Every finding on record at Middleton Oaks Health and Rehabilitation

Based on record review, interview, observation and facility policy review the facility failed to implement the comprehensive person-centered care plan related to contracture management and splinting to prevent decline in Range of Motion (ROM) for one (1) of three (3) resident reviewed. Resident #1. Findings Included:Record review of the facility policy titled Prevention of Decline in Range of Motion revealed .3. Appropriate Care Planning, a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion .Record review of the Care Plan Report for Resident #1 revealed Focus: I have an ADL (activity of daily living) self-care performance deficit related to Stroke, Hemiplegia, and immobility putting me at risk for functional decline.Interventions: Apply splint to right ankle after breakfast. Provide passive stretch to right ankle after applying splint. Remove splint to right ankle at lunchtime. Apply splint to right ankle after supper. Provide passive stretch to right ankle after applying splint. Remove splint to right ankle at bedtime. Date initiated 8/1/25.Observation on 3/31/26 at 10:15 AM, revealed the resident's ankle splint was not in use and was lying in a chair in the resident's room.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure when the splint was last applied.An interview with the Physical Therapy Assistant (PTA) on 3/31/26 at 1:10 PM revealed the resident now had foot drop and the ankle splint could not be placed without additional therapy. PTA confirmed this was related to the splint not being applied daily as ordered.Interview with the Director of Nursing (DON) on 3/31/26 at 3:40 PM, revealed the care plan was used to inform staff how to care for the resident and verified staff failed to follow the care plan when they did not apply the ankle splint.Record review of the admission Record revealed that the facility admitted Resident #1 on 1/16/25 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side.Record review of Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 1/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating that the resident is cognitively impaired.

Based on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve Range of Motion (ROM) and prevent further decline for one (1) of three (3) resident reviewed for ROM limitations Resident #1. Findings Included:Record review of the facility policy Prevention of Decline in Range of Motion, date reviewed/revised 11/10/2025 revealed Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Observation on 3/31/26 at 10:15 AM, revealed a foot splint lying in the chair in Resident #1's room. Resident #1's right hand was contracted into a fist with no hand roll in place.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure of the last time staff had applied the splint to her foot and stated she had never had a hand roll.Interview with Licensed Practical Nurse #1 (LPN) on 3/31/26 at 10:30 AM, revealed she did not know why the splint was in the resident's room and stated the resident was not required to wear it. She further verified the resident did not have a hand roll.Record review of the Physician Order Summary revealed physician orders dated 7/29/25, to apply a splint to the right ankle after breakfast and after supper with passive stretching following application.Record review of Occupational Therapy (OT) evaluation dated 2/1/25, revealed decreased ROM to the right upper extremity and recommendations for a resting hand splint and restorative splint and brace program upon discharge. Further review of OT evaluation dated 7/31/25, recommended continuation of the contracture management and splinting program.Record review of a Physician Order dated 4/24/25 revealed Apply splint to right hand after breakfast. Provide passive stretch to right elbow, wrist, and hand after applying splint one time a day for decrease contractures.remove the splint before dinner. Further review revealed an order dated 5/2/25 to discontinue the splint with a note per RP (responsible party) request. States it is too painful for her mom to wear.Interview with the Occupational Therapist on 3/31/26 at 12:30 PM, revealed she had not been notified that the hand splint had been discontinued and stated that a hand roll should have been initiated when the splint was discontinued. She further stated the resident's hand was now contracted into a fist.Record review of Physical Therapy (PT) Discharge summary dated [DATE], revealed the resident's right ankle ROM improved during therapy and recommended a PODUS boot (a specialized orthopedic brace designed to treat foot drop) daily up to five (5) hours.Interview with the Physical Therapy Assistant (PTA) on 3/31/26 at 1:10 PM revealed the resident now had foot drop and the ankle splint could not be placed without additional therapy. PTA confirmed this was related to the splint not being applied daily as ordered.Interview with the Director of Nursing (DON) on 3/31/26 at 3:30 PM, verified the resident had physician orders for ankle splinting daily and stated the expectation was for staff to apply the splint to prevent decline in ROM. The DON further verified the right-hand splint was discontinued without alternative interventions to prevent contracture.Record review of the admission Record revealed that the facility admitted Resident #1 on 1/16/25 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side.Record review of Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 1/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating that the resident is severely cognitively impaired.

Based on staff interview, record review, facility investigation review and facility policy review the facility failed to ensure residents were free from misappropriation of property when narcotics belonging to two residents were unaccounted for two (2) of three (3) residents reviewed for misappropriation. Resident #1 and Resident #2. Findings Include Findings Include Findings Include Review of the facility policy titled “Abuse, Neglect, Exploitation and Misappropriation” revised 11/16/22 revealed, “Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property…” Record review of the facility investigation revealed that on 8/16/25 at approximately 5:15 PM, Licensed Practical Nurse (LPN) #1 identified a discrepancy on the Controlled Drug Count Sheet. The narcotic count was altered, with numbers scratched out and rewritten, resulting in a two-card difference. Review of the narcotic count sheets documented 34 cards/packages on 8/15/25, but 31 on 8/16/25 without documentation of removal. Further review revealed that the Master List Controlled Drug form for 8/3/25 through 8/15/25 was missing. The Director of Nursing (DON) identified that Resident #1's Norco 5-325 milligrams (mg) (discontinued in March 2025 but never removed from the cart) and Resident #2's Norco 7.5-325 mg were unaccounted for. Record review of the Narcotic Count Sheet revealed the following: On 8/15/25 during the beginning of the 11:00 PM to 7:00 AM shift, 34 packages/sheets were documented on the cart and signed by LPN #3 and LPN #4. On 8/16/25 at the beginning of the 7:00 AM to 3:00 PM shift, the count numbers were marked out, and the number thirty-one (31) was written on the side, circled, and signed by LPN #4 and LPN #2. On 8/16/25 at the beginning of the 3:00 PM to 11:00 PM shift, thirty-three (33) was documented as the number of packages/sheets present. This was subsequently written over as thirty-one (31), and both entries were signed by LPN #2. Record review of the Master Narcotic List for the [NAME] Front Hall cart revealed no Master List Controlled Drug form was available for the period of 8/3/25 through 8/15/25. Additional review identified a Master List Controlled Drug form dated 8/16/25, which documented that one (1) empty card had been removed from the cart by LPN #4 on 8/16/25. Record review of the Order Summary Report revealed Resident #1 had an order for Norco 5-325 mg from 2/17/25 through 3/19/25. Record review of the Physician Orders revealed Resident #2 had an order for Norco 7.5-325 mg from 1/13/25 through 8/18/25. An interview with LPN #1 on 9/17/25 at 8:40 AM, revealed that narcotics are reconciled each shift by on-coming and off-going nurses, with additions or subtractions documented and witnessed. She stated that when she reconciled the cart on 8/16/25, she observed counts scratched through and a decrease from 34 to 31 without documentation of additions or removals. She reported the discrepancy to the DON immediately. An interview with LPN #2 on 9/17/25 at 9:04 AM, confirmed that she reconciled the narcotics with LPN #4 on 8/16/25 and verified the number was changed to 31 and circled but could not explain the discrepancy. She further stated that she sometimes did not check the Master List Controlled Drug form and acknowledged that Resident #1's discontinued narcotics remained on the cart. An interview with the DON on 9/17/25 at 9:30 AM, revealed she was notified of the discrepancy on 8/16/25 at approximately 5:15 PM. She confirmed that narcotics were missing, and that Resident #1's discontinued Norco and Resident #2's active Norco were not accounted for. She further stated the missing Master List Controlled Drug form could not be located. She verified that LPN #4, the nurse on duty during the shift in question, refused to assist with the investigation and was suspended on 8/17/25 and terminated on 8/21/25. An interview with the DON and Administrator on 9/17/25 at 2:30 PM, verified that a reconciliation and match back was completed on 8/16/25 of all narcotics and that corrective actions were initiated, including weekly audits implemented with continuation at least monthly and an in-service on narcotic security and misappropriation prevention. A follow-up interview with the DON and Administrator on 9/18/25 at 8:40 AM, confirmed that the incident and investigation results were presented to the Quality Assurance Committee on 8/18/25, during which the facility policy was reviewed with no revisions made. Based on the implementation of the facility's corrective actions on 8/16/25, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 8/18/25. The SA validated on 9/18/25, through interview and record review that all corrective actions had been implemented as of 8/16/25, and the facility was in compliance as of 8/18/25, prior to the SA's entrance on 9/17/25. Record review of the “admission Record” revealed that the facility admitted Resident #1 on 10/18/23 with a diagnosis of Hypertensive Disease without Heart Failure. Record review of the “admission Record” revealed that the facility admitted Resident #2 on 6/9/23 with a diagnosis of Cerebral Infarction.

Based on staff interview, record review and facility policy review, the facility failed to maintain complete and accurate medical records for one (1) of three (3) residents reviewed for post-operative care. This deficient practice resulted in the omission of a physician-ordered post-operative appointment from the resident's medical record and contributed to the resident missing the appointment. (Resident #3).Findings Include Review of the facility policy titled Physician's Orders revealed Policy The center will ensure that all physician orders are accurately documented, promptly implemented, and authenticated in the resident's medical record in accordance with Center for Medicare and Medicaid (CMS) regulations and state requirements . Record review of Resident #3's “After Visit Summary” (AVS) upon admission revealed an order for a post-operative visit on 5/6/25 at 1:00 PM with the Orthopedic Physician. Record review of Resident #3's Order Summary Report revealed an entry for an appointment on 5/20/25 at 10:15 AM with the Orthopedic Physician, with an onset date of 5/6/25. No order was documented for the 5/6/25 post-operative appointment. An interview with the Director of Nursing (DON) on 9/17/25 at 11:00 AM, revealed that Resident #3 did not attend the 5/6/25 orthopedic appointment because the order was not entered into the record. The DON stated it is facility practice that the admitting nurse enters all admission orders, and verified the resident was admitted on the 3–11 shift. The DON stated the 3–11 supervisor performed the admission and entered the orders, but the 5/6/25 appointment was missed. She further stated that she and the Assistant Director of Nursing (ADON) review admission orders in their clinical meeting the following day, but acknowledged they missed the order as well. The DON verified that the resident missed the 5/6/25 appointment due to the missed order. Record review of the “admission Record” revealed that the facility admitted Resident #3 on 4/17/25 with a diagnosis of Acquired absences of left leg below the knee.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene (Resident #5, #12, #51), wound treatment (Resident #11), staff assistance with meals (Resident #42) and treatment for nausea and vomiting (Resident #75), for six (6) of 22 resident care plans reviewed. Findings include: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Resident #5 Record review of Resident #5's Activities of Daily Living (ADL) care plan revealed .I have the potential for an ADL self-care performance deficit r/t (related to) .impaired vision and arthritis .Interventions .Diabetic nail care weekly Friday 7-3 and Bathing/Showering: Check nail length and trim and clean on bath day and as needed. Report any changes to nurse . On 3/25/25 at 11:16 AM and again on 3/26/25 at 10:25 AM an observation and interview of Resident #5 revealed gray facial hair that measured approximately one-fourth (1/4) an inch in length and his fingernails were one-eighth (1/8) inch in length, jagged with a brown substance underneath. Resident #5 stated that he needed a bath, a shave, and he would like his nails to be trimmed. An interview with Licensed Practical Nurse (LPN) # 3, she confirmed that Resident #5 had an odorous smell, and a brown substance under his long nails. LPN #3 confirmed his nails needed cleaning and cut and indicated the nurses were responsible for trimming his nails because he was a diabetic. Review of the Admission Record revealed that the facility admitted Resident #5, on 1/03/2020 with a medical diagnosis that included Type 2 Diabetes Mellitus without Complications. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #5 was cognitively intact. 41878 Resident #11 Record review of Resident #11's care plan for pressure ulcer revealed intervention to administer treatments as ordered and monitor for effectiveness. Record review of Resident #11's Electronic Treatment Administration Record (ETAR) revealed there were 12 days in 03/2025 with missed pressure ulcer treatments documented. On 3/27/25 at 8:15 AM, an interview and record review with the Wound Care Registered Nurse (RN) confirmed the 12 undocumented wound treatments in the ETAR for Resident #11. She revealed that she worked Monday through Friday and had performed the wound treatments for this resident each day she worked but confirmed that accurate documentation was needed to verify that the care was done. On 3/27/25 at 8:10 AM, during an interview the Director of Nursing (DON) confirmed that wound treatments should be documented upon completion of the care, and this was not done for 12 of Resident #11's wound treatments for this month. She confirmed the facility failed to accurately document the wound care treatment which was a part of the wound care treatment process, so therefore, the care plan was not followed. An interview with the MDS Coordinator on 03/27/25 11:39 AM revealed she was responsible for the care plans. She confirmed the documentation was part of the treatment procedure. She confirmed the facility failed to document the treatments multiple times in the month of March for Resident #11's wound treatments, therefore the care plan was not followed. Record review of Resident #11's Admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included Pressure Ulcer of Sacral Region and Type 2 Diabetes Mellitus. Record review of MDS Section C with ARD of 2/21/25 revealed the resident was unable to participate in the BIMS as he is rarely or never understood. Resident #51 Record review of Resident #51's care plan revealed the resident had an ADL self-care performance deficit related to morbid obesity and immobility. One intervention listed was to check nail length and trim and clean on bath day and as necessary. On 3/25/25 at 11:20 AM, during an observation and interview Resident #51 revealed he wanted his toenails to be trimmed. An observation of the resident's feet revealed his big toe nail on his right foot was extending approximately three-fourths (3/4) inch from the tip of the nailbed and the left big toe nail was extending approximately one-half (1/2) inch from the tip of the nailbed. All other toenails were approximately one-third (1/3) inch long from the tips of each nailbed, jagged and uneven. On 3/26/25 at 10:25 AM, an interview and observation with the Director of Nursing (DON)confirmed that Resident #51's foot and nail care had not been done. She confirmed the facility failed to maintain the resident's toenails within a safe and comfortable length and as the resident preferred. She stated the care plan was a guide for the residents' care. She confirmed the facility failed to implement this resident's care plan for ADL's. During an interview with the MDS Coordinator on 03/27/25 at 11:39 AM, she confirmed the care plan for Resident #51's ADL care which included to check nail length and trim and clean on bath days and as necessary was not followed. Record review of Resident #51's Admission Record revealed the facility admitted the resident on 1/13/25. Diagnoses included Complete Lesion at T2-T6 Level of Thoracic Spinal Cord, Peripheral Vascular Disease, Lymphedema, and Need for Assistance with Personal Care. Record review of Resident #51's MDS with ARD of 3/10/25 revealed the resident had a BIMS of 13 which indicated the resident was cognitively intact. Resident #75 Record review of Resident #75's care plans initiated 2/15/24 revealed his diagnosis of gastroesophageal reflux disease (GERD) put the resident at risk for heartburn, nausea/vomiting, pain, and other gastrointestinal complications. Interventions included to give medications as ordered and observe/document/report as needed signs and symptoms of GERD including nausea/vomiting and increased gag response. Record review of the care plan for the history of an alteration in gastrointestinal status related to sigmoid colon resection revealed an intervention dated 2/15/24 to give medication as ordered. Record review of Resident #75's Order Recap Report revealed an active order for Zofran Oral Tablet 4 milligrams (mg) by PEG (percutaneous endoscopic gastrostomy) every six hours as needed for vomiting dated 3/11/24. Record review of Progress Note dated 10/20/24, revealed, Resident can't tolerate, starts gagging. Record review of Resident #75's Electronic Medication Administration Report (EMAR) revealed the as needed Zofran was not given on 10/20/24. Record review of Progress Note dated 10/28/24, revealed, Resident vomiting/gagging and can't tolerate feeding. Record review of Resident #75's EMAR revealed the as needed Zofran was not given on 10/28/24. Record review of Progress Note dated 2/22/25, revealed, Resident in bed, gave resident his med per PEG and flushes, as soon as I finished, he started vomiting his feeding, vomiting several times, feeding cut off at this time. Record review of EMAR revealed the as needed Zofran medication was not given on 2/22/25. On 3/27/25 at 9:20 AM and 10:11 AM, during interviews the DON confirmed that Resident #75 had documentation of nausea and vomiting and the ordered medication for relief of these symptoms was not administered. She stated the care plan gives the staff information for the care of each resident. She confirmed the facility failed to implement the care plan related to the administration of an ordered medication for relief or nausea/vomiting. An interview with the MDS Coordinator on 03/27/25 at 11:39 AM, confirmed the care plan for Resident #75 related to administering medications as ordered was not followed. Record review of Resident #75's Admission Record revealed the facility admitted the resident on 3/7/24. Diagnoses included Dysphagia following Cerebral Infarction, Gastrostomy Status, Gastro-esophageal Reflux Disease, and Acquired Absence of Other Specified Parts of Digestive Tract. Record review of Resident #75's MDS Section C with an ARD of 2/27/25, revealed a BIMS of 6 which indicated the resident had severe cognitive impairment. 46013 Resident #12 A record review of Resident #12's Care Plan revealed that he had an ADL self-care deficit related to abnormal gait, lack of coordination, hx (history) of CVA (cerebrovascular vascular accident) with left sided hemiplegia, with interventions that included Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse .Personal Hygiene: I require extensive/substantial assistance of 1 staff with personal hygiene . On 3/25/25 at 10:50 AM, an observation and interview revealed Resident #12's fingernails to be approximately one (1) inch long past the tips of the fingers, dirty in appearance, with a dark brown substance under the nail beds. Facial hair was noted on the chin and sides of the face that was approximately 1/2 (one-half) inch. Resident #12 stated, I would like to have my fingernails trimmed and would also like to be shaved. On 3/26/25 at 10:25 AM, in an interview and observation LPN #1 confirmed Resident #12's fingernails were long, jagged, and had a brown substance under them. LPN #1 confirmed the resident needed to be shaved and should have been shaved when he received his bed bath yesterday. LPN #1 confirmed the residents' ADL care plan was not being followed and it should have been. On 3/26/25 at 11:05 AM, during an interview the Director of Nurses (DON) confirmed the resident should have been adequately groomed, which includes shaving and nail care. The DON revealed the resident's care plan regarding his personal hygiene was not being followed, and it should have been. A review of the Admission Record revealed the facility admitted Resident #12 on 3/3/2014 with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the Left Non-Dominant Side. Record review of Resident #12's Section C of the MDS dated [DATE] revealed a BIMS score of 11, indicating the resident has moderate cognitive impairment. Resident #42 A record review of the Resident #42's care plan revealed I require staff assistance with ADLs related to joint pain/stiffness and impaired cognition .Interventions Eating: I am dependent on one staff to feed me my meals and snacks . On 3/25/25 at 11:50 AM, an observation revealed Resident #42 unassisted, eating her lunch. During an observation and interview on 3/25/25 at noon, the Assistant Director of Nurses (ADON) confirmed that Resident #42 is supposed to have a CNA (Certified Nursing Assistant) assisting her with her meals. An observation on 3/26/25 at 8:10 AM, revealed Resident #42 was eating her breakfast in her room unassisted. An observation on 3/26/25 at 11:50 AM, revealed Resident #42 was eating her lunch in her room unassisted. On 3/26/25 at 2:30 PM, during an interview with Registered Nurse (RN) #2, she stated, The resident is supposed to be assisted with all her meals. In an interview on 3/27/25 at 08:20 AM, the MDS Nurse confirmed that according to Resident #42's ADL care plan, she is to be assisted by a staff member for all meals, and if she wasn't being assisted with her meals by a staff member, then her plan of care was not being followed. Record review of the Admission Record revealed the facility admitted Resident #42 on 12/26/2023 with medical diagnoses that included Sequelae of Cerebral Infarction, Muscle Weakness and Need for Assistance with Personal Care. Record review of the MDS with an ARD of 12/31/2024 revealed under Section GG-Functional Abilities that the resident required Substantial/maximal assistance with eating, which details The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure necessary care and services were provided for one (1) of 38 residents (Resident #75) reviewed for PEG (percutaneous endoscopic gastrostomy) tube management and PRN (as needed) medication administration. Specifically, nursing staff failed to administer Zofran 4 mg (milligrams) PRN for vomiting/gagging on multiple documented occasions, despite physician orders and clinical indications. This failure resulted in Resident #75 experiencing vomiting and feeding intolerance, requiring cessation of tube feeding, and caused unnecessary discomfort. Findings include: Record review of the facility policy titled, Enteral Feedings - Enteral Nutrition Pump, with revision date of 11/12/18, revealed, Nurses administer enteral feedings when volume control is indicated and as ordered by physician. Record review of facility policy titled, Administering Medication, dated 4/19, revealed, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame . During the initial tour on 3/25/25 at 11:05 AM, an observation revealed Resident #75 lying in bed awake, alert and responsive, but not interviewable. He had a tube feeding of Glucerna 1.5 infusing by feeding pump at 50 milliliters per hour. Record review of Progress Note dated 10/20/24, revealed, Resident can't tolerate, starts gagging. Record review of Resident #75's Order Recap Report revealed an active order for Zofran Oral Tablet 4 milligrams (mg) via PEG (percutaneous endoscopic gastrostomy) tube every six hours as needed for vomiting dated 3/11/24. Record review of Resident #75's Electronic Medication Administration Report (EMAR) revealed the as needed Zofran was not given on 10/20/24. Record review of Progress Note dated 10/28/24, revealed, Resident vomiting/gagging and can't tolerate feeding. Record review of Resident #75's EMAR revealed the as needed Zofran was not given on 10/28/24. Record review of Progress Note dated 2/22/25, revealed, Resident in bed, gave resident his med per PEG and flushes, as soon as I finished, he started vomiting his feeding, vomited several times, feeding cut off at this time. Record review of EMAR revealed the as needed Zofran medication was not given on 2/22/25. During an interview on 3/27/25 at 8:44 AM, the Regional Director of Clinical Services stated Resident #75 had nausea and vomiting and was not given an ordered medication for the relief of the vomiting. She confirmed the facility failed to administer an ordered medication to a resident with nausea/vomiting to decrease his discomfort. During interviews on 3/27/25 at 9:20 AM and 10:11 AM, the Director of Nursing (DON) stated the review of the documentation on 10/20/24, 10/28/24, and 2/22/25 revealed the resident was gagging with vomiting and he did not receive the ordered medication for nausea relief. She confirmed the facility failed to administer an ordered medication to a resident with nausea and vomiting. Record review of Resident #75's Admission Record revealed the facility admitted the resident on 3/7/24. Diagnoses included dysphagia following cerebral infarction, gastrostomy status, gastro-esophageal reflux disease, and acquired absence of other specified parts of digestive tract. Record review of Resident #75's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that staff received adequate education and training regarding the use and implementation of Enhanced Barrier Precautions (EBP). As a result, staff did not utilize the required personal protective equipment (PPE) during four (4) high-contact resident care activities observed, potentially putting all residents residing in the facility at risk for the spread of multidrug-resistant organisms (MDROs). Findings include: cross-reference F 880 Review of the facility policy titled, Enhanced Barrier Precautions, with an effective date of 9/01/22, revealed the following: Policy: Enhanced barrier precautions (EBP) are used to reduce the spread of multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high-contact resident care activities. Procedure: 4.) Educate the staff on EBP, including but not limited to: a.) use of PPE (personal protective equipment) . b.) High-contact care areas . During observations of four (4) high-contact resident care activities, staff were not observed at any time using EBP for Residents #11, # 25, # 32, and #75. On 3/26/25 at 8:00 AM, an observation of Resident #75 during medication pass revealed Licensed Practical Nurse (LPN) #4 administered the resident's medications via PEG (percutaneous endoscopic gastrostomy) tube without wearing a gown for EBP. On 3/26/25 at 10:35 AM, during an observation the Wound Care Registered Nurse (RN), assisted by Certified Nursing Assistant (CNA) #5, provided wound care for Resident #11. Neither staff used enhanced barrier precautions (EBP) during the wound care procedure. On 3/26/25 at 11:50, during an observation of wound care for Resident #32 AM with the Wound Care Nurse and CNA #5 there was no observation of the wound care nurse or CNA #5 applying a gown as part of the EBP. On 3/26/25 at 12:15 PM, an observation of Resident #25's wound care with the Wound Care Nurse assisted by CNA #5 revealed that the care was provided without using a gown for EBP. During an interview with the Wound Care Nurse and Certified Nurse Assistant (CNA) #5 on 3/26/25 at 12:22 PM, they confirmed they had not been in-serviced or trained on EBP. During an interview with the Corporate Nurse on 3/26/25 at 12:30 PM, she confirmed that staff had not been educated, and the precautions had not been implemented. During an interview with CNA #6 on 3/26/25 at 1:25 PM, she confirmed she had not been trained or had knowledge of EBP or its purpose. During an interview with the Infection Control Nurse on 3/26/25 at 2:51 PM, she revealed that she was aware of what EBP was because she learned it in her infection control (IC) training. She also confirmed she had never received any education in the facility related to EBP and was unaware of why the facility had not educated staff or implemented the EBP practice. During an interview with the Administrator on 3/26/25 at 3:00 PM, he revealed he was not aware that staff were not using EBP. He stated that the facility had been using EBP at one point but experienced a breakdown in its practice due to significant staff turnover in the past six months. During an interview with the Staff Educator on 03/27/25 at 10:30 AM, she revealed she had been in her position since July of 2024 and conducts skill competencies for staff and new hires. She confirmed that EBP was not part of the education provided and stated that since her hire date, there had been no education on EBP for any staff. She also stated she was unable to locate any education on EBP prior to her hire date. During an interview with Licensed Practical Nurse (LPN) #1 on 3/27/25 at 10:41 AM, he revealed he had been employed for over a year and confirmed he did not know what EBP was and had never been educated on it. During an interview with CNA #9, on 3/27/25 at 10:44 AM, she confirmed she had been employed at the facility for a year. She confirmed she had never been educated on EBP and did not know what it was. During a follow-up interview with the Administrator on 3/27/25 at 10:48 AM, he confirmed that, due to staff not being educated on EBP and the lack of documented proof of education, the facility had failed to ensure staff had the knowledge necessary to understand and implement EBP. He stated that the concern resulting from failing to educate the staff on EBP was that high-risk residents would not receive the precautions they needed.

Based on observations, staff interviews, record reviews, and policy review, the facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) for five (5) of thirty-eight (38) sampled residents (Residents #11, #25, #32, #65, and #75). Specifically, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact resident care activities (wound care and percutaneous endoscopic gastrostomy (PEG) tube handling), failed to prevent the reuse of a single-use medical device (PEG tube declogger), and failed to store a biliary drainage collection bag in a sanitary manner. These failures created an increased risk for the transmission of infectious organisms among residents requiring complex care. Findings include: Cross- reference F726 Review of the facility policy titled Infection Prevention and Control Program with a revision date of 10/2018 revealed under, Policy Statement: An infection prevention and control program (IPCP) Is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility policy titled, Enhanced Barrier Precautions, with an effective date of 9/01/22, revealed the following: Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high-contact resident care activities . High-contact care activities provide opportunities for the transfer of MDROs to staff hands and clothing . High-contact care activities include: feeding tube care, wound care . Record review of facility's letterhead revealed, This facility does not have a policy on storage of a biliary tube bag. Resident #11 During an observation and interview on 3/26/25 at 10:35 AM, the Wound Care Registered Nurse (RN) and Certified Nursing Assistant (CNA) #5 performed wound care for Resident #11. The RN performed the wound treatment on the resident's sacral area and CNA #5 assisted. Neither staff used enhanced barrier precautions (EBP) during the wound care procedure. During an interview on 3/27/25 at 8:15 AM, the Wound Care RN revealed she was unaware of the EBP guidelines and did not dress out during her wound care treatments. She stated she had now been in-serviced on EBP and the purpose to decrease the risk for infection. Record review of Resident #11's Admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included pressure ulcer to sacral region and type 2 diabetes mellitus. Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/21/25 revealed the resident was rarely or never understood. 47874 Resident #25 Record review of Resident #25's Order Listing Report revealed an order dated 12/27/24, Cleanse unstageable pressure ulcer to tip of left great toe with wound cleanser or NS (normal saline), pat dry with 4 x 4 gauze, paint with betadine and cover with bordered gauze dressing q (every) Monday, Wednesday and Friday. An observation of Resident #25's wound care with the Wound Care Nurse assisted by CNA #5 on 3/26/25 at 12:15 PM revealed that the care was provided without using a gown for EBP. An interview with both the Wound Care Nurse and CNA #5 on 3/26/25 at 12:20 PM confirmed they did not dress out in a gown for EBP during Resident #25's wound care. They both revealed they had no knowledge of these precautions and indicated they had not been in-serviced or had any training on the subject. An interview on 3/26/25 at 12:25 PM with CNA #2 and CNA #6 confirmed neither had been trained nor had knowledge of EBP. An interview with the Regional Director of Clinical Services (RDCS) on 3/26/24 at 12:30 PM revealed the facility was currently working on getting EBP into place and confirmed staff had not been educated, and the precautions had not been practiced at the facility. She confirmed the purpose of using EBP was to protect the residents from infection. Record review of the Admission Record revealed the facility admitted Resident #25 on 9/15/23 with a medical diagnosis that included metabolic encephalopathy. Resident #75 An observation of Resident #75 during medication administration on 3/26/25 at 8:00 AM revealed Licensed Practical Nurse (LPN) #4 attempted to flush the resident's PEG tube with water, but the tube was clogged. LPN #4 retrieved an opened package off the bedside table and indicated it was a peg tube declogger. The opened package was undated, and she inserted the declogger inside the resident's peg tube multiple times. Afterward, she rinsed the de-clogger and placed it back into the package. She administered the resident's medications via PEG tube without wearing a gown for EBP. Review of the Bionix Enteral Feeding Tube Declogger manufacturer's instructions online revealed single use and discard after using. An interview with LPN #4 on 3/26/25 at 8:47 AM confirmed the manufacturer's instructions revealed the tube declogger was for single use and revealed reusing the declogger placed Resident #75 at risk for infection. LPN #4 confirmed she did not wear a gown to administer the medications and indicated she had not been trained or had any in-services on using EBP. On 3/26/25 at 3:21 PM, an interview with the RDCS with the Director of Nursing (DON) in attendance revealed the staff should not be using feeding tube de-cloggers and voiced there were other alternatives to handle a clogged tube. Record review of the Admission Record revealed the facility admitted Resident #75 on 3/07/24 with medical diagnoses that included sequelae of cerebral infarction and gastrostomy status. 47157 Resident # 32 During an observation of wound care for Resident #32 on 3/26/25 at 11:50 AM with the Wound Care Nurse and CNA #5, revealed the Wound Care Nurse or CNA #5 did not don a gown as part of the EBP. A review of the March 2025 Treatment Record for Resident #32 revealed the following: Clean diabetic/PVD (peripheral vascular disease) right heel wound with wound cleanser, pat dry, apply collagen dressing with silver, cover with kerlix and secure with tape daily, signed off as completed on 3/26/25. During an interview with the Wound Care Nurse and CNA #5 on 3/26/25 at 12:22 PM, it was confirmed that they did not wear any special PPE for EBP during Resident #32's wound care and that they had not been in-serviced or trained on EBP. A review of Resident #32's Admission Record revealed that he was admitted on [DATE], with a diagnosis of Type II diabetes. During an interview with the Infection Control (IC) Nurse on 3/26/25 at 2:51 PM, she revealed that she was aware of what EBP was because she learned about it in her Infection Control training. She stated that EBP is used as an extra layer of protection between residents and staff to reduce the spread of infection for residents with open wounds and indwelling devices. She confirmed that the facility was not using EBP for any residents. She also revealed she was unaware of why the facility did not educate staff or implement EBP practice. During an interview with the Administrator on 3/26/25 at 3:00 PM, he revealed that he was not aware staff were not using EBP. He stated that the facility had been using EBP at one point but experienced a breakdown in its practice due to significant staff turnover in the past six months. During a follow-up interview with the Administrator on 3/27/25 at 10:48 AM, he confirmed that concerns from failing to educate and implement EBP is that high-risk residents would not receive the necessary precautions. 48845 Resident # 65 During an observation on 3/25/25 at 11:05 AM of Resident #65 revealed he was lying in bed with a biliary drain connected to a drainage bag. The biliary drainage collection bag with a brown, foamy substance was lying on the floor visible from the doorway. During an observation and interview on 3/26/25 at 10:07 AM with LPN) #2, it was confirmed the biliary drainage collection bag should not be on the floor. She further confirmed that the bag being on the floor was an infection control issue. She stated, the floor is the nastiest place! During an interview on 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) it was confirmed the that the biliary drainage collection bag should not have been on the floor as that is an infection control concern that could lead to an infection to the resident. Record review of Order Summary Report confirmed Resident #65 had orders related to a biliary drain with start date 2/28/25. Record review of Admission Record revealed the facility admitted Resident #65 on 3/9/25 with medical diagnoses that included Malignant Neoplasm of Pancreas, and Obstruction of Bile Duct.

Based on observation, resident/staff interview and record review, the facility failed to ensure a resident's medications were not left unattended in the resident's room for one (1) of 38 sampled residents. Resident #28. The scope/severity for this deficiency was increased to E due to previous citation on the last annual recertification survey. Findings include: Record review of a statement on the facility's letterhead dated 3/27/25 and signed by the Administrator revealed, (Proper name of the facility) does not have a specific policy for unattended medication. During an observation and interview on 3/25/25 at 10:45 AM, a small bag of intravenous (IV) fluids with a vial of medication attached to the bag was observed from the open doorway, lying on Resident #28's bedside table. The resident confirmed it was her antibiotic medication, and the nurse needed to restart her peripheral IV before administering it. During an observation on 3/25/25 at 1:37 PM with Registered Nurse (RN) #1, confirmed the presence of the IV antibiotic medication on the bedside table. RN #1 acknowledged that the medication should not have been left unattended, as another resident might have accessed it with the door open to the hallway. During an interview on 3/25/25 at 2:30 PM with the RN Supervisor confirmed that leaving the IV medication unattended was inappropriate and that it posed a risk of access by another resident. During an interview on 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) confirmed the medication should not have been left on the bedside table. A record review of the Admission Record for Resident #28 revealed that she was admitted to the facility on [DATE] with a diagnosis of polyneuropathy, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #28 is cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment and staff assistance for three (3) of three (3) dining observations. Resident #42 Findings include: Review of the facility policy titled Assistive Devices with a revision date of 10/2022 revealed under, Policy Statement .Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently. An observation on 3/25/25 at 11:50 AM revealed Resident #42 unassisted, eating her lunch; her meal was on a regular plate, and the resident was struggling with holding her spoon. No adaptive utensil equipment was noted. During an observation and interview on 3/25/25 at 12:00 PM, the Assistant Director of Nurses (ADON) confirmed that Resident #42 did not have her divided plate and stated that it was on her meal ticket to have one, and the resident is supposed to have a Certified Nurse Aide (CNA) assisting her with her meals also. On 3/26/25 at 8:10 AM, an observation revealed Resident #42 eating her breakfast in her room unassisted with no adaptive utensils were noted. On 3/26/25 at 11:50 AM, an observation revealed Resident #42 eating her lunch in her room unassisted with no adaptive utensils noted. During an observation and interview on 3/26/25 at 12:00 PM, CNA #10 stated, I'm new, and I'm not sure if the resident requires assistance with eating. An interview on 3/26/25 at 2:30 PM, Registered Nurse (RN) #2 stated, The resident is supposed to be assisted with all her meals, and she uses big utensils and a divided plate also. In an interview on 03/26/25 at 2:40 PM, the Occupational Therapist (OT) revealed she was aware that the resident required a divided plate and revealed when the resident was discharged from occupational therapy last month, she had recommended for her to use adaptive built-up utensils to assist the resident in holding her spoon or fork in addition to using her divided plate. Record review of the Physicians Orders revealed no order for the built-up utensils or the divided plate. Record review of the Admission Record revealed the facility admitted Resident #42 on 12/26/2023 with medical diagnoses that included sequelae of Cerebral Infarction, muscle weakness and need for assistance with personal care. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 12/31/2024 revealed under Section GG-Functional Abilities that the resident required Substantial/maximal assistance with eating, which details The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for three (3) of 38 sampled residents. Resident #5, #12 and #51. The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 02/01/2022, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, care and assistance as necessary. ADL's includes bathing, dressing, grooming hygiene, toileting and eating. Resident #5 An observation and interview on 3/25/25 at 11:16 AM and again on 3/26/25 at 10:25 AM with Resident #5 revealed the resident had numerous visible gray facial hairs that measured approximately one-fourth (1/4) in length and his fingernails on both hands were one-eighth (1/8) inch in length past the tips of the fingers, long and uneven with some sharp edges and a brown substance underneath. During an interview for both observations Resident #5 stated that he needed a bath, shaved and he would like his nails to be trimmed. An observation and interview with Licensed Practical Nurse (LPN) # 3, she revealed that Resident #5's fingernails were the responsibility of the nurses because he was diabetic and confirmed they needed to be cleaned and cut. She admitted that the resident had an odor, and his nails had some sort of a brown substance underneath the nail beds. Review of the Admission Record revealed that the facility admitted Resident #5, on 1/03/2020 with a medical diagnosis that included type 2 diabetes mellitus without complications. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #5 was cognitively intact. Resident #12 An observation and interview on 3/25/25 at 10:50 AM with Resident #12 revealed all of his fingernails had a dark brown substance underneath them and were long extending approximately one (1) inch long past the tips of the fingers. The resident had approximate one-half (1/2) long facial hair covering his chin and sides of his face. The resident admitted he wanted to be shaved and have his nails cut because it had been too long. During an observation on 3/26/25 at 8:25 AM and again at 10:10 AM, Resident #12's appearance remained the same as the previous day. An interview and observation on 3/26/25 at 10:15 AM Certified Nurse Aide (CNA) #1 revealed that she gave Resident #12 a bath yesterday. She confirmed that he needed to be shaved, but he did not ask her to do it, and she did not ask if he wanted it done. She stated that she doesn't cut any of the resident's nails. She confirmed the resident's fingernails were dirty and needed cutting and admitted that the CNA's are supposed to ask the nurses if residents are diabetic, but she never has. In an interview and observation on 3/26/25 at 10:25 AM, LPN #1 confirmed that Resident #12's nails were dirty with a brown substance underneath, too long and rough. He stated the resident could cut himself with those sharp nails and possibly cause a skin infection. He revealed that the resident is a diabetic and usually the CNA's will let the nurses know when those residents need their nails trimmed. LPN #1 also confirmed the resident needed shaving and should have been shaved with his bath yesterday. During an interview on 3/26/25 at 11:05 AM, the Director of Nurses (DON) confirmed that Resident #12 and all residents should always be groomed as needed and on bath days, that includes nails and shaving. She stated that it is not the resident's responsibility to request grooming. Record review of the Admission Record revealed the facility admitted Resident #12 on 3/3/2014 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Record review of Resident #12's Section C of the MDS dated [DATE] revealed a BIMS score of 11, indicating the resident has moderate cognitive impairment. Resident #51 During an observation and interview on 3/25/25 at 11:20 AM with Resident #51 he stated that his toenails needed trimming. An observation of the resident's feet confirmed that all of his toenails were long and jagged extending at least 1/2 inch past the tip of the nailbed except for the right big toe. The right big toe was approximately three-fourths (3/4) inch past the nail bed. An interview with CNA #11 on 3/26/25 at 10:10 AM revealed Resident #51 was assigned to her, and it was her responsibility to trim the fingernails and toenails who were not diabetic but confirmed that she had not trimmed Resident #51's toenails. During an interview and observation with Resident #51 on 3/26/25 at 10:15 AM, LPN #1 confirmed that the resident needed his toenails tended to. She revealed that the resident is not diabetic and therefore the CNAs are responsible for trimming nails. During the observation LPN #1 stated the nails were long and jagged and should not look that way and they should have been trimmed long before now. An interview and observation with the DON on 3/26/25 at 10:25 AM, confirmed the resident's toe nails needed cut. She confirmed the facility failed to maintain the resident's toenails within a safe and comfortable length and as the resident preferred. Record review of Resident #51's Admission Record revealed the facility admitted the resident on 1/13/25. Diagnoses included Complete Lesion at T2-T6 Level of Thoracic Spinal Cord, Peripheral Vascular Disease, Lymphedema, and Need for Assistance with Personal Care. Record review of MDS with ARD of 3/10/25 revealed Resident #51 had a BIMS of 13 which indicated the resident was cognitively intact.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide a safe homelike environment as evidenced by missing air conditioner unit cover, damaged furniture, no fitted sheets and a foul odor from a stopped-up toilet for four (4) of 93 residents residing in the facility. Residents #3, #22, #28 and #47 The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings Include: Review of the facility policy titled Policies and Procedures unrevised revealed under, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Review of the facility policy titled, Resident/Patient Room Cleaning with a revision date of 2/1/25 revealed, (Proper Name) is committed to providing a safe, clean, and hygienic environment for residents . Resident #3 On 03/25/25, at 11:00 AM, and again on 3/26/25, at 10:21 AM, an observation of Resident #3's room revealed his air conditioner/heating unit cover was on the floor. In an interview, Resident #3 voiced that staff were aware and they were looking for a clip. During an interview with Licensed Practicing Nurse (LPN) # 3, she confirmed the unit cover should not be off the unit. She stated that all maintenance repairs should be reported to the maintenance supervisor. During an interview with the Maintenance Supervisor on 3/26/25 at 10:31 AM regarding the air conditioner/heating unit cover on the floor, he reports that the staff usually contacts via text, in person, or records in the maintenance book. He reports he was unaware of the cover being on the floor in Resident #3's room. The Maintenance Supervisor confirmed the resident should have a homelike environment. Record review of the Admission Record revealed that the facility admitted Resident #3 on 11/20/23 with a medical diagnosis that included Alzheimer's Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #3 was cognitively intact. 48845 Resident #22 An observation on 03/25/25 at 03:29 PM of Resident # 22's room revealed an approximate 18-inch section of trim with jagged, sharp edges sticking out of the top section of her dresser. An interview on 03/26/25 at 10:14 AM with Certified Nurse Assistant (CNA) #3 confirmed that Resident #22's dresser had an approximate 18-inch section of trim with jagged, sharp edges sticking out of the top section. She stated the resident could cut herself or get herself in the eye. She stated she wasn't sure how long the dresser had been in that condition. An interview on 03/26/25 10:36 AM with the Maintenance Supervisor, he stated that he was not aware of loose trim on Resident #22's dresser. He confirmed the resident could get scratched or hit her face on it. He revealed after review of the maintenance log that he was unable to find any documentation for the broken equipment. An interview on 03/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) revealed she was not aware of the loose trim on the dresser and confirmed it needed to be fixed. Record review of Resident #22's Admission Record revealed the facility admitted the resident on 9/15/22 with medical diagnoses that include Need for Assistance with Personal Care. Resident #28 An observation and interview on 03/25/25 10:45 AM for Resident # 28 revealed that the resident's approximate 18-inch auscultating fan, located at the head of the bed, had a large buildup of a gray substance on the fan blades and fan guard. The resident mentioned that she had asked for the fan to be cleaned, but it had not been done yet and that she had not been using it because it was dirty An observation and interview on 03/26/25 at 10:05 AM with the Housekeeping Supervisor confirmed that Resident #28's fan was covered in lint and dust. She stated she thinks maintenance is responsible for cleaning these type items. She stated this could cause allergies. An interview on 03/26/25 10:36 AM with the Maintenance Supervisor, he stated that the CNAs are responsible for cleaning resident's personal items. An interview on 03/26/25 at 10:47 AM with the ADON confirmed that CNAs are responsible for cleaning resident's personal items such as the fan. Record review of Resident #28's Admission Record revealed the facility admitted the resident on 7/14/22 with medical diagnoses that included Need for Assistance with Personal Care. Record review of Resident #28's MDS with an ARD of 1/27/25 revealed a BIMS score of 15, which indicates the resident is cognitively intact. 46013 Resident #47 Upon entering Resident #47's room on 3/25/25 at 10:55 AM, a foul pungent smell was noted. An interview at this time with Resident #47 she stated that the toilet was not flushing and that she had told the staff about it. An observation revealed the toilet was full of a brown liquid and a brown substance that was approximately 10 inches from the top of the rim of the toilet seat. An interview on 3/25/25 at 11:00 AM, Housekeeper #1 revealed the toilet in Resident #47's room had been stopped up on and off for quite some time. She stated that they just go in and clean around the bottom of the base of the toilet and try to plunge it. She admitted that the staff report it all the time to maintenance. She revealed this had been a problem on and off for about a month and confirmed the resident's room smelled bad from the stopped-up toilet. In an interview on 3/25/25 at 11:10 AM, the Administrator (ADM) confirmed the stopped up smelly toilet was not a homelike environment and should have been taken care of. During an interview on 3/25/25 at 11:25 AM, the Maintenance Supervisor confirmed Resident #47's toilet being stopped up had been an ongoing issue and he was not sure what else to do. He revealed that they find all kinds of stuff in the toilet because they think the resident in the adjoining room has been putting wipes in the toilet. He confirmed it has been an ongoing issue. Record review of Resident #47's Admission Record revealed the facility admitted Resident #47 on 5/17/2024 with medical diagnoses which included Dementia, and Generalized Anxiety Disorder. Record review of Resident #47's MDS with an ARD of 2/14/25 revealed a BIMS score of 7 which indicated the resident had severe cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to honor a resident's right to be treated with dignity and respect as evidenced by improper feeding practices and failure to cover biliary and urinary catheter drainage devices with privacy covers for three (3) of 93 residents residing in the facility. Resident #57, #65, and #439 The scope and severity of this deficiency was increased to E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings Include: Record review of the facility policy titled, Policies and Procedure with a revision date of 9/19/2017 revealed Subject; Catheterization, Male and Female Urinary .Foley bag to be covered by a privacy bag to preserve dignity of resident . Review of the typed statement on facility letterhead, signed by the Administrator and dated 3/27/25 revealed, (Proper name of the facility) does not have a specific policy for privacy bags for biliary drainage tubes. Resident #57 An interview with the Regional Director of Clinical Services (RDCS) on 3/27/25 at 11:04 AM revealed the facility did not have a policy related to providing dignity while assisting a resident with meals. On 3/25/25, at 12:25 PM, an observation of Resident #57 revealed Certified Nursing Assistant (CNA) #8 was standing over Resident #57 while he was in bed, feeding him his lunch meal. During an interview with CNA #8 on 3/26/25 at 11:04 AM, she confirmed that she was standing over Resident #57 feeding him. She reported that sometimes she sits to feed him but often feeds him while standing at bedside. During an interview with the Nursing Educator on 3/26/25 at 11:08 AM, she stated that Resident #57 should be fed while sitting in a chair at bedside. She stated standing over him would be a dignity issue. Review of the Admission Record revealed that the facility admitted Resident #57 on 11/04/22 with a medical diagnosis that included Unspecified Sequelae of Cerebral Infarction. 48845 Resident #65 An observation on 3/25/25 at 11:05 AM revealed Resident #65 had a urinary catheter bag attached to the left side of the bed without a privacy cover and was half full of light-yellow colored urine. This observation also revealed that the resident had a biliary drain leading to a drainage bag that had a foamy, brown colored substance. Both the biliary drainage bag and the urinary catheter bag were visible from the doorway. Observation and interview on 3/26/25 at 10:07 AM with Licensed Practical Nurse (LPN) #2 confirmed that both the urinary catheter bag and the biliary drainage bag should have a privacy cover. She stated it is a dignity issue. An interview on 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) confirmed the urinary catheter bag and biliary drainage bags should have had a privacy cover and that it is a dignity issue. Record review of Resident #65's Admission Record revealed the facility admitted the resident on 3/9/25 with medical diagnoses that included Malignant Neoplasm of Pancreas, Unspecified. 47874 Resident #439 An observation of Resident #439 on 3/25/25 at 11:27 AM revealed he was lying in bed and had a urinary catheter drainage bag hanging on the lower bed rail that contained yellow urine and was visible from the hallway. An observation on 3/26/25 at 10:23 AM from Resident #439's doorway revealed he was lying in bed interacting with visitors. His catheter drainage bag was hanging on the lower bed rail without a privacy cover, and yellow urine was visible. An observation and interview with LPN # 3 on 3/26/25 at 10:25 AM confirmed Resident #439 did not have a privacy cover on his urinary drainage bag and stated, It's a dignity issue if they do not have a cover on their bag. Record review of the Admission Record revealed the facility readmitted Resident #439 on 3/03/25 with a medical diagnosis that included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side.

Based on observation, staff interview, and record review the facility failed to ensure there was a physician's order and provide catheter care to a resident with an indwelling catheter for one (1) of eight (8) residents with an indwelling catheter reviewed. Resident #439 Findings Include: Review of the facility provided statement on letterhead dated 3/27/25 and signed by the Administrator revealed, (Proper name of the facility) does not have a specific policy for obtaining physician orders. An observation of Resident #439 on 3/25/25 at 11:27 AM revealed he was lying in bed. His catheter drainage bag was hanging on the lower bed rail, with yellow urine visible from the hallway. Record review of Resident #439's Order Summary Report with active orders as of 3/26/25 revealed the resident did not have an order for the urinary catheter or catheter care orders. An interview with Licensed Practical Nurse (LPN) #3 on 3/26/25 at 2:58 PM, she indicated Resident #439 returned from the hospital on 3/21/25 with an indwelling catheter. She confirmed the resident did not have any physician orders related to the catheter. LPN #3 revealed the admitting nurse on 3/21/25 should have done a hospital return assessment and ensured the orders were put into the system. LPN #3 further indicated the facility had a stand-up meeting every day to ensure all the new orders were captured and corrected from any admissions. She confirmed the resident would not get the proper catheter care and monitoring without orders in place. Record review of Resident #439's Progress Notes dated 3/21/25 revealed, Catheter is indwelling. Record review of the Admission Record revealed the facility readmitted Resident #439 on 3/03/25 with a medical diagnosis that included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side. An interview with the Minimum Data Set (MDS) Nurse on 3/26/25 at 3:06 PM revealed that when Resident #439 came back from the hospital on 3/21/25, his discharge paperwork did not mention that he had a catheter. She revealed the admitting nurse would have been responsible for contacting the physician to obtain orders. She confirmed that without the orders in place, the resident would not get the proper catheter care needed and proper monitoring for complications.

Based on observation, staff interview, and facility policy review, the facility failed to provide accommodation of needs for a residents call light not being within reach for two (2) of three (3) survey days. Resident #71 Findings Include The facility provided a statement on letterhead signed by the Administrator and dated 3/27/25, (Proper name of the facility) does not have a specific policy for Call Lights. Resident #71 An observation of Resident # 71 on 3/25/25 at 11:25 AM revealed he was lying in bed. Further observation revealed his call light was hanging over a small picture on the wall, and the end of the call button was on the floor behind a bedside dresser. The resident did not have access to his call light. An observation on 3/26/25 at 10:43 AM of Resident #71 revealed he was sitting in a chair in his room. His call light was unreachable and hanging over a small picture on the wall with the end of the call button on the floor behind a beside dresser. An observation and interview with Licensed Practical Nurse (LPN) #3 on 3/26/25 at 10:47 AM revealed Resident #71 knew how to use the call light if he needed something. She confirmed the call light was unreachable. LPN #3 stated, I'm on them all the time about keeping the call lights in reach; I find them on the floor and all over the place. She confirmed anything could happen to the resident, such as falling or choking, and he would not have access to call for help. An interview with Certified Nursing Assistant (CNA) #8 on 3/26/25 at 10:55 AM confirmed Resident #71's call light should be in reach, so the resident could call staff if he required something. She revealed if the light was not in reach the resident could fall, or something could happen, and he would not be able to get help. Record review of the Admission Record revealed the facility admitted Resident #71 on 9/11/23 with a medical diagnosis that included but was not limited to Parkinson's disease with Dyskinesia.

Based on staff interviews, record review, and facility policy review, the facility failed to document if wound treatments had been completed for a resident with a Stage 4 pressure ulcer for one (1) of three (3) residents with wounds reviewed. Resident #11 Findings include: Record review of facility policy titled, Dressing Change, dated 12/6/17, revealed, A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Document in medical record. Record review of Order Listing Report revealed an order dated 2/21/25 for wound care to stage four pressure ulcer to sacral region to clean with one-quarter (1/4) strength Dakins, pat dry with 4x4 gauze, apply collagen with silver sheet, cover with bordered dry dressing daily until healed every day shift. This order was discontinued on 3/25/25. Record review of Electronic Treatment Administration Record (ETAR) for March 2025 revealed wound treatments for 3/1/25, 3/4/25, 3/5/25, 3/6/25, 3/7/25, 3/12/25, 3/13/25, 3/14/25, 3/16/25, 3/18/25, 3/24/25, and 3/25/25 were not documented as administered. An interview and record review with the Wound Care Registered Nurse on 3/27/25 at 8:15 AM, revealed she worked Monday through Friday and had performed the wound treatments for Resident #11 each day she worked. A record review with the Wound Care RN confirmed there were 12 undocumented treatments in the electronic treatment administration record (ETAR) for this month. She stated she thought that she always documented her care but admitted she missed documenting multiple treatments. She stated it might be due to how it was put into the computer, behind multiple respiratory entries and she failed to see it. She stated accurate documentation was needed to verify that the care was done on each resident's record. During an interview on 3/27/25 at 8:10 AM, the Director of Nursing (DON) confirmed that wound treatments should be documented upon completion of the care, and this was not done for 12 of Resident #11's wound treatments for this month. She stated that documenting care is part of the continuity of care and treatment. She verified that treatments should be done and documented accurately. Record review of Resident #11's Admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included Pressure Ulcer to Sacral Region and Type 2 Diabetes Mellitus. Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/21/25 revealed that Resident #11 was rarely or never understood.

Based on record review, staff interviews, resident interview and facility policy review, the facility failed to complete timely reporting of a resident involved accident in the facility's wheelchair lift van to the State Agency, for one (1) of four (4) residents reviewed for wheelchair transportation safety. Resident #1 Findings Include: Review of the facility policy titled, Policies and Procedures, with a revision date of 11/16/2022, revealed . Employee Obligation . to report such information immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . to other officials in accordance with State law. Report the result of all investigations . to the State Survey Agency, with five (5) working days of the incident. A telephone interview on 10/18/23 at 11:30 AM with the Ombudsman revealed she was not notified by the nursing facility of the incident for Resident #1 regarding his wheelchair tilting over in the wheelchair lift van during transport. Record review of the Verification of Investigation, facility reported incident form, for Resident #1, revealed RESIDENT NAME: (Resident #1's name removed) . DATE/TIME OF OCCURRENCE: 10/05.23 @ (at) approx. (approximately) 10:30 AM . PROVIDED DETAILED DESCRIPTION OF EVENT/ALLEGATION: Resident was being transported to appointment on facility van. Resident fell backward in van during transport and hit left shoulder on floor. Seat belt remained intact throughout event. ASSESSMENT OF RESIDENT/DESCRIBE INJURY: No bruising, redness, or skin tears noted to resident post incident. Resident refused to go to emergency room (ER) to be evaluated. RESIDENT INTERVIEW SUMMARY: Resident stated that he was secured in wheelchair and when they stopped at red light and went forwards, his wheelchair tipped backward and he hit his left shoulder on the floor. He denied any other injuries or pain and refused to go to the ER to be evaluated. FIRST REPORTED BY NAME: (Certified Nurse Aide (CNA)#1 name removed), NAME/TITLE REPORTED TO: (Registered Nurse (RN) #1 (name removed), DATE REPORTED: 10/5/23, TIME REPORTED 10:35 AM . STATE AGENCY NOTIFIED: YES, CONTACT NAME: Reporting Line, DATE: 10/5/23, TIME: 10:45 AM . PRINTED NAME: (Former Director of Nursing (DON) name removed), DATE: 10/05/23. Record review of the time stamp of the initial telephone report by the nursing facility, provided by the SA Complaint Division, revealed WIRELESS CALLER, Voice Message From: WIRELESS CALLER, 1 (662) 7691195 [DATE], 11:10 20.8 sec. Record review of the documentation for the incident revealed DON and NP (Nurse Practitioner)/MD (Medical Director) aware and resident is his own RP (Responsible Party). MD gave orders to continue with transportation and upon return to center can follow up at the ER for an X-Ray. An interview on 10/18/23 at 12:38 PM with CNA #1 revealed she immediately called and reported the incident of Resident #1's wheelchair tilting over during transport. An interview on 10/18/23 at 2:09 PM with Resident #1 revealed he was sitting in the wheelchair during transport on 10/5/23, when the driver pulled off from the red light and his chair flipped over, causing him to bump his left shoulder and the left side of his head. An interview on 10/18/23 at 3:01 PM with RN #1 revealed she did receive the initial report and witness statement from CNA #1 of the incident with Resident #1' wheelchair tilting over in the wheelchair van during a transport to an appointment, on 10/5/23 before 10:30 AM, and immediately returned to a meeting with the Administrator, the Former DON, the MD, and his NP, and informed them of the incident. A telephone interview on 10/18/23 at 04:22 PM with the Former DON, revealed she called the report in to the State Agency (SA) hotline on 10/5/23 shortly after she was informed of the information by the RN #1 on the same day. She revealed she was not aware of why the SA reported her call recorded on 10/9/23 at 11:10 AM. She revealed she emailed her report a couple of days later and did not include findings because there were none. She noted she did not have to add a conclusion because she did not prove something went wrong. She shared she was not late calling in the initial report and was not late sending the written report. A telephone interview on 10/18/23 at 05:07 PM with the SA Complaint Division confirmed the initial report time of 10/9/23 at 11:10 AM from the Former DON at the nursing facility. SA was allowed to listen to the initial recorded report, from the Former DON, that warranted the SA Complaint Division to need to call back for clarification of what the incident entailed, and emailed SA a copy of the time stamp for the recording of the initial report from the Former DON at the nursing facility. The SA Complaint Division also verified the Former DON's personal cell phone number that was recorded as the number the incident was called in from, provided 10/11/23 at 02:20 PM as the first submission for the final/completed written investigation, and provided 10/15/23 at 09:22 PM for a resubmission of the final/completed written investigation. An interview on 10/18/23 at 05:20 PM with the Administrator revealed the Former DON was the one responsible, at the time of the incident, for reporting facility incidents to the SA Complaint Division, and confirmed that the Former DON did not follow the federal regulations for timely reporting of a resident involved incident in a timely manner. Record review of the Admission Record for Resident #1 revealed an admitted [DATE]. Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/18/2023, for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on observation, and staff and resident interview the facility failed to provide a safe clean environment as evidenced by a dirty wheelchair with a torn arm rest for Resident #249 and dirty floors throughout the facility, scuffed painted areas, gouged sheetrock, broken drawers, broken window and sharp areas on resident doors for four (4) of 4 survey days. Findings include: An interview with the Administrator on 9/28/23 at 9:00 AM revealed the facility did not have a policy addressing a safe and clean environment. An observation on 9/25/23 at 1030 AM, revealed blackish build up along the edges of all of the hallways at the baseboards and around the door frames of resident's room entry and bathroom doors. There are several brownish stain spots scattered along the floor of the east hall between room [ROOM NUMBER] to room [ROOM NUMBER]. Observations on 09/25/23 at 11:25 AM and 9/26/23 at 9:03 AM, revealed Resident #249 sitting in a wheelchair that had a thick brown and gray substance on the frame and the spokes of the wheels. The right vinyl armrest was tattered and torn with jagged edges exposed. An observation on 9/25/23 at 3:30 PM, revealed the drawers under the closet in room [ROOM NUMBER] are broken, hanging down and unable to be closed. An observation on 9/25/23 at 3:33 PM, in room [ROOM NUMBER] revealed the paint scuffed off and the wall had areas gouged out of the sheet rock behind the bed. The clothes closet cabinet had scuffed areas with missing paint and broken edges. An observation and interview on 09/25/23 at 03:36 PM, with Resident #52 revealed the drawer under the clothes closet was broken and hanging and will not close properly. The top of the counter space on the right side of the room has paint scuffed and peeled off the top. Resident #52 stated that she would not want this in her house if she wasn't in the nursing home. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/23 revealed a Brief Interview for Mental Status (BIMS) score of nine (9 )which indicated Resident #52 had moderate cognitive impairment. An observation on 9/25/23 at 4:00 PM, revealed the wall behind the A and B bed in room [ROOM NUMBER] below the chair rail had approximately 75% of the paint off. The chair rail was broken behind the bed with a sharp edge on it and was pulled away from the wall. An observation and interview on 09/26/23 at 02:10 PM, with the housekeeping District Manager confirmed the dark areas on the tile in the hallways, the build up of brownish-black material against the walls and noted the build up was worse near the hand sanitizer dispensers. He stated that some of the stuff on the floor was where they put down new baseboards and left strips of adhesive. He stated that they would try to get it up. He confirmed the black colored build up in the corners at the doors should not be there. He confirmed that the building is the resident's home and the floors should not have all the spots and build up on the tiles. If the tiles could not be cleaned the only thing to do would be to replace them. An observation and interview on 9/26/23 at 3:30 PM, the Maintenance Director confirmed the broken drawers, scuffed paint , gouged walls and loose broken chair rail should not be like that. He confirmed he would not want to live in a house with these issues. He stated that they make daily rounds, if possible, to check on things like this, but the staff should also report anything they find that needs repair. An observation and interview on 09/26/23 at 03:35 PM, the Director of Nurses (DON) confirmed that Resident #249's wheelchair was dirty and needed to be cleaned. She stated the wheelchair was disgusting. The DON revealed that it should have been cleaned last weekend and she wasn't sure when the last time it was cleaned. She revealed she had assigned one Certified Nurses Assistant (CNA) every weekend to clean the wheelchairs and had just put that in place about a month ago because the wheelchairs were not getting cleaned. She revealed we don't have a checklist in place at this time but that is something we are working on. The DON confirmed the right armrest was torn and jagged and could cause the resident to get a skin tear and she would get that taken care of. An observation on 9/27/23 at 8:55 AM, on the west hall of all the room doors revealed where the door frame meets the floor had a blackish build up on the floor approximately one half (1/2) to one (1) inch wide. An interview on 9/28/23 at 8:42 AM, with the Floor Technician revealed they stripped the floors last month and he buffed the floors yesterday. He stated he thinks the stains are rust left from a few years ago when the sewer overflowed and will not come up. During an observation and interview on 9/28/23 at 8:45 AM, with the Administrator (ADM) she revealed the floors were stained and dirty in the halls and the resident's rooms and that they needed new floors. She confirmed room [ROOM NUMBER] had paint scuffed off the closet door, room [ROOM NUMBER] clothes closet and drawers needed repair and the shelf needed to be repainted. She confirmed the gouged walls behind the beds and the broken, loose chair rail behind the bed needed fixing. She confirmed the metal plate on the door of room [ROOM NUMBER] had rough gouged areas and the metal plate corner was bent outward approximately two (2) inches. The ADM stated that the bent metal plate could possibly cut somebody. She confirmed the hole in the window in room [ROOM NUMBER] should have been fixed instead of putting tape over it and the tape no longer covered the actual hole. She stated that the building was dirty and in need of attention and updating. The ADM stated that her house did not look like this and confirmed the residents home should not look like it does.

Based on resident and staff interview, record review, and facility policy review, the facility failed to follow up on a grievance from Resident Council meetings related to answering call lights in a timely manner for two (2) of 10 residents in the Resident Council Meeting. Resident #39 and #66 Findings include: Record review of facility policy titled Policies and Procedure - Subject: Complaint/Grievance, dated 11/30/14, revealed, The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution Resident Council meeting was held with State Agency on 9/26/23 at 3:00 PM with 10 residents present. An interview on 9/26/23 at 3:00 PM, at the Resident Council meeting revealed Resident #39 (Resident Council President) and Resident #66 had concerns that the call lights were not always answered timely. They both stated that this concern had been mentioned in previous Resident Council meetings and they did not receive a resolution or follow-up for this grievance. They also stated that it had improved in the past, but they were now having concerns again. The other eight residents attending the meeting revealed they had no concerns with their call lights being answered timely. An interview with the Activity Director on 9/26/23 at 3:40 PM, revealed the residents had mentioned the call lights not being answered timely several times in Resident Council meetings and the department head was notified. During an interview on 9/27/23 at 3:00 PM, the Director of Nursing (DON) confirmed she was aware of the ongoing concern of the call lights not being answered timely. She confirmed it is the facility's responsibility to follow up on all grievances and the facility failed to discuss a resolution and follow-up with the council members concerning the grievance. Record review of Resident Council minutes dated 7/26/23, revealed, several concerns related to call lights. Record review of Resident Council minutes dated 8/24/23, revealed a concern with call lights was mentioned. Record review of the Admission Record for Resident #39 revealed she was admitted to the facility on [DATE]. Record review of Resident #39's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of the Admission Record for Resident #66 revealed she was admitted to the facility on [DATE]. Record review of Resident #66's MDS with ARD of 8/22/23 revealed a BIMS score of 15 which indicated the resident was cognitively intact.

Based on observations, staff interviews, record review and facility policy review the facility failed to honor a resident's dignity as evidence by posting a sign on a resident's door concerning care for one (1) of 96 residents residing in the facility. Resident # 81 Findings include: Record review of the facility policy titled Notice Of Privacy Practices undated, revealed under, Our Responsibilities: Our nursing facility is required to: Maintain the privacy of your health information . An observation, of Resident #81's room door on 09/25/23 at 10:48 AM, revealed a sign posted that read, Patient to wear helmet at all times. The resident was observed sitting in a wheelchair in her room and was unable to communicate verbally. An observation, of Resident #81's room door on 9/26/23 at 9:15 AM confirmed a sign posted that read, Patient to wear helmet at all times and three (3) identical signs posted on the walls in the resident's room that read, Patient to wear helmet at all times. An interview on 9/26/23 at 11:08 AM, with Licensed Practical Nurse (LPN) # 2 confirmed a sign posted on Resident #81's door that read, Patient to wear helmet at all times and LPN confirmed that it should not be posted visible to the public. She revealed posting clinical information on the door was a privacy issue. An interview with Registered Nurse (RN) #2 on 9/26/23 at 11:12 AM, confirmed the sign posted on Resident #81's door. She revealed that the sign was private care information that should not be visible to the public due to honoring residents' privacy. An interview with the Director of Nursing (DON) on 9/26/23 at 11:40 AM, revealed Resident #81's care information should not be posted on the door and she confirmed it was a privacy concern. Record review of the Admission Record revealed that Resident #81 was admitted to the facility on [DATE] with medical diagnoses that included Metabolic Encephalopathy, Major Depressive Disorder, Generalized Anxiety Disorder, Pseudobulbar Affect and Alcohol Abuse with Alcohol-Induced Psychotic Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/12/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score was not conducted due to Resident #81 is rarely/never understood.

CI MS #9517 Based on observation, interview, record review and policy review, the facility failed to ensure that residents received adequate supervision consistent with resident needs to prevent leaving the facility without supervision for one (1) of six (6) residents reviewed, Resident #1. Resident #1 was assessed and care planned as a risk for elopement and wore a Wander Guard Bracelet and required hourly visual observation. Resident #1's hourly visual check was not performed as required by the nurse on duty. Resident #1 was left on the porch without supervision and walked 0.8 miles from the facility on highways that had areas of deep ditches and areas that had no sidewalks. Resident #1 was returned to the facility by a family member. The facility's failure to supervise and ensure that hourly visual checks were performed on Resident #1 to prevent the resident from leaving the facility was deemed an Immediate Jeopardy on 7/19/11 at 12:05 p.m.. The Immediate Jeopardy began on 7/6/11 and was determined to be removed on 7/8/11. The Administrator was notified of the Immediate Jeopardy on 7/19/11 at 12:08 p.m. The facility provided a Credible Allegation of Compliance (AoC) on 7/20/11. Based on the facility's implementation of corrective actions and an acceptable Credible Allegation of Compliance, the Immediate Jeopardy was removed and the scope and severity was lowered on 7/8/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor and evaluate interventions for effectiveness by the facility's Quality Assurance (QA) Committee. Findings Include: The facility reported the following information to the state agency: "Elopement Reporting Form" dated 7/7/11 for Resident #1 with the date of occurrence 7/6/11. "Elopement discovered 7/6/11 on (Resident #1) when he was missing from front porch of (facility). (Resident #1) was last seen at 3:45 p.m. on front porch, grand-daughter picked him up at 4:21 p.m. in parking lot of the local general store on Hwy 51. Assessment of resident done on return to facility with no abnormalities found." The State agencies were notified. Prior to facility entrance on 7/19/11 at 8:45 a.m. the distance from the facility to the local general store on Highway 51 south was measured to be approximately 0.7 miles. The road directly in front of the facility parking lot that led off from the porch had two (2) lanes of traffic that had numerous vehicles traveling both ways. There were areas of deep ditches on both sides of the roads and no sidewalk. This road intersected Highway 51 South. The local general store was on the west side of the road on Highway 51 South. There was no sidewalk from the intersection to the local general store and there were four (4) lanes of heavy traffic. There were inclines of the road and curbs due to off-leading roads. Upon entrance to the facility on [DATE] at 8:50 a.m. a sign was noted on the front entrance door: "Always check with nurse before assisting any resident out of the facility". A review of the "Monthly Forecast" for the facility area revealed that the high for 7/6/11 was 91 degrees Fahrenheit with a low of 71 degrees and no precipitation. On 7/19/11 there were 15 residents identified in the facility with an elopement risk. Resident #1 was admitted to the facility 12/2/10 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/11 revealed that he had a Brief Interview for Mental Status (BIMS) score of 14. Resident #1 was not able to recall the day of the week. There were no signs of delirium or behaviors documented on the MDS. Resident #1 was independent with ambulation and transfer ability. He was coded with no balance problems and had functional limitation in range of motion on one side of his upper extremity. Resident #1 was coded for mobility devices of a cane/crutch. Review of a nurse's "Progress Note" dated 4/1/11 at 11:00 a.m. revealed that Resident #1 was having some confused periods and continued to look under the bed. Resident #1 was on an antibiotic for a Urinary Tract Infection (UTI) and fluids were encouraged. Review of a "physician's orders [REDACTED]. Review of a nurse's "Progress Note" for Resident #1 dated 4/1/11 at 6:00 p.m. revealed a new order to apply Wander Guard with every (q) one (1) hour observation related to confusion. The Responsible Party (RP) was notified. Review of Resident #1's current "Care Plan" through 8/18/11 revealed that he was at risk for elopement related to confusion at times. Approaches included: Resident to wear a wanderguard at all times. Q 1 hr visual observation. Check wanderguard daily for proper functioning. Check daily for proper functioning of door alarms. Check for wanderguard placement q shift. Keep current picture of resident in elopement book. Encourage to participate in activities. Further review of nurse's "Progress Note" dated 4/1/11 at 9:40 p.m. revealed that Resident #1 continued to have confusion and the Wander Guard was on with q 1 hour observation being done. Nurse's "Progress Note" dated 5/2/11 at 12:05 a.m. and 11:00 a.m. revealed that Resident #1 had increased confusion and an order was at received at 11:00 a.m. for Lactulose 15 cubic centimeters (cc) daily for increased ammonia and confusion. Nurse's "Progress Note" dated 5/2/11 at 9:10 p.m., 5/12/11 at 6:00 p.m., 5/13/11 at 11:00 a.m. 5/13/11 at 9:10 p.m., and 5/17/11 at 4:30 p.m. revealed that Resident #1 had some confusion noted. Review of physician's "Progress Notes" dated 5/11/11 at 1:15 p.m. revealed that Resident #1 was doing better since starting Lactulose but was still somewhat confused. A note dated 6/8/11 at 3:00 p.m. revealed that Resident #1 was doing better but still confused-hyperamonemia-increase Lactulose. Further progress note on 7/13/11 at 4:00 p.m. revealed that Resident #1 was doing ok, confusion worse and to increase the Lactulose to twice daily. These orders were written and carried out. Review of a nurse's "Progress Note" dated 7/6/11 at 4:00 p.m. documented that Resident #1 ambulated from the facility after being noted sitting on the front porch and was returned to the facility per family members. Further note on 7/6/11 at 4:50 p.m. revealed that Resident #1 returned to the facility with no acute distress noted. Respiration's were even and non-labored and his skin was warm, dry and normal in color. He ambulated into the facility with a cane and family members were at his side. A full body audit revealed no signs of injury and he was answering questions appropriately with clear speech. Resident #1 denied pain or discomfort and when asked stated that he had not fallen or stumbled. The Wander Guard was intact to his ankle. Thrill and bruit noted to fistula of left arm. Blood pressure was 164/88, pulse 82, respirations 18 and temperature 96.4 degrees. Review of a "Change in Condition Evaluation" dated 7/6/11 at 4:50 p.m. revealed that Resident #1 ambulated from the facility and was oriented to person, place and time with no complaint of pain. The physician was notified at 5:15 p.m. and the RP was present. Review of a "Conference Sheet" dated 7/7/11 revealed that the Medical Director was notified that Resident #1 had eloped from the premises the day before and was brought back to the building with no complaints or injury. The patient had stated "I was just going home". The response documented/signed by the Medical Director was "ok. Monitor hourly". Review of a "Visual Observation" record for July 2011 revealed that q 1 HR (hour) visual checks were documented for Resident #1 on 7/6/11. The 4:00 p.m. visual check was initialed on 7/6/11 while Resident #1 was out of the building. (He was last seen on the porch at approximately 3:45 p.m. and didn't return to the facility until approximately 4:30 p.m.) Review of a "Care Management Summary" dated 7/8/11 revealed that Resident #1 had an elopement on 7/6/11 and was at risk of elopement. Interventions were: Wanderguard-check q shift for placement, Q 1 hr checks, don't allow outside unsupervised, and always check with the nurse before assisting outside the facility. There was documentation that the resident had confusion at times. Observation and Interview with Resident #1 on 7/19/11 at 9:45 a.m. revealed that he was alert and oriented to person and place. He was aware that it was July 2011 but was not sure of the date. He was sitting on the bedside dressed and groomed. Fistula was noted to the left arm. Resident #1 stated that he gets dialysis. When asked about the trek he took, Resident #1 recalled the event. He stated that he was going home to see about things. Resident #1 stated that he had left the front porch and cut down by the local gas station and the grocery store. He stated that Family Member #1 had picked him up around the local church. He stated that he did not get too hot, that he was used to being hot because he'd been out in it all of his life. When the dangers/hazards of being out by himself on the busy road was explained, Resident #1 stated that he wasn't crazy, had his right mind and didn't know why they kept him locked up. He stated that he didn't know why he had to wear that bracelet (observed Wander guard bracelet on his right ankle) and everyone else didn't have to wear one and they went outside. Resident #1 denied falling down and stated that he had his cane with him. He stated that he had been at the facility since Christmas and wanted to go home, so that's what he did. Resident #1 was ambulatory with a fairly steady gait. Observation of Resident #1 on 7/19/11 at 11:50 a.m. and 4:35 p.m. revealed that he was alert and oriented to person, place and time and made no attempts to go to exit doors or wander up and down the hallway. Observation and interview with Resident #1 on 7/20/11 at 3:20 p.m. revealed that he had returned from dialysis and was alert and oriented to person, place and day of the week and a Wander guard bracelet was intact to the right ankle. Resident #1 stated that he was not going to leave and walk down the road anymore, that he would wait until his granddaughters took him out to his house. He stated that he had stayed out of the middle of the road when he had walked before. Resident #1 stated: "ya'll act like I ain't got no sense, I got plenty of sense". Interview with the Director of Nursing (DON) on 7/19/11 at 9:00 a.m. revealed that Resident #1's granddaughter, Family Member #1, had let the resident out on the front porch before leaving the facility. Family Member #1 had called the facility later and said that someone had seen Resident #1 walking around the local general store. The DON stated that Resident #1 always wanted to go home and that his house was only a few blocks away. She stated that Resident #1 was alert but did have some periods of confusion. The weather had been sun shiny and hot that evening. The DON stated that in-service education had been done that included the policy on elopement/drills and that any resident with a Wander Guard bracelet was not to sit on the porch unattended by staff. The DON stated that there had not been a formal Quality Assurance (QA) meeting but there had been a Care Management meeting on 7/8/11. She stated that the physician was notified, all wanderers were accounted for, Wander guards intact/functional, elopement books checked and care plans updated. The DON stated that they had guessed the distance from the facility to where Resident #1 was located to be approximately 1 ? miles. Further interview with the DON on 7/19/11 at 11:05 a.m. revealed that it had always been a policy that staff was to be with a resident outside if they had on a Wander Guard and this was just re-enforced during the in-service. She stated that Family Member #1 and Family Member #2, which were both employed by the facility, had both been trained on elopement and should have told someone that Resident #1 was on the porch because they were aware that he wore a Wander Guard bracelet. Interview with the DON on 7/20/11 at 8:48 a.m. revealed that Resident #1 was assessed and care planned for an elopement risk because he had some intermittent confusion. She also stated that he would try to follow people out of the door when they left so an order was gotten for a Wander Guard. She stated that Resident #1 was not always confused and that she was not aware that he had ever been on the porch before by himself. Interview with the RN Consultant on 7/19/11 at 11:00 a.m. revealed that she had spoken to Resident #1 on 7/7/11 and the resident was alert and oriented and had told her that he was going home and told her of the route that he had taken. She stated that she wasn't sure that the resident had needed a Wander Guard but stated that he did have documentation of confusion and agreed that it was hazardous for the resident to have been left unattended because of the heat and terrain. She stated that he was care planned for the risk of elopement due to periods of confusion. Interview with RN #2 on 7/19/11 at 10:51 a.m. revealed that she had been informed by RN #1 that a call had been received from Resident #1's granddaughter and that the resident had been seen walking out away from the building. She stated that RN #1 and herself searched for the resident inside and went outside to look and couldn't find him. RN #2 stated that an alert had been called and the DON was notified and the DON and RN #1 continued to look for Resident #1 outside and she had returned to search inside. She stated that she received a call from the DON that Resident #1's family was bringing him back to the facility. She stated that this was probably around 4:30 p.m. She stated that Resident #1 had ambulated into the facility with his cane and once he had gotten settled into his room that she performed a body audit and found no injuries. She stated that Resident #1 didn't complain of any pain and said that he wasn't hot. She stated that he had on long pants, a shirt, and tennis shoes. RN #2 stated that Resident #2's blood pressure may have been a little elevated but she did not recall him having a temperature. RN #2 stated that Resident #1's Wander Guard was on his ankle and was functional. She stated that all other residents were accounted for and that LPN #3 started an in-service about elopement that evening. She stated that Resident #1's family stayed with him for a long while and hourly visual checks continued with no further concerns. A Conference was held with the Administrator, DON and Consultant on 7/19/11 at 12:05 p.m. to inform them of the Immediate Jeopardy that existed because of Resident #1's elopement. The DON stated that there had been signs on the exit doors at one time to check with nursing prior to assisting residents outside but due to some painting and renovations in the facility the signs must have been taken down. The Administrator agreed that the signs had been there prior to renovation. The Administrator noted that she had placed signs on the Exit doors the evening of Resident #1's elopement to check with the nurse prior to assisting residents out of the facility. Interview with Family Member (FM) #1, (who is also Resident #1's RP and a CNA staff member of the facility), on 7/19/11 at 12:15 p.m. revealed that CNA #1 had told her that Resident #1 was trying to go out the back door. She stated that she was getting ready to clock out and that she told Resident #1 that he couldn't go out that way but that he could sit on the front porch. FM #1 stated that Resident #1 wanted to wait on the secretary so that he could get some money from his account. She stated that she told Resident #1 to wait on the front porch for the secretary and she left the facility while he was still sitting on the porch. FM #1 stated that a neighbor had called her around 4:00 p.m. and said they had seen Resident #1 walking up a path. She stated that she called the facility and they kept putting her on hold. She stated that her sister (FM #2) had called and said that the neighbor had called her and said that Resident #1 was by the local general store. FM #1 stated that she got in the car and found Resident #1 across from the local church just a piece up from the local general store. She stated that FM #2 had arrived and she and Resident #1 got in the car and they went back to the facility. She stated that Resident #1 did not complain of being hot and wouldn't take any water when offered. She stated that he was not sweaty and he was not hurt and had his cane. She stated that Resident #1 did have confusion occasionally due to increased ammonia levels but that he was not confused that day, just going home. FM #1 stated that she had been trained on elopement and knew that Resident #1 wore a Wander Guard bracelet and that he was checked every hour to make sure that he was in the building, but just didn't think that there would be a problem to let him sit on the porch because he wasn't confused that day. She stated that she had not let anyone know that Resident #1 was on the porch, but looking back she should have. She stated that she had no idea that he would have left. Interview with FM #2, (who is also Resident #1's RP and a CNA staff member of the facility), on 7/19/11 at 12:40 p.m. revealed that she had clocked out around 3:15 p.m. and Resident #1 was sitting on the porch. She stated that Resident #1 had wanted her to bring him some tobacco and she had told him to sit on the porch and she would bring some back. FM #2 stated that Resident #1 had never left the premises before. She stated that FM #1 had called and told her that a neighbor had seen Resident #1 at the local general store. She stated that she met FM #1 just past the local general store and Resident #1 was standing on the side of the road. FM #2 rode with the surveyor to the point where Resident #1 had been observed and picked up. The distance was 0.8 miles from the facility driveway on a hill across from the local church. The sidewalk started just above the local general store and FM #2 stated that Resident #1 was standing on the sidewalk. She stated that she now knew not to leave Resident #1 outside by himself without staff. She stated that she had not notified any staff that Resident #1 was on the porch and that FM #1 had taken him outside. She stated that she did not think that he would leave. She stated that Resident #1 did get confused sometimes. She stated that she had been in-serviced on elopement and had elopement drills. Interview with RN #1 on 7/19/11 at 1:45 p.m. revealed that there had been a meeting at work the day that Resident #1 had left the facility grounds. She stated that she had seen Resident #1 with FM #1 and FM #2 around 3:00 p.m. but had not seen them go outside and was not aware that the resident had gone outside. She stated that to her knowledge Resident #1 had never tried to leave before but that he had talked about going home and checking on things before. She stated that residents with Wander guards were visualized every hour by herself/LPNs/CNAs and documentation was done by the LPN. She stated that she had received a phone call from FM #1 who asked if Resident #1 was at the facility because a friend had called her and said that Resident #1 was seen walking down the road. She stated that she checked his room and Resident #1 was not found. She stated that an Amber alert was called and she and RN #2 went outside to look for the resident and had ridden to Highway 51 merger and did not find the resident. She stated that the DON got a call that Resident #1 had been found and was being brought back to the facility. She stated that Resident #1 had on jeans, shirt and tennis shoes when he got back to the facility and had his walking cane. She stated that Resident #1 was not stumbling and that his gait was steady. She stated that Resident #1 refused any water and had said that he was going home to check on things and make sure that his grass was mowed. She stated that LPN #3 started an in-service that evening on elopement. She stated that all residents were accounted for and signs were placed to make sure everyone checked before letting residents outside. She stated that she thought there had been signs before and didn't know what had happened to them. She stated that later there was a Care conference meeting with other department heads about the wanderers and to make sure the books were updated. Also the care plans and elopement policy were checked. She stated that Resident #1 was confused at times but had not been on that day. Interview with LPN #4 on 7/19/11 at 2:50 p.m. revealed that she was on duty 7-3 shift on 7/6/11. She stated that Resident #1 was his normal self and was not confused or agitated. She stated that there had been a staff meeting from 2:00 p.m. until 3:00 p.m. and that she had stayed on the floor during that meeting. She stated that she had seen Resident #1 out on the porch around 3:00 p.m. from the front window sitting with other residents before she had gone into the nurse's meeting that was held from 3:00 p.m. until 4:00 p.m. She stated that she had gone to parts of both meetings and that her relief, LPN #5, had come to the floor around 4:00 p.m. She stated that she had visualized Resident #1 every hour that shift up until 3:00 p.m. She stated that she had not visualized him at 4:00 p.m. but had documented the next day on the 4:00 p.m. square for 7/6/11 because it had been left blank. She stated that she shouldn't have documented the visual check if she did not actually see Resident #1. She stated that she had not been aware that Resident #1 was missing when she had left the facility that day. LPN #4 stated that Resident #1 could carry on a good conversation but that he had confused moments. Further interview with LPN #4 on 7/20/11 at 1:15 p.m. confirmed that she was pretty sure it was after 4:00 p.m. on 7/6/11 and that she had documented the 4:00 p.m. visual check of Resident #1 without seeing him for 7/6/11. She stated she thought she'd just forgotten to document because she'd been here at 4:00 p.m. so she went ahead and documented. Interview with LPN #5 on 7/19/11 at 3:15 p.m. revealed that she was in a meeting the day that Resident #1 had left and had not found out until a call came from the granddaughter that the resident was missing and that she had seen him last on the porch. She stated that this had to be after 4:00 p.m. She stated that she saw Resident #1 when he came back to the facility with street clothes on and his cane. She stated that Resident #1 had said that he wanted to go to his house. She stated that she normally did visual checks every hour on residents that wore Wander Guards. She stated that LPN #4 should have made the 4:00 p.m. checks because she had not made rounds until after getting report and this was after 4:00 p.m. LPN #5 stated that Resident #1 was alert and oriented and not confused and did not attempt to leave the facility again. She stated that elopement in-services began that night and there had been elopement drills also. She stated that signs had been posted to check with the nurses before letting residents outside. She stated that residents with Wander Guard bracelets were not to be left unattended outside. Further interview with LPN #5 on 7/20/11 at 5:15 p.m. revealed that she had left the 4:00 p.m. visual check on the MAR blank on 7/6/11 because she thought that LPN #4 had made the check and had just forgotten to document. Interview with CNA #2 on 7/19/11 at 3:30 p.m. revealed that she was in a meeting until approximately 3:30 p.m. She stated that when she made her rounds that Resident #1 was not in his room and when she went to the nurse's desk she heard them talking about the resident not being in the facility and they all started looking for him. CNA #2 stated that residents who wore Wander Guards were checked every hour to make sure they were okay and they weren't supposed to be outside unattended. She stated that there was an in-service that night about the elopement policy. She stated that Resident #1 had occasional confusion but was okay that night. Interview with RN #3 on 7/19/11 at 10:32 a.m. revealed that residents who wore Wander Guard bracelets were visualize every hour and documented on the Medication Administration Record (MAR) and should not be left outside unattended. RN #3 stated that all residents were periodically checked if they were outside even if they didn't wear a Wander Guard bracelet due to the heat. Interview with LPN #3 on 7/19/11 at 5:10 p.m. revealed that she had notified the Medical Director of Resident #1's elopement on 7/7/11 and had begun in-services on 7/6/11 on elopement policy/procedure. She stated that residents who were at risk for elopement should not be left outside unattended. Further interview with LPN #3 on 7/20/11 at 12:35 p.m. revealed that she had done an in-service on abuse/neglect on 7/6/11 and that all staff had been in-serviced on abuse/neglect and elopement and confirmed by the schedule. Interview with LPN #8 on 7/19/11 at 5:30 p.m. revealed that she had received a phone call from FM #1 and FM #2 that someone had seen Resident #2 walking. She stated that it wasn't long before Resident #1 was brought back to the facility. She stated that she had told the CNAs to stop what they were doing and look for the resident after she had received the call. She states that residents with Wander Guards are visually checked every hour and documentation was done on the MAR. Interview with LPN #1 on 7/20/11 at 11:20 a.m. revealed that when she left the faciity on [DATE] around 3:45 p.m. she saw Resident #1 sitting on the front porch with other residents and no staff was outside. She stated that she was not aware at that time that Resident #1 was an elopement risk or would have notified someone or taken the resident back inside the facility. She stated that the DON had called her later that evening and asked if she'd seen Resident #1 and had gone over the elopement policy. She stated that there were elopement books on each nurse's station that included all residents who were at risk for elopement and visual checks were documented every hour. She stated that residents were not to be taken out and left without staff present. LPN #1 stated that she had been in-service prior and after the incident on elopement. Interview with the DON on 7/20/11 at 1:00 p.m. revealed that she had confirmed that LPN #4 had documented the visual check for Resident #1's at 4:00 p.m. on 7/6/11 without actually seeing the resident. She stated that the visual check had not been documented on the MAR when she started the investigation that day and was unaware that LPN #4 had documented the MAR at a later time. Review of the facility's policy "Elopement Prevention & Management " dated 8/10 revealed: Elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or necessary supervision. Unsafe wandering may occur when a resident/patient enters an area that is physically hazardous or that contains potential safety hazards ....A resident/patient identified as cognitively intact and capable of making independent decisions and identified as their own person is instructed on facility sign out procedures prior to leaving the facility. Documented in handwriting was a statement "*Nobody (with) a wanderguard sits on porch unless a staff member is with them* ". Review of the facility's policy "Abuse Prevention Program & Reporting Policy" dated 03/11 revealed: The facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of resident/patient property by anyone including but not limited to: staff, family, or friends. Employees are appropriately screened and trained to prevent abuse. Each employee is responsible to report any suspected abuse. Each incident will be investigated, and required reporting completed. "Under the "Definitions" section: "Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness." "Credible Allegation of Compliance" "Resident #1 had been assessed and care planned by LPN #5 on 4-1-2011 at 9:40 p.m. for risk of elopement related to confusion. A Wander Guard bracelet was applied to Resident #1 by LPN #5 at 9:40 p.m. on 4-1-2011. On 7-6-2011 at approximately 3:15 p.m. Resident #1 was taken outside by Family Member #1. At approximately 3:20 p.m. Family Member #2 walked out of the facility and witnessed Resident #1 on the front porch with other residents. Family Member #2 got in the car with Family Member #1 and left the facility parking lot. LPN #1 stated that she saw Resident #1 on the porch on 7-6-2011 at approximately 3:45 p.m. on 7-6-2011 and no other staff were present. Resident #1 left the porch sometime after 3:45 on 7-6-2011 and walked approximately 1.5 miles. It was later determined that the distance that Resident #1 walked was 0.8 of a mile. Family Member #1 called the facility at approximately 4:15 p.m. and informed RN #1 that her grandfather (Resident #1) was seen walking past the (local general store) by her neighbor. An Amber alert was called by RN #1 after the phone call was received on 7-6-11 at approximately 4:15 p.m. and a search was conducted of the facility and grounds by the staff members that were present. Family Member #1 and #2 ( responsible parties of Resident #1) brought Resident #1 back to the facility on [DATE] at approximately 4:30 p.m.. Resident #1 was evaluated by RN #2 at approximately 4:50 p.m. and was found to have no adverse affects. Resident #1's primary physician was notified by LPN #2 on 7-6-2011 at approximately 5:00 p.m.. The responsible party who is also Family Member #1 and Family Member #2 were present. It was determined after further investigation that LPN #4 didn't visualize Resident #1 on 7-6-2011 at 4 p.m. and hourly visual checks began again at 5 p.m. on 7-6-2011 by LPN #5. Family Member #1 and Family Member #2 stayed with Resident #1 for several hours after his return to the facility. Signs were placed at 11 exit doors on 7-6-2011 at approximately 5:00 p.m. by the Administrator that reminded visitors and staff that they should check with the nurse before allowing anyone out of the door. Family Member #1 and Family Member #2 were in-serviced on the elopement policy by Staff Development LPN #3 on 7-6-2011 at approximately 5:15 p.m.. The DON (Director of Nursing) in-serviced LPN #1 by phone at approximately 6:00 p.m. on the elopement policy. The information that was reviewed with Family Member #1, #2 and LPN #1 included the importance of not allowing residents that wear Wander guard bracelets out of the facility unattended. It also included that signs were now placed at each exit door to remind visitors and staff not to allow anyone out of the door with out checking with the nurse. The in-service also included information about the binders that are kept at each nursing station with each resident's Elopement Risk Alert form and picture. The Staff Development LPN #3 began in-servicing on the Elopement Policy to all staff that were present in the facility on the evening of 7-6-2011 at approximately 6:00 p.m. and no staff member was allowed to work until this was completed. This in-service included the importance of not allowing resident that wear Wander guard bracelets out of the facility unattended. It also included that signs were now placed at each exit door to remind visitors and staff not to allow anyone out of the door without checking with the nurse. They were also in-serviced on the binders that were kept at each nursing station with each residents Elopement Risk Alert form and picture and in-serviced on the importance of visual check of residents that wear Wander guard bracelets. An Abuse and Neglect in-service was held at 2:00 p.m. on 7-6-2011 by LPN #3 and no employee was allowed to work until this was completed. The in-service included the four types of abuse, the seven components of abuse prevention and management which are screening, training,

CI MS #9517 Based on observation, interview, record review and policy review, the facility failed to implement policies and procedures that prohibit neglect and to provide adequate supervision to prevent one (1) of six (6) sampled residents reviewed, Resident #1, from leaving the facility unsupervised and without staff knowledge. Resident #1 was assessed and care planned as a risk for elopement and wore a Wander Guard Bracelet. Resident #1 required hourly visual checks which had not been performed at 4:00 p.m. on 7/6/11. Resident #1 was left out on the porch on 7/6/11 sometime after 3:45 p.m. without staff supervision and walked approximately eight tenths (0.8) of a mile on major highways that had areas of deep ditches and no sidewalk. Resident #1 was returned to the facility by family members on 7/6/11 at approximately 4:30 p.m. The facility's failure to supervise and ensure that hourly visual checks were performed and measures taken to prevent Resident #1 from leaving the facility unassisted was deemed an Immediate Jeopardy on 7/19/11 at 12:05 p.m. The Immediate Jeopardy began on 7/6/11 and was determined to be removed on 7/8/11. The Administrator was notified of the Immediate Jeopardy on 7/19/11 at 12:08 p.m. The facility provided a Credible Allegation of Compliance (AoC) on 7/20/11. Based on the facility's implementation of corrective actions and an acceptable Credible Allegation of Compliance, the Immediate Jeopardy was removed and the scope and severity was lowered on 7/8/11 to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross Refer to F-323 for the facility's failure to ensure that Resident 1 did not leave the facility without staff knowledge and supervision. "Credible Allegation of Compliance" "Resident #1 had been assessed and care planned by LPN #5 on 4-1-2011 at 9:40 p.m. for risk of elopement related to confusion. A Wander Guard bracelet was applied to Resident #1 by LPN #5 at 9:40 p.m. on 4-1-2011. On 7-6-2011 at approximately 3:15 pm Resident #1 was taken outside by Family Member #1. At approximately 3:20 pm Family Member #2 walked out of the facility and witnessed Resident #1 on the front porch with other residents. Family Member #2 got in the car with Family Member #1 and left the facility parking lot. LPN #1 stated that she saw Resident #1 on the porch on 7-6-2011 at approximately 3:45 pm on 7-6-2011 and no other staff were present. Resident #1 left the porch sometime after 3:45 on 7-6-2011 and walked approximately 1.5 miles. It was later determined that the distance that Resident #1 walked was 0.8 of a mile. Family Member #1 called the facility at approximately 4:15 pm and informed RN #1 that her grandfather (Resident #1) was seen walking past the local general store by her neighbor. An Amber alert was called by RN #1 after the phone call was received on 7-6-11 at approximately 4:15 pm and a search was conducted of the facility and grounds by the staff members that were present. Family Member #1 and #2 ( responsible parties of Resident #1) brought Resident #1 back to the facility on [DATE] at approximately 4:30 pm. Resident #1 was evaluated by RN #2 at approximately 4:50 pm and was found to have no adverse affects. Resident #1's primary physician was notified by LPN #2 on 7-6-2011 at approximately 5:00 pm. The responsible party who is also Family Member #1 and Family Member #2 were present. It was determined after further investigation that LPN #4 didn't visualize Resident #1 on 7-6-2011 at 4 pm and hourly visual checks began again at 5 pm on 7-6-2011 by LPN #5. Family Member #1 and Family Member #2 stayed with Resident #1 for several hours after his return to the facility. Signs were placed at 11 exit doors on 7-6-2011 at approximately 5:00 pm by the Administrator that reminded visitors and staff that they should check with the nurse before allowing anyone out of the door. Family Member #1 and Family Member #2 were in-serviced on the elopement policy by Staff Development LPN #3 on 7-6-2011 at approximately 5:15 pm. The DON (Director of Nursing) in-serviced LPN #1 by phone at approximately 6:00 pm on the elopement policy. The information that was reviewed with Family Member #1, #2 and LPN #1 included the importance of not allowing residents that wear Wander guard bracelets out of the facility unattended. It also included that signs were now placed at each exit door to remind visitors and staff not to allow anyone out of the door with out checking with the nurse. The in-service also included information about the binders that are kept at each nursing station with each resident's Elopement Risk Alert form and picture. The Staff Development LPN #3 began in-servicing on the Elopement Policy to all staff that were present in the facility on the evening of 7-6-2011 at approximately 6:00 pm and no staff member was allowed to work until this was completed. This in-service included the importance of not allowing resident that wear Wander guard bracelets out of the facility unattended. It also included that signs were now placed at each exit door to remind visitors and staff not to allow anyone out of the door without checking with the nurse. They were also in-serviced on the binders that were kept at each nursing station with each residents Elopement Risk Alert form and picture and in-serviced on the importance of visual check of residents that wear Wander guard bracelets. An Abuse and Neglect in-service was held at 2:00 pm on 7-6-2011 by LPN #3 and no employee was allowed to work until this was completed. The in-service included the four types of abuse, the seven components of abuse prevention and management which are screening, training, prevention, identification, protection, investigation and reporting. Visual checks of the 15 residents that had been identified of being at risk for elopement was completed by RN #2 and RN #4 on 7-6-2011 at approximately 5:30 pm. All 15 residents were determined to be safe and present in the facility. The Medical Director was notified on 7-7-2011 by LPN #3 at approximately 9:00 am of the elopement of Resident #1. A Care Management Meeting was held on 7-8-2011 at approximately 10:00 am with the Director of Nursing, Social Service Director, RN #1, RN #2, LPN #3, MDS Director, and MDS Nurse, Activity Director and Director of Rehabilitation. During the Care Management Meeting the care plans and resident profiles were updated on the 15 residents that had been identified of being at risk for elopement. Elopement Risk Alert binders were reviewed at this time to ensure that each resident had an updated picture and information. The following measures have been taken to ensure that the facility is in compliance: ? Weekly elopement drills. ? Hourly visual checks are being documented on the MAR for residents with Wander guards. ? Daily monitoring of the exit doors to ensure proper functioning by maintenance or designee. ? Review of MAR documentation completed daily. ? Wander guard bracelets are checked every shift for placement. ? Wander guard bracelets are checked daily for function. The results of these interventions are monitored by the administrative staff and any further problems are presented to the QA committee for review and possible recommendations." Verification of the AoC: Random interviews with Maintenance, Activity, Nursing staff (RNs and LPNs), Certified Nursing Assistants (CNAs), and Administrative staff and observations on 7/19/11 and 7/20/11 were conducted to verify placement of signs on all exit doors that directed staff and visitors to the nurse prior to letting anyone out of the facility. Random interviews confirmed that staff had been in-serviced on elopement and abuse/neglect. Observation of all residents that were identified as elopement risk to ensure that Wander Guard bracelets were intact and that residents were present in the building was conducted on 7/19/11 beginning at 9:55 a.m. and again on 7/20/11 at 2:30 p.m. Interview with the Staff Development Nurse on 7/20/11 at 12:35 p.m. was conducted with verification of the schedule that all staff had completed in-services on abuse/neglect and elopement. Verification also consisted of random interviews with the nursing staff and observation of the MAR that visual checks had been documented hourly on residents at risk for elopement. Observation on 7/19/11 and 7/20/11 revealed no residents attempting to exit the facility unsupervised. Review of the Care Management Meeting report dated 7/8/11 verified that the Interdisciplinary Team had reviewed all residents that were identified at risk for elopement and updated the profile/information sheets. Observation on 7/19/11 and 7/20/11 revealed Elopement Books at each nursing station with profile information and pictures of those residents that were identified at risk for elopement. Interviews with nursing staff revealed that they had knowledge of the Elopement Books on each station. After verification of the facility's corrective action through observations, staff interviews and in-service reviews, the Immediate Jeopardy was removed and the scope and severity was lowered on 7/8/11 to a "D" level, which is no actual harm with the potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview, policy/procedure review and inservice review, the facility failed to meet professional standards of care for Resident #3, one (1) of four (4) residents reviewed ). The facility failed to implement physician's orders [REDACTED]. Resident #3 had a urinalysis obtained on 1/18/11. The Physician was notified and an order was received [MEDICATION NAME] mg one (1) twice daily. The facility failed to take the order off and start [MEDICATION NAME] ordered. On 1/24/11, Resident #3 spiked a temperature of 101.4, complained of nausea and vomiting, and experienced decreased oxygen saturation levels. Resident #3 was transferred to the hospital emergency room for evaluation and treatment. Resident #3 was diagnosed with [REDACTED]. Findings Include: Record review on revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of (Name of Lab Company) lab results revealed that the "Draw date" was 01/18/11 at 2:50 a.m. At the top of the report it stated: "Delivered 01/18/2011 5:37 PM." The lab results were "clarity sl (slightly) cloudy; protein = 100 (Normal) is negative; large amount of blood; leukocytes-small amount (normal = negative); WBC 10-25 (normal = none); URBC 25 -50 (normal = none); and bacteria was moderate amount normal = none). " At the bottom of the lab report was a handwriting statement: "1/21/11 allergy: PCN ([MEDICATION NAME]), [MEDICATION NAME]. Awaiting C&S. Was notified by (name of lab company) only U/A ordered. Sample discarded.[MEDICATION NAME] BID X 7 days. Repeat U/A + c/s 3 days p (after) abx (antibiotics)." There were initials at the top of this note in the same handwriting. Review of the January 2011 Medication Administration Record (MAR) revealed that there was no documented evidence of [MEDICATION NAME] or that it was administered to Resident #3. Review of the Medical Doctor (MD) orders for January 2011 revealed no handwritten order [MEDICATION NAME] the time frame of the MD order that was on the lab results dated 01/21/11. The MD order dated 01/24/11 at 8:15 a.m. stated: "Administer O2 (oxygen) @ (at) 2 lpm (liters per minute) BNC (by nasal cannula) PRN (as needed) - SOB (shortness of breath). [MEDICATION NAME] 25 (mg) IM (q) 4 hours PRN-N/V (nauseas/vomiting). May send resident to (local hospital) to be evaluated by ER (emergency room ) physician." The next MD order dated 01/24/11 at 1:30 p.m. stated: "Resident transported to (Name of 2nd hospital) due to DX (diagnoses): Urosepsis from (local hospital)." Review of the nurses notes revealed that there was no documentation related to [MEDICATION NAME] dated 1/21/11-1/24/11. Review of the nurses notes through 01/19/11 revealed no documented evidence related to a UTI (Urinary Tract Infection) or of the [MEDICATION NAME] administered. The nurses note dated 01/24/11 at 6:30 a.m. revealed: "Temp (temperature) 101.3 orally. Exudates noted in eyes esp (especially) right eye. Has coughed some...". The nursing note on 01/24/11 at 7:00 a.m. revealed: "PO (by mouth) meds given for c/o (complaints of ) increased temp." On 01/24/11 at 7:45 a.m. "Resident pale all over, alert et (and) responds well to all stimuli, condition weak, skin hot to touch, temp 101.4 AX (auxillary), O2 Sats @ 88% room air, Pulse = 84 R = 22, B/P-140/60 @ rest with hob (head of bed) up, audible congestion to chest, resp. moist, nonprod cough, eyes matted in corners with purulent thick drainage (exudate)." At 8:45 a.m. "Apap ([MEDICATION NAME]) given by 11-7 nurse for increased temp, fluids encouraged, tries to eat breakfast, exhibits N/V after few bites, exhibits N/V after fluids. MD notified order for [MEDICATION NAME] 25 mg IM given N/V, speech clear, states "I'm alright." Accucheck = 83, orders noted to send resident to (local hospital) ER to be eval by ER physician. O2 applied @ 2 lpm Sats remains 88 with O2 in use few mins. Report of resident's status to (local hospital) by (RN#1)'s name, (Name of Ambulance Company) notified to transport resident. RP (Responsible Person) unable to contact, notified 2nd contact." Resident was transported per ambulance service on 01/24/11 at 8:50 a.m. O2 sats at that time was 81%, BP 60/38. On 1/24/11 at 11:00 a.m. a late entry for 8:15 a.m. stated: "discussed current status/vital signs with primary MD per telephone. Reminded him of U/A results discussed with him on 1/21/11 & asked if resident to be started [MEDICATION NAME] transported to ER. Order to transport to (local hospital) and follow any hospital orders. Called (Name of RP) who stated thanks for sending to hospital for possible IV abt (antibiotics) " might be best " (name of ambulance company) notified for need for transport." On 1/24/11 at 1:30 p.m. "Calls (local hospital) resident was transported to (name of 2nd hospital) with Dx: Urosepsis." On 1/24/11 at 1:35 p.m. " Calls (name of 2nd hospital) Nurse reports resident is fine for now but remains in ICU. " Review of Resident #3's careplans (with no implementation date) revealed a careplan stating Dx: S/P (status [REDACTED]." Approaches stated: "Labs as ordered with results to MD. Report s/sx of UTI: discolored or concentrated urine, foul odor to urine, decreased output, c/o pain or discomfort when urinating, elevated temp, change in LOC (level of consciousness) or behavior-document and report as indicate. Encourage fluids as tolerated. Meds as ordered. Obtain U/A 1/18/11." Interview on 04/6/11 at 1:10 p.m. with the Director of Nurses (DON) revealed: "Yes, there was a med error. (Name of RN #1) got the lab slip on 01/21/11 and the order was written on it. (Name of RN #1) said she gave it to (Name of LPN #2). (LPN #2) says she doesn't remember (RN #1) giving it to her. RN #1 took the order [MEDICATION NAME] the MD and wrote it on the lab slip." The DON stated that she did not call this incident into the State Agency. A write up was done on LPN #1 for not transcribing MD orders. LPN #1 says that she did not realize RN #1 had given her an order. "We have done inservices since on taking medication MD orders. We have also talked about it in QA (Quality Assurance). (Resident #3's) primary MD is also our Medical Director. The Medical Director is aware that the order wasn't followed through with. I did not call this in the the Nursing Board." Interview on 04/6/11 at 1:30 p.m. with RN #1 revealed: "On 01/21/11, I mentioned to the MD (Resident #3's) allergies and then I called (Name of Lab Company) about the U/A to see if it could be cultured. They said only a U/A was ordered and the specimen had been thrown away. The primary MD [MEDICATION NAME] MG BID X 7 days, repeat U/A with C&S 3 days post ABT completion." RN #1 stated that she wrote that on the lab slip and gave the whole paper (lab and order) to LPN #1. "I explained the whole situation to her. She told me to put it on the desk where she usually sat. I did just that. If I'm not mistaken this was late Friday afternoon. I did not work the weekend. I found out the order had not been done when I came in early Monday morning (morning of 01/24/11). The LPN on duty mentioned to me that (Resident #3) was ill. I remarked that the antibiotic must not be working. She asked me what antibiotic and that is when we started investigating. I confirmed it, there was not an order for [REDACTED]. No orders had been written for (Resident #3). I notified the MD. I discussed it with the DON. The MD told me that if the family wanted (Resident #3) to go to the ER to do whatever the family wishes. (Resident #3) was transferred to ER. I called (LPN #1) about not ordering the medicine. She didn't recall the order, then I reminded her. (LPN #1) said she never saw any paperwork. I told her it wasn't on the chart but I would try to locate it and that we would talk about this when she came to work. I found the lab slip at the nurses station between two (2) binders. I believe (LPN #1) got written up. I let the family know that the Antibiotic wasn't given. They were upset and wanted to know what would be put in place to ensure it didn't happen again. Now, whoever calls the Physician would be the one to carry out the order. It was late in the afternoon Friday when it (lab) came in and I addressed it then." Interview on 04/6/11 at 1:35 p.m. with Resident #3's primary physician and the facility's Medical Director revealed: "(Name of Resident #3) was already sick when I ordered the antibiotic, so I can't say the lack of antibiotics caused the Urosepsis. It certainly didn't contribute to her death which was one month later. I was furious that the antibiotic order wasn't followed. I think the nursing home has been admonished plenty by me since then. She may have got sicker because she didn't get the Antibiotic sooner." Interview on 04/6/11 at 2:45 p.m. with LPN #1 revealed: "I was (Resident #3's) 3:00 p.m. to 11:00 p.m. medication LPN. I was given a phone call saying that (Resident #3) wasn't given her antibiotic. I don't know the date. I never received or took an order for [REDACTED].#1) and the DON. We figured out that RN #1 took the order and wrote it on the lab sheet. She never gave me a copy of it. I never saw anything about it. I told my DON if I knew an antibiotic was ordered, I would have given it. They wrote a coaching plan and changed it so that if the RN gives us something like an order, she has to initial it and so do we." The DON stated the facility did not have a specific policy/procedure for following MD orders and medication administration and they follow basic nursing practice and principle for following MD orders. Review of an inservice given in the facility on 01/31/11 at 2:00 p.m. stated: "Program/session: blood-borne pathogens, Infection control, Medication administration/errors" stated on page 1 of information given to staff during this inservice: "Medication Administration: Always give meds according to orders and facility policy. " Review of the facility's "NOTIFICATION OF RESIDENT/PATIENT CHANGE IN CONDITION" Policy/Procedure revealed " rocedure #11: Record any physician orders [REDACTED]. Review of an inservice dated 12/16/10 at 2:00 p.m. revealed on page 2 of information given during inservice stated, "#4. 24 hour reports - Nurses on every shift must complete the twenty-four hour report. All order go on the 24 hour report. Any variances such as increased behavior, treatment of [REDACTED].". Both RN #1 and LPN #1 signed the signature form indicating they attended this inservice.