resident is up in wheel chair at this time. Quiet, skin is warm to touch; respirations are even and unlabored. Resident is alert but non-verbal. Medications verified per Nurse Practitioner. Obtained order to admit to Secure Unit. Medication orders faxed to pharmacy. No date/time Resident sitting in wheel chair in hallway. Heard another resident yelling. Resident on floor in front of wheel chair. Resident assisted back to wheel chair to assess cut and initiate neuro checks. Resident shows no sign or symptom of pain at this time. CNA asked to sit by resident until Emergency Medical Service arrives. 6p: Call placed to Nurse Practitioner. Order noted to send to emergency room for evaluation and treatment. 6:20 p.m.: Resident attempted to get out of wheel chair. CNA lowered resident to floor. Resident assisted.back to chair and temporarily restrained for patient safety until Emergency Medical Service arrived. 6:30 p.m.: Resident left facility via Emergency Medical Service. Unable to reach family; no numbers in chart for family. Review of Pre-Admission Record Review completed by Director of Clinical Evaluations RN on 11/16/12 revealed the following in part..: General Information: 1. Date Received: 11/06/12 2. Prospective Patient Name: Resident #1 Clinical Information 1. History/Physical Yes 2. Chest X-Ray/PPD: Yes 11/8/12 3. Advanced Directives: Full Code (Checked) 4. Infections/Communicable Disease (Explain) (Blank) 5. Medications/Tx Sheets: Yes 6. Skin/Wounds: No 7. Rehab anticipated: No 8. Respiratory Needs: No 9. Anticipated Level of Care: NF 10. Anticipate that the facility is currently able to clinically serve the patient: Yes 11. I.V. Antibiotics: No Signature and Date of Reviewing Nurse: M..K..RN 12/06/12 Accept (Checked) Director of Clinical Evaluations RN 11/12/12 Assessment Notes: 71 y/o Dx(s): Atypical Psych, [MEDICAL CONDITION], Alzheimer, Aphasic Violent at NH, Biting Resistant to care @ NH; Poor prognosis; needs Behavior Management Wt. 170 lbs. Ht: 5 ' 9 " Cognitive Status: Alert & oriented x 1 Restraints: Y SR x 4 & vest Fall Risk: Y Explain: Based upon [DIAGNOSES REDACTED]. Wound: Abrasion/laceration Equipment Needed: Geri Chair - Noted per violent/aggressive behavior @ N.H. Pt. violent toward roommate only. Does not need locked unit per Doctor. Pt. non mobile in geri chair *Sundowners - agitated p.m. PATIENT ASSESSMENT A copy of the patient's Medical Records was copied on 11/12/12. *NOTE: Must be restraint free 24 hrs. prior to discharge. Following our assessment pending financial approval by Social Worker at A.. M..K..RN, Director of Clinical Evaluations Review of Nursing Admission assessment dated [DATE] and completed by S6LPN revealed the following: Assessment Date: 11/19/12 Birth date: 2/16/41 Gender: M Age: 71 Race: 1 Admitting Information: Check all that apply New Admission Time admitted : 4:10 p.m. Transported by: AASI: CNA Admitting Information obtained from: Chart from local hospital Temperature/Pulse/Blood Pressure (BP)/Respiration: (Check all that apply) Temperature: 98 Pulse: 117 Respiration: 14 Systolic/BP: 167 Diastolic BP: 75 Respiratory related: No checks Resident have a [DIAGNOSES REDACTED]. Pain: (Check all that apply) Frequency: complains/shows pain - No pain Communication/Sensory: Not completed Hearing: Not completed Hearing Appliances: Not completed Modes of Expressions: None of above Primary Language: English Is resident ' s language the same as the dominate language of the facility? Yes Speech Clarity (In the last 7 days): No speech Making Self Understood: Rarely/never understood Ability to Understand Others: Comments: unknown, resident does not speak *Note: The rest of the Nursing Admission Assessment was not completed. Facility's Nursing Admit Packet: Unable to complete. Resident out to ER Post-Incident 72 Hour Follow Up: Not completed Cumulative [DIAGNOSES REDACTED]. Resident Care ---: Not completed Resident Vaccine Record - Not completed Informed Consent Form For Pneumococcal Vaccine and Flu Vaccine: Not completed Assessment of Pressure Ulcer --: Not completed Pain Assessment: Not Completed Assessment of Nutritional Risk: Not completed Risk Assessment for Elopement: Not completed Movement Scale (AIMS) Assessment of Contracture Risk: Not completed Weekly Skin Assessment Record: Not Completed Interim Admission Care Plan: Not completed Review of OTIS report revealed the following in part..: Occurred: 11/19/2012 05:50 pm Discovered: 11/19/2012 05:50 pm Reported in facility: 11/20/2012 09:00 am Entered: 11/20/2012 02:36 pm CEO/finding/determination: 11/22/2012 Findings: Facility/CEO: Substantiated Accused/Allegation: S6LPN Neglect: Caregiver Substantiated Victims: Resident #1 DOB: SSN: Injury: Fracture Description: On November 19, 2012, resident #1fell in the facility, fracturing his C-7 vertebrae: Summary: On the morning of November 20, 2012, Administrator and DON were advised that resident had suffered a fractured C-7 vertebra. At this time, a thorough investigation began. CNAs and Nurse were suspended pending investigation. Interviews were conducted with nurse and CNAs on duty in the area. All confirmed that none actually saw the resident fall the first time due to being in other resident rooms but did hear it along with another resident calling them for help. In review of the surveillance tape, it was noted that resident climbed out of his wheelchair to his hands and knees on the floor. At that point he began to lose balance and fell face down to the floor. Nurse and CNA's came to resident's side. Resident was then lifted back into wheelchair and was noted to have a cut over right eye. At this point, S9CNA sat by resident monitoring him. S10CNA was sitting in another chair monitoring the rest of the hall. During this time, resident was seen constantly trying to kick S9CNA. S6LPN then came over and assessed the resident ' s eye. Resident moved his wheelchair a short distance from S9CNA. He then attempted to get out of the wheelchair again. Both S9CNA and S10CNA caught Resident #1 and lowered him to the floor. Again resident was put back in chair by CNAs and Nurse. At this time, S10CNA took a gown and tied it around the waist of the resident while other CNA and nurse S6LPN were standing there. In her interview, CNA stated that she knew we did not do restraints but saw him in one earlier in the hospital when she went to pick him up. She stated that she was only doing that for his protection and safety until Emergency Medical Technicians could arrive. CNA stayed with resident until Emergency Medical Technician's arrived. Then, Emergency Medical Technician's arrived, restraint was removed and resident was transported to hospital via stretcher. Conclusion: The allegation of neglect is substantiated as S6LPN neglected to assess resident twice on floor before having resident moved back to wheelchair. She also allowed S10CNA to restrain resident in her presence, although only for a short time. Final Report: After receiving the fall report with injury this warranted to viewing the security cameras due to information not clear on report. Upon reviewing the tape, resident was noted to have had 2 falls and it was witnessed it is classified as a fall due to resident being moved from one level to the next. No immediate assessment was done by assigned nurse S6LPN or first aid. S10CNA verbalized cleaning resident ' s eye. There was a delay in calling the Emergency Medical Service until after resident ' s 2nd fall. No restraints should have been allowed by any staff on a resident. Nurse was present during the restraining of the resident for his safety per the CNAs and nurse. Otis Report is substantiated. Review of the facility' Fall Report for 9/1/12 through 11/23/12 revealed a total of 43 falls. Review of local hospital's emergency room report for Resident #1 revealed the following in part.. Arrival Date: 11/19/2012 18:48 Primary Diagnosis 1) Fracture of cervical spine Chief Complaint 1) Fall History of Present Illness in part...: Summary: 71 y/o m s/p fall from wheel chair. Patient was sitting in chair and fell forward. 3 centimeter laceration over left eye. No active bleeding on arrival. Patient not able to communicate HPI: Exam started at 19:02. It is unclear when the presenting problem started. The patient is poorly responsive and therefore unable to give a reliable history. The patient fell from wheelchair landing on head. It is estimated that the patient fell approximately 2 feet. Injury can be coded as occurring in a health care environment. Review of Radiology Report with an order date of 11/19/2012 revealed the following in part..: CT Cervical Spine W/Ext cuts Cervical spine CT without contrast. History: Trauma. Neck pain Technique: Axial CT of the spine with coronal and sagittal reformations. Findings: There is a fracture involving the left lateral mass of T1 as well as the left C7 pedicle near the most inferior aspect of the left vertebral artery canal. No additional fractures. Discharge Summary dated 11/23/2012: Hospital Course: This is a [AGE] year old, Caucasian male with a history of profound dementia with aggressive hostile features. The patient apparently just arrived at A. Nursing Home when he fell out of a bed and had a fracture of his C7 pedicle fracture (nondisplaced near the vertebral artery canal). He also had a [MEDICAL CONDITION] mass ([MEDICATION NAME] process). He has no evidence of spondylolisthesis. The patient is able to move all extremities. A cervical collar has been placed on this patient. Interview was held with S2DON on 12/3/12 at 12:13 p.m. regarding incident with Resident #1. She stated that typically, they do not admit residents in restraints and that the resident must be without restraints for 24 hours prior to admittance to the facility. She stated that she was informed that they were sending the resident to the hospital after falling on 11/19/12 but did not get full details until 11/20/12 during the morning nursing meeting. She stated that the incident report was reviewed as well as chart documentation and other follow-ups. She said that they reviewed the documentation and that there were some things missing. She stated that a call was placed to S6LPN, but she did not get an answer. She said that S6LPN did not complete the assessment and that the nurse wrote on the assessment that she was unable to complete the assessment due to the resident having to go to the hospital. S2DON further stated that that was the reason she called the nurse. She stated that staff reported that when they went to get the resident, he was in restraints. She stated that she was not present but that S6LPN was interviewed by the Administrator, Regional Nurse and Regional Vice President and S3ADON where S6LPN was suspended pending the investigation. She also stated that the decision was made to terminate S6LPN. She stated that she talked to S6LPN via phone along with the Administrator regarding the investigation of Resident #1 relative to the lack of documentation, restraint and reporting of the incident. She further stated that because of S6LPN's failure to complete documentation of her nursing assessment and other pertinent documents contained in the admission's packet, S6LPN was informed that the facility was terminating her services. On 12/3/12 at 10:45 a.m., an interview was conducted with S4ClinicalCoordinator/Risk Manager. She stated that S6LPN did not complete any assessments of Resident #1 at the time of admission on 11/19/12 and that was one of the reasons she was no longer with the facility. She said that after the incident, she conducted in-services on Use of Restraints and Emergency Transfers as directed by the Regional Director of Clinical Operations. An interview was conducted with S1Administrator on 12/3/12 at 3:50 p.m. regarding falls of Resident #1. He stated that S6LPN was interviewed by him, along with the Corporate Nurse on 11/20/12, the next day after they had looked at the camera. According to S1Administrator, S6LPN said she was at the nurse's station and heard a resident and looked and saw that he (Resident #1) had fallen and she noted a cut to his eye. He said S6LPN stated that they moved Resident #1 back to his wheel chair. S1Administrator said S6LPN then called the ambulance at that time and that the CNA was seated with him. He stated that the resident had a 2nd fall shortly thereafter- He stated that the first fall was when he suspected the injuries occurred. He said the resident was not placed on any special observations and had been only in the building approximately 2 ? hours. He said that the CNA saw that he was restrained when he was at the hospital. He said the facility required that residents are required to be restraint free for 24 hours prior to being admitted to the facility. He then stated that the Assessment nurse went to the hospital and assessed him at the hospital before he was admitted to the facility. He said that she probably had an assessment sheet and documentation. He stated that S6LPN did not tell them why she did not document both falls and gave no excuse. When asked if they identified that as a problem by S6LPN not documenting the fall, S1Administrator stated that there were consequences for her lack of action, lack of documentation, moving the resident prior to a full assessment being done and allowing one of the CNAs to restrain the resident and by not stepping in as a supervisor. He was then asked if the restraint procedure allowed for an emergency restraint. S1Administrator stated he was not sure. As a result of this, the S1Administrator was asked what he did to ensure no reoccurrences of this nature and he stated that staff was in-serviced on restraints and emergency transfers. He further verified that in-services did not include documentation and reporting. He stated that he was not aware if the in-service had been conducted with other staff, but he had talked to S6LPN. According to S1Administrator, Resident #1 sustained injuries and returned from hospital with a cervical collar. On 12/3/12 at 4:12 p.m. an interview was conducted with the Regional Director of Clinical Operations. She stated she came over when she found out about Resident #1. She stated that she was told that there were 2 falls and S6LPN had only reported one. She stated that she interviewed the nurse and asked what happened that night step by step and what she did and how soon she did it. She said S6LPN stated that the resident had fallen; that he had gotten out of his chair, got on the floor and then fell on his face. She the stated that she asked S6LPN if she called 911 after the 1st fall and she said she did but it was an hour and 40 minutes before the ambulance arrived at the facility. Regional Director of Clinical Services said that she asked S6LPN if she called after the second time and the nurse denied it to her and she told her that everything that she had reported to her did not add up. She stated again that there were a lot of discrepancies in what S6LPN reported and said that she put her on a suspension. She further stated that she did not feel comfortable about what S6LPN said. The Regional Director then stated that there were no admit assessment or documentation completed by S6LPN. She said that she asked S6LPN to show her the documentation and the nurse stated that she had to leave her shift and was going to do it the next day. She said she stated to S6LPN that it was a basic nursing function that when an incident occurred she was required to document what happened. She again stated that S6LPN was not forthcoming about the events of the fall and said that there was only one fall and then acknowledged that there were two. At that point, the Regional Director stated that she did not feel comfortable with S6LPN taking care of the residents. She said she told S6LPN that it looked like when she got Resident #1 off the floor, she did not do an assessment and had not done what her nursing judgment told her, S6LPN said she couldn't assess him on the floor. The Regional Director of Clinical Operations said she asked S6LPN if an emergency restraint was allowed and the LPN stated that S10CNA put it on, but there was no documentation that she tried any other interventions. She further said that she believed that the CNA did what she thought was best for safety reasons, however, she did not have the oversight and that S6LPN should have made that call. She then asked the nurse how she thought that was okay, and asked if she put the resident in a geri chair or what else did she try, and she did not answer. She further stated from the start, supervision should have been increased. According to the Regional Director the resident had only been at the facility for a couple of hours. She said that the facility did not know about the resident being in restraints at the hospital before being admitted to the facility. She then stated that she then talked to the Vice President, Administrator and DON and informed them that the nurse should have been able to manage the unit and have better judgment and she felt that she could not take care of the residents. When asked what in-services were conducted of the two falls, she stated reporting of incidents, restraints, emergency transferring and not moving a person with a fall without being assessed. She further stated that she did not think that notification was included in the in-services. The Regional Director stated that S6LPN told her that Resident #1's family was not contacted because the number was not on the face sheet. She then asked S6LPN if she called anybody else and she replied "no". When asked who determined what in-services were taught to staff she said she did. When asked if assessment, documentation and reporting were included in the in-services, she stated she only instructed S4RiskManager to in-service the staff regarding restraints and transfers. An interview was conducted with the Director of Clinical Evaluations for the facility on 12/3/12 at 5:20 p.m. She said that her job entailed responding to the referral source by evaluating a resident at whatever facility they were in. She stated that she has a referral form that she completed, along with the Pre-Admission Record Review. She said that this was a two- fold process consisting of medical and financial. She further stated the criteria for medical acceptance was that the facility must be able to take care of the resident and provide for the need of a resident in the facility. When asked what would prohibit admission to this facility; she said if we can't provide for the medical need for patients with violent behaviors, on occasion IV therapy, issues related to staffing, if the patient is actively suicidal or homicidal. When asked if restraints would be something that would prohibit consideration, she said that restraints are not permitted in a long-term facility. She then stated that the Admission Form, which is inclusive of emergency contacts should be at the facility, along with the clinical record; and that this information is generally a copy or faxed record. She further stated that concerns are communicated verbally and written to the Admission's Coordinator. She added that the Administrator took care of the financial part. If a resident is found in restraints at a facility, she request that the restraint be discontinued a minimum of 24 hours prior to admission and that information is communicated to the admitting staff. An interview was conducted with S3ADON on 12/3/12 at 5:41 p.m. regarding the Admission's Process. She said that once S5SSD received the paper work from the Director of Clinical Evaluations, S5SSD disseminated it to the DON to be reviewed. S3ADON stated that S5SSD would then give a copy of that faxed info to S2DON and she and the DON reviewed the information. S3ADON said the Admit information is on the resident's chart. She said that she or the DON would communicate any concerns with the pre-admit and this is information is communicated to the Social Worker and nurse on the unit for required care for a prospective resident. An interview was conducted with S5SSD on 12/4/12 at 8:35 a.m. regarding the intake process. S5SSD stated that the intake process involved the Director of Clinical Evaluations being contacted from the hospital. She stated that she scans and e-mail the information sends it to the Director of Clinical Evaluations because they (facility) don't determine, accept or deny residents. She also said that she only keeps the referral log. S5SSD said that when the Director of Clinical Services get a referral packet completed she then determines if they are medically cleared. According to S5SSD, the packet comes to her and she gives the packet to the DON, Administrator, ADON, MDS Coordinator and business office for financial reasons. S5SSD said that if there were any psychiatric behaviors, S2DON and nurses reviewed all intake information for clinical appropriateness and needs and then determine if the resident goes on the secure or open unit. S5SSD said that S7LPN makes sure that this information is in the chart. On 12/4/12 at 9:24 a.m., an interview was held with S2DON regarding the intake process. She stated that there is a liaison that does the intake. S2DON was asked what was done when an assessment was received. S2DON said that a determination is made as to whether the resident is medically approved and when they get the paper work, they were to determine what the resident's needs were and what area was appropriate for the resident. S2DON said that the nurse is called to the unit and she takes the report. According to S2DON, S7LPN then sets up the chart. How was the information communicated to the nurse? S2DON stated that this information is communicated in the nursing meeting. She stated that the unit nurse gets the admission report S2DON was asked whose job was it to ensure that staff received the admission packet and she replied that S5SSD normally disseminated the packets and she (S2DON) hands it to the nurse and if there is any additional information, S5SSD would also get that information to us. She stated that before the resident gets to the facility, the nurse has a copy of the admissions packet. According to S2DON, a CNA was sent there with transportation. She stated that if the CNA got to the hospital and saw the resident in restraints, she should have known to call the facility to report what she had observed and those observations should have been communicated to the staff. She further stated that she was not at the facility when the incident happened but was informed on the next day during the morning meeting. An interview was held with S7LPN on 12/4/12 at 9:53 a.m. S7LPN said that she receive the Admission packet from S5SSD. She said that the Interdisciplinary Team determines where the patient it going. She said that S6LPN should have had the admissions packet which would have contained all the pertinent information about Resident #1. S7LPN said that she did not attend the morning meeting that day and was unaware that Resident #1 was being admitted that day. An interview was conducted with S10CNA. She stated that she was working over that evening and she went to a local hospital to pick Resident #1 up but did not know what condition he was in. When she got there she said she asked hospital staff questions because he was in a geri chair and they had a vest on him and saw that the bottom of the vest was tied to the geri chair. She said before they left the hospital the nurse had given him his medication and he was cooperative during the transport. She said when she arrived to the facility she let the aides and S6LPN know what she had observed and what kind of situation she saw while she was at the hospital. S10CNA said she was told by hospital staff that the resident was a fighter and when they came out of the room he was in a geri chair with a vest applied to him. She stated that she gave S6LPN the admissions packet from the local hospital and informed her that the patient was in a geri chair with a vest on that was tied to the chair. She said S6LPN named the type of vest. She said he was transported back by yellow cab. She said after she told the nurse everything all she (S6LPN) said was okay. When questioned about the resident's fall, she said that one of the aides was sitting with the resident after the first fall because he could not sit by himself. She said it was about 6 and she got up to do rounds and asked the other aide for help. One of the residents' called S8CNA and when she made it to the hall she said "Oh my God" and S9CNA and S8CNA assisted Resident #1. She said the resident was lying on the floor on his stomach. She said that she looked at him and the nurse was doing his vitals and she noticed that the resident had a gash on his eye. S10CNA stated that she got a warm towel and cleaned his face up. She said the resident bent over as if he was picking up a piece of paper the second time and she said that he needed something around him. She looked at the nurse and she didn't tell her no, so she put the gown around him and the nurse (S6LPN) said "at least he ain't going anywhere". After the incident with Resident #1, S10CNA said S4RiskManager gave her two in-services. S10CNA said that she has never been told that she was not to receive a patient in restraints because this was a restraint free facility. She said that the Restorative Aide told her that once she got to the hospital and saw the resident in restraints, she should have called the facility and not bring him to the facility. According to S10CNA, she was a new employee and was shocked when they asked her to go and get a patient from the hospital because she had never done that before and was not sure what to expect or to do but did as she was told and that was to bring the patient back to the facility. A telephone interview was held with S6LPN on 12/4/12 at 10:20 a.m. She stated that she was told in report that she was receiving Resident #1 to the unit. She said that she did not receive an admission packet. She stated that she did receive information on the residents ' medications, history and stuff like that. She also stated that she did not know a resident had to be restraint free for 24 hours before being admitted to the faciility. She said that she saw that in the packet from the hospital after he arrived. She said the aide told her that the patient had a restraint on when she arrived at the hospital to pick him up. S6LPN said Resident #1 was only on the unit for approximately 2? hours before he fell and she mentioned as to why was he (Resident #1) even there. She said that they were not happy that the aide put the restraint on him and acknowledged that she did not intervene or stop her when she applied the gown on the resident. As stated by S6 LPN, the facility's policy was to do an assessment as well as to perform neurological checks on a

Based on interviews and record review the facility failed to ensure that there was adequate supervision/monitoring and assistive devices in place for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents to prevent falls for a cognitively impaired resident. The facility failed to ensure that fall interventions for a cognitively impaired resident were appropriate to meet Resident #1's needs by failing to: 1. Ensure that supervision/monitoring was increased for a resident with a history of falls (#1) 2. Ensure that Resident #1 was assessed and monitored after each of two falls on 11/19/12. 3. Ensure that the LPN (Licensed Pratical Nurse) conducted and completed a physical assessment after each fall on 11/19/12 on a resident who experienced two falls from his wheel lchair on 11/19/12. (#1) The Immediate Jeopardy began on 11/19/12 at 5:55 p.m. when Resident #1 experienced his first fall on 11/19/12. The facility failed to increase supervision of a resident identified as a fall risk on his Pre-Admission Record Review. The Immediate Jeopardy (IJ) ended on 11/19/12 at 6:30 p.m. when he was transferred to the hospital. The Administrator was informed of the IJ for Resident #1 on 12/4/12 at 12:45 p.m. The Immediate Jeopardy was lifted on 11/19/12 at 6:30 p.m. when Resident #1 was transferred to the hospital. The Immediate Jeopardy was lowered to actual harm for Resident #1 when he sustained a cervical fracture and head laceration as a result of the falls. The deficient practice remains at a potential for more than minimal harm for all 28 residents (#2, #3, #4, #5 - #29) identified by the facility as having experienced a fall. Findings: Review of the clinical record revealed Resident #1 was a [AGE] year old who had the following Diagnoses: [REDACTED]. Review of the Pre-Admission Record Review completed by the Director of Clinical Evaluations RN on 11/16/12 was sent to the facility and revealed that Resident #1 had been identified as a fall risk. This information is sent to S5SSD, who disseminates the Pre-Admission packet to the DON, Administrator, ADON, MDS Coordinator and the business office for financial reasons. The Director of Nursing or Assistant Director of Nursing ensures that the unit nurse receives the Admission report before the resident gets to the facility. Review of Resident #1's Investigative Report revealed the following: Incident Date: 11/19/12 Time: 5 p.m. Category: Fall Describe Injury: Cut over left eye Incident Level: fell from wheel chair unwitnessed. Temperature: 98 Pulse: 117 Respiratory: 14 Blood Pressure: 167/95 Pain Scale: ? Notified: Physician: Medical Doctor/Nurse Practitioner Date/Time Contact Initiated: 6 p.m. 11/19/12 Date/Time Responded: 11/19/12 6pm Resident Condition at Time of Incident Physical Restraint: Not checked Meds taken during first 8 hours: Psychotropic/Antipsychotics (Checked); Tranquilizers/Sedatives (Checked) Mobility: w/c Mental: A & O x 1 Other current conditions: Confusion/Disorientation Narrative of Incident and description of injuries: Resident was sitting in hallway in wheel chair; fell forward to floor and cut L eye. Immediate intervention put into place to prevent further incidents: Resident assisted to chair. Pressure to eye until it stopped bleeding. Sat aide next to patient. to prevent him from trying to get up until EMS (Emergency Medical Service) arrived. Assessment, Vital Signs, Neuro checks Review of the facility Nurse's Notes revealed the following documentations: 11/19/12 at 4:10 p.m.: admitted to Secure Unit per Nurse Practitioner. Local Hospital record state resident was readmitted to their Geri Psych unit for violent behaviors from a long term nursing facility. Obtained order to admit to Secure Unit. No date/time Resident sitting in wheel chair in hallway. Heard another resident yelling. Resident on floor in front of wheel chair. Resident assisted back to wheel chair to assess cut and initiate neuro checks. Resident shows no signs or symptoms of pain at this time. CNA (Certified Nursing Assistant) asked to sit by resident until (EMS) Emergency Medical Service arrives. 6p: Call placed to Medical Doctor/Nurse Practitioner. Order noted to send to emergency room for evaluation and treatment. 6:20 p.m.: Resident attempted to get out of wheel chair. CNA lowered resident to floor. Resident assisted back to chair and temporarily restrained for patient safety until EMS arrived. 6:30 p.m.: Resident left facility via EMS. Unable to reach family; no numbers in chart for family. Review of the Nursing Admission Assessment and Admit Packet dated 11/19/12 revealed that S6LPN (Licensed Practical Nurse) did not complete the assessment and contained the following hand written note: *Note: The rest of the Nursing Admission Assessment was not completed. Facility's Nursing Admit Packet: Unable to complete. Resident out to ER Review of OTIS report revealed the following in part..: Description: On November 19, 2012, Resident #1 fell in the facility, fracturing his C-7 vertebrae: Summary: On the morning of November 20, 2012, Administrator and DON were advised that resident had suffered a fractured C-7 vertebra. At this time, a thorough investigation began. CNAs and Nurse were suspended pending investigation. Interviews were conducted with nurse and CNAs on duty in the area. All confirmed that none actually saw the resident fall the first time due to being in other resident rooms, but did hear it along with another resident calling them for help. In review of the surveillance tape, it was noted that resident climbed out of his wheel chair to his hands and knees on the floor. At that point he began to lose balance and fell face down to the floor. Nurse and CNA's came to resident's side. Resident was then lifted back into wheel chair and was noted to have a cut over right eye. At this point, S9CNA sat by resident monitoring him. S10CNA was sitting in another chair monitoring the rest of the hall. During this time, resident was seen constantly trying to kick S9CNA. S6LPN then came over and assessed the resident's eye. Resident moved his wheelchair a short distance from S9CNA. He then attempted to get out of the wheel chair again. Both S9CNA and S10CNA caught Resident #1 and lowered him to the floor. Again resident was put back in chair by CNAs and Nurse. At this time, S10CNA took a gown and tied it around the waist of the resident while other CNA and nurse S6LPN were standing there. In her interview, CNA stated that she knew we did not do restraints, but saw him in one earlier in the hospital when she went to pick him up. She stated that she was only doing that for his protection and safety until EMTs (Emergency Medical Teams) could arrive. CNA stayed with resident until EMT's arrived. Then, EMT's arrived, restraint was removed and resident was transported to hospital via stretcher. Conclusion: The allegation of neglect is substantiated as S6LPN neglected to assess resident twice on floor before having resident moved back to wheel chair. She also allowed S10CNA to restrain resident in her presence, although only for a short time. Final Report: After receiving the fall report with injury this warranted to viewing the security cameras due to information not clear on report. Upon reviewing the tape, resident was noted to have had 2 falls and it was witnessed and classified as a fall due to resident being moved from one level to the next. No immediate assessment was done by assigned nurse S6LPN or first aid. S10CNA verbalized cleaning resident's eye. There was a delay in calling the EMS until after resident's 2nd fall. No restraints should have been allowed by any staff on a resident. Nurse was present during the restraining of the resident for his safety per the CNAs and nurse. Otis Report is substantiated. Review of local hospital's emergency room report for Resident #1 revealed the following in part.. Arrival Date: 11/19/2012 18:48 Primary Diagnosis 1) Fracture of cervical spine Chief Complaint 1) Fall History of Present Illness in part...: Summary: 71 y/o m s/p fall from wheel chair. Patient was sitting in chair and fell forward. 3 cm. laceration over left eye. No active bleeding on arrival. Patient not able to communicate HPI: Exam started at 19:02. It is unclear when the presenting problem started. The patient is poorly responsive and therefore unable to give a reliable history. The patient fell from wheel chair landing on head. It is estimated that the patient fell approximately 2 feet. Injury can be coded as occurring in a health care environment. Review of Radiology Report with an order date of 11/19/2012 revealed the following in part..: CT Cervical Spine W/Ext cuts Findings: There is a fracture involving the left lateral mass of T1 as well as the left C7 pedicle near the most inferior aspect of the left vertebral artery canal. No additional fractures. Discharge Summary dated 11/23/2012: Hospital Course: This is a [AGE] year old, Caucasian male with a history of profound dementia with aggressive hostile features. The patient apparently just arrived at Nursing Home when he fell out of a bed and had a fracture of his C7 pedicle fracture (nondisplaced near the vertebral artery canal). He also had a fracture of the lateral mass (transverse process). He has no evidence of spondylolisthesis. The patient is able to move all extremities. A cervical collar has been placed on this patient. An interview was held with S2DON on 12/3/12 at 12:13 p.m. regarding incident with Resident #1. She stated that typically, they do not admit residents in restraints and that the resident must be without restraints for 24 hours prior to admittance to the facility. She stated that she was informed that they were sending the resident to the hospital after falling on 11/19/12, but did not get full details until 11/20/12 during the morning nursing meeting. She stated that the incident report was reviewed as well as chart documentation and other follow-ups. She said that they reviewed the documentation and that there were some things missing. As a result of the missing documentation, S2DON stated that she placed a call to S6LPN who normally worked 2-10 but she did not get an answer. She said that S6LPN did not complete the assessment and that the nurse wrote on the assessment that she was unable to complete the assessment due to the resident having to go to the hospital. S2DON further stated that that was the reason she called the nurse. She stated that staff reported that when they went to get the resident, he was in restraints. She stated that she was not present, but that S6LPN was interviewed by the Administrator, Regional Nurse and Regional Vice President and S3ADON where S6LPN was suspended pending the investigation. She stated that she talked to S6LPN via phone along with the Administrator regarding the investigation of Resident #1 relative to the lack of documentation, restraint and reporting of the incident. She further stated that because of S6LPN's failure to complete documentation of her nursing assessment and other pertinent documents contained in the admission's packet, S6LPN was informed that the facility was terminating her services. An interview was conducted with S1Administrator on 12/3/12 at 3:50 p.m. regarding falls of Resident #1. He stated that S6LPN was interviewed by him, along with the Corporate Nurse on 11/20/12, the next day after they had looked at the camera. According to S1Administrator, S6LPN said she was at the nurse's station and heard a resident and looked and saw that he (Resident #1) had fallen and she noted a cut to his eye. He said S6LPN stated that they moved Resident #1 back to his wheel chair. S1Administrator said S6LPN then called the ambulance at that time and that the CNA was seated with him. He stated that the resident had a 2nd fall shortly thereafter.when CNAs lowered Resident #1 to the floor after he attempted to get out of his wheelchair. He stated that the first fall was when he suspected the injuries occurred. He said the resident was not placed on any special observations and had only been in the building approximately 2 ? hours. He said that the CNA saw that he was restrained when he was at the hospital. He said the facility required that residents be restraint free for 24 hours prior to being admitted to the facility. He then stated that the Assessment nurse went to the hospital and assessed him at the hospital before he was admitted to the facility. He stated that S6LPN did not tell them why she did not document both falls and gave no excuse. According to S1Administrator, Resident #1 sustained injuries and returned from the hospital with a cervical collar. On 12/3/12 at 4:12 p.m. an interview was conducted with the Regional Director of Clinical Operations. She stated that she was told that there were 2 falls and S6LPN had only reported one. She stated that she interviewed the nurse and asked what happened that night step by step and what she did and how soon she did it. She said S6LPN stated that the resident had fallen; that he had gotten out of his chair, got on the floor and then fell on his face. She stated again that there were a lot of discrepancies in what S6LPN reported. The Regional Director then stated that there were no admit assessment or documentation completed by S6LPN. The Regional Director of Clinical Operations said she asked S6LPN if an emergency restraint was allowed and S6LPN stated that S10CNA put it on, but there was no documentation that she tried any other interventions. She further stated that from the start supervision should have been increased. An interview was conducted with the Director of Clinical Evaluations for the facility on 12/3/12 at 5:20 p.m. She further stated the criteria for medical acceptance was that the facility must be able to take care of the resident and provide for the need of a resident in the facility. If a resident is found in restraints at a facility, she request that the restraint be discontinued a minimum of 24 hours prior to admission and that information is communicated to the admitting staff. An interview was conducted with S3ADON on 12/3/12 at 5:41 p.m. regarding the Admission's Process. She said that once S5SSD received the paper work from the Director of Clinical Evaluations, S5SSD then disseminated it to the DON to be reviewed. She said that she or the DON would communicate any concerns with the pre-admit and that this information was communicated to the Social Worker and nurse on the unit for required care for a prospective resident. An interview was conducted with S5SSD on 12/4/12 at 8:35 a.m. regarding the intake process. S5SSD stated that the intake process involved the Director of Clinical Evaluations being contacted from the hospital. S5SSD said that if there were any psychiatric behaviors, S2DON and nurses reviewed all intake information for clinical appropriateness and needs and then determine if the resident goes on the secure or open unit. S5SSD said that S7LPN makes sure that this information is in the chart. On 12/4/12 at 9:24 a.m., an interview was held with S2DON regarding the intake process. S2DON said that a determination is made as to whether the resident is medically approved and when they get the paper work, they were to determine what the resident's needs were and what area was appropriate for the resident. S2DON said that the nurse is called to the unit and she takes the report. According to S2DON, S7LPN then sets up the chart. S2DON stated that this information is communicated in the nursing meeting. She stated that the unit nurse gets the admission report. S2DON replied that S5SSD normally disseminated the packets and she (S2DON) hands it to the nurse and if there is any additional information, S5SSD will also get that information to us. She stated that before the resident gets to the facility, the nurse has a copy of the admissions packet. According to S2DON, a CNA was sent there with transportation. She stated that if the CNA got to the hospital and saw the resident in restraints, she should have known to call the facility to report what she had observed and those observations should have been communicated to the staff. An interview was held with S7LPN on 12/4/12 at 9:53 a.m. S7LPN said that she receive the Admission packet from S5SSD. She said that the Interdisciplinary Team determines where the patient it going. She said that S6LPN should have had the admissions packet which would have contained all the pertinent information about Resident #1. An interview was conducted with S10CNA. She stated that she went to a local hospital to pick Resident #1 up but did not know what condition he was in. When she got there she said she asked hospital staff questions because he was in a geri chair and they had a vest on him and saw that the bottom of the vest was tied to the geri chair. She said before they left the hospital the nurse had given him his medication and he was cooperative during the transport. She said when she arrived to the facility she let the aides and S6LPN know what she had observed and what kind of situation she saw while she was at the hospital. S10CNA said she was told by hospital staff that the resident was a fighter and when they came out of the room he was in a geri chair with a vest applied to him. She stated that she gave S6LPN the admissions packet from a local hospital and informed her that the patient was in a geri chair with a vest on that was tied to the chair. She said S6LPN named the type of vest. She said that one of the aides was sitting with the resident after the first fall because he could not sit by himself. She said it was about 6 and she got up to do rounds and asked the other aide for help. One of the residents called S8CNA and when she made it to the hall she said "Oh my God" and S9CNA and S8CNA assisted Resident #1 off of the floor and into his whee lchair. She said the resident was lying on the floor on his stomach. She said that she looked at him and the nurse was doing his vitals and she noticed that the resident had a gash on his eye. S10CNA stated that she got a warm towel and cleaned his face. She said the resident bent over as if he was picking up a piece of paper the second time and she said that he needed something around him. She looked at the nurse and she didn't tell her no, so she put the gown around him and the nurse (S6LPN) said "at least he ain't going anywhere". S10CNA said that she had never been told that she was not to receive a patient in restraints because this was a restraint free facility. She said that after she left the hospital with Resident #1 and got to the facility, she reported to the nurse (S6LPN) and the Restorative Aide. S10CNA then stated that the Restorative Aide told her that once she got to the hospital and saw the resident in restraints, she should have called the facility and not bring him to the facility. According to S10CNA, she was a new employee and was shocked when they asked her to go a get a patient from the hospital because she had never done that before and was not sure what to expect or to do but did as she was told and that was to bring the patient back to the facility. A telephone interview was held with S6LPN on 12/4/12 at 10:20 a.m. She stated that she was told in report that she was receiving Resident #1 to the unit. She said that she did not receive an admission packet. She stated that she did receive information on the residents' medications, history and stuff like that. She said the aide told her that the patient had a restraint on when she arrived at the hospital to pick him up. S6LPN said Resident #1 was only on the unit for approximately 2? hours before he fell . As stated by S6 LPN, the facility's policy was to do an assessment as well as to perform neurological checks on a resident after a fall and I did not do that. S6LPN stated, "I screwed up and I know I did". She again acknowledged that she did not assess him before she moved him after the first fall. She stated that she witnessed only one fall. According to S6lPN, the first time Resident #1 fell the aides got him up and blood was observed over the residents' eye. She then stated the aides sat with him after the fall. She stated that she had not done his admission assessment or anything because he came right before med pass. She said that she did not know that a patient would have to have been restraint free before being admitted to the facility. She also said that she got a report from the hospital where the nurse mentioned the resident was placed in a geri chair but she did not recall the nurse saying anything about restraints. S6LPN further stated that Resident #1 was sent to the emergency room around 6:30 p.m. on 11/19/12 and had sustained fractures of the vertebrae. An interview with S8CNA was held on 12/4/12 at 12:04 p.m. She said she did not see Resident #1 fall because she was with another resident. She said that she called for S9CNA and S10CNA and waited until the nurse came and assisted the resident back into the wheel chair. She said when the nurse came over she asked if he was okay and the resident was mumbling and they then got him off the floor and sat him back in the wheel chair. She said the nurse then got vital signs and called the front desk to call the ambulance. An interview was held with S9CNA on 12/4/12 at 2:10 p.m. regarding the incidents surrounding the fall of Resident #1. She stated that he was sitting in his wheelchair and she and two other aides heard another patient yell for help and they all ran out. Resident #1 was on the floor face down. S9CNA stated that she picked him up and sat him in his chair. She said that S6LPN was sitting at her desk and ran over with the aides. S9CNA said that Resident #1 had a cut on his eyebrow and it was bleeding. She said after that she sat with him until EMS came. She said he started leaning over and the nurse and other aide told her to unlock the chair so he could move around. She further said that S10CNA moved him from the wall and she locked only one side of the chair. She said Resident #1 leaned over in his chair and she ran to catch him because he was about to fall again. She said that she lowered him to the floor with S10CNA. According to S9CNA the nurse came and she didn't do anything. She said when Resident #1 sat in chair the 2nd time S10CNA suggested to tie something around him so that he would not fall again. She said that S10CNA went and got a gown and tied it around him. She also stated that S10CNA thought it was okay because she had reported to us that she saw him at the hospital and saw him with a vest on and tied to the chair. She said that she and the nurse stood by Resident #1's chair while S10CNA tied him down. S9CNA stated that S6 LPN did not tell S10CNA not to do it.

Based on interviews and clinical record reviews, the facility failed to ensure the residents ' environment remained as free of accident hazards as possible for 1 (#2) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: 1.) Increase supervision of a resident (#2) after he made verbal threats to physically harm himself. 2.) Monitor a resident (#2) for the possession of sharp objects after he had made a verbal threat to cut his wrists. The failed practices resulted in resident #2 cutting both his wrists and being transferred to the hospital. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/25/11 resident #2 verbalized a desire to die to the nurse. When asked how he would do this, the resident produced a razor and stated he had done it before. The nurse removed the razor, and he said he would hang himself. Resident #2 was sent to the hospital on [DATE], and he returned on 7/28/11. On 7/29/11 he was sent to the hospital again after he had cut both of his wrists. The immediate jeopardy began on 7/28/11 when resident #2 returned to the facility, and the facility failed to increase supervision of resident #2 and monitor him for the possession of sharp objects. The immediate jeopardy ended for resident #2 on 7/29/11 when he was transferred to a local hospital. The deficient practice continues at a scope and severity of a level II, potential for more than minimal harm, for all the residents in the facility as the facility failed to put a system in place to prevent the deficient practice from reoccurring if another resident developed suicidal ideations or was admitted with suicidal ideations. Findings: Resident #2 Review of the clinical record revealed that the resident was admitted on [DATE] and, he was his own responsible party. Review of the Cumulative [DIAGNOSES REDACTED]. Review of the admit Nursing Evaluation dated 6/30/11 at 1540 revealed the following: Physical Function: independent Level of Consciousness: awake, alert, oriented, forgetful Emotional Factors: none of the above Abnormal Behaviors: None of the above Musculoskeletal: No assist with locomotion, transfers, bed mobility, eating, or toileting Mode of Locomotion: slow steady gait Elimination: continent Skin: intact; scars noted to left knee and right and left outer ankles. Review of the admit physician's order [REDACTED]. diet regular, Omeprazole 20 milligrams (mg) by mouth (po) every (q) day (d), Colace 100 mg 2 po twice a day (bid), Keppra 500 mg 2 po bid, Topamax 25 mg po q night (hs), Ambien 5 mg po q hs, Norvasc 10 mg po q d, Lexapro 20 mg po q d, Folic Acid 1 m po q d, Vitamin B 100 mg po q d, ASA 325 po q d, MVI po q d, Dilantin 100 mg 2 po three times a day (tid), Norco 5/325 po q 4 as needed (prn). Review of the physician's order [REDACTED]. 7/14/11 at 1550 - Seroquel 25 mg po q 12 hrs for agitation 7/11/11 (no time) - Antabuse 250 mg po q hs Review of the nurse ' s notes revealed the following: 7/17/11 at 1600 Despite being on Antabuse, resident seen by nurse drinking a 24 ounce Miller Light in a can in his room with no apparent ill effects. 7/20/11 at 2020 Summoned back to nursing station. Patient is up at nursing station requesting Ensure. Short term memory loss as evidence by patient is unable to recall conversation twenty minutes ago. Patient did voice that he only had 3 beers this evening. I expressed to pt that he only gets this forgetful and aggressive with staff after drinking. Patient stated " I haven ' t yell at one s---, I don ' t care. " Patient given a snack at this time with juice, pt then ambulated back to room. Will continue to monitor. 7/21/11 at 1730 Patient is outside in front drinking, advised patient to not drink on front that he ' s able to drink in room. Patient stated " Hell I do what I want to do " . 7/21/11 at 2030 Patient is back inside patient stated " I ' ve only had 3 beers. " Patient went into room and slam door. 7/25/11 at 12:15 a.m. Resident came to nurse ' s station in a rage with complaints his roommate snoring. Tried to redirect resident to no avail. Resident wreaked of alcohol, started using profane language, threatening the nurse, calling her b------, et m----- f-----. Male CNA tried to redirect resident finally he got resident to go to his room with the assistance of another CNA. 7/25/11 2 a.m. CNA came to nurse ' s station stated resident said he wanted the nurse to come, and give him a lethal injection because he wanted to die. S3LPN and S4LPN went to his room to talk to him. No date 2:05 a.m. Arrived to resident room along with S4LPN. Resident observed sitting up in bed with his back resting on head board. Observed a 16 ounce can of beer at bedside. Resident anxious, speaking loudly and fast, Resident verbalized a desire to die. Resident stated " I am ready to die. I have a razor and I have cut my wrist before. Nurse asked resident how he would do this, resident produced a razor and stated I have done it before. This nurse observed old healed areas to bilateral wrist. The nurse removed the razor and resident states I will hang myself but I will die tonight. This nurse reported to primary nurse S5LPN, someone remained with resident. 7/25/11 2:30 a.m. Resident monitored for suicide attempts / CNA, called placed to Dr. A ... ' s office talked with on call practitioner D ... I ... made aware of resident threats of suicide, orders noted to call 911 and transfer to hospital. 7/25/11 at 2:42 a.m. Ambulance here to transport resident to hospital to be evaluated for suicidal threats. Resident continues to talk about killing himself stated " I don ' t have no reason to live. My children brought me here and left me, I haven ' t seen them since. " 7/28/11 at 12:35 p.m. Resident entered facility via ambulatory holding two white bags. Stated " I ' m back. " Stated " I walked back here. " Then stated " Nah the taxi cab brought me back. " When asked how did he get to facility. Resident in upbeat mood, visited with other residents then went to his room. No complaints voiced at this time. Review of the physician's order [REDACTED]. q hs, Vitamin B1 100 mg po q d; Folic Acid 1 mg po q d; Multivitamin po q d, Seroquel 100 mg po q hs; and Antabuse 25 mg po q hs. Review of the Plan of Care revealed: Original Date: 7/1/11 Problem: Impaired decision making ability related to history (hx) of alcohol (ETOH) abuse and subdural hematoma hand written - & alcohol dementia. Resident becomes intoxicated very quickly after 1-2 drinks. (no date to identify when information added to typed care plan) Goals: Residents needs will be met daily. Review quarterly. Estimated Date: 10/1/2011 Interventions: Task segmentation as needed. Provide short, simple instructions. Explain procedures and care before performing. Offer simple choices and only present two choices to avoid confusion. Use short phrases and questions which require yes and no answers. Use gestures as needed. Provide simple, structures activities that help resident ' s orientation, self directed activities, social environment. Provide reality orientation in small group activities that promote choice, self expression and/ or responsibility. Provide social services oversight during important decision making tasks: i.e. care changes, room changes etc. Ensure resident is informed at all times. Hand written 7/5 Counseled by medical doctor (MD). Original Date: 7/1/11 Problem: Injury risk related to hx of subdural hematoma. Hand written - Alcohol dementia & Depression (no date to identify when information added to typed care plan) Goals: No complications related to acute cerebrovascular accident as evidenced by no coma, hyperthermia, cardiopulmonary arrest. Estimated Date: 10/1/2011 Interventions: Notify MD of signs and symptoms (s/s) such as severe headache, or weakness of the extremities. Assess neurologic function and document. Date: 7/1/11 Problem: Resident has potential for worsening of depression, suicidal thoughts and/or behaviors, unusual changes in behavior, continued depressive symptoms, falls, significant weight changes, and insomnia related to Lexapro, no confusion about nursing home (NH) placement with no family involvement. Strengths: Resident is able to understand verbal instructions. Resident is able to report symptoms. Goals: Resident will not experience worsening of depression, suicidal thoughts and /or behaviors, or unusual behavioral changes. Resident will not experience medication -induced falls. Goal Date: 10/1/11 Interventions: Encourage resident to report feelings of depression to include any suicidal thoughts. Observe for signs and symptoms of worsening depression, suicidal thoughts, or unusual changes in behavior. Report any signs of worsening depression or suicidal thoughts immediately to physician. Observe for changes in depression symptoms after mediation has been used at least four weeks: if no improvement report to physician. Observe for changes that could identify potential for falls to include dizziness, unsteady gait (especially with initiation and dosage changes of medication), drowsiness, etc. Report identified changes that could potentially lead to falls to physician. Encourage resident to report changes in sleeping habits. Observe for signs and symptoms of insomnia to include difficulty falling asleep, waking up often during the night and having difficulty going back to sleep, feeling tired upon waking, sleepiness during the day, irritability, and difficulties with concentration or memory. Report signs and symptom of insomnia to physician. Handwritten 7/29 Suicide attempt Send to emergency room (ER). Date: 7/22/11 Problem: Behavior Problem resist care as evidenced by refusing medication related to alcohol dementia. Goal: Resident will have fewer episodes of refusing meds. Goal Date: 10/22/11 Interventions: Report physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Share with resident other options for dealing with feelings. Reinforce positive behavior. Invite and encourage activity programs consistent with resident ' s interests. Monitor behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person, involved etc. Intervene as needed to protect the rights & safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed. If reasonable, discuss behavior with resident; explain/reinforce why behavior is unacceptable. Reapproach resident later, when s/he becomes agitated. Provide opportunities for positive interaction, attention - Stop and talk with him/her as passing by. Date: 7/25/11 Problem: Behavior Problem verbally inappropriate as evidenced by suicidal ideations with cutting of wrists related to alcohol consumption & poor family relationships (no family involvement) son does not answer/return calls. Goal: Resident will not harm themselves or others secondary to their behaviors through next review date: 10/25/11. Goal Date: 10/25/11 Interventions: Report physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Reduce the following stressors that may be contributing to the resident ' s inappropriate behavior: (blank). Share with resident other options for dealing with feelings. Reinforce positive behavior. Administer and observe the effectiveness and side effects of medications as ordered - see physician's order [REDACTED]. Investigate/observe need for psychological/psychiatric support. Provide services if desired by resident/responsible party and as ordered by the physician. Invite and encourage activity programs consistent with resident ' s interests. Observe behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person, involved etc. Intervene as needed to protect the rights & safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed. Reapproach resident later, when s/he becomes agitated. Provide opportunities for positive interaction, attention - Stop and talk with him/her as passing by. Date: 7/9/11 Problem: Behavior Problem verbally inappropriate as evidenced by verbally threatening staff with physical harm, screaming, 7/14 cursing, yelling at other residents related to alcohol consumption Goal: Resident will not harm themselves or others secondary to their behaviors through next review date: 10/9/11. Goal Date: 10/9/11 Interventions: Report to physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Share with resident other options for dealing with feelings. Reinforce positive behavior. Educate the resident/responsible party on the causal factors of the behavior and the planned intervention. Address wandering behavior by walking with resident; redirect from inappropriate area; engage in divisional activity. Administer and observe the effectiveness and side effects of medications as ordered - see physician's order [REDACTED]. Provide services if desired by resident/responsible party and as ordered by the physician. Invite and encourage activity programs consistent with resident ' s interests. Observe behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person, involved etc. Intervene as needed to protect the rights & safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed. If reasonable, discuss behavior with resident; explain/reinforce why behavior is unacceptable. Provide opportunities for positive interaction, attention - Stop and talk with him/her as passing by. Date: 7/25/11 Problem: Behavior Problem as evidenced by suicide attempt Resident cut wrists related to depression 7/29/11 Suicide attempt. Goal: Resident will not harm themselves or others secondary to their behaviors through next review date: (blank) Goal Date: 10/25/11 & 10/29/11 Interventions: Report to physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Administer and monitor the effectiveness and side effects of medications as ordered - see physician's order [REDACTED]. 7/25/11 Sent to hospital. Review of the nurse ' s notes revealed the following: 7/29/11 at 1730 Patient (pt) returned to facility, pt yelled out " I need to go to detox. " Slurred speech noted. Pt stated " I haven ' t seen my son " Pt is very emotional. He couldn ' t recall how many/much he consumed. Advised to calm down, redirected pt to room. 7/29/11 at 1915 Pt is up at doorway of his room. Pt yelled out " I ' m not going to take this, I don ' t want to be here, " Pt started cutting self with razor, several times I tried to redirect pt, unable to redirect at this time. I went to nursing station summoned S5LPN to call 911/Acadian. I went back to pt I grabbed pt wrist and applied pressure and held onto them tightly, pt also experiencing hallucination at this time. Several attempts made, pt started threatening other residents at this time, pt physically push me out of his way running towards another resident cursing and swinging arms back and forth. 7/29/11 at 9:35 p.m. Nurse called down hall needing assistance with resident who had apparently cut both wrists with razor blades. Pt was profusely bleeding applied 4 X 4 gauze to both wrists. Nurse on phone with emergency medical services (EMS). Pt smells of alcohol belligerent: able to be redirected at times but wants to fight other residents. Continues to state he hear people talking to him. Will call doctor and fax communication to office. 7/29/11 at 1925 Ambulance arrived along with police. 7/29/11 at 1940 Resident sent via ambulance to hospital. An interview was held with S6LPN on 10/5/11 at 8:39 a.m. She said that she had been working at the facility since May 2011. She verified that she was assigned to resident #2 on the 2 p.m. - 10 p.m. shift on 7/28/11. She said that she was also assigned to him on the 2 p.m. - 10 p.m. shift on 7/29/11. She explained that on 7/29/11 he went outside the building and sat with another resident and came back in about 1 hour later with slurred speech. She said he was saying he needed detox, and he could not see his grandson. She said that she heard him cussing, and he was slashing his wrists. She said that he was hearing things. She said that his plan of care did not change from when he returned on 7/28/11 after his hospitalization for threats of cutting his wrists and hanging himself. She said that his Keppra was changed when he came back, and he was given 500 mg bid instead of 1000 mg bid. She said they also increased his Colace to 100 mg tid instead of bid, and his Seroquel was changed from 25 mg po q 12 hours to Seroquel 100 mg po q hs. She said that she saw him at least every 2 hours before he went to the hospital on [DATE] and when he returned on 7/28/11. She said that there was no change in her care for him. She explained that he was using a disposable razor to cut his wrists on 7/29/11. She said the residents that were capable of shaving themselves were able to be issued a disposable razor and shave themselves. She said that resident #2 was capable of shaving himself. She said the resident would dispose of the razor by giving back to the nurse or the CNA. She said that he was never monitored for razors in his possession. She said that they never had to monitor for sharp objects in his possession even when he came back from the hospital on [DATE]. An interview was held with S7MDSCoordinator on 10/5/11 at 9:22 a.m. She said when he returned from the hospitalization on [DATE], the care plan had been updated by adding remove sharp objects from his room on 7/25/11. An interview was with S6LPN on 10/5/11 at 9:40 a.m. She said that resident #2 was never on 1 on 1 supervision. An interview was held with S8MDSCoordinator on 10/5/11 at 9:47 a.m. She said that nothing was changed in his care plan other than removing sharp objects from his room on 7/25/11 when he was sent to the hospital for threats of cutting his wrists. She explained that on 7/29/11 she added that he was to have 1on1 supervision when he came back from the hospital after being treated for [REDACTED]. An interview was held with S9LPN on 10/5/11 at 10:00 a.m. She said that she worked the day shift on 7/28/11 and 7/29/11 and was assigned to resident #2. She said when he returned to the facility on [DATE] his plan of care did not change. She said that she did not monitor him for sharp objects, and she did not know he threatened suicide. She said they did not have to monitor him on the day shift because he did not have behavior problems. She said that he was not on 1on 1supervision. An interview was held with S10SocialServicesDirector on 10/5/11 at 10:10 a.m. She verified that she was resident #2 ' s social worker. She said that she was not aware that he was consuming alcohol, and she did not provide any counseling regarding alcohol. She said that he was not depressed; he just wanted to be closer to his son, so she never provided any counseling for depression. She said that she never provided any counseling for suicide. She said that he never showed that he was suicidal. An interview was held with S1Administrator and S2DON on 10/5/11 at 11:00 a.m. S2DON said that resident #2 ' s admit [DIAGNOSES REDACTED]. When asked what the facility did upon admission regarding his [DIAGNOSES REDACTED]. She said that he was on Lexapro 20 mg po q d for his Depression. She said that he did not attend a day program or go to alcohol abuse program. She said that he was to be monitored every 2 hours, and this did not change except for the one instance on 7/25/11 when they stayed with him until the ambulance came and got him. She said that residents were allowed to have disposable razors in their possession, and they were usually kept in their drawers. She said the following medications were changed when the resident returned from the hospital on [DATE]: Before hospitalization - Seroquel 25 mg po q 12 hrs After hospitalization - Seroquel 100 mg po q hs Before hospitalization - Geodon 20 mg po q d After hospitalization - discontinued She explained when resident #2 returned from the hospital on [DATE], they did not do anything different in his plan of care other than the changes in medications listed above. After reviewing the care plan, she verified that it revealed remove sharp objects from his room. She said she searched his room on 7/25/11, and she removed a disposable razor from his room. She said that resident #2 was in a room by himself. She said that she went in his room on 7/28/11 to make sure there were no sharp objects in his room, and she did not find any. She said there was no change in how often he was to be monitored. She said he had to be checked on every 2 hours. S2DON said she did not know where he got the razor from that he used to cut both wrists on 7/29/11. She verified that no one was monitoring him for possession of sharp objects. She said that she talked to the physician before he came back, and the physician said that he was fine. An interview was held with S2DON on 10/5/11 at 8:00 a.m. She said that they did not have a policy regarding suicide or attempted suicide. An interview was held with S1Administrator on 10/5/11 at 10:50 a.m. She said the facility did not have a policy regarding suicide. She explained that they did not have a policy for this because they did not accept residents that were actively suicidal. Resident #2 voiced threats of suicide on 7/25/11 and was transferred to the hospital on [DATE]. The resident was placed in immediate jeopardy when upon return from the hospital on [DATE], supervision for the resident was not increased and he was not monitored for possession of sharp objects. The resident cut his wrists on 7/29/11 and required hospitalization .

Based on interviews and record reviews, the facility failed to be administered in a manner that used its resources effectively and efficiently to attain and maintain the physical, mental and psychosocial well-being for1 (#2) resident with suicidal threats out of 5(#1, #2, #3, #4, & #5) sampled residents. The Administration failed to: 1. Have a policy in place to ensure that residents admitted with or developed [MEDICAL CONDITION] received increased monitoring (#2). 2. Ensure that increased monitoring for sharp objects was provided after a resident reported that he planned to cut his wrists (#2). 3. Assess, care plan, and implement meaningful interventions (#2). 4. Involve the social worker in assessing and intervening to control the resident's depressive and suicidal behaviors (#2). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/25/11 resident #2 verbalized a desire to die to the nurse. When asked how he would do this, resident produced a razor and stated he had done it before. The nurse removed the razor, and he said he would hang himself. Resident #2 was sent to the hospital on [DATE], and he returned on 7/28/11. Resident #2 was in Immediate Jeopardy beginning 7/28/11 after returning from the hospital after treatment for [REDACTED].#2 and monitor him for the possession of sharp objects. On 7/29/11 he was sent to the hospital again after he had cut both his wrists. The Social Worker failed to assess the resident's depressive and suicidal behaviors. The resident was not assessed for individualized meaningful interventions. The immediate jeopardy ended for resident #2 on 7/29/11 when he was transferred to a local hospital. The deficient practice continues at a scope and severity of a level II, potential for more than minimal harm, for all the residents in the facility as the facility failed to put a system in place to prevent the deficient practice from reoccurring if another resident developed [MEDICAL CONDITION] or was admitted with [MEDICAL CONDITION]. Findings: Resident #2 Review of the clinical record revealed that the resident was admitted on [DATE] and, he was his own responsible party. Review of the Cumulative [DIAGNOSES REDACTED]. Review of the admit Nursing Evaluation dated 6/30/11 at 1540 revealed the following: Physical Function: independent Level of Consciousness: awake, alert, oriented, forgetful Emotional Factors: none of the above Abnormal Behaviors: None of the above Musculoskeletal: No assist with locomotion, transfers, bed mobility, eating, or toileting Mode of Locomotion: slow steady gait Elimination: continent Skin: intact; scars noted to left knee and right and left outer ankles. Review of the admit physician's order [REDACTED]. diet regular, [MEDICATION NAME] 20 milligrams (mg) by mouth (po) every (q) day (d), [MEDICATION NAME] 100 mg 2 po twice a day (bid), [MEDICATION NAME] 500 mg 2 po bid, [MEDICATION NAME] 25 mg po q night (hs),[MEDICATION NAME] mg po q hs, [MEDICATION NAME] 10 mg po q d, [MEDICATION NAME] 20 mg po q d, folic acid 1 m po q d, vitamin B 100 mg po q d, ASA 325 po q d, MVI po q d, [MEDICATION NAME] 100 mg 2 po three times a day (tid), [MEDICATION NAME] 5/325 po q 4 as needed (prn). Review of the physician's order [REDACTED]. 7/14/11 at 1550 - [MEDICATION NAME] 25 mg po q 12 hrs for agitation 7/11/11 (no time) - [MEDICATION NAME] 250 mg po q hs Review of the nurse ' s notes revealed the following: 7/17/11 at 1600 Despite being on [MEDICATION NAME], resident seen by nurse drinking a 24 ounce Miller Light in a can in his room with no apparent ill effects. 7/20/11 at 2020 Summoned back to nursing station. Patient is up at nursing station requesting ensure. Short term memory loss as evidence by patient is unable to recall conversation twenty minutes ago. Patient did voice that he only had 3 beers this evening. I expressed to pt that he only gets this forgetful and aggressive with staff after drinking. Patient stated " I haven ' t yell at one[***] I don ' t care. " Patient given a snack at this time with juice, pt then ambulated back to room. Will continue to monitor. 7/21/11 at 1730 Patient is outside in front drinking, advised patient to not drink on front, that he ' s able to drink in room. Patient stated " Hell I do what I want to do " . 7/21/11 at 2030 Patient is back inside patient stated " I ' ve only had 3 beers. " Patient went into room and slam door. 7/25/11 at 12:15 a.m. Resident came to nurse ' s station in a rage with complaints his roommate snoring. Tried to redirect resident to no avail. Resident wreaked of alcohol, started using profane language, threatening the nurse, calling her b ..., et m ... f .... Male CNA tried to redirect resident finally he got resident to go to his room with the assistance of another CNA. 7/25/11 2 a.m. CNA came to nurse ' s station stated resident said he wanted the nurse to come, and give him a lethal injection because he wanted to die. S3LPN and S4LPN went to his room to talk to him. No date 2:05 a.m. Arrived to resident room along with S4LPN. Resident observed sitting up in bed with his back resting on head board. Observed a 16 ounce can of beer at bedside. Resident anxious, speaking loudly and fast, Resident verbalized a desire to die. Resident stated " I am ready to die. I have a razor and I have cut my wrist before. Nurse asked resident how he would do this, resident produced a razor and stated I have done it before. This nurse observed old healed areas to bilateral wrist. The nurse removed the razor and resident states I will hang myself but I will die tonight. This nurse reported to primary nurse S5LPN, someone remained with resident. 7/25/11 2:30 a.m. Resident monitored for suicide attempts / CNA, called placed to Dr. A ... ' s office talked with on call practitioner D ... I ... made aware of resident threats of suicide, orders noted to call 911 and transfer to hospital. 7/25/11 at 2:42 a.m. Ambulance here to transport resident to hospital to be evaluated for suicidal threats. Resident continues to talk about killing himself stated " I don ' t have no reason to live. My children brought me here and left me, I haven ' t seen them since. " 7/28/11 at 12:35 p.m. Resident entered facility via ambulatory holding two white bags. Stated " I ' m back. " Stated " I walked back here. " Then stated " Nah the taxi cab brought me back. " When asked how did he get to facility. Resident in upbeat mood, visited with other residents then went to his room. No complaints voiced at this time. Review of the physician's order [REDACTED]. q hs, Vitamin B1 100 mg po q d; folic acid 1 mg po q d; multivitamin po q d, [MEDICATION NAME] 100 mg po q hs; and [MEDICATION NAME] 25 mg po q hs. Review of the Plan of Care revealed: Original Date: 7/1/11 Problem: Impaired decision making ability related to history (hx) of alcohol (ETOH) abuse and subdural hematoma hand written - & alcohol dementia. Resident becomes intoxicated very quickly after 1-2 drinks. (no date to identify when information added to typed care plan) Goals: Residents needs will be met daily. Review quarterly. Estimated Date: 10/1/2011 Interventions: Task segmentation as needed. Provide short, simple instructions. Explain procedures and care before performing. Offer simple choices and only present two choices to avoid confusion. Use short phrases and questions which require yes and no answers. Use gestures as needed. Provide simple, structures activities that help resident ' s orientation, self directed activities, social environment. Provide reality orientation in small group activities that promote choice, self expression and/ or responsibility. Provide social services oversight during important decision making tasks: i.e. care changes, room changes etc. Ensure resident is informed at all times. Hand written 7/5 Counseled by medical doctor (MD). Original Date: 7/1/11 Problem: Injury risk related to hx of subdural hematoma. Hand written - Alcohol dementia & Depression (no date to identify when information added to typed care plan) Goals: No complications related to acute [MEDICAL CONDITION] as evidenced by no coma, hyperthermia, cardiopulmonary arrest. Estimated Date: 10/1/2011 Interventions: Notify MD of signs and symptoms (s/s) such as severe headache, or weakness of the extremities. Assess neurologic function and document. Date: 7/1/11 Problem: Resident has potential for worsening of depression, suicidal thoughts and/or behaviors, unusual changes in behavior, continued depressive symptoms, falls, significant weight changes, and [MEDICAL CONDITION] related to [MEDICATION NAME], no confusion about nursing home (NH) placement with no family involvement. Strengths: Resident is able to understand verbal instructions. Resident is able to report symptoms. Goals: Resident will not experience worsening of depression, suicidal thoughts and /or behaviors, or unusual behavioral changes. Resident will not experience medication -induced falls. Goal Date: 10/1/11 Interventions: Encourage resident to report feelings of depression to include any suicidal thoughts. Observe for signs and symptoms of worsening depression, suicidal thoughts, or unusual changes in behavior. Report any signs of worsening depression or suicidal thoughts immediately to physician. Observe for changes in depression symptoms after mediation has been used at least four weeks: if no improvement report to physician. Observe for changes that could identify potential for falls to include dizziness, unsteady gait (especially with initiation and dosage changes of medication), drowsiness, etc. Report identified changes that could potentially lead do falls to physician. Encourage resident to report changes in sleeping habits. Observe for signs and symptoms of [MEDICAL CONDITION] to include difficulty falling asleep, waking up often during the night and having difficulty going back to sleep, feeling tired upon waking, sleepiness during the day, irritability, and difficulties with concentration or memory. Report signs and symptom of [MEDICAL CONDITION] to physician. Handwritten 7/29 Suicide attempt Send to emergency room (ER). Date: 7/22/11 Problem: Behavior Problem resist care as evidenced by refusing medication related to alcohol dementia. Goal: Resident will have fewer episodes of refusing meds. Goal Date: 10/22/11 Interventions: Report physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Share with resident other options for dealing with feelings. Reinforce positive behavior. Invite and encourage activity programs consistent with resident ' s interests. Monitor behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person, involved etc. Intervene as needed to protect the rights & safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed. If reasonable, discuss behavior with resident; explain / reinforce why behavior is unacceptable. Reapproach resident later, when s/he becomes agitated. Provide opportunities for positive interaction, attention - Stop and talk with him/her as passing by. Date: 7/25/11 Problem: Behavior Problem verbally inappropriate as evidenced by [MEDICAL CONDITION] with cutting of wrists related to alcohol consumption & poor family relationships (no family involvement) son does not answer / return calls. Goal: Resident will not harm themselves or others secondary to their behaviors through next review date: 10/25/11. Goal Date: 10/25/11 Interventions: Report physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Reduce the following stressors that may be contributing to the resident ' s inappropriate behavior: (blank). Share with resident other options for dealing with feelings. Reinforce positive behavior. Administer and observe the effectiveness and side effects of medications as ordered - see physician's order [REDACTED]. Provide services if desired by resident / responsible party and as ordered by the physician. Invite and encourage activity programs consistent with resident ' s interests. Observe behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person, involved etc. Intervene as needed to protect the rights & safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed. Reapproach resident later, when s/he becomes agitated. Provide opportunities for positive interaction, attention - Stop and talk with him/her as passing by. Date: 7/9/11 Problem: Behavior Problem verbally inappropriate as evidenced by verbally threatening staff with physical harm, screaming, 7/14 cursing, yelling at other residents related to alcohol consumption Goal: Resident will not harm themselves or others secondary to their behaviors through next review date: 10/9/11. Goal Date: 10/9/11 Interventions: Report to physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Share with resident other options for dealing with feelings. Reinforce positive behavior. Educate the resident / responsible party on the causal factors of the behavior and the planned intervention. Address wandering behavior by walking with resident; redirect from inappropriate area; engage in divisional activity. Administer and observe the effectiveness and side effects of medications as ordered - see physician's order [REDACTED]. Provide services if desired by resident / responsible party and as ordered by the physician. Invite and encourage activity programs consistent with resident ' s interests. Observe behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person, involved etc. Intervene as needed to protect the rights & safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed. If reasonable, discuss behavior with resident; explain / reinforce why behavior is unacceptable. Provide opportunities for positive interaction, attention - Stop and talk with him/her as passing by. Date: 7/25/11 Problem: Behavior Problem as evidenced by suicide attempt Resident cut wrists related to depression 7/29/11 Suicide attempt. Goal: Resident will not harm themselves or others secondary to their behaviors through next review date: (blank) Goal Date: 10/25/11 & 10/29/11 Interventions: Report to physician changes in behavioral status. Provide non-confrontational environment for care. Anticipate care needs and provide them before the resident becomes overly stressed. Explain care to resident in advance, in terms resident understands. Administer and monitor the effectiveness and side effects of medications as ordered - see physician's order [REDACTED]. 7/25/11 Sent to hospital. Review of the nurse ' s notes revealed the following: 7/29/11 at 1730 Patient (pt) returned to facility, pt yelled out " I need to go to detox. " Slurred speech noted. Pt stated " I haven ' t seen my son " Pt is very emotional. He couldn ' t recall how many/ much he consumed. Advised to calm down, redirected pt to room. 7/29/11 at 1915 Pt is up at doorway of his room. Pt yelled out " I ' m not going to take this, I don ' t want to be here, " Pt started cutting self with razor, several times I tried to redirect pt, unable to redirect at this time. I went to nursing station summoned S5LPN to call 911/ Acadian. I went back to pt I grabbed pt wrist and applied pressure and held onto them tightly, pt also experiencing hallucination at this time. Several attempts made, pt started threatening other residents at this time, pt physically push me out of his way running towards another resident cursing and swinging arms back and forth. 7/29/11 at 9:35 p.m. Nurse called down hall needing assistance with resident who had apparently cut both wrists with razor blades. Pt was profusely bleeding applied 4 X 4 gauze to both wrists. Nurse on phone with emergency medical services (EMS). Pt smells of alcohol belligerent: able to be redirected at times but wants to fight other residents. Continues to state he hear people talking to him. Will call doctor and fax communication to office. 7/29/11 at 1925 Ambulance arrived along with police. 7/29/11 at 1940 Resident sent via ambulance to hospital. An interview was held with S6LPN on 10/5/11 at 8:39 a.m. She said that she had been working at the facility since May 2011. She verified that she was assigned to resident #2 on the 2 p.m. - 10 p.m. shift on 7/28/11. She said that she was also assigned to him on the 2 p.m. - 10 p.m. shift on 7/29/11. She explained that on 7/29/11 he went outside the building and sat with another resident and came back in about 1 hour later with slurred speech. She said he was saying he needed detox, and he could not see his grandson. She said that she heard him cussing, and he was slashing his wrists. She said that he was hearing things. She said that his plan of care did not change from when he returned on 7/28/11 after his hospitalization for threats of cutting his wrists and hanging himself. She said that his [MEDICATION NAME] was changed when he came back, and he was given 500 mg bid instead of 1000 mg bid. She said they also increased his [MEDICATION NAME] to 100 mg tid instead of bid, and his [MEDICATION NAME] was changed from 25 mg po q 12 hours to [MEDICATION NAME] 100 mg po q hs. She said that she saw him at least every 2 hours before he went to the hospital on [DATE] and when he returned on 7/28/11. She said that there was no change in her care for him. She explained that he was using a disposable razor to cut his wrists on 7/29/11. She said the residents that were capable of shaving themselves were able to be issued a disposable razor and shave themselves. She said that resident #2 was capable of shaving himself. She said the resident would dispose of the razor by giving back to the nurse or the CNA. She said that he was never monitored for razors in his possession. She said that they never had to monitor for sharp objects in his possession even when he came back from the hospital on [DATE]. An interview was held with S7MDSCoordinator on 10/5/11 at 9:22 a.m. She said when he returned from the hospitalization on [DATE], the care plan had been updated by adding remove sharp objects from his room on 7/25/11. An interview was with S6LPN on 10/5/11 at 9:40 a.m. She said that resident #2 was never on 1 on 1 supervision. An interview was held with S8MDSCoordinator on 10/5/11 at 9:47 a.m. She said that nothing was changed in his care plan other than removing sharp objects from his room on 7/25/11 when he was sent to the hospital for threats of cutting his wrists. She explained that on 7/29/11 she added that he was to have 1on1 supervision when he came back from the hospital after being treated for [REDACTED]. An interview was held with S9LPN on 10/5/11 at 10:00 a.m. She said that she worked the day shift on 7/28/11 and 7/29/11 and was assigned to resident #2. She said when he returned to the facility on the 7/28/11 his plan of care did not change. She said that she did not monitor him for sharp objects, and she did not know he threatened suicide. She said they did not have to monitor him on the day shift because he did not have behavior problems. She said that he was not on 1on 1supervision. An interview was held with S10SocialServicesDirector on 10/5/11 at 10:10 a.m. She verified that she was resident #2 ' s social worker. She said that she was not aware that he was consuming alcohol, and she did not provide any counseling regarding alcohol. She said that he was not depressed he just wanted to be closer to his son, so she never provided any counseling for depression. She said that he never provided any counseling for suicide. She said that he never showed that he was suicidal. An interview was held with S1Administrator and S2DON on 10/5/11 at 11:00 a.m. S2DON said that resident #2 ' s admit [DIAGNOSES REDACTED]. When asked what the facility did upon admission regarding his [DIAGNOSES REDACTED]. She said that he was on [MEDICATION NAME] 20 mg po q d for his depression. She said that he did not attend a day program or go to [MEDICAL CONDITION] program. She said that he was to be monitored every 2 hours, and this did not change except for the one instance on 7/25/11 when they stayed with him until the ambulance came and got him. She said that residents were allowed to have disposable razors in their possession, and they were usually kept in their drawers. She said the following medications were changed when the resident returned from the hospital on [DATE]: Before hospitalization - [MEDICATION NAME] 25 mg po q 12 hrs After hospitalization - [MEDICATION NAME] 100 mg po q hs Before hospitalization - [MEDICATION NAME] 20 mg po q d After hospitalization - discontinued She explained when resident #2 returned from the hospital on 7/28/11, they did not do anything different in his plan of care other than the changes in medications listed above. After reviewing the care plan, she verified that it revealed to remove sharp objects from his room. She said she searched his room on 7/25/11, and she removed a disposable razor from his room. She said that resident #2 was in a room by himself. She said that she also went in his room on 7/28/11 to make sure there were no sharp objects in his room, and she did not find any. She said there was no change in how often he was to be monitored. She said he had to be checked on every 2 hours. S2DON said she did not know where he got the razor from that he used to cut both wrists on 7/29/11. She verified that no one was monitoring him for possession of sharp objects. She said that she talked to the physician before he came back, and the physician said that he was fine. An interview was held with S2DON on 10/5/11 at 8:00 a.m. She said that they did not have a policy regarding suicide or attempted suicide. An interview was held with S1Administrator on 10/5/11 at 10:50 a.m. She said the facility did not have a policy regarding suicide. She explained that they did not have a policy for this because they did not accept residents that were actively suicidal. Resident #2 voiced threats of suicide on 7/25/11 and was transferred to the hospital on [DATE]. The resident was placed in immediate jeopardy when upon return from the hospital on [DATE], supervision for the resident was not increased and he was not monitored for possession of sharp objects. The resident cut his wrists on 7/29/11 and required hospitalization .